WOE BY WOE v. Cuomo

• Decision Date: 01 July 1986
• Docket Number: No. 75 CV 1029 (ERN).,75 CV 1029 (ERN).
• Citation: 638 F. Supp. 1506
• Parties: Walter WOE, by his mother and guardian, Wilma WOE, on behalf of themselves and all others similarly situated, Plaintiffs, v. Mario CUOMO, individually and as Governor of the State of New York; Dr. Steven Katz, M.D., individually and as Commissioner of the Department of Mental Hygiene of the State of New York; Dr. E. Richard Feinberg, M.D., individually and as Director of Bronx Psychiatric Center; Dr. Ordogan Tekben, M.D., individually and as Director of Mid-Hudson Psychiatric Center, Defendants.
• Court: U.S. District Court — Eastern District of New York

638 F. Supp. 1506

Walter WOE, by his mother and guardian, Wilma WOE, on behalf of themselves and all others similarly situated, Plaintiffs, v. Mario CUOMO, individually and as Governor of the State of New York; Dr. Steven Katz, M.D., individually and as Commissioner of the Department of Mental Hygiene of the State of New York; Dr. E. Richard Feinberg, M.D., individually and as Director of Bronx Psychiatric Center; Dr. Ordogan Tekben, M.D., individually and as Director of Mid-Hudson Psychiatric Center, Defendants.

No. 75 CV 1029 (ERN).

United States District Court, E.D. New York.

July 1, 1986.

Morton Birnbaum, Brooklyn, N.Y., Burton H. Zuckerman, Mark J. Kurzmann, New York City, for plaintiffs.

Robert Abrams, Atty. Gen., State of N.Y., New York City, for defendants by Caren S. Brutten, Arnold D. Fleischer, Asst. Attys. Gen.; New York State Office of Mental Health, New York City, by John Petrila, and Nancy H. Halleck, of counsel.

MEMORANDUM AND ORDER

NEAHER, District Judge.

This case returns to the Court on remand from the Court of Appeals, which entered the following order,

"Accordingly, we affirm the judgment of the district court with respect to the state law and equal protection claims, and reverse and remand the right-to-treatment claim to the extent we have hitherto indicated."

Woe v. Cuomo, 729 F.2d 96, 108 (2nd Cir. 1984), cert. denied, ___ U.S. ___, 105 S.Ct. 339, 83 L.Ed.2d 274 (1984).

To comprehend the nature of its responsibility under the Court of Appeals' mandate, the Court must examine the entire opinion of the Court of Appeals. See Cherokee Nation v. Oklahoma, 461 F.2d 674, 678 (10th Cir.1972). The significance of this observation stems from plaintiffs' contention that the Court of Appeals, in essence, has decided the case in their favor by adopting their propostion of law, to wit: absence of JCAH (Joint Commission on Accreditation of Hospitals) accreditation of a hospital for the mentally ill establishes that the hospital is not rendering care of a constitutionally adequate quality. See Youngberg v. Romeo, 457 U.S. 307, 102 S.Ct. 2452, 73 L.Ed.2d 28 (1982). To support their contention, they rely on the following passage,

"Of course, where a facility lacks accreditation by JCAH, not even a prima facie showing of adequacy exists."

729 F.2d at 107.

To comply with the Court of Appeals order, this Court held hearings on May 15, 16, and 17, June 5 and 6, and August 20 and 21, 1985, to receive testimony and documentary evidence on the issue of constitutionally adequate care as related to plaintiffs' claims concerning the quality of care at Mid-Hudson Psychiatric Center (Mid-Hudson) and Bronx Psychiatric Center (BPC).¹ In accord with the Court of Appeals' order, the following constitutes the Court's findings of fact and conclusions of law pursuant to Fed.R.Civ.P. 52(a).

At the outset, the Court is concerned about defendants' posture at the hearings and in their subsequent papers. Defendants assert that neither the record nor the law support the granting of the relief proposed by plaintiffs. Defendants seemingly overlook that,

"The district court has broad discretion to fashion an equitable remedy that meets the practical demands of the situation, as well as the requirements of the Constitution."

Felton v. Secretary, etc., 787 F.2d 35, 37 (2d Cir.1986). Thus, even if the record does not support the precise relief requested by plaintiffs, this Court is not prohibited from granting less or different relief. See Perfect Fit Industries, Inc. v. Acme Quilting Co., 646 F.2d 800, 806 (2d Cir.1981), cert. denied, 459 U.S. 832, 103 S.Ct. 73, 74 L.Ed.2d 71 (1982) ("It is well settled that the district court's equity jurisdiction empowers it `to mould each decree to the necessities of the particular case.' Hecht Co. v. Bowles, 321 U.S. 321, 329 64 S.Ct. 587, 591, 88 L.Ed. 754 (1944); Electronic Specialty Co. v. International Controls Corp., 409 F.2d 937, 947 (2d Cir.1969)."). Additionally, to clarify the record, 729 F.2d at 107, the parties agree that Mid-Hudson has never sought JCAH accreditation and that BPC lost its JCAH accreditation, effective August 1984.

