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									Delaware Psychiatric Center
 Investigative Committee

       Final Report

       January 2008
I.     Introduction

        On behalf of all members of the Delaware Psychiatric Center House Investigative
Committee, the committee chairman Representative Richard C. Cathcart submits to the members
of the 144th General Assembly this Final Report of the findings and recommendations following
a thorough examination of the Delaware Psychiatric Center (DPC).

        The Committee was created in July 2007 by Speaker Terry R. Spence after public outrage
over the alleged abuses, rapes and mistreatment of patients and employees at the state run
psychiatric center. It fell to the Legislative Branch to provide a public forum for discussion of
conditions at the DPC. For a period of almost five months the Committee held public and
confidential hearings, executed subpoenas for testimony and documents and solicited the public
at large for any information regarding the conditions and patient treatment at the DPC.

         After reading through thousands of pages of documents and receiving sworn testimony
from more than 60 witnesses, with varying degrees of familiarity and experiences at the DPC, it
is clear that an atmosphere of abuse, neglect and intimidation continues to exist. It is
disappointing that no one in the facility’s administration has been successful in discouraging or
disbanding these inexcusable acts. This includes administrators at every level of the Department
of Health and Social Services (DHSS), including Susan Robinson (Former Director, DPC),
Renata Henry (Director, Division of Substance Abuse and Mental Health-DSAMH) and the
Secretary of DHSS, The Honorable Vincent P. Meconi. Ultimately, this senior leadership team
must be held accountable for the conditions and the existing atmosphere of abuse, neglect and
intimidation. The Committee has no faith in the leadership of this department as it relates to the
operation of the DPC and, therefore, will be recommending in this report that the DPC be
removed from DHSS altogether and be made an independent authority to be run by a governing
board. In the interim a medically-trained director should be appointed by the Governor.
Operation of the DPC should be permanently removed from the purview of DHSS and be
directly overseen by the Governor.

        The Committee finds this to be a very sad time in the history of the center as it was
brought to the attention of the Committee that the DPC was once considered a premier
psychiatric institution at the national level. To see that the DPC has fallen to a level of disrepair
and neglect and that the patients are treated with disdain and disregard by a handful of
problematic employees is a blemish on the luster of the many social services delivered by DHSS
on a daily basis. The Committee, however, recognizes that the vast majority of the employees at
the DPC are dedicated individuals who care very deeply about the protection, treatment and
quality of care the patients receive in the facility. Some employees have testified that they are
embarrassed to be associated with the reports filed in the local media regarding the DPC. The
Committee stands with these employees and is equally appalled at the many horrible deeds and
transgressions that have occurred. The patients of the DPC and their families have a right to
expect that the environment at this facility is one that guarantees the basic rights of all those
seeking compassionate care and mental wellness and provides an atmosphere that is free from
abuse and neglect. Further, employees of the DPC have a right to a work atmosphere that is safe
and free of intimidation and retaliation.

        Regardless of the ultimate resolution of this terrible situation at the DPC, the Governor
should and must order the immediate restoration of these basic rights and protections of both
patients and employees until a more permanent overall solution is in place.

II.    Findings and Recommendations

       Throughout the testimony period of this investigation the Committee heard many
suggestions that would improve the conditions, atmosphere and delivery of care at the DPC.
Below are the findings and recommendations that need to be addressed immediately.

Finding # 1

        The Disabilities Law Program (DLP) is a special project of Community Legal Aid
Society and is charged with protecting patient safety under the federal Protection and Advocacy
for Individuals with Mental Illness Act (PAIMI). The DLP is charged with investigating
allegations of abuse and neglect and advocating for the rights of its constituents. Currently, the
DLP Patient Advocate, based at the DPC, only learns about a case of abuse and neglect directly
from patients, instead of by automatic notification by the facility that an incident report (which is
currently referred to as a PM-46 and/or RI-33 report) was filed. The current policy structure
greatly impedes the patient advocate’s efforts to serve the patients because of the lack of
automatic notification.

Recommendation # 1

           All incident investigations (currently referred to as PM-46 and RI-33 reports), patient
on patient incident reports, patient seclusions, serious injuries and deaths (including ones that
occur after a patient is transferred to another facility) - whether substantiated or not - shall be
given directly to the DLP, in a form mutually agreeable to the DPC and the DLP, within 24 hours
of the incident report filing. It is our understanding that this process has yet to be incorporated as
part of DPC policy, and the General Assembly may propose, if necessary, legislation to
accomplish this result. These filings must also have a sequence order to ensure a proper
accounting of all reports being filed. Other states that require this type of automatic reporting to
the patient advocate are Illinois, Maine, Maryland, North Carolina and Virginia. This
recommendation presumes that the probable cause standard for full disclosure of these reports
will remain the same.

