Davis v. Hubbard

• Decision Date: 16 September 1980
• Docket Number: No. C 73-205.,C 73-205.
• Citation: 506 F. Supp. 915
• Parties: John DAVIS et al., Plaintiffs, v. Ronald HUBBARD et al., Defendants, United States of America, Amicus Curiae.
• Court: U.S. District Court — Northern District of Ohio

506 F. Supp. 915

John DAVIS et al., Plaintiffs, v. Ronald HUBBARD et al., Defendants United States of America, Amicus Curiae.

No. C 73-205.

United States District Court, N. D. Ohio, W. D.

September 16, 1980.

Gerald B. Lackey, Toledo, Ohio; C. Thomas McCarter, Joseph F. Vargyas, John C. Lamb, Kathleen Jolly and John Holme, Advocates for Basic Legal Equal., Toledo, Ohio, for plaintiffs.

David J. Young, Murphy, Young & Smith, Columbus, Ohio, Lucy L. Thomson, Civ. Rights Div., U. S. Dept. of Justice, Washington, D. C., for defendants.

OPINION AND ORDER

WALINSKI, District Judge:

PRELIMINARY STATEMENT

This is the third in a series of Orders addressing the single-judge issues herein.¹ Said orders shall serve as the Court's findings of fact and conclusions of law, pursuant to Rule 52, F.R.Civ.P.

ISSUES PRESENTED

ISSUE 5: WHETHER THE METHODS USED BY THE PROFESSIONAL STAFF TO CLINICALLY EVALUATE AND DIAGNOSE PATIENTS AT LIMA STATE HOSPITAL IS A VIOLATION OF THE FOURTEENTH AMENDMENT. THIS IS MEANT TO INCLUDE, BUT IS NOT LIMITED TO, TESTING, LACK OF TREATMENT, LACK OF PROFESSIONAL QUALIFICATIONS OF THE STAFF.

A review of the subissues and arguments presented in support of the parties' respective positions on this issue indicate to the Court that they have been addressed elsewhere through the Order of December 9, 1974 and subsequent supplemental Orders, including the Order issued this date.

It is therefore the opinion of the Court that this issue requires no individual discussion.

ISSUE 6: WHAT SHOULD BE APPROPRIATE STANDARDS FOR NUMBERS AND QUALIFICATIONS OF STAFF.

A. Numbers of Staff

The stipulations filed herein reflect the following staff (for a population at that time of approximately seven hundred fifty (750)) Stip 408:

6 Physician Specialists 3 Medical Assistants (unlicensed physicians) 8 Psychologists 1 Caseworker 10 Social Workers 21 Activity Therapists 10 Teachers 1 Educational Specialist 1 Principal 14 Nurses 1 Pharmacist 1 Pharmacist Aide 1 Psychoatric Nurse Director 271 Attendants 1 Institutional Administrator 2 Chaplains

There appears to be no question that an adequate staff in size and qualifications is an indispensible component in the delivery of treatment to the institutionalized. Both plaintiffs and defendants approached the Court with proposed plans for staffing.

The plaintiffs submitted the depositions of three (3) experts, each of whom proposed certain patient/staff ratios much like those ordered in Wyatt v. Stickney, 344 F.Supp. 373, 383 (M.D.Ala.1972).

The defendants propose a programmed staffing method development for the California Department of Mental Hygiene known as SCOPE (Staffing the Care of Patients Effectively). The SCOPE program grew out of a request by the California Legislature for a study to evaluate the treatment manpower needs of the state hospitals and to develop recommendations for new standards. A Committee was then formed of representatives of:

American Association for Mental Deficiency, Region III

American Psychiatric Association, Northern California Psychiatric Society

American Psychiatric Association, Southern California Psychiatric Society

California Association for Mental Health

California Council for Retarded Children

California Medical Association

California Nurses Association

California Society of Psychiatric Technicians

California State Psychological Association

California State Council of National Association of Social Workers

Rehabilitation Service Association

The Committee met for approximately eighteen (18) months and prepared a report which was designed "to establish basic levels of treatment staff time" for patients in the state's mental health facilities. Essentially, the SCOPE program is a statistical and engineering approach to evaluating the time requirements for the performance of medical, psychological, social work, rehabilitative and ward service functions within the hospital. The actual implementation involves stopwatch measurements of the times needed for trained, experienced personnel to perform needed custodial tasks; work samplings were then performed at random times, twenty-four (24) hours a day, over a seven (7) day period; finally, physicians, psychologists, rehabilitation therapy specialists, social workers, nursing supervisors, as well as nurses and psychiatric technicians were asked to report their work activities under eleven (11) different headings over a seven (7) day period. The Committee then made an input decision as to the level of care to be provided each patient and, by inputing the various factors (including, inter alia, a variable dependent upon a cross-sectional study of the average patient's demand reflected by a study of personal characteristics and individualized treatment plan content) was able to translate task requirements into a usable calculation of needed staff time to perform those functions. (See generally Ex. 1, 2 to Naleway Depo.)