In the course of the hearings, apart from cross-examination, defendants presented no evidence. As a result, plaintiffs reason very simply that the Court of Appeals has adopted JCAH accreditation as the yardstick of constitutionally adequate care, and since BPC and Mid-Hudson are not JCAH accredited, these two factors establish a prima facie case of violation of plaintiffs' right to adequate treatment as recognized in Youngberg, supra. In turn, plaintiffs assert, that the prima facie case thus shifts to defendants the burden of demonstrating that BPC and Mid-Hudson nevertheless deliver constitutionally adequate care but since defendants have never attempted to satisfy that burden, plaintiffs are entitled to injunctive relief. This reasoning does not follow from the Court of Appeals opinion.

Recognition of JCAH accreditation as prima facie proof of adequate care merely allows plaintiffs to examine and probe the conditions of a JCAH accredited facility. In the context of litigation, the burden of demonstrating entitlement to injunctive relief rests upon the applicant, whom, as the Court of Appeals observed, may seek to establish, either in general or as applied to a specific facility, that JCAH standards are below constitutional benchmarks. 729 F.2d at 106. The Court of Appeals said nothing specific about the kind or quality of evidence necessary to establish a prima facie case of constitutionally inadequate care apart from a reference to the standard enunciated in Youngberg, supra. In terms of its anticipation of further proceedings, inferentially relevant to this issue, the Court of Appeals did state,

"In any event, we believe the entry of summary judgment, denying appellants plaintiffs an opportunity to prove their allegations, would be inappropriate as to that or any other institution losing accreditation or approval prior to final judgment." (Emphasis supplied)

729 F.2d at 107. This conclusion is consistent with the earlier statement that,

"Although fully cognizant of the critical importance of the rights appellants plaintiffs seek to vindicate in this action, we are nevertheless persuaded that the district court was correct in holding that appellants had failed to assert an adequate factual basis for many of their claims. At the same time, we believe that the dismissal of certain claims was premature. Accordingly, we remand so that appellants may have an opportunity to document the constitutional defects they allege."

729 F.2d at 98-99.

In sum, the Court of Appeals did not decide the issue in plaintiffs' favor. On the contrary, the Court of Appeals, by its remand and opinion, has left it to this Court to determine the issue after a hearing in which plaintiffs would have the opportunity to prove their allegations and to document the constitutional defects they allege. Clearly, the absence of JCAH accreditation does not mean that the care rendered by a hospital is constitutionally inadequate.

To meet their burden of proof, plaintiffs called Dr. Henry Pinsker, Associate Director of Psychiatry at Beth Israel Medical Center in New York, as an expert (curriculum vitae, Pl. Exh. 15). He painted a harsh picture of the unaccredited institution. He noted that if his facility were to lose its accreditation, it would close in two weeks because third party payments (e.g., Medicare and Blue Cross) would cease. Concerning the adequacy of medical care, he stated, "It's hard to imagine." He hypothesized nevertheless that an institution could be deficient in environmental areas (e.g., fire hazards, dangerous conditions, poor heating) yet deliver adequate medical care, "but it might not be an adequate place for anybody to live." He opined that JCAH "bends over backwards" not to withdraw accreditation and that "some awfully miserable hospitals throughout the country have their accreditation."

Assuming the existence of a deficient environment, he testified that poor conditions would negatively affect patients. For example, individuals suffering from a chronic illness whose treatment is poor, are less likely to experience an improvement or periods of remission. He characterized descriptions of chronic schizophrenia in psychiatric literature as actually describing "chronic institutional care and understimulating environment." On cross-examination he reiterated that there is a possibility that a patient may be receiving satisfactory care in an unaccredited institution.

Also qualified as an expert (curriculum vitae, Pl. Exh. 3), Dr. Steven Rachlin, currently chairman of clinical services at Nassau County Medical Center, had once worked as a staff psychiatrist at BPC. He oversees a 90 bed JCAH accredited and HHS (Department of Health and Human Services) certified facility and has testified as an expert on individual treatment issues. He identified the JCAH manual, Pl. Exh. 4, and the Consolidated Standards manual, Pl. Exh. 5, which pertains more specifically to mental health facilities. These publications contain the standards against which JCAH measures the quality of a hospital's care for purposes of accreditation. He explained that the manual refers to "substantial compliance" because no one expects "perfection" or "100%". He also elaborated that the standards do not set a high level of care.

"Q. To your mind, what kind of standards are they?

"A. This is the minimal acceptable standards that a hospital or other facility ought to be able to comply with.

"Q. And if a hospital does not comply with those standards, sir, can it provide adequate patient care?

"A. Probably not."

Tr. May 15, 1985 at 82.

As Dr. Rachlin elaborated, accreditation occurs after a lengthy process in which a hospital is surveyed. See Woe v. Cuomo, 559 F.Supp. 1158, 1163-64 (E.D.N.Y.1983) (describing the JCAH accreditation process). The facility has advance notice of the visit by...