Finding # 2

        The Committee heard disconcerting testimony regarding the use of the four-point
restraint (code green) in de-escalating a patient at the DPC. Particularly troubling to the
Committee was conflicting testimony in the application of the four-point restraint in regard to the
chain of command. The facility’s Seclusion or Restraint policy states that the four-point restraint
allows for ―the use of leather bracelets or other hospital-approved restraints to restrict the
movement of a patient’s limbs. The bracelets are attached by means of a belt to a bed frame so
that the patient is maintained in a supine position.‖

Recommendation # 2

        The Committee recognizes the need for patients to be de-escalated in a manner that
protects their safety, as well as the safety of other patients and staff. However, the Committee
finds that the use of the antiquated four-point restraint is problematic at best.

        In August 2007 the U.S. Department of Justice found after investigating the Connecticut
Valley Hospital (CVH) that the use of the four-point restraint is ―no longer considered acceptable
restraint use‖ because of ―potential serious patient injuries.‖[1] The Justice Department states
that the use of the four-point restraint is ―in contrast to generally accepted professional
standards.‖[2] The Justice Department stated that use of the four-point restraint ―should be
prohibited at CVH.‖ [3]

        The Committee recommends that the DPC immediately revise its policy on the use of the
four-point restraint to reflect that it is no longer accepted as a primary method for de-escalating a
patient at the DPC. The policy should also reflect that other less intrusive interventions have been
attempted and fully documented thereafter.

       To that end, the Committee also recommends the following:


         An important step in creating a culture of recovery is to commit to phase out the practice
of seclusion and restraint altogether. Several states, including Connecticut, New Jersey, New
York and Texas, have received grants from the Substance Abuse and Mental Health Services
Administration (SAMHSA) to implement plans to eliminate seclusion and restraint practices.
Although Delaware is not a recipient of one of these grants, the DPC should nevertheless create
such a plan. By way of contrast, the Division of Developmental Disabilities Services (DDDS)
prohibits the use of seclusion and only permits restraints after full documentation that other less
intrusive interventions have been attempted. DDDS further requires a review of all interventions by
its PROBIS committee and a Human Rights Committee. If other states and a Division within the
DHSS system try to minimize seclusion and restraints of challenging populations, the DPC should
as well.


       The Committee believes that additional training on de-escalation and trauma-informed
care will help equip staff to work with patients so that restraints and seclusion rarely become an

    U.S. Department of Justice’s Civil Rights Division August 6, 2007 ruling. Available at

        Trauma-informed care focuses on treating patients with an understanding of their life
experiences, past trauma, and individualized needs.[4] An alternative may be to invite patients to
write their own plans that identify their stress triggers and strategies to manage agitation and
anger.[5] When patients plan their own recovery, they can become empowered and staff can
become more knowledgeable of individualized needs.

        However, circumstances exist when patients may need to be restrained if other
alternatives fail. In those cases, the Committee recommends the following actions:


        The Committee believes that patients should debrief initially with staff who are not
involved in the seclusion or restraint incident. Patients may divulge more information about how
they were treated to a neutral staff member. (Once the initial debriefing is done with a non-
participant, the Committee recommends that the treatment team converge to debrief the
incident.) The DPC shall offer patients the opportunity to have the DLP Patient Advocate
present during the initial debriefing. This will help ensure that patients’ rights are protected and
that there is transparency in the seclusion/restraint practices.


        Currently, clinical leadership is notified the next ―regular work day‖ when a patient
experiences prolonged or multiple episodes of seclusion or restraint. However, every time a
patient is placed in restraints, executive staff should be called, in their office or at home. They
should come to the unit, if at all possible, to see what happened and talk to staff and patients
involved as soon as possible. Some hospitals use an on-call system to rotate which staff member
is contacted. The purpose of this is to emphasize that restraints are systems failures and that each

    Ann Jennings, NASMHPD, Models for Developing Trauma-Informed Behavior Health Systems and Trauma
Specific Services (2004), 15-16 available at
    Stephan Haimowitz, et. al., Restraint and Seclusion – A Risk Management Guide 22 (2006) (discussing the
Advance Crisis Management Program). Development with the patient of de-escalation safety plans, psychiatric
advance directives. Id. at 20.

restraint is a serious issue. Witnessing promotes strong leadership and the opportunity to
examine the incident.


        The Delaware Mental Health Patient’s Bill of Rights, as defined in 16 Del C.
§5161(b)(6), entitles patients at the DPC to be free from ―abuse, mistreatment and neglect, and
unjustifiable force.‖ It further prohibits ―seclusion, physical restraint, drugs or other
interventions‖ unless ―documented contemporaneously by the written order of an authorized
mental health professional to the extent necessary to prevent physical harm to self or others.‖
This law does not go far enough to protect the rights of patients in mental health facilities
because it does not explicitly outline what is and is not an acceptable practice. The Committee
recommends that Delaware expand its Mental Health Patient’s Bill of Rights to include
additional language on the use of restraints.

       For example, an improved restraint policy shall include the following:

               (1) A strong purpose statement.

               (2) Definitions and conditions for use of restraint.

               (3) A limit on the types of restraints permitted (including minimizing the use of
                   the four-point restraint).