Plaintiffs' experts suggested that a method for determining adequate staff size was to propose certain set ratios of staff to patients which would be maintained as minimums. Unfortunately there was a wide variance in the opinions of the various experts. See Amicus Brief, Chart at 60-61. Even while proposing ratios, Dr. Clark qualified his recommendation with "I think the make up of the treatment team would depend to some extent on type of patient and their particular needs. It could include some of the following types of individuals, not necessarily all of them and not necessarily limited to them * * *." Clark Depo. at 64. Dr. Brelje suggested a detailed staffing proposal but followed with:

Now, that I hold out as one possible way of staffing a unit of 70 patients. It seems to me that still meeting, say, accreditation standards, it's possible to staff that 70 with a differing of consultation within it * * *. So I would hate to have that staffing pattern propogated as an ideal or the ultimate or something.

Brelje Depo. at 112.

Dr. Walter Fox, who testified in Wyatt, also proposed minimum staffing levels as set figures but, in response to an inquiry about whether a more flexible method might be preferable answered:

"Yes, I think there is a better system. The Joint Commission, for instance, does not set ratios, but uses such terms as `there shall be adequate staffed social service departments or functions'".

Fox Depo. at 58. Dr. Fox then explained that the Commission The Joint Commission on the Accreditation of Hospitals uses a voluminous questionnaire and an on-site survey coupled with a computer analysis of the data to determine the adequacy of staffing levels. Fox Depo. at 59.

The plaintiffs seem to base their objections to the SCOPE system on the premise that it is simply quantitative in nature. Unfortunately any system of setting staff levels must address that problem. Only qualified, well-trained staff members dedicated to their respective professions can assure that quality treatment is being provided.

Another objection to an implementation of the system (at least in the form which it is used in California) is that it is premised upon an unacceptably low level of custodial care (i. e. three (3) baths per week). That objection is well taken; however, this Court has, in its earlier Orders, set out very detailed and specific levels of care to be afforded the patients at LSH. It is assumed that any computerized time-study audits used by these defendants would input, as standards, the details of the Orders herein.

Finally, the plaintiffs contend that the SCOPE audit and survey conducted at LSH by defendants prior to trial of this action are, of necessity, deficient in that no individualized treatment plans were in effect and that, therefore, it would have been impossible to project the needed professional staff times to provide psychiatric and rehabilitative treatment. Such is no longer the case. Individualized treatment plans have been ordered and implemented for each of the patients at LSH. Again, it is presumed that those plans would provide the treatment criteria upon which to base a need for specific numbers of professional treatment personnel.

It therefore appearing to the Court that a systems approach to staffing is a scientifically valid and reasonable method, applied within the parameters of this and the earlier Orders of the Court, it is

ORDERED that the defendants prepare forthwith an analysis of staffing needs based upon the methodology developed for the California Department of Mental Hygiene. In order to monitor compliance with this Order, defendants will provide the Special Master with copies of preliminary input data including, but not limited to, service needs of patients as well as proposed diagnostic and treatment programs necessary to meet those service needs most effectively. (It is expected that these proposed programs will find their genesis in the individual treatment plans). The proposed programs will be broken down into specific tasks by specific types of individuals, and attaching to each task the time necessary for effective performance. Again, following the methodology proposed by defendants, it is assumed that the tasks and task times will be classified by patient type and within one of three (3) program phase headings-intake program, residential treatment program (including non-professional custodial functions and professional treatment tasks) and release programs (including both intramural and extramural prerelease planning services).

Providing such input data before translating functional needs into requisite staffing levels will allow this Court to monitor compliance with the crux of this entire matter-the delivery of treatment guaranteed plaintiffs by the earlier remedial orders of this Court.

As a postscript, the Court notes that the defendants have repeatedly asserted that preliminary studies have indicated that SCOPE may well result in higher gross numbers of staff than the ratios reflected in Wyatt. While ...