STATE OF MAINE
KENNEBEC, SS.
DOCKET NO. 89-88

SUPERIOR COURT
CIVIL ACTION

PAUL BATES, JOAN CAMERON,
Simone Johnson, guardian and
next friend of ROBERT JOHNSON,
RAYMOND DUTIL, JR., SHIRLEY
GIFFORD, MARTHA BRADEEN,
MATILDA PERRIN, Betty Chapman,
guardian and next friend of
TOM CONNORS, Janice Burns,
guardian and next friend of
WRENDY HAYNES, JOHN BARTON,
JOSEPH HORNING and
DANA LEONARD,
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Plaintiffs
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v.
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ROBERT GLOVER, in his
capacity as Commissioner
of the Department of Mental
Health and Mental
Retardation, LINDA BRESLIN,
in her capacity as
Superintendent of the Augusta
Mental Health Institute, and
the MAINE DEPARTMENT OF MENTAL
HEALTH AND MENTAL RETARDATION )
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and
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H. ROLLIN IVES, in his
capacity as Commissioner of
the Department of Human
Services and the MAINE
DEPARTMENT OF HUMAN SERVICES
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Defendants

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) SETTLEMENT AGREEMENT
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 TABLE OF CONTENTS
Page
I.
A.
B.
C.
D.
E.
F.

GENERAL JURISDICTIONAL MATTERS
Introduction
Jurisdiction and Venue
Scope of the Class
Allegations of the Complaint
Purposes of Settlement
Interpretation of the Agreement

II.

DEFINITIONS

Parties
Terms
III.
A.
B.
C.
D.

2
2
2
2
3
4
4
6
6
6

CLIENTS' RIGHTS
Grievances
Complaints
Reports
Rights Regulations

9
9
12
14
14

IV.
PRINCIPLES GOVERNING A COMPREHENSIVE
COMMUNITY MENTAL HEALTH SYSTEM

15

V.
DEVELOPMENT OF A COMPREHENSIVE
MENTAL HEALTH SYSTEM

18

A. General
B. Development Plan

18
19

VI.

24

INDIVIDUALIZED SUPPORT PLANS

A. Delivery System
B. Application/Referral for Services
C. Individualized Support Plan
D. AMHI Hospital Treatment and
Discharge Plan
E. Community Hospital Treatment and
Discharge Plans

24
25
27

VII.

38

COMMUNITY RESOURCES, SERVICES AND PROGRAMS

A. Hospitalization

35
38

41

 B. Housing
C. Residential Support Services
D. Crisis Intervention and
Resolution Services
E. Vocational Opportunities and Training
F. Treatment Options
G. Recreational/Social/A vocational
Opportunities
H. Transportation
I. Family Support
VIII.

STANDARDS FOR COMMUNITY PROGRAMS

42
44
45
47
48
48
49
49
51

A. Personnel: Qualifications,
Recruitment, Evaluation and Training
B. Other Standards

51
55

IX.
STANDARDS GOVERNING AUGUSTA MENTAL
HEALTH INSTITUTE

57

A. General
B. Environment
C. Admissions
D. Treatment
E. Psychoactive Medication
F. General Health Care
G. Dental Care
H. Seclusion, Restraint and
Protective Devices
I. Patient Abuse, Neglect and Exploitation
J. Patient Injury and Death
K. Staff/Patient Ratios
L. Personnel: Qualifications,
Recruitment, Evaluation and Training
M. Patient Records
X.

STANDARDS GOVERNING TREATMENT OF MINORS

57
57
60
63
66
70
73
74
86
88
89
91
95
97

XI.
STANDARDS GOVERNING TREATMENT OF
NURSING HOME PATIENTS

105

XII.
STANDARDS GOVERNING TREATMENT OF
FORENSIC PATIENTS

110

XIII.

111

PUBLIC EDUCATION

XIV.
DEPARTMENT OF HUMAN SERVICES PUBLIC WARDS
AND ADULT PROTECTIVE SERVICES

112

 XV.

PLANNING, BUDGETING AND RESOURCE DEVELOPMENT

114

XVI.

MISCELLANEOUS

116

A.
B.
C.
D.

Budgets
Capacity
Defendant's Designees
Attorney's Fees

116
116
117
117

XVII. QUALITY ASSURANCE, INTERNAL MONITORING,
REPORTING AND IMPLEMENTATION

118

A.
B.
C.
D.
E.

118
118
119
120
121

Licensing
Contracts
Quality Assurance and Internal Monitoring
Progress Reports
Enforcement of Regulations

XVIII.MONITORING AND ENFORCEMENT ROLE
OF THE MASTER

122

XIX.

