D.C. Circuit Upholds Virginia/Kansas Medicaid IMD Disallowances

Virginia Department of Medical Assistance Services v. U.S. Department of Health and Human Services, et al., 2012 U.S.App. LEXIS 9293 (May 8, 2012)

The District of Columbia Court of Appeals has upheld the Centers for Medicare and Medicaid Services (“CMS”) disallowance of matching federal financial participation (“FFP”) funds for medical services the Virginia Department of Medical Assistance Services and the Kansas Health Policy Authority paid for individuals under age 21 in inpatient psychiatric facilities under the Institutions for Mental Disease (“IMD”) exclusion.

Since its enactment in 1965, the Medicaid program has excluded Medicaid payments for services provided to otherwise eligible individuals in IMDs who have not attained the age of 65 years or older. In 1972, Congress added an exception to the exclusion for “inpatient psychiatric hospital services for individuals under age 21.” 42 U.S.C. § 1396d(a)(16). In order to be eligible for FFP, the inpatient services provided to those under age 21 (1) must be provided in an institution, or distinct part thereof, which is a psychiatric hospital or other inpatient setting specified by the Secretary in regulation; 2) must involve active treatment provided by a team, consisting of a physician and other qualified mental health professionals, which has determined the inpatient services are necessary and can reasonably be expected to improve the patient’s condition to the extent that such services will no longer be necessary; and 3) are provided prior to the date the individual attains age 21 or, if the individual is receiving services immediately preceding attaining age 21, the date the individual no longer requires such services, or attains age 22. 42 U.S.C. § 1396d(h)(1)(A)-(C).

In 2001-2002, the Department of Health and Human Services Inspector General audited claims submitted for IMD residents under age 21 in several states, including Virginia and Kansas, and found that certain claims were not documented to be for “psychiatric hospital services provided in and by an IMD.” As a result, CMS disallowed $3,948,532 in claims for Virginia, and $3,883,143 for Kansas. Virginia’s disallowed claims included physician services, pharmacy, outpatient hospital clinical services, inpatient acute care and other services, such as laboratory, x-ray and community mental health and mental retardation services. Both Virginia and Kansas separately appealed the disallowances to HHS’ Departmental Appeals Board and then to the United States District Court for the District of Columbia, which both ruled in favor of CMS. Virginia’s and Kansas’ subsequent appeals to the District of Columbia Circuit were then consolidated. The law firm of Covington and Burling represented both states instead of their respective Attorneys’ General.

Virginia and Kansas argued, among other things, that the statute was ambiguous because it conflicted with the “comparability principle” that requires a state to provide medical assistance to individuals meeting eligibility requirements which are not less in amount, duration, or scope than the medical assistance made available to any other individuals. The States also argued that the interpretation was contrary to the legislative history that reflected Congress’ intent to improve and expand treatment for children with mental illness to permit them to rejoin and contribute to society. The States further argued that CMS’ narrow interpretation of the under-21 exception conflicts with the requirements for provisions of services under the early and periodic screening, diagnostic, and treatment (“EPSDT”) mandate and the requirement in the Home and Community Based waiver program that services provided in the community be “cost-neutral.” By failing to reimburse for expensive inpatient services, the argument went, the provision of necessary services in the community will necessarily be more expensive and thus fail the waiver test.

In upholding the CMS determination, the Appeals Court found that the legislation was clear on its face that the only exceptions to the IMD rule pertained to eligible recipients age 65 and older and individuals under age 21 receiving inpatient psychiatric hospital services. When a statute is clear on its face, no further interpretation or referral to legislation history is necessary. In rejecting all of the States’ arguments, the Court wrote that the under-21 exception to the IMD rule “may not reflect the most compassionate or even the most prudent approach to treating young patients in IMDs, but it marks the extent of assistance the Congress unambiguously authorized in 1972 when it first decided to fund such services.” The courts are therefore obligated to interpret the law as unambiguously written by Congress.

Found in DMHL Volume 31 Issue 4

Eleventh Circuit Holds Florida Medicaid Program Required to Provide ABA Therapy When Medically Necessary As Treatment for Autism Spectrum Disorders

Garrido v. Interim Secretary, Florida Agency for Health Care Administration, 731 F.3d 1152 (11th Cir. 2013)

The Eleventh Circuit Court of Appeals upheld on September 30, 2013 the district court’s determination that Applied Behavioral Analysis (“ABA”) is not an experimental treatment and therefore must be provided to children screened under Florida Medicaid’s Early Periodic Screening, Diagnostic and Treatment Services (“EPSDT”) when the child’s physician determines the services are medically necessary.

Plaintiff K.G., through his next friend, Iliana Garrido, filed a complaint in federal district court in February 2011 against the Secretary of Florida’s Agency for Health Care Administration (“AHCA”) and Florida’s Medicaid administrator alleging that Florida’s denial of ABA therapy violates the Medicaid Act’s EPSDT provisions. Several months thereafter, I.D. and C.C. by their next friends were joined as plaintiffs. All three were Medicaid recipients under age 21 who had been diagnosed with autism or autism spectrum disorders during EPSDT screenings and had been prescribed ABA treatment by their physicians.

