Case: Navarro-Ayala v. Hernandez-Colon

On November 25, 1974, patients at the Rio Piedras Psychiatric Hospital (RPPH) in San Juan, Puerto Rico filed a class action under 42 U.S.C. § 1983 against the Commonwealth of Puerto Rico in the U.S. District Court for the District of Puerto Rico. The plaintiffs, represented by Puerto Rico Legal Services and the Civil Action and Education Corporation, asked the court for declaratory and injunctive relief. They alleged that their constitutional rights had been violated by overcrowding, inadequacies in the physical facilities, lack of security for personal belongings, lack of pillows, poor laundry service, unpleasant odors, insufficient therapeutic treatment, insufficient staffing, inadequate classification standards, and discrimination on the basis of geographical origin. The plaintiffs also alleged that the defendants would place them naked in isolation rooms, which lacked toilet facilities. Amicus Curae in the case included the National Alliance for the Mentally Ill, the Comite De Convergencia Por La Salud Mental En Puerto Rico, and the Colegio De Medicos Cirujanos De Puerto Rico.

On June 3, 1977, the court issued a consent decree and closed the case. The decree detailed 86 standards that the parties stipulated would be observed at RPPH in the future, and it included short term plans to remove patients with intellectual disabilities, as well as other long-term patients who didn't require hospitalization to the Cayey and Bayamon Psychosocial and Rehabilitation Centers. It also included the placement of additional patients in a foster care home program. The decree contained no express provisions that any of the 86 standards would be effectuated at any other facility than RPPH.

There was little activity in the case for seven years. On February 8, 1985, the district court (Judge Hector Manuel Laffitte) appointed Dr. David Helfeld as Special Master in the case and instructed him to report back to the court on the defendants' progress. On August 10, 1987, in response to the Special Master's report detailing the overcrowding at RPPH, the district court (Judge Laffitte) ordered that 144 patients be transferred to the Guerrero facility, noting that the patients should receive care and treatment consistent with the 86 stipulations in the original consent decree.

On June 28, 1988, the defendants asked the district court to reclose the case, arguing that they had substantially complied with the court's orders. On December 8, 1988, the district court (Judge Laffitte) denied this motion, ruling that the defendants were not in full compliance with the decree.

On June 12, 1989, the plaintiffs asked the district court to hold the defendants in contempt, alleging that the patients that had been transferred to the Guerrero facility were not receiving adequate treatment. The defendants objected to this, arguing that the district court didn't have jurisdiction over Guerrero because the consent decree only pertained to RPPH. On December 28, 1989, the district court (Judge Laffitte) ruled that the consent decree did apply to RPPH patients being treated at the Guerrero facility.

On January 16, 1990, the defendants asked the district court for sanctions, stating that the plaintiff class had never been properly certified by the court. On March 6, 1990, the district court (Judge Laffitte) dismissed the defendants' request, holding that the action had been maintained as a class action since class certification was satisfied when the court approved the original stipulated agreement. The court also found that the notice requirement had been satisfied because no class member had complained during the entire 14 years of the litigation. The court stated that the defendants' arguments were frivolous and assessed sanctions of $1,500.00 in attorneys' fees against the counsel for the defendants. The defendants appealed this order. On December 18, 1991, the First Circuit (Judge Levin H. Campbell) affirmed the district court's ruling that the lawsuit could proceed as a class action, but reversed and remanded the district court's ruling that the consent decree would apply to the Guerrero facility. Navarro-Ayala v. Hernandez-Colon, 951 F.2d 1325 (1st Cir. 1991).

On remand, the district court (Judge Laffitte) ordered the parties to submit briefs on an appropriate remedial action for the defendants' systematic denial of rights under the Mental Health Code. The court also ordered the Special Master to investigate whether the medical directors at Guerrero were implementing the provisions of the Mental Health Code at that time. The defendants appealed both orders. On February 7, 1992, the First Circuit dismissed the appeal, holding that the appellate court had no jurisdiction in the matter since the district court's orders were not final orders. Navarro-Ayala v. Hernandez-Colon, 956 F.2d 348 (1st Cir. 1992).

The plaintiffs asked the district court to impose sanctions on the Assistant Secretary of Mental Health for violating Rule 11 of the Federal Rules of Civil Procedure by falsely certifying to the court that patients at the institution could leave the hospital "at any time they want." On July 8, 1991, the district court (Judge Laffitte) granted the plaintiffs' request and issued monetary sanctions in the amount of $20,000.00. Navarro-Ayala v. Hernandez-Colon, 143 F.R.D. 460 (D.P.R. 1991). The defendants appealed. On July 13, 1992, the First Circuit Court of Appeals (Judge Bruce Marshall Selya) affirmed the district court's decision to impose sanctions, but reduced the amount from $20,000.00 to $6,500.00. Navarro-Ayala v. Nunez, 968 F.2d 1421 (1st Cir. 1992).