130

ENFORCEMENT

I. GENERAL JURISDICTIONAL MATTERS
A. Introduction
1. This case was filed by the plaintiffs on February 27, 1989, pursuant to Rules 80C (a) and (i)
of the Maine Rules of Civil Procedure, 5 M.R.S.A. § 11001, 34-B M.R.S.A. §§1430, 3003,
3004, 3803 and 3871, 18-A M.R.S.A. § 5-601, Article 1 Sections I and VI-A of the
Constitution of the State of Maine, the Fourteenth Amendment to the United States
Constitution and 42 U.S.C. § 1983.
B. Jurisdiction and Venue
2. This Court has jurisdiction to decide this action pursuant to 4 M.R.S.A. § 105, and may
grant declaratory relief pursuant to 14 M.R.S.A. §§ 5951 et seq.
3. Venue is proper pursuant to 14 M.R.S.A. § 501.

 C. Scope of the Class
4. By order dated June 15, 1989, this Court certified the class in this matter pursuant to Rule
23(b)(2) of the Maine Rules of Civil Procedure as consisting of all persons who, on or after
January 1, 1988, were patients at the Augusta Mental Health Institute (henceforth referred to as
"AMHI") and all persons who will be admitted to AMHI in the future. The Court also certified
a subclass consisting of those persons who are class members and who also have been public
wards of the Maine Department of Human Services or who in the future become public wards.
5. In accordance with Rule 23(c)(3), the judgment in this action shall apply to all those
persons defined in the foregoing paragraph, subject to the limitation set forth in the Consent
Decree.
D. Allegations of the Complaint
6. The fifteen count Complaint alleges that the Defendants have violated Plaintiffs' rights to
the following: a reasonable opportunity for physical exercise and recreational activities;
adequate sanitation, ventilation and light; protection against physical and psychological abuse;
adequate professional medical care and treatment; individualized treatment and service plans;
freedom from unnecessary seclusion and restraint; appropriate privacy, humane care and
treatment and a humane treatment environment; provision of treatment and related services in
the least restrictive appropriate setting; adequate community support services systems and
programs following discharge; timely discharge when conditions justifying hospitalization no
longer exist; provision of protective services to meet the needs of incapacitated adults; and, for
those patients who are public wards, a public guardian who properly and faithfully exercises
his duties and responsibilities.
E. Purposes of Settlement

 7. The parties to this action agree that the interests of all class members can best be served by
entering into this Settlement Agreement (henceforth referred to as "Agreement") rather than by
engaging in protracted, expensive litigation.
8. The provisions of this Agreement are a full, fair and appropriate resolution of this case.
They address the allegations of the Complaint and provide an appropriate remedy. The
Agreement is intended by the parties to assure, inter alia, that conditions at AMHI and services
provided to class members in the community will meet constitutional, statutory, and regulatory
standards, as applicable.
F. Interpretation of the Agreement
9. In entering into this Agreement, the Defendants do not admit any violation of law. This
Agreement shall not be interpreted in any court, administrative or other proceeding as evidence
of defendants' liability.
10. The parties agree that the care and treatment of class members implicate rights secured and
protected by the Fourteenth Amendment of the United States Constitution, Article 1, Sections I
and VI-A of the Maine Constitution, 42 U.S.C. § 1983, 34-B M.R.S.A. § § 1430, 3003, 3004,
3803, and 3871, and State rules entitled "Rights of Recipients of Mental Health Services" and
"Rights of Recipients of Mental Health Services Who are Children in Need of Treatment."
11. This Agreement is legally binding and judicially enforceable. This Agreement shall be
applicable to and binding upon all the parties; their officers, agents and employees, and their
successors; and, to the extent incorporated in contracts as otherwise specified in this
Agreement, to agencies which enter into contracts with the defendants for the provision of
services to class members.
12. Until the Agreement's termination pursuant to the terms of the Consent Decree, the parties