Medicaid is a jointly funded federal-state program that assists states in providing medical services to their needy citizens. Subject to the provisions of the Medicaid Act, states design their program. A state’s participation is voluntary, with all states now participating. But once a state decides to participate, it must comply with all federal statutory and regulatory requirements. One service states must provide is EPSDT for Medicaid-eligible minors under the age of 21. The EPSDT catch-all provision requires states to provide Medicaid-eligible minors “[s]uch other necessary health care, diagnostic services, treatment, and other measures…to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.” 42 U.S.C. § 1396(r)(5). Such services, including preventive and rehabilitative services, must be provided if the service is medically necessary to “correct or ameliorate” a condition or defect discovered during an EPSDT screening.

Medicaid permits states to place appropriate limits on services based upon medical necessity. Under Florida’s regulatory scheme medically necessary services excludes treatment that is experimental or investigational. Florida defines a treatment as “experimental” when “reliable evidence shows that the consensus among experts regarding the drug, device, or medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, toxicity, safety, or efficacy as compared with the standard means of treatment or diagnosis.” Fla. Admin. Code r.59G-1.010(84)(a)3. Florida’s Medicaid Handbook enumerates the specific behavioral health services covered by Florida Medicaid, and specifically excludes community behavioral health services for treatment of autism or pervasive developmental delay.

At a four-day bench trial, AHCA employees testified that the Agency did not follow the standard process for determining whether ABA therapy was experimental. By contrast, the plaintiffs presented testimony from numerous experts that ABA is the standard means for treating autism spectrum disorders. Experts also testified that ABA treatment was medically necessary for the individual plaintiffs. The district court thus found that ABA is a preventive or rehabilitative service that is medically necessary and not experimental. It therefore found that Florida is required to provide the service to Medicaid eligible minors under age 21 if necessary to correct or ameliorate a condition discovered in an EPSDT screen. The district court then entered a permanent injunction and declaratory judgment in favor of the plaintiffs and ordered Florida to provide ABA services.

On appeal, the Eleventh Circuit upheld the decision of the district court as not an abuse of discretion, but remanded the case to the district court to clarify its order that the declaratory judgment order and permanent injunction did not eliminate the requirement that Florida make individual medical necessity determinations, consistent with that court’s own findings and written decision.

Found in DMHL Volume 32 Issue 4

Tenth Circuit Requires Treatment Plan with Medications and Maximum Dosages before Authorizing Involuntary Medication of Incompetent Defendant

United States v. Chavez, 734 F.3d 1247 (10th Cir. 2013)

The Tenth Circuit Court of Appeals overturned on November 13, 2013, the district court’s order authorizing treatment of an incompetent defendant with antipsychotic medication over his objection. Following the precedent of three other circuits, the Tenth Circuit held that the government must submit a treatment plan containing the proposed medications and maximum dosages before the trial court can determine whether the second and fourth prongs required under United States v. Sell, 539 U.S. 166 (2003), have been met in order to justify an involuntary medication order. In order to authorize medication of an incompetent defendant under Sell, the government must establish 1) that important governmental interests are at stake, 2) the involuntary medication will significantly further those interests, 3) the involuntary medication is necessary to further those interests, and 4) the administration of the mediation is medically appropriate and in the defendant’s best medical interests.

Reydecel Chavez, a Mexican citizen, was arrested in New Mexico and charged with being a felon in possession of a firearm, being an illegal alien in possession of a firearm, and reentry into the United States as a removed alien. Soon after he was charged, both his attorney and the government agreed that Chavez should be evaluated for his competency to stand trial. The district court committed him to the Bureau of Prisons medical center in Springfield, Missouri for a competency determination. The psychologist performing the evaluation reported that Chavez was diagnosed with paranoid schizophrenia and was not competent to stand trial. He also reported that Chavez was not a danger to himself or others while in custody and could likely be restored to competency with antipsychotic medication, which he was refusing.

At the competency hearing, the district court found Chavez incompetent to stand trial, and at the court’s suggestion, the government filed a motion to require him to undergo treatment with medication over his objection. The same evaluator testified in general terms as to the treatment Chavez would likely receive, but the government presented no individualized treatment plan. The evaluator testified that an individualized treatment plan would be prepared for Chavez only after involuntary treatment was authorized by the court. He also testified that as a psychologist he could not prescribe medication for Chavez, but that the “typical” treatment plan would involve injection with Haldol. Side effects could be addressed with a change in medication or administration of drugs specifically designed to treat them. He further testified that three-fourths of defendants treated with antipsychotic medications are successfully restored to competency. Following this testimony, and over Chavez’s objection, the district court found that a specific treatment plan was not necessary to meet the Sell requirements and ordered his treatment over objection, requiring only a status report in about six weeks.