               (4) Admissions screening to determine whether the patient has been a victim of
                   abuse or to determine what triggers may escalate a patient’s behavior.

               (5) A designation of who may order the restraint. A strong law would require a
                   physician to order the restraint, or have the doctor examine a patient within an
                   hour of the restraint when it is not possible for the doctor to order it. The
                   current law provides that a restraint order come from an ―authorized mental
                   health professional‖ pursuant to 16 Del C. §5161(b)(6).

               (6) Monitoring, assessment and comfort to ensure that the patient is constantly
                   observed and assessed for comfort.

               (7) Limited duration of the restraint order—(but allow for possibility of renewal
                   if a restraint is still necessary after the time frame has expired.)

               (8) Debriefing—patient and staff should debrief together to determine what steps
                   could prevent a restraint in the future.

               (9) Staff Training—require training on an annual/biannual basis. Ensure that the
                   training is uniform among staff.

               (10) Data Collection—ensure that the facility is tracking the incidents of
                    seclusion and restraint, the staff shifts, durations, etc.

               (11) Witnessing/leadership notification—Executive staff should be
                    informed and involved in restraint decisions. In addition, leadership
                    should emphasize a culture of recovery as a model for the entire staff.

               (12) Family notification—The treatment team should ask the
                    patient whether notifying his or her family is appropriate.

Finding # 3

        The Committee learned that there is not an independent board that regularly reviews PM-
46 reports or other significant incidents or deaths within the DPC. This is of concern due to the
inherent nature of oversight of a system that largely reports to itself. Again, the Committee does
not believe that the administration of the DPC accepts that this is a significant issue and the will
to change this process is lacking.

Recommendation # 3

         An independent committee should be created to regularly review all PM-46 reports and
other significant incidents or deaths that occur within the DPC. This committee should meet at
least quarterly to review all incident investigations, sentinel events[6] and deaths. This committee
should be comprised of two boards. The first board would review all deaths. The second board
would focus on abuse, neglect, and other significant incidents. Significant incidents will include
seclusions, restraints, deaths, or serious injuries. (Serious injuries will be defined to include loss
of limb or function.) Annually, the Boards should be charged with producing a public report to
track patterns and trends of morbidity and mortality within the DSAMH system as a way to
foster transparency and accountability.

         The DLP has suggested, and the Committee concurs, that the first board be comprised of
community organization representatives to ensure that the human rights of individuals being
treated at the DPC are protected. The second board should be created similarly to the
Department of Correction and the Division of Developmental Disabilities Services
mortality/morbidity review boards. The DLP has requested DSAMH on many occasions in the
past nine months to create these boards, but, to date, none has been created. It is the
Committee’s understanding that this policy has yet to be implemented and the Committee will
propose legislation to accomplish this endeavor. The Committee fully expects DHSS to create
these boards and, immediately thereafter, to appoint the membership reflective of the community
and appropriate parties, respectively. Other
states that have statutory mandates for these committees are Maryland and New Hampshire.

Finding # 4

       The director of the DPC and the director of DSAMH do not have nor are they
required to have any medical training.

Recommendation # 4

       Both the director of the DPC and DSAMH should either be a board-certified psychiatrist
and/or a Master’s level Nurse Administrator properly trained in psychiatry and must also have a
proven track record in behavioral health and hospital administration. The director of the DPC
should report directly to the Secretary of DHSS or proposed governing board of the facility and

     A sentinel event, as defined by the Joint Commission on Health is ―an unexpected occurrence involving death
or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or
function. The phrase 'or the risk thereof’ includes any process variation for which a recurrence would carry a
significant chance of a serious adverse outcome.‖ Available at
shall no longer report to the director of DSAMH. The patients and staff of the DPC should have
every confidence that the decisions made by administrators have the highest level of clinical skill
and expertise available and, more importantly, will ensure the continuity and standard of patient
care. It is the Committee’s understanding that this policy has yet to be implemented and the
Committee will propose legislation to accomplish this.

Finding # 5

        The Committee heard testimony as it relates to reports of alleged staff intimidation,
discrimination, retaliation and personal property vandalism at the DPC. The Committee believes
that most of the testimony to this fact is credible and, in many cases, substantiated by police
reports and incident reports.

Recommendation # 5

         Security cameras at the DPC have been installed and the Committee applauds that effort.
These cameras should be used to review every instance of alleged patient abuse or neglect or
staff intimidation, discrimination or retaliation. The Committee also recommends that a zero-
tolerance policy, consistent with personnel practices, be adopted immediately that would result in
the termination of any employee of the DPC proven to have committed such acts of patient
abuse, neglect, intimidation, discrimination, retaliation or vandalism.