 hereby consent to the court's continuing supervision in this matter, until further order of the
Court, and to its authority to interpret the provisions of this Agreement, to review and adopt
plans necessary to implementation of its terms, to modify its terms as may be needed to effect
its purposes, and to take appropriate actions within its equitable powers to ensure its
enforcement and the fulfillment of its terms and purposes.
13. The parties acknowledge that this case is one of first impression for the courts of the State
of Maine and that there exists uncertainty and ambiguity as to the questions of law that form
the bases of the claims in this action. Acknowledging the foregoing, the parties have elected to
enter into this Agreement.
14. The terms of this Agreement shall be interpreted consistent with its overall purposes and
principles.
II. DEFINITIONS
l5. As used in this Agreement, the following terms shall have the meanings as set forth below:
Parties
a. Plaintiffs/Class Members. "Plaintiffs" or "class members" are all persons who, on or after
January 1, 1988, were patients at AMHI and all persons who will be admitted to AMHI in the
future, subject to the limitation set forth in the Consent Decree.
b. Defendants. "Defendants" are Robert Glover, in his capacity as Commissioner of the
Department of Mental Health and Mental Retardation; the Department of Mental Health and
Mental Retardation; Linda Breslin, Superintendent of the Augusta Mental Health Institute; H.
Rollin Ives, Commissioner of the Maine Department of Human Services; Maine Department of
Human Services; and their successors and assigns.
Terms

 c. Abuse. "Abuse" means the infliction of injury, unreasonable confinement, intimidation or
cruel punishment with resulting physical harm, pain, mental anguish, or death; sexual abuse or
exploitation; or the willful deprivation of essential needs.
d. Designated representative. "Designated representative" means any person who has been
designated in writing by a class member, or by his guardian, to aid the class member in
protecting his rights under this Agreement and mental health regulations. Such person shall
not be a current patient of or a staff person currently employed in an in-patient facility.
e. Exploitation. "Exploitation" means the illegal or improper use of an individual or his
resources for another's profit or advantage.
f. Individualized Support Plan. "Individualized Support Plan" (henceforth referred to as
"ISP") means a written document prepared by a team of persons including the class member,
which includes an assessment of the class member's strengths and needs, and describes the
class member's goals and objectives and the services the class member needs to meet those
goals and objectives. The document is described in greater detail in Section VI of this
Agreement.
g. Informed consent. "Informed consent" means consent given by a person who has capacity
to make reasoned decisions. Informed consent is based on an actual understanding of: (i) the
nature of the proposed treatment; (ii) the expected benefits of the treatment; (iii) the known
risks of a particular treatment, including the common side-effects of a particular medication;
(iv) the anticipated duration of the treatment; (v) reasonable alternatives to the proposed
treatment, if any; and (vi) the right to give or withhold consent to the proposed treatment. Any
consent given must be free from express or implied coercion.
h. Neglect. "Neglect" means an act or omission which threatens a person's health or welfare

 by placing the person at risk of physical or mental injury or impairment, deprivation of
essential needs or lack of protection from these.
i. On-call. "On-call" means accessible by telephone or other electronic means of
communication and available to report to the work site within 30 minutes of being called.
j. Patient advocate. "Patient advocate" shall mean an employee of the Office of Advocacy of
the Department of Mental Health and Mental Retardation appointed pursuant to 34-B M.R.S.A.
§ 1205 and performing duties at AMHI.
k. Peer advocate. "Peer advocate" shall mean a consumer of mental health services trained in
peer advocacy and selected by the class member to advocate on his or her behalf.
l. Physician. "Physician" means, unless otherwise specified, a medical doctor lawfully
entitled to practice medicine.
m. Physician Extender. "Physician Extender" means a physician assistant or a professional
nurse practitioner performing duties defined in 32 M.R.S.A. § 2102 in accordance with rules
promulgated by the Board of Registration in Medicine.
n. Psychiatrist. "Psychiatrist" means a physician who either is certified by or is eligible for
certification by the American Board of Psychiatry and Neurology or who has successfully
completed an approved residency program in psychiatry and upon completion of
post-residency requirements will become eligible for examination for such certification.
o. Rehabilitation. "Rehabilitation" means activities designed to prevent or minimize
disability while restoring the individual to the optimal level of physical, cognitive and
behavioral functioning.
p. Serious Injury. "Serious injury" means a bodily injury which creates a substantial risk of
death or which causes serious, permanent disfigurement or loss or substantial impairment of