On appeal, the Tenth Circuit found that the first two prongs of the Sell test were purely issues of law for the appellate court to decide de novo, but the third and fourth prongs were factual determinations that the appellate court would reverse only if they were clearly erroneous with no evidence in the record to support them. The Tenth Circuit then analyzed the evidence supporting the Sell requirements and agreed with Chavez’s arguments that without a specific treatment plan identifying which medications would be administered to him and at what doses, the district court had insufficient information to make the required findings. The Court of Appeals found that the need for a high level of detail is plainly contemplated by the Sell case. Without evidence in the record that a psychiatrist who will be prescribing the drugs solely to render him competent to stand trial, the court cannot ensure as a legal matter under the second Sell prong that the administration of the drugs will be substantially unlikely to produce side effects that will interfere with Chavez’s ability to assist his attorney in presenting a defense. Also, without knowing which drugs the government might administer and at what dosage, the court has no evidence upon which it can determine under the fourth prong whether the treatment will be medically appropriate for Chavez. In addition, the court’s order sets no meaningful limits on the government’s discretion in treating Chavez and is so open-ended that it would give treatment staff carte blanche to experiment with what might be dangerous drugs or dangerously high dosages of drugs.

In making these findings, the Tenth Circuit followed the decisions from three other circuits. The Ninth Circuit held in United States v. Hernandez-Vasquez, 513 F.3d 908 (9th Cir. 2007), that to pass muster under Sell, 1) the district court’s order must identify the specific medication or range of medications the physicians are permitted to use, 2) the maximum dosages, and 3) the duration of time the involuntary medication may continue before requiring a report back to the court. Similarly, the Fourth Circuit held in United States v. Evans, 404 F.3d 227 (4th Cir. 2005), that the government must set forth the particular medication, including the dosage. The Sixth Circuit in United States v. Green, 532 F.3d 538 (6th Cir. 2008), also upheld a specific treatment plan that set forth the specific medications, alternative means of injecting it, the specific dosage, and the potential side-effects.

In following these cases, the Tenth Circuit decided that a balance must be struck between the judicial oversight needed to protect the defendant’s constitutional rights and the need of medical staff to retain flexibility in providing effective treatment. The Court then held that a court may approve a treatment plan as long as all drugs that might be administered to a defendant and their maximum dosages are specified. In so doing, the Tenth Circuit found that the district court’s order lacked sufficient information to determine whether the second and fourth requirements under Sell were met, reversed the order and remanded the case for further proceedings.

Found in DMHL Volume 33 Issue 1

Treatment of Mentally Ill Individuals in Custodial Settings: Liberty Interest Deprivation and Eighth Amendment

Claim of prisoner with mental illness that liberty deprivations from facility’s Behavior Action Plans were imposed without due process and resulted in Eighth Amendment violations raises genuine issues of fact and survives motion for summary judgment

Townsend v. Cooper, 759 F.3d 678 (7th Cir. 2014)

Townsend, a prisoner at the Green Bay Correctional Institution (GBCI), sued GBCI officials for civil rights violations. Townsend suffered from significant mental illness and engaged in disruptive behavior, including suicide attempts and fighting. Townsend was repeatedly subjected to observation placements and Behavioral Action Plans (BAPs). Vacating the judgment below, the Seventh Circuit held that Townsend had raised genuine issues of material fact regarding whether the imposition of the BAP violated his due process rights by imposing an atypical and significant hardship compared to the ordinary incidents of prison life, without appropriate notice and an opportunity to be heard and whether the BAP imposed conditions of confinement that denied Townsend the minimal civilized measures of life’s necessities.

To succeed on his Fourteenth Amendment due process claim, Townsend was required to “establish that he ha[d] a liberty interest in not being placed in the [BAP]—as it was administered to him—without procedural protections,” noting that it was “undisputed that he received no procedural due process, so the claim turns on whether he can establish a liberty interest.” Prisoners have a liberty interest, guaranteed by the Fourteenth Amendment, in “avoiding transfer to more restrictive prison conditions if those conditions result in an atypical and significant hardship when compared to the ordinary incidents of prison life.” In order to succeed on an Eighth Amendment claim, a prisoner must show that the BAP “imposed conditions that denied him the minimal civilized measure of life's necessities” and that defendants “acted in disregard of a substantial risk of serious harm to him.”

Found in DMHL Volume 34 Issue 1

Involuntary commitment (Alabama)

Hospital mental health professionals have sovereign immunity protection for decision-making regarding discharge of involuntarily committed patients, provided that required procedures regarding such discharge are followed

Ex parte Kozlovski, No. 1140317, 2015 WL 1877656 (Ala. Apr. 24, 2015) (not yet released for publication)

Jeffrey Brown, a 19-year-old man with a long history of mental illness as well as chronic runaway behaviors and periodic violent outbursts, was involuntarily committed to an Alabama psychiatric hospital after physically attacking his father. After a course of treatment at the hospital, the treatment team, led by Dr. Kozlovski, found Mr. Brown met the criteria for discharge and return to the community, and arranged for his placement in a group home, against the wishes of family members who feared the consequences of his runaway behaviors. Within a day of his admission to the group home, Mr. Brown ran away from the group home. He was found dead three days later, apparently struck and killed by a motor vehicle. Mr. Brown’s estate filed a wrongful death action against the hospital and Dr. Kozlovski. After discovery, Dr. Kozlovski filed a motion for summary judgment based on “State agent immunity,” but the trial court denied the motion. Following that denial, Dr. Kozlovski appealed to the Supreme Court of Alabama and requested a writ of mandamus requiring the trial court to grant the summary judgment motion.