Finding # 6

        The Committee heard sworn testimony about an atmosphere of staff intimidation and
threats at the DPC. The Committee believes that all employees have the right to work in a safe

Recommendation # 6

       The Secretary of DHSS or proposed governing body of the DPC should immediately
implement a zero-tolerance policy, consistent with personnel practices, for any substantiated
claims of staff intimidation or threats. The DPC cannot effectively function as a safe refuge for

patients seeking mental wellness if the staff is gripped with an attitude of fear and reprisals. This
severely impacts the level of care that can be administered to patients and, ultimately,
undermines any clinical efforts to administer the standard of care. The Committee appreciates
that it is often very difficult to deal with these types of situations but recognizes the need to
immediately address such instances. Delaware State Police must be called in to investigate any
claims of staff intimidation, retaliation or vandalism. The Committee is prepared to ask State
Police to consider a report from the DPC a high priority and to fully investigate any matter being

Finding # 7

        The Committee heard sworn testimony in which an investigator with the Division of
Long Term Care (LTC) Residents Protection stated that they did not interview the victim of an
alleged abuse during the PM-46 investigation process. The Committee has transcripts of the
investigator’s testimony that substantiates this fact.

Recommendation # 7

         In concurrence with DPC policy, the Committee believes that it is incumbent upon all
DPC and LTC investigators to interview every person involved/named in any PM-46 or RI-33
report. The patient should be afforded an opportunity to be interviewed by investigators
following any reported incident. Not interviewing the patient who lodged the complaint should
result in disciplinary action against the investigator found to be in violation of current DPC

Finding # 8

      The Committee heard testimony regarding the abuse of overtime monies and dual
employment arrangements.

Recommendation # 8

         In an era of nursing shortages the state must remain competitive with employment
packages that are equal or superior to the private sector. This should include affording nurses
every reasonable opportunity to work overtime shifts to the extent that patient care is not
compromised. The Committee does not suggest, however, that any nurse or attendant should
work, for example, 80 or more hour weeks for weeks on end. The Committee suspects that
patient care is being compromised in these situations and recommends that this practice cease
immediately. The $4.5 million state appropriation used annually for overtime should more than
compensate/justify the hiring of several full-time registered nurses, clinical social workers and
assistants. Overtime in the healthcare industry is a necessary expense. However, overtime
should be merit based and accessible to all employees on a rotational basis. In addition, the one-
on-one and two-on-one supervisions of patients should be reviewed hourly. For example, a
patient may de-escalate within a few minutes of being placed on a one-to-one observation.
Currently, a review of that observation would happen only after 24 hours. The Committee
recognizes that a review only after 24 hours may be a waste of resources and calls on DHSS to
research industry standards and best practices to ensure resources are being used efficiently and
Finding # 9

         The Committee heard testimony and saw first-hand the physical conditions of the DPC.
It is an aged center that has many deferred maintenance issues.

Recommendation # 9

        While the Committee believes strongly that a new building is not a panacea, it does
believe that deferred maintenance issues should be addressed immediately and that great
consideration should be given during the Fiscal Year 2009 budget process toward upgrading the
current center. It is preferable that the center have a non-industrial/non-institutional atmosphere.
The Committee believes steps can be made to mitigate the negatives of the building through
regularly scheduled maintenance of the building. The Committee urges and will advocate to the
Joint Finance Committee to give great weight to allocating additional funding directly to the
DPC to fund these necessary improvements of the facility.

Finding # 10

         The Committee heard testimony regarding the lack of medical certification needed to
attain the post of unit director at the DPC.

Recommendation # 10

        All units should be run by either a board-certified psychiatrist or a Master’s level Nurse
Administrator. Much like requiring that the director of both the DPC and DSAMH be board-
certified psychiatrists and/or Master’s level Nurse Administrators the patients and staff should
have every confidence that decisions on each unit are being made with the highest level of
clinical skill and expertise. More importantly this requirement will ensure the continuity and
standard of patient care.

Finding # 11

      In many instances of alleged patient abuse administrators and staff failed to notify
Delaware State Police.

Recommendation # 11 (See Attachments A and B—Delaware Psychiatric Center
Investigatory Process Flow Chart and Long Term Care Residents Protection

        The staff at the DPC should adhere to the investigatory process as detailed in the internal
flow chart provided to the Committee during its examination of the facility. This flow chart
requires State Police to be called in situations of sexual assault, suspected physical abuse,
immediate danger and property loss. In an ambiguous case the DPC should ―error on the side of
caution‖ as stated by the DPC Interim Director, Guy Perrotti, at the December 3, 2007 public
hearing. A zero-tolerance policy should be implemented and an employee found not adhering to
the policy should be immediately terminated. The Committee expects State Police to consider
reports of this nature by the DPC a high priority call and be treated with the utmost importance.
The Committee calls on Delaware State Police and the DPC to work out a Memorandum of
Understanding to be submitted to the Committee within 30 days of the submission of this report.
This policy memorandum needs to be issued by the administration of the DPC to all staff
delineating the responsible party charged with placing the call to State Police.

Finding # 12

        The Committee heard testimony regarding the need for the protection of patients who file
reports of abuse, neglect and/or crimes.