 the function of any bodily member or organ, or which requires extended convalescence
necessary for recovery of physical health.
q. Treatment. "Treatment" means any activity meant to prevent, ameliorate, prevent
deterioration of, or cure a person's mental health problem or mental illness and shall include
behavioral, psychological, medical, social, psychosocial and rehabilitative methods which meet
usual and customary standards in the field of mental health treatment.
r. Weekdays. "Weekdays" means Mondays, Tuesdays, Wednesdays, Thursdays and Fridays,
excluding legal holidays.
III. CLIENTS' RIGHTS
A. Grievances
16. Notwithstanding any other remedies available under law, class members, or guardians
acting on their behalf, may bring grievances claiming that the practices, procedures or policies
of the defendants or of any agency licensed, funded or contracted by the defendants to provide
services elsewhere described in this Agreement, violate the terms of this Agreement or any
other applicable law or regulation.
17. By February 1, 1991, defendants shall draft rules for the processing of grievances. Said
draft rules shall be submitted to counsel for the plaintiffs and to the master for his approval in
accordance with paragraph 293 of this Agreement. Defendants shall thereafter promulgate said
rules in accordance with the Maine Administrative Procedure Act, 5 M.R.S.A. §§ 8051 et seq.
18. Said rules shall include provisions for the giving of adequate notice to class members of
their right to file grievances, of the process whereby grievances may be filed, and of their right
to be assisted throughout the grievance procedure by a representative of their choice. The
notice shall list and briefly describe the advocacy services available through the Office of

 Advocacy, the protection and advocacy program established pursuant to 42 U.S.C. §§ 10801 et
seq., peer advocates, and the Ombudsman program established pursuant to 22 M.R.S.A. §
5112(2).
19. The grievance procedure shall be designed to assure speedy resolution of matters
aggrieved. It shall include provision for a hearing, recorded verbatim, before an impartial
hearing officer. An expedited procedure shall be available for emergency complaints and for
all complaints regarding the development, substantive terms or implementation of ISP's or
hospital treatment and discharge plans. Grievances which include allegations of employee
misconduct shall be processed, except that no disciplinary action may be taken nor facts found
with regard to the alleged misconduct except in accordance with personnel rules and labor
contract provisions.
20. Grievances regarding AMHI shall be addressed to the Superintendent, who shall refer
them to the appropriate supervisor or director for decision. These decisions may be appealed
to the superintendent and finally to the Commissioner of the Department of Mental Health and
Mental Retardation. Grievances arising in the community shall be addressed to the agency
employee designated to hear grievances. Decisions may be appealed to the Director of the
Bureau of Mental Health and finally to the Commissioner of the Department of Mental Health
and Mental Retardation. The hearing before an impartial hearing officer shall be convened at
either of the two appellate levels. The decision rendered at the commissioner level shall be
final agency action subject to judicial review pursuant to the Maine Administrative Procedure
Act.
21. Grievances may be brought by or on behalf of individual clients or groups of clients.
B. Complaints

 22. By February 2, 1991, defendants shall draft rules for the processing of complaints as
described herein. Said draft rules shall be submitted to counsel for the plaintiffs and to the
master for his approval in accordance with paragraph 293 of this Agreement. Defendants shall
thereafter promulgate said rules in accordance with the Maine Administrative Procedure Act, 5
M.R.S.A. §§ 8051 et seq.
23. The complaint procedure shall be available to any person or agency which is charged with
investigating violations of client rights or with delivering or monitoring mental health services.
The complaint procedure may be used when:
a. such person or agency knows or has reason to believe that the practices, procedures or
policies of defendants or of any agency licensed, funded or contracted by the defendants to
provide services elsewhere described in this Agreement, violate the terms of this Agreement or
any other applicable law or regulation; and
b. the information was obtained during the general course of the person's or agency's
performance of their responsibilities.
24. Complaints which include allegations of employee misconduct shall be processed, but no
disciplinary action may be taken nor facts found with regard to the alleged misconduct except
in accordance with applicable personnel rules and labor contract provisions.
25. The complaint procedure shall be designed to assure speedy resolution of issues giving rise
to complaints. Complaints regarding AMHI shall be addressed to the Superintendent, who
shall refer them for decision to the appropriate supervisor or director for decision. The
decisions may be appealed to the superintendent and finally the Commissioner of the
Department of Mental Health and Mental Retardation. Complaints arising in the community
shall be addressed to the agency employee designated to receive complaints and may be