The Supreme Court of Alabama granted the writ, holding that the psychiatrist was discharging duties imposed by state statute, rules, and regulations, and so was entitled to state agent immunity. The Court also noted that, although the State agent asserting immunity bears the initial burden of demonstration that the plaintiff’s claims arise from actions that would normally entitle the agent to immunity, that burden shifts to the plaintiff to show that an exception to state-agent immunity is applicable.

Found in DMHL Volume 34 Issue 2

Corrections

Because no Supreme Court precedent established a right to suicide prevention protocols, corrections officials were entitled to qualified immunity in case involving claim that inmate suicide arose from facility’s violation of inmate’s Eighth Amendment right to appropriate suicide screening, treatment and monitoring

Taylor v. Barkes, 135 S.Ct. 2042 (2015) (per curiam)

Christopher Barkes was arrested in 2004 for violating probation and was taken to a Department of Corrections (DOC) facility in Wilmington, Delaware, where he underwent a suicide screening based on a model form developed by the National Commission on Correctional Health Care (NCCHC) in 1997 as part of intake procedures. The intake was completed by a nurse from the contractor employed by the facility (First Correctional Medical, Inc. [FCM]). Barkes stated that he had attempted suicide in 2003 and disclosed that he had a history of psychiatric treatment, but said that he was not currently contemplating suicide. The nurse gave Barkes a routine referral to mental health services and did not initiate any special suicide prevention measures. Barkes was placed in a cell by himself. He placed a call to his wife that evening and expressed his intention to kill himself, but his wife did not inform the DOC. The next morning, Barkes was observed lying on his bed at 10:45, 10;50, and 11:00 am. At 11:35 am, an officer delivered lunch to the cell and discovered that Barkes had hanged himself with a bedsheet.

The Third Circuit held that Barkes’s constitutional right to “proper implementation of adequate suicide prevention tools” was clearly established at the time of his suicide. It also held that summary judgment was inappropriate given evidence that “FCM’s policies and procedures…created an unreasonable risk of a constitutional deprivation” and evidence of DOC’s awareness of FCM’s non-compliance with NCCHC standards. Finally, it held that a reasonable jury could have found that Barkes’s suicide was caused by the DOC’s failure to supervise FCM despite the fact that Barkes did not self-report suicidal ideation or exhibit suicidal behavior. In the court’s view, “had Appellants properly supervised FCM and ensured compliance with the national standards, Barkes’s answers during his screening would have resulted in additional preventive measures being taken.”

The Supreme Court reversed per curiam, holding that the right “to proper implementation of adequate suicide prevention protocols” was not clearly established “in a way that placed beyond debate the unconstitutionality of the [facility’s] procedures.” Although the Third Circuit found the right established by its own precedents, the Court emphasized that no Supreme Court decisions have established a right to proper implementation of adequate suicide prevention protocols or discussed suicide screening protocols. Thus, the defendants were entitled to qualified immunity because they were not “contravening clearly established law,” even if the suicide screening and prevention measures had shortcomings.

Found in DMHL Volume 34 Issue 2

Criminal Sentencing

United States v. Garcia, No. 15-40252, 2016 WL 386141 (5th Cir. Feb. 1, 2016) (per curiam)

Special condition of sentence requiring mental health treatment under supervised release agreements failed to meet statutory standards for probation conditions.

Background: After receiving a sentence from the trial court that included a requirement to participate in a mental health treatment program, Ruben Garcia appealed his sentence to the Fifth Circuit. Garcia contended that the district court had committed reversible error by failing to explain “how the mental health condition was reasonably related to the pertinent statutory factors.” Additionally, he argued that the record did not justify an inference that such a condition was reasonable.

Holding: Because Garcia did not challenge the mental health condition in the trial court, the appellate court’s review was limited to plain error. Even under this standard, the Fifth Circuit vacated the condition of Garcia’s supervised release that required him to participate in mental health treatment, and remanded the case to the district court for reconsideration. According to the Fifth Circuit, the district court abused its discretion by failing to explain how the special condition (i.e. mental health treatment) was reasonably related to all statutory factors. Without any clear explanation for the imposition of a special condition and a lack of implied justification in the record, the Fifth Circuit held that it was “incumbent upon [them] to vacate [the judgment below].” Because it was not obvious from the record that there was a basis for the mental health condition (and because such a condition affects Garcia’s substantial rights), the Fifth Circuit held that the lower court had committed plain error.