Recommendation # 12

         There are strident statutory anti-retaliation protections in the current Delaware Code
(Title 16 Del.C. Secs. 1117, 1135, and 1154) which apply to complainants and persons
cooperating with an investigation involving a long-term care (LTC) facility. However, these
protections only apply to licensed LTC facilities. The only part of the DPC that is a licensed
LTC facility is the Carvel Unit. For the non-Carvel portion of the DPC, there is only a very
weak statute (Title 16 Del.C. Sec. 1161(b)(17)) which protects patients from retaliation (not
employees or other cooperating persons) and has no ―teeth‖ (e.g. no fines or damages).
Moreover, the PM-46 Policy (which covers the entire DPC) has no anti-retaliation provision at
all. It is important that an anti-retaliation statute be adopted (patterned on Title 16 Del.C. Secs.
1117, 1135, and 1154) which would cover the DPC and similar facilities.

       Without such protection, patients and employees can be overtly or subtly terrorized or
intimidated into simply ―keeping their mouths shut.‖

Finding # 13

         The Committee heard during the course of its investigation that many patients currently
in the DPC could not be transitioned into community placements due to the seriousness of their
diagnosis. However, the DPC recently decided that at least 35 patients are in fact well enough to
live in community placement.

Recommendation # 13

         The Committee commends the effort to place more individuals in the community. As a
result the announcement to discharge 35 DPC patients into the community, the Committee
encourages the DPC to carve out requirements for safe and appropriate discharge. To effectuate a
safe transition, the Committee encourages discharge plans to include an individualized
assessment; secure housing; a crisis plan; the level of appropriate supervision; and identification
of needs for personal care, psychiatric, medical, medication, legal and financial considerations.
Furthermore, the Committee urges the DPC to work to ensure as many able patients as possible
are placed in community-based settings.

        The Committee recommends the steady planned expansion and enhancement of new and
existing community-based programs for persons currently living at the DPC, as well as for
individuals who might avoid hospitalization if the right combination of services existed in the
community. It is recommended that a target of 50 placements per year for the next three to four
years from both the DPC and those in the community in need of services should be considered.
These placements should be adequately funded based on the individualized assessments.

Finding # 14

       The Committee finds that the current administration of the DPC has lost the public’s
confidence and calls for an immediate change of oversight of the DPC, directed by an
independent and professional body.

Recommendation # 14

        The General Assembly should enact legislation that will create a structure for the DPC to
be run as an independent authority directed by a governing board. The Committee recommends
that the state continue to fully fund this authority at or above current levels to assure its success
and smooth transition. All current employees of the DPC should be rehired under conditions that
ensure all employees are re-evaluated and deemed productive to the center and, most
importantly, to its patients. The Committee will propose legislation to accomplish this endeavor.
In the interim a medically-trained director should be appointed by the Governor. Operation of
the DPC should be permanently removed from the purview of DHSS and be directly overseen by
the Governor.

Finding # 15

         The Committee finds that the majority of staff at DPC are dedicated, competent, and
caring professionals. It is recognized that DPC has made efforts to increase the number of
certified nursing assistants and create new position categories among attendants. But, there
remains unclear overlaps in the uncertified job categories. These include activity therapists,
institutional attendants, nursing assistants, clinical support specialists (CSS) and active treatment
facilitators (ATF). It is reported that the largest group of direct care providers, ―attendants,‖ have
the opportunity for some mental health training, but are not certified. The State of Delaware
does not require certification or licensure of mental health attendants/psychiatric technicians.
There were confidential reports from patients’ family members recognizing the ―good will‖ of
many patient care attendants, but the need for them to have more skills with mental health care
therapies. In addition, there were confidential reports and documented incidents of patient
neglect/abuse at DPC, involving attendants. The majority of attendant or psychiatric technician
positions are static, with no apparent opportunity for professional advancement and limited merit

       In turn, it was reported that attendants or psychiatric techs at the DPC, unlike their
counterparts at other institutions, are limited in their ability to provide comprehensive life skills
education to their patients.

Recommendation # 15
        The State of Delaware should implement within one year of submission of this report a
certification program for mental health associates/attendants or psychiatric technicians, starting
with those at the DPC and later expanding to public and private inpatient and community based
mental health facilities.

         A Certification Program would offer providers of care, not only at the DPC but
statewide, with a broader base of knowledge and incentive for ongoing professional development
to allow them to function in a job role that would include a variety of treatment settings and
patient populations (e.g., inpatient acute and chronic psychiatric conditions, substance abuse,
developmental disability, community settings). The DPC is recognized for creating a career
ladder for some of the attendant positions (i.e., ATFs or clinical support specialists), but can be
strengthened by a certification requirement.