In February 1992, the defendants filed a motion asking the district court to reconsider its reappointment of the Special Master. After considering and rejecting the motion, the district court (Judge Laffitte) decided that Colon had violated Rule 11 of the Federal Rules of Civil Procedure and sanctioned him $500.00. Colon appealed. On August 20, 1993, the First Circuit reversed the district court's sanctions, holding that they were unwarranted. Navarro-Ayala v. Hernandez-Colon, 3 F.3d 464 (1st Cir. 1993).

As recounted in the District Court Order from January 10, 2005 (Judge H. Laffitte), the parties, on August 11, 2000, filed a Joint Stipulation and Order of Dismissal, asserting substantial compliance with the Consent Decree. The defendants agreed to maintain the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation, to maintain a yearly appropriated budge of at least $18,929,000.00, and to adequately provide for the health, welfare, safety and treatment of the patients at RPPH. The Court adopted the joint stipulation and order, and on January 28, 2002. The court dismissed the case and retained jurisdiction to enforce the agreement.

From June 2003 through August 2004, the Special Master filed five compliance reports that described as untrue the allegations regarding the reduction in budget, the diversion of hospital funds, the closure of the San Patricio Mental Health Center, and the use by a managed behavioral health organization of thirty hospital beds. In 2003, the RPPH confronted a budgetary crisis that, according to the Special Master, was not affected by the failure to assign the stipulated budget or diversion of funds, but rather the assumption that the hospital’s prior court ordered budget would suffice to maintain functioning after the consent decree. The parties met with the Special Master following the fourth report to discuss the 1996 Rehabilitation Plan. While the Special Master insisted that the plan had to be followed, the parties of the action thought that it was not legally, procedurally, or substantively required in light of the accomplishments described in the compliance reports.

In the fifth report, the Special Master indicated that defendants were not in compliance with the 1996 Rehabilitation Plan by continuing to house patients who obtained the maximum benefit of hospitalization and could be moved out of acute care in the hospital and into rehabilitation services (maximum-benefit patients).

In response to the fifth and final report in 2004, the plaintiffs acknowledged that the Special Master’s reports did not indicate conditions as severe as when patients filed the original 1974 complaint. While highlighting the presence of maximum benefit patients as concerning, the plaintiffs also noted that the Special Master’s reports sought to establish a new remedial agenda that would extend beyond the hospitals at issue in this case to multiple health care facilities in Puerto Rico. Plaintiffs’ counsel explained that the Special Master’s suggestions seek to “straightjacket the Puerto Rico Department of Health” by controlling budgets, staffing, programming, and administrative structures. Plaintiffs’ counsel made clear to the court that they did not agree to adopt any statements with respect to facilities beyond the scope of the current case. The parties therefore asked the court to close the case without full adherence to the 1996 plan or extra considerations posited by the Special Master.

On January 10, 2005, the Court (Judge H. Laffitte) entertained a motion asserting that the RPPH budget was reduced beneath the court-ordered amount and that the pre- and post-hospitalization services were inadequate. The Court determined that RPPH had in fact increased its budget and improved its pre- and post-hospitalization services. Nonetheless, the Court increased the budgetary mandate of $18,929,000.00 to $23,000,000.00 per fiscal year. It also reasserted its prior dismissal of the case, concluding that there was no evidence of further constitutional violations that warrant further judicial involvement in the case.

On September 26, 2014, a group of mental health patients at RPPH moved to reopen the case, claiming that RPPH had failed to maintain adequate staffing and funding levels, and that the patients feared that important services would be eliminated. The case officially reopened on June 18, 2015. The court appointed monitor Daniel Wathen to compile compliance reports.

In the first compliance report submitted on September 2, 2016, the monitor declared that until 2014, RPPH was a “model operation” and services were based on the 1996 Rehabilitation Plan. Before 2014, RPPH received support by block grants from the United States Government in addition to payments from patients enrolled in the Government Health Plan. During a budget session in 2014, though, the federal Substance Abuse and Mental Health Services Administration informed RPPH that block grant funds could not be used to supplement mental health treatment services. A privately managed care provider then took over those services and part of the premises, resulting in the elimination of a number of previously offered services including partial hospitalization, pharmacy services, recreational therapy, ambulance services, vocational services, and case management. A change in compensation measures for employees also resulted in shorter visits, less continuity of care, delays in appointment scheduling, and no visits for patients without healthcare accepted by the private care provider. The monitor conceded that the plaintiffs were factually correct in alleging that these changes breached court orders.

After almost an additional year of litigation, Judge Francisco A. Besosa ordered the Commonwealth on February 22, 2016 to pay plaintiffs’ attorney’s and the monitor’s fees accruing from the time the case reopened. Defendants completed payments on December 2, 2016. Judge Besosa denied a motion to reopen the case on October 17, 2017 and the case remains closed.