Found in Found in DMHL Volume 35, Issue 1

Liability of Public Officials for Care of Mentally Ill Inmates in Correctional Setting

Saylor v. Nebraska, 812 F.3d 637 (8th Cir. 2016), as amended (Mar. 4, 2016)

Claim by jail inmate with mental illness against jail doctors and staff under 42 USC § 1983 did not establish deliberate indifference required under the Eighth Amendment to establish liability. Summary judgment granted to all defendants based upon qualified immunity.

Background: James Saylor sued the State of Nebraska, the Nebraska Department of Correctional Services (“NDCS”), Correct Care, LLC, and several individuals alleging violations of his First, Eighth, and Fourteenth Amendment rights under 42 U.S.C. § 1983. Saylor alleged that defendants acted with deliberate indifference to his serious medical needs by failing properly to treat him for PTSD. He claimed that his level of care at Nebraska State Prison was so low as to constitute cruel and unusual punishment. The district court dismissed Saylor’s claims against the State of Nebraska and the NDCS and the claims for monetary relief against the individual defendants in their official capacities. The district court then denied the remaining defendants’ motions for summary judgment on the basis of qualified immunity.

Holdings: On appeal, the Eighth Circuit reversed, holding that there were not genuine disputes concerning “the predicate facts material to the qualified immunity issue.” Because the Court found that the record showed that all defendants “met Saylor’s medical needs beyond the minimum standard required,” there was no deprivation of Saylor’s Eighth Amendment rights. Thus, defendants were entitled to qualified immunity.

Notable Points:

Qualified immunity for non-medical defendants: In order to overcome a defense of qualified immunity for the non-medical defendants, a plaintiff must show that supervisors had direct responsibility for the alleged violations, had actual knowledge of the violation, or gave tacit authorization for the violation. The Court held that the non-medical prison supervisors who approved Saylor’s transfer were not indifferent to his PTSD in violation of the Eight Amendment because Saylor provided “no specific evidence that they were involved in, or directly responsible for, his allegedly insufficient medical care.”

Qualified immunity for medical defendants: In order to overcome a defense of qualified immunity for the medical defendants, a plaintiff must show that defendants were personally responsible for violations, or were responsible for a systematic condition that violated Constitution. Here, the Court held that the State prison’s medical staff was not deliberately indifferent to Saylor’s PTSD even though Saylor argued that he received treatment that rose to the level of cruel and unusual punishment after his original treating physician left. Records showed that medical staff provided beyond the minimum standard required after his previous treater left, first providing Saylor with another physician at the same facility and then ultimately a physiatrist at a different facility. They also continued his medication consistent with their independent medical judgment. The staff also granted Saylor’s request for a private cell and sought his agreement for certain deviations from his original treatment plan.

Found in Found in DMHL Volume 35, Issue 1

Liability of Public Entities in Caring for Persons during Involuntary Commitment Process

Anderson v. Marshall Cty., Miss., No. 15-60051, 2016 WL 143303 (5th Cir. Jan. 12, 2016) (per curiam)

Estate of mentally ill person, who was taken into involuntary custody due to mental health crisis and later died in County Sheriff Department’s custody, failed to meet requirements for claims against hospital and County under 42 USC § 1983, as evidence did not demonstrate that defendants had a policy or practice amounting to deliberate indifference, as required under Monell. 

Background: After Princess Anderson arrived at a hospital in Marshall County Mississippi, she became increasingly agitated and physical with emergency room staff. Anderson tested positive for marijuana and opiates, and was diagnosed with acute psychosis. After a mental health evaluation, it was determined that Anderson required psychological care, but she refused voluntary admission. The chancery court granted the doctors’ request to have Anderson involuntarily committed and ordered the DeSoto County sheriff to take custody of her. Because Anderson was a resident of Marshall County, she was transported from DeSoto to Marshall County jail on Tuesday, February 8th. On arrival, DeSoto deputies told the Marshall County jail officer that Anderson had become agitated during the transport requiring that she be restrained. The Marshall jail officer did not review Anderson’s medical records (believing she was not entitled to view Anderson’s health information), and Anderson was placed in a cell. Although other inmates reported that Anderson needed emergency medical attention, she was not taken to a hospital until Friday, February 11th when Anderson’s mother arrived at the jail to take her to a hospital for follow-up tests. Shortly after arriving there, Anderson died of multisystem organ failure. Her mother, Angela Anderson, sued Marshall County and the Sheriff for violations of Princess Anderson’s rights under 42 U.S.C. § 1983. The district court determined that there was no § 1983 violation.

Holding: The Fifth Circuit held per curiam that Angela Anderson did not meet “the high bar required for Monell liability” under § 1983 and upheld the district court’s grant of summary judgment against her. On the failure to train claim, the Court held that the plaintiff failed to establish that Marshall County acted with deliberate indifference to the constitutional rights of inmates when adopting its training procedures. The Court also found the single incident exception to Monell’s general requirement of a pattern of unconstitutional conduct was not applicable given the evidence presented by the plaintiff.