         The Certification Program will expand the concept of professionalism to the
―Attendant/Psychiatric Technician‖ role, placing selection on individuals entering the field from
the start. Requirements for entry into the Certification Program should be established that are
feasible and realistic to the position. It is suggested that the program be based on a formalized
educational curriculum with an allotted number of hours that includes basic psychopathology,
mental health assessment and interpersonal communications, together with practical experience
and the successful passage of a certification exam. In order to uphold certification, the program
would require minimum designated continuing education credits that could be specialized to the
specific work environment. Specialization within the Certification Program will provide
opportunity for advancement and offers a means to create a professional career ladder and
improve qualify of care for patients.

        The educational content of the Certification Program will support implementation of new
care trends in mental health which have been shifted towards a system-of-care approach and the
use of evidence-based practices. Execution of these practices requires knowledgeable staff
starting at the base of the healthcare structure. The other goal of the professional learning
program is to ―unlearn‖ an array of attitudes, assumptions, and practices developed through
social biases and stigmas. (―An Action Plan on Behavioral Health Workforce Development,‖
prepared for SAMHSA by the Annapolis Coalition on the Behavioral Health Workforce, 2007).

        In the absence of a proposed governing authority under Recommendation # 14, the
statewide Certification Program will help to manage labor relation issues, and it is expected that
labor unions will be engaged and provide feedback as the program is designed. The certification
process provides for the enforcement of a Professional Standards of Conduct and a registry of
baseline care provider education measures that should be included for employment and
articulated in the attendants’ union requirements. To ensure high education standards are upheld,
the program needs to be sponsored and administered by an external organization. Four states,
California, Colorado, Arkansas and Kansas have this baseline certification requirement, and they
collaborate with the American Association of Psychiatric Technicians (AAPT). Delaware should
create a similar program.

Finding # 16

       As stated in Recommendation # 15, the State of Delaware does not require certification
of psychiatric technicians or mental health attendants in public or private settings. In turn,
Delaware does not have any independent professional regulatory oversight of these positions.

Recommendation # 16

        The State should create a professional regulatory board or designate an existing state
regulatory board or regulatory office to monitor the registration and certification of mental health
attendants and investigate allegations of misconduct that may affect the certification of the
professional. This board should be independent of the DPC or any ambulatory nonprofit or profit

         A phased-in, comprehensive approach, including all public and private mental health
facilities, should collaborate with the Delaware Division of Professional Regulations and the
General Assembly to develop or designate an existing regulatory body. This board will provide
additional patient care protections at the DPC and other settings. Legislation will be necessary to
accomplish this.

        Certification establishes a minimum entry of education standards, continuing education
requirements, and opportunities for career development and job satisfaction. In turn, an external
board directed by the Delaware Division of Professional Regulations adds an important
additional external review of the behavior of the mental health associates/attendants if there are
allegations of misconduct. This might be structured to be similar to other boards now in nursing,
medicine, social work, etc. They have clear minimum requirements and independently
investigate and review allegations of misconduct. Four states—California, Colorado, Arkansas
and Kansas—have baseline certification requirements and oversight bodies.

Finding # 17

        There is not a clear pre-employment screening process for criminal background checks or
drug testing for all employees at the DPC.

Recommendation # 17

        State code should be revised to require pre-employment criminal background checks and
periodic drug testing for all direct care employees, who work in community or residential mental
health facilities.

        Criminal background checks have become required by state law for certain professionals
since the late 1990s. A criminal background check was enacted into state law in 2006 for initial
registered nurse (RN) licensure. It is important to expand to others in direct care of those
vulnerable populations in mental health. Most state hospitals and private not-for-profits do these
screens as a matter of course.

Finding # 18

       The DPC offers various therapy activities and has documentation recording these
processes, but the ongoing outcomes and utilization patterns per patient are not strongly
identifiable. Individuals have been hired to fill new positions for teaching groups. However, it is
vague as to how therapy is monitored and tracked for individualized quality outcomes for
inpatient care and discharge planning. In confidential meetings, patients’ family members
voiced concern over the need for more therapy hours and/or individualized plans for monitored
therapy and discharge planning.

Recommendation # 18

        It is recommended that the DPC develop a comprehensive system to monitor and track
patient assessments, treatment plans, therapy sessions, and discharge documentation, utilizing the
hospital’s record keeping policies and procedures and DPC’s Performance Improvement Unit

        The tracking system should not only include the type of session, but also the hours
delivered, and should link to individualized plan of care outcomes. This tracking, in turn, can
augment individualized plans of care as well as unit performance indicators. Decisions made in
daily treatment team meetings should be documented whenever decisions reflect changes in
treatment approaches or indicate resolution of difficulties related to treatment and discharge
planning. A follow-up procedure for discharged patients whose aftercare plans do not include
attendance at a Delaware outpatient clinic should also be developed to ensure the discharge plans
are implemented.

