Case: U.S. CRIPA Investigation of Western State Hospital (VA)

No Court

Filed Date: Oct. 6, 1999

Closed Date: 2003

Clearinghouse coding complete

Case Summary

On June 29, 1998, the Department of Justice Civil Rights Division (DOJ) opened an investigation, pursuant to the Civil Rights of Institutionalized Persons Act (CRIPA) of the Western State Hospital, a state mental health facility in Staunton, Virginia. The facility held approximately 370 patients, with one-third of the patients having a dual diagnosis of mental illness and substance abuse.On July 23, 1999, Pennsylvania’s Attorney General notified the DOJ that Western State was taking steps to re…

On June 29, 1998, the Department of Justice Civil Rights Division (DOJ) opened an investigation, pursuant to the Civil Rights of Institutionalized Persons Act (CRIPA) of the Western State Hospital, a state mental health facility in Staunton, Virginia. The facility held approximately 370 patients, with one-third of the patients having a dual diagnosis of mental illness and substance abuse.

On July 23, 1999, Pennsylvania’s Attorney General notified the DOJ that Western State was taking steps to remedy concerns about the conditions of Western State and was developing a plan of correction. The Attorney General suggested the DOJ defer its findings letter until the plan of correction was finalized and Pennsylvania’s own expert had toured Western State.

The DOJ declined to wait for the plan of correction and proceeded to issue its findings letter to the Governor of Pennsylvania on October 6, 1999. The DOJ alleged violations of Fourteenth Amendment due process rights, Medicare/Medicaid regulations requiring adequate staffing and discharge planning, and Title II of the American with Disabilities Act (ADA). The DOJ found that the unlawful conditions of Western State included:

  • inadequate mental health treatment;
  • failure to provide necessary medications to patients;
  • inappropriate use of restraints and seclusion;
  • inadequate nursing and medical care;
  • failure to protect patients from injuries, dangerous behaviors and abuse;
  • unsafe and inadequate physical conditions; and
  • inadequate discharge planning and placement into the most integrated setting.
The DOJ reported that many of the unlawful conditions stemmed from a lack of protocols, monitoring of patients, and an insufficient number of adequately trained staff. The report cited multiple examples of patient injuries and death due to the lack of monitoring and failure to receive timely medical care. In addition, the DOJ highlighted how Western State placed patients in restraints in a face-down position and failed to set objective criteria for the release of patients from restraints and seclusion.

In its findings letter, the DOJ recommended Pennsylvania's plan of correction implement minimal remedial measures at Western State. These remedial measures included:

  • reformation of Western State’s mental health treatment, medical care, and emergency care in accordance with generally accepted medical standards;
  • prescription of medications based on clinical need, rather than budgetary constraints;
  • ending the use of six-point chair restraints, use of eight-point bed restraints, and placing patients in restraints in a face-down position;
  • documentation and monitoring the use of seclusion and restraints;
  • development and implementation of nursing protocols to ensure proper supervision;
  • abatement of suicide hazards in bedrooms and bathrooms;
  • development of a system to oversee discharge planning and aftercare services; and
  • increasing staffing, particularly psychiatrists and nurses.
Based on information acquired from the DOJ in a Freedom of Information Act request, a complaint was not filed in response to these allegations. According to an article in Developments in Mental Health Law, a publication by the Institute of Law, Psychiatry, & Public Policy at the University of Virginia, Western State implemented its plan of correction removing the need for a settlement agreement or the filing of a complaint. 31 Dev. Mental Health L., Oct. 2012 at 12, 15 n.12. According to the DOJ’s fiscal year 2003 report, the DOJ closed the investigation on September 5, 2003.

Summary Authors

Emily Kempa (8/4/2019)

People


Attorneys(s) for Plaintiff

Crouch, Robert P. Jr. (Virginia)

Lee, Bill Lann (District of Columbia)

Attorneys(s) for Plaintiff

Crouch, Robert P. Jr. (Virginia)

Lee, Bill Lann (District of Columbia)

Documents in the Clearinghouse

Document

Re: Findings from CRIPA Investigation of Western State Hospital, Staunton, Virginia

Oct. 6, 1999

Oct. 6, 1999

Findings Letter/Report

Resources

Docket

Last updated May 11, 2022, 8 p.m.

Docket sheet not available via the Clearinghouse.

Case Details

State / Territory: Virginia

Case Type(s):

Mental Health (Facility)

Key Dates

Filing Date: Oct. 6, 1999

Closing Date: 2003

Case Ongoing: No

Plaintiffs

Plaintiff Description:

Department of Justice Civil Rights Division, to enforce the rights of individuals housed in the Western State Hospital.

Plaintiff Type(s):

U.S. Dept of Justice plaintiff

Attorney Organizations:

U.S. Dept. of Justice Civil Rights Division

Public Interest Lawyer: Yes

Filed Pro Se: No

Class Action Sought: No

Class Action Outcome: Not sought

Defendants

Western State Hospital (Staunton, VA, Staunton), State

Defendant Type(s):

Hospital/Health Department

Case Details

Causes of Action:

42 U.S.C. § 1983

Civil Rights of Institutionalized Persons Act (CRIPA), 42 U.S.C. § 1997 et seq.

Americans with Disabilities Act (ADA), 42 U.S.C. §§ 12111 et seq.

Medicaid, 42 U.S.C §1396 (Title XIX of the Social Security Act)

Medicare, 42 U.S.C. 1395-1395lll (Title XVIII of the Social Security Act)

Constitutional Clause(s):

Due Process

Special Case Type(s):

Out-of-court

Availably Documents:

None of the above

Outcome

Prevailing Party: None Yet / None

Nature of Relief:

None

Source of Relief:

None yet

Issues

General:

Assault/abuse by residents/inmates/students

Failure to supervise

Incident/accident reporting & investigations

Neglect by staff

Restraints : physical

Staff (number, training, qualifications, wages)

Suicide prevention

Disability:

Integrated setting

Least restrictive environment

Mental impairment

Mental Disability:

Depression

Schizophrenia

Medical/Mental Health:

Medication, administration of

Mental health care, general

Self-injurious behaviors

Suicide prevention

Type of Facility:

Government-run