Notable Points:

Plaintiff did not show evidence of a pattern of deliberate indifference: Anderson came forward with no evidence to show or allege a pattern of deliberate indifference to the constitutional rights of prisoners in Marshall County’s training, policies, or procedures. Without evidence of a pattern, Marshall County could not be found to have been on notice that its current training was producing unconstitutional results. Absent a pattern, the plaintiff must show deliberate indifference through the single incident exception.

Plaintiff’s evidence was not sufficient to meet § 1983’s single incident exception: The single incident exception would require that Marshall County’s training be so inadequate that the county was on notice that an untrained officer would have neglected a prisoner in the way Marshall jail officer was alleged to have done. The Fifth Circuit reiterated that “it is not enough to say that more or different training or supervision would have prevented Princess’s injuries.” It is almost always the case that more or better training could have prevented a poor outcome, so that cannot be enough to subject a county to governmental liability. Specifically, the Court said that, given the training provided, Marshall County “could not have anticipated that Officer Anderson and other correctional officers would ignore Princess’s litany of obvious ailments.”

Found in Found in DMHL Volume 35, Issue 1

Provider Liability

Binkley v. Allina Health Sys., 877 N.W.2d 547 (Minn. 2016)

In a case involving a minor with history of suicidal behavior, hospital’s affirmative defense of statutory immunity applied to the decision to deny admission to an inpatient mental health unit, but not to decisions regarding what care to provide the patient after leaving the hospital. 

Background: Binkley sued Allina Health System (“Allina”) for negligence in failing to properly examine, evaluate, and provide services to her son, Lloyd, who committed suicide after being denied admission into an inpatient mental health unit. In 2009, Lloyd began to experience suicidal thoughts and ideation, which resulted in his participation in the “United Partial Program” (“partial program”), an outpatient mental health treatment program. About nine months after completing the program, Lloyd again experienced suicidal ideation and self-harm behavior. He told his mother that he wanted to go to United in order to get help and stop his pattern of self-harm. Binkley and Lloyd went to the United Health emergency room and repeatedly requested that Lloyd, who consented, be admitted to United's inpatient mental health unit. Lloyd was examined by United staff, but was informed that he would not be admitted to the inpatient unit and, further, he was not “a good candidate” for the outpatient program because of a previous failure to follow through with that program. Lloyd returned home with his mother and committed suicide less than 24 hours later. Respondents asserted an affirmative defense of statutory immunity and, in the alternative, claimed that Binkley's expert affidavit failed to satisfy the statutory requirements under Minnesota law. The district court denied the motion for summary judgment.

Holding: On appeal, the Minnesota Supreme Court held that Respondents' good-faith decision to deny Lloyd admission to the inpatient mental health unit was entitled to immunity. However, the court also held that decisions regarding what care to provide to Lloyd after he left the hospital were not entitled to immunity.

Notable Points:

The immunity provision of the Minnesota Commitment and Treatment Act (“CTA”) applies to both voluntary and involuntary commitments: The CTA creates a state policy in favor of voluntary treatment. The voluntary treatment section of the CTA, which applied to Lloyd's circumstances, prohibits the arbitrary denial of admission and requires that treatment facilities use “clinical admission criteria consistent with the current applicable inpatient admission standards established by the American Psychiatric Association or the American Academy of Child and Adolescent Psychiatry” when “making decisions regarding admissions.”

Found in DMHL Volume 35, Issue 2

Provider Liability; Claims by Third Parties

Mitchell v. State, 369 P.3d 299 (Idaho 2016)

Idaho Supreme Court rules that the victim of a shooting by a person with mental illness who had been discharged from treatment services by the state’s mental health services program may pursue a claim against the state that his injury was the result of a negligent termination of services.

Background: Gerald Simpson had been receiving mental health services from the Idaho Department of Health and Welfare’s (IDHW) Adult Mental Health program until he was released on June 23, 2010. On September 27, 2010, Simpson shot Ryan Mitchell in the back outside of a coffee shop. Approximately ten days after the shooting, psychologist Daniel Traughber, Ph.D., prepared a memorandum on behalf of the IDHW explaining the processes and procedures that were used to terminate mental health services, subsequent to budget cuts, in a way that “reduced the risk of harm to patients and/or the community.” In August 2012, the district court dismissed the criminal charges against Simpson due to Simpson’s lack of competency to stand trial. Shortly thereafter, Mitchell filed this suit alleging that the State violated Mitchell’s constitutional and victims’ rights and was negligent when it discontinued Simpson’s mental health services. The district court issued an order granting summary judgment to the State on all claims.

Holding: On appeal, the Supreme Court of Idaho held that Mitchell’s victims’ rights claim was properly dismissed, but that the claim for negligence had been dismissed in error. The court determined that there was insufficient admissible evidence for the district court to make a determination as to whether the decision to cut Simpson from IDHW's mental health services was operational or discretionary. Thus, the district court erred in holding that the State’s decision to close Simpson’s file was discretionary and therefore erred in granting summary judgment to the State on Mitchell’s negligence claim.