Finding # 19

        Like other acute care, 24 hour facilities nationwide, the DPC had seen an increase in
patient acuity, staff shortages, and patient to staff workload ratios, and in turn, an increase in
reports of challenges with workplace communication and culture matters as well as staff
interpersonal conflict. In turn, there has been a significant rise in national documentation on
workplace adversity or nonphysical hostility known as ―lateral violence.‖ The term was
developed to describe distasteful behavior nurses and other hospital staff sometimes portray
toward colleagues. This negative interpersonal behavior entails overt or covert nonphysical
hostility such as criticism, infighting, finger pointing, retaliation, and ultimately impacts morale,
professional satisfaction, organizational culture, job turnover and nurse vacancy rates, and
patient outcomes. (Duffy, 1995, Hutton, 2006, Kindly et al, 2005, Kingma, 2001, Martin et al,

        The DPC has made progress over the past decade to fill positions and eliminate the use of
contracted agency staff and to develop collaborative agreements with leading area academic
settings for clinical staff education and clinical advancement. Continuing education is available
for workplace issues, but it is not clear as to how structured and frequently it is utilized. There
has been an increase in staff vacancy rates and overtime that is reported to occasionally
contribute to workplace stress and conflict. There is a need for staff to be accountable for their
actions and the DPC to offer workplace culture and cooperation training for professionalism and
patient care.

Recommendation # 19

         The DPC’s Performance Improvement Unit and DHSS Training offices should develop
within one year of submission of this report a mandatory and ongoing staff training program that
facilitates a culture of cooperation, staff accountability, and addresses interpersonal conflict. A
Peer Review Committee as part of the Incident Management Program is suggested as well.

         The DPC needs to continue to work towards restoring a culture of cooperation. Building
upon Recommendations 5 and 12, there should be zero tolerance for any lateral hostility and
retaliation. Regular workplace trainings to prevent lateral hostility have been documented to be
successful in improving professional job satisfaction, interpersonal relations, a culture of
cooperation, and patience care outcomes (Griffin et al 2004, Jackson et al 2007, Leiper 2005,
Vonfrolio 2005). A statement outlining desired workplace culture, values and behaviors should
be integrated into such trainings.

        This is a national phenomenon at many 24 hour acute care facilities, and it is
recommended that the new or interim director of the DPC consult with a leading national expert
to assist with development of such training. It is essential that appropriate strategies be put in
place within the workplace to:

   1. Recognize and acknowledge that interpersonal conflict or lateral hostility exists in the
   2. Address the workplace culture issues that allow conflict to exist.
   3. Require management to adopt a continuous, consistent and integrated approach to
      promote a culture of cooperation and address instances of lateral hostility.
   4. Provide regular education for all staff on the subject of cooperation and the elimination of
      lateral hostility (For example: what it is, how to address it, etc.).
   5. Institute mechanisms that enable and allow staff members to safely address issues of
   6. Produce a statement outlining desired workplace culture attributes, values and behaviors
      and have it displayed in prominent places throughout the institution. (See Attachment D
      of this report)
   7. Talk to all staff members about the phenomenon.

        In turn, a Peer Review Committee as part of DPC’s Performance Improvement Unit is
suggested. It is a method of ensuring high quality healthcare by investigating reportable conduct
of registered nurses (RN), licensed practical nurses (LPN), certified nursing assistants (CNA)
and other direct care staff. Individual competence and ethical conduct are essential components
of quality healthcare.

        The peer review process is one involving fact-finding, analysis and study of events by
licensed nursing staff and other care providers in a climate of collegial problem-solving focused
on obtaining all relevant information about an event. The intent is that peer review will be a
collegial, non-adversarial review of a nurse or an event. It is not intended to be a form of

       Peer review should evaluate nursing services and direct care services, the qualifications
of nurses or direct care providers, the quality of patient care rendered by nurses or direct care
providers, the merits of complaints concerning nurses and direct care providers, and

determinations or recommendations regarding complaints. In establishing the Peer Review
Committee, guidelines must be developed and should consider:

          Reportable Conduct
          Who reports Conduct
          Director of Nursing or Relevant Administrator Duties
          Nurse Supervisor/Manager Duties
          Peer Review Committee Functions
          Committee Composition
          Peer Review Committee Processes

Finding # 20

       Currently employees of the DPC do not wear uniforms denoting their positions as
professional staff.

Recommendation # 20

        All employees of the DPC are to wear appropriate attire/uniforms within one year of
submission of this report to help delineate themselves from the patients. This is necessary to
help patients and visitors differentiate staff. This also serves as a safety measure to allow visitors
and patients to alert appropriate personnel in an emergency. The Committee expects that DHSS
will institute a mandatory uniform policy for all staff of the DPC immediately.

III.       Conclusion

        The citizens of the state of Delaware have benefited from the creation and work of the
bipartisan Delaware Psychiatric Center Investigative Committee. All of the Representatives
have contributed a significant amount of time to this process. By doing so, they have ensured
that the Legislative Branch fulfills its Constitutional duty in providing a check on the Executive
Branch, especially in circumstances when the Executive Branch has been unresponsive or
laggard to the outcries of its citizenry. The Committee sincerely regrets that the patients,
families and staff at the DPC have had to endure mistreatment of any kind. The Committee
expects, however, that through the findings and recommendations of this report these individuals
will soon be able to find some solace and hope for a better future at the DPC. The Committee
will endeavor to immediately change the atmosphere at the DPC by implementing the proposed
recommendations. Ultimately, however, the effort will require all persons connected with the
Delaware Psychiatric Center to stand up and make sure their voices are heard. In this vain the
Committee will make available all information gathered during the course of its investigation to
the Delaware Attorney General’s Office and to the United States Attorney’s Office to aid the
agencies in their respective investigations.