Notable Points:

Mitchell’s negligence claim turns on whether IDHW's decision to release Simpson from its Adult Mental Health program was a discretionary function or an operational function: If the State’s decision to discontinue Simpson’s mental health services was a discretionary function then it would entitle the State to immunity. Here, there were insufficient facts for the trial court to determine whether IDHW's decision to cut Simpson from its health services was operational or discretionary. The evidence did not indicate who made the decision to close Simpson's file or how that decision was made.

Found in DMHL Volume 35, Issue 2

ADA Integration Mandate

Steimel v. Wernert, 15-2377, 823 F.3d 902 (7th Cir. 2016)

For the purposes of the ADA integration mandate, protection is not limited to just those who are institutionalized. A state may violate the integration mandate if it refuses to provide already-existing treatment to disabled people where such services would improve community integration.

Background: Section 1915(c) of the Social Security Act established the Home and Community-Based Care Waiver Program, which allowed states to diverge from the traditional Medicaid program to provide community-based care for Medicaid receivers who would have otherwise been institutionalized. Nonetheless, the states must comply with the ADA’s integration mandate, which requires that the states administer services in “the most integrated setting appropriate” for qualified individuals.

The Indiana Family and Social Services Administration (The Agency) runs three of many home- and community-based services in the Medicaid program: the Aged and Disabled Medicaid Waiver Program (A & D waiver), the Community Integration and Habilitation Medicaid Waiver Program (CIH waiver), and the Family Supports Medicaid Waiver Program (FS waiver). The relevant differences between the three are the monetary cap on services and what must be demonstrated to qualify for said services. The FS waiver had a service cap of $16,545, whereas the CIH and A & D waivers did not have caps. In 2011, The Agency felt that it needed to change its policies to better adhere to A & D rules. The plaintiffs were moved to the FS waiver and were ineligible for the CIH waiver; they subsequently filed their claim, alleging that, because of this change, they enjoyed 30 fewer hours in the community than they did before the change. Furthermore, plaintiffs’ guardians alleged that the restriction of services led to lapses in supervision of plaintiffs that had and would result in injuries. The plaintiffs argued that this waiver structure violated the integration mandate because it effectively institutionalized the plaintiffs within their own homes and put them at risk for being institutionalized. The district court granted summary judgment to the defendants; plaintiffs appealed.

Holding: The Seventh Circuit extended the meaning of “institutionalized” to include in one’s own home, thus qualifying plaintiff’s argument. The court further noted that a state may be in violation of the integration mandate if it refuses to provide already-available services to individuals who could be more integrated into the community with such services. And because the plaintiffs sought services that already existed within the structure, the state was obligated to provide them if they enabled the plaintiffs to live in a more community-integrated setting.

Found in DMHL Volume 35, Issue 2

Employment Discrimination in Mental Health Facilities

Blackburn v. Dep't of Soc. & Health Servs., 375 P.3d 1076 (Wash. 2016)

Washington Supreme Court rules that psychiatric hospital cannot modify staff assignments to accommodate racial prejudices of patient, even when patient threatens violence if staff members of a particular race are assigned to him.

Background: Plaintiffs were employees of a psychiatric hospital and challenged alleged discriminatory staffing practices. Employees were generally assigned a particular home ward, but could be reassigned based on a “pull list.” The pull list was meant to ensure that employees were reassigned to other wards on an equal basis. M.P., a particularly violent patient, threatened an African-American staff member, which resulted in a decision not to assign any African-American staff to that patient’s ward to ensure staff safety. The following day, a nurse directed that a white staff person be assigned to M.P.’s ward, which would have been a deviation from the pull list assignment system. The plaintiff employees sued claiming employment discrimination and disparate treatment. The trial court dismissed the claims, concluding the adverse employment action was not severe enough to be actionable and the overriding factor was safety. The plaintiffs appealed.

Holding: The Washington Supreme Court ruled that there were no valid legal justifications for the race-based determinations in the staffing directive. The court reversed the decision of the trial court on this claim and remanded for a determination of damages.

Notable Point:

Bona fide occupational qualification (BFOQ): The court found it doubtful that a BFOQ defense could apply in this case, but ruled that it had been waived by the defense at trial.

Found in DMHL Volume 35, Issue 3

Mental Health Treatment Regulation and First Amendment Claims of Patients

Welch v. Brown, No. 15-16598, 2016 U.S. App. LEXIS 17867 (9th Cir. Oct. 3, 2016)

Ninth Circuit upholds California statute prohibiting state-licensed mental health providers from engaging in sexual orientation change efforts (SOCE) with minor patients, rejecting claims under the Free Exercise and Establishment clauses of the First Amendment.

Background: California SB 1172 went into effect prohibiting mental health providers from engaging in SOCE with patients under 18 years of age. Plaintiffs provided counseling and other services involving SOCE and appealed the denial of a motion for a preliminary injunction to prevent the enforcement of California SB 1172. Plaintiffs claimed that SB 1172 violated the Free Exercise and Establishment Clauses by excessively entangling the state with religion and advancing or inhibiting a religion. Plaintiffs also claimed that SB1172 violated a substantive due process right to privacy in seeking a particular type of treatment.