        Our society will be judged by how well it treats those most vulnerable among us and the
DPC has a checkered past in this regard. However, through the immediate implementation of
these recommendations, it is the Committee’s hope that a level of respectability can be restored
and the journey of rebuilding the reputation and exceeding standard of care delivered by the
Delaware Psychiatric Center can commence once again.

Respectfully submitted:

The Honorable Richard C. Cathcart, Chairman
The Honorable Joseph W. Booth
The Honorable Bruce C. Ennis (Resigned Office)
The Honorable Bethany A. Hall-Long
The Honorable James Johnson
The Honorable Pamela S. Maier
The Honorable Nick T. Manolakos (Alternate)
The Honorable Melanie George Marshall
The Honorable William A. Oberle, Jr.
The Honorable Hazel D. Plant
The Honorable Robert J. Valihura, Jr.
The Honorable Nancy H. Wagner

                                   ATTACHMENT A

     Delaware Psychiatric Center Investigatory Process Summary

                  ATTACHMENT B

Long Term Care Residents Protection Investigations

                                              ATTACHMENT C

                         References for Recommendations 15-19
        Annapolis Coalition on the Behavioral Health Workforce,(2007). Prepared for SAMSHA. An Action Plan
on Behavioral Health Workforce Development Rockville: Author

         Duffy, E. (1995). Horizontal violence: a conundrum for nursing. Collegian, 2(2), 5-17.

         Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly
licensed nurses. The Journal of Continuing Education in Nursing, 35(6), 257-263.
         Hutton, S. A. (2006). Workplace Violence: State of the Science. Journal of Nursing Administration, 36(1),
         Jackson, D. Firtko A & Edenborough, M. . (2007) Personal resilience as a strategy for surviving and
thriving in the face of workplace adversity: a literature review. Journal of Advanced Nursing 60:1, 1–9
       Joint Commission Perspectives on Patient Safety. Maintaining Safety and Reducing Risk. Joint
Commission Resources Publication, 6(1). 1,2 & 8.

        Kindly, D., Petersen, S., & Parkhurst. D. (2005). Perilous Work: Nurses’ Experiences in Psychiatric Units
with High Risks of Assault. Archives of Psychiatric Nursing, 19(4), 169-175.

          Kingma, M. (2001). Workplace violence in the health sector: A problem of epidemic proportion [Guest
editorial]. International Nursing Review, 48(3), 129-130.
         Leiper, J. (2005). Nurse against nurse: How to stop horizontal violence. Nursing 2005, 35(3), 44.

        Martin, M. Perspectives in Psychiatric Consultation Liaison NursingThe Role of the Psychiatric
Consultation Liaison Nurse in Evidence-Based Approaches to Lateral Violence in Nursing , Perspectives In
Psychiatric Care January 2008 44 (1), 58–60.
       Myers, D., Kriebel, D., Karasek, R., Punnett, L., & Wegman, D. (2005). Injuries and Assaults in a Long-
Term Psychiatric care Facility. AAOHN Journal, 53(11), 489-498.
         Vonfrolio, L.G. (2005). End horizontal violence. RN, 68(2), 60.

                                      ATTACHMENT D

                              Interaction Conduct Code
        As part of Recommendation # 19, an Interaction Conduct Code will be implemented as
part of an effort to improve the working relationship at the Delaware Psychiatric Center. This
Code, as agreed to by all parties, will ensure that all interactions will be characterized by:

      Handling all matters in a common sense way within the bounds of common decency.
      Using extraordinary effort to maintain and enhance the individual’s self- esteem.
      Listening and responding one to the other with empathy.
      Asking for help in solving mutual problems.
      Giving background information and describing why a change is necessary.
      Remaining calm during emotional situations and discussing such matters in private.
      Express confidence in each individual’s ability to carry out their responsibilities.
      Share objectives so that there will be a consistent flow of energy toward accomplishing
       those objectives.
      Freely acknowledge difficulties to allow for a non-threatening problem solving
      Respect the judgment of people at all levels and positions
      Openly request the help others and be willing to give help in return.
      Encourage a high degree of trust among all people with a sense of freedom and mutual
      Never assume that all persons know why they are requested to do something.
      Confront poor performance and develop positive resolutions.
      Recognize that threats only cause people to concentrate on the threat and not on the job to
       be done.
      Allow for methods and policies to be questioned and changed if they no longer apply.

       In support of the Code, the parties will commit to a joint training program. Such training
will work toward enhancing people’s ability to deal with one another in a positive way and will
include all DPC employees.

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