Holding: On appeal, the Ninth Circuit affirmed the district court's judgment upholding the California statute. The court held that plaintiffs' claims failed because the scope of the law regulated conduct only within the confines of the counselor-client relationship and the prohibition against sexual orientation change efforts applied without regard to the nature of the minor's motivation for seeking treatment. The court also ruled that substantive due process rights did not extend to the choice of type of treatment or provider.

Notable Point:

Confines of the counselor-client relationship: The court specifically held that SB 1172 does not apply to clergy or pastoral counselors “as long as they do not hold themselves out as operating pursuant to their license.”

Found in DMHL Volume 35, Issue 3

Medical Care and Substantive Due Process Violations in Correctional Facilities

Daniel v. Cook Cnty., No. 15-2832, 2016 U.S. App. LEXIS 14886 (7th Cir. Aug. 12, 2016)

Seventh Circuit rules that a plaintiff may submit into evidence a DOJ report showing “systemic flaws” in the jail’s medical care of inmates under the hearsay exception for “factual findings from legally authorized investigations.” [Editor’s note: While the substandard care addressed in this case did not involve mental health care, the court’s ruling has important implications for litigation involving mental health care in public facilities.].

Background: Alex Daniel was a pretrial detainee when he suffered multiple fractures in his wrist after falling during a basketball game. Daniel was initially treated by an on-duty general practitioner with an elastic bandage and a sling and after a delay was eventually treated by an orthopedic specialist. Daniel was placed in a long arm cast, which was replaced by a short arm cast three weeks later. The orthopedic specialist instructed Daniel to return in another three weeks to have the short arm cast removed; however, Daniel’s cast was not removed until ten weeks later. During this delay, Daniel filed multiple grievances with the jail staff seeking treatment for his wrist. Daniel was examined by another orthopedist who concluded that Daniel suffered from “residual and permanent stiffness of his left hand and wrist,” more likely than not caused by the long immobilization in the short arm cast. Daniel filed suit and offered as evidence a report from the DOJ detailing systemic health care problems at the jail. The district court granted summary judgment for defendant Cook County ruling that the DOJ report was inadmissible hearsay.

Holding: The Seventh Circuit ruled that the DOJ report met the requirements for a presumption of admissibility in civil cases for “factual findings from a legally authorized investigation” under the Federal Rules of Evidence. The court reversed the grant of summary judgment and remanded for further proceedings.

Found in DMHL Volume 35, Issue 3

Conditions of Pre-trial Confinement

Montano v. Orange Cnty., Tex., 842 F.3d 865 (5th Cir. 2016)

Fifth Circuit upholds jury verdict finding a county jail liable for unconstitutional conditions of pre-trial confinement that resulted in the death of an inmate who was mentally ill, but assumed to be under the influence of bath salts, because evidence showed a “de facto” policy of prolonged detention without proper medical supervision for inmates held in a jail infirmary observation room for detoxification.

Background: Robert Montano was arrested for public intoxication and was taken to the county jail after a judge signed an affidavit of probable cause. The arresting officer told the intake officer at the jail that she suspected Montano was under the influence of bath salts. Montano was placed in an observation cell because he was determined to be incoherent and unable to complete the booking process. The cell did not have a sink, toilet or toilet paper. Montano was previously treated for mental illness and was in the state mental-health database, but no database query was run during his intake despite a Texas requirement to do so. While in the cell, Montano was observed by a Licensed Vocational Nurse (LVN), the Texas equivalent of a Licensed Practical Nurse, but no contract physician visited the jail during the four-and-one-half days that Montano was in the cell. There was little or no attention given to Montano during his time in the cell, and no jail staff entered the cell until the morning of his death, more than four days later. There was evidence at trial that 1) the view of Montano’s cell was partially obscured by paper taped over the cell’s glass walls, 2) his vitals were taken no more than once, and 3) food was offered through a slot in the door. More than four days after being detained in the cell, an LVN reported that it appeared as though Montano was not breathing. At that time, the cell was littered with uneaten food and human waste. The LVN reported Montano’s condition to the jail control room, but waited 20 minutes for a corporal to respond before calling an ambulance or entering the cell. Montano was pronounced dead 34 minutes later and the cause of death was determined to be acute renal failure. An action was filed against the county for unconstitutional confinement and episodic acts or omissions. A jury found in favor of the plaintiffs and awarded $1.5 million for pain and $917,000 for wrongful death. The county appealed seeking a new trial contending that insufficient evidence had been presented to support the jury’s verdict and the damages awarded were excessive.

Holding: The Fifth Circuit denied the county’s motion and upheld the jury verdict finding that sufficient evidence was presented for a reasonable jury to conclude that the conditions of confinement caused Montano’s death, and that those conditions were the result of a “de facto” policy that denied detainees adequate care for an indefinite period of time. The Court further found that the damages awarded were not excessive.

Found in DMHL Volume 35, Issue 4