 appealed to the Director of the Bureau of Mental Health and finally to the Commissioner of the
Department of Mental Health and Mental Retardation. Investigations shall be conducted at
each level of the complaint and shall include, as needed, interviews, site visits, or other data
collection activities. At the conclusion of each investigation, a written summary of the results
of the investigation and a statement of the remedial action to be taken, if any, shall be provided
to the complainant.
26. Under no circumstances shall the remedies requested in a grievance be denied nor shall the
processing of a grievance be refused because of the availability of the complaint procedure.
The complaint procedure is intended to offer additional protection to clients under the
circumstances where information of violations of clients' rights is acquired but no client is
known or is available who might process a grievance.
D. Reports
27. Defendants shall prepare semi-annual reports of all complaints and of all grievances
appealed to the Superintendent of AMHI, the Director of the Bureau of Mental Health and the
Commissioner. Said reports shall summarize the issues raised, findings made, and remedial
action taken, and shall be submitted to the master, counsel for the plaintiffs, and the Office of
Advocacy.
C. Rights Regulations
28. By February 1, 1991, defendants shall draft revisions of the "Rights of Recipients of
Mental Health Services" and the "Rights of Recipients Who are Children in Need of Services"
as needed to incorporate the rules governing grievances and complaints, required above, and
all other terms of this Agreement. The draft revisions shall be submitted to counsel for the
plaintiffs and the master for his approval. Defendants shall thereafter adopt said rules in

 accordance with the Maine Administrative Procedure Act, 5 M.R.S.A. §§ 8051 et seq.
29. Defendants shall not by rule diminish the rights guaranteed clients under the existing
regulations and this Agreement.
30. Defendants shall include in the revised regulations the right of all clients to exercise their
rights under said regulations and this Agreement without reprisal, including reprisal in the form
of denial of or termination of services.
IV. PRINCIPLES GOVERNING A COMPREHENSIVE MENTAL HEALTH SYSTEM
31. The parties recognize that while the State has invested significant resources in AMHI,
improvements in the quality of care to class members can only be achieved by reducing
AMHI's census and admissions, reallocating AMHI's resources and increasing community
services as alternatives to hospitalization. Defendants shall undertake these efforts as part of
an overall effort to establish and maintain a comprehensive mental health system which meets
the terms of this Agreement.
32. The following principles shall govern defendants in the development and in the overall and
day-to-day administration and maintenance of a comprehensive mental health system to meet
class members' needs:
a. Class members are at all times entitled to respect for their individuality and to recognition
that their personalities, abilities, needs, and aspirations are not determinable on the basis of a
psychiatric label.
b. Class members have individualized needs which may change or vary in intensity over time
and according to the individual's circumstances. Needs may span those for housing, financial
security, health and dental care, socialization and companionship, spiritual growth, recreation,
transportation, education, vocational opportunity and training, emotional support, psychiatric

 treatment and crisis intervention and resolution services. Services to meet these needs must be
delivered according to flexible models which accommodate changes in individual class
members' needs and the variations in the intensity of their needs. The services shall be flexible
so that support and supervision may be increased or decreased as the class member's needs
change and, to the extent possible, without requiring the class member to move to another
setting.
c. Hospitalization physically separates individuals from their families and friends and creates
difficulties for these persons in reintegrating into the community upon discharge.
Hospitalization at AMHI additionally uproots many individuals from their home communities.
All services within the comprehensive mental health system shall be oriented to supporting
class members to continue to live in the community and to avoid hospitalization. When class
members require psychiatric hospitalization due to medical necessity, services shall be oriented
to hospitalizing them in facilities nearest their homes and thereafter discharging them to the
community with all necessary supports as soon as is medically possible.
d. Patients have the right to receive treatment in the least restrictive available setting according
to the least restrictive means appropriate to their needs.
e. The comprehensive mental health system shall be designed and services shall be delivered
based on identified individual needs.
f. Class members have the same rights as do all other citizens of Maine, including the right to
live in the community of their choice without constraints upon their independence, except
those constraints to which all citizens are subject.
g. Non-class members shall not be deprived of services solely because they are not members
of the plaintiff class.

 h. Class members have the right to refuse all or some of the services offered, subject to the
exceptions noted below. A person's refusal of a particular mode or course of treatment shall
not per se be grounds for refusing a class member's access to other services which the person
accepts. Only the following services may be imposed against a class member's wishes:
i. involuntary hospitalization pursuant to 34-B M.R.S.A. §§ 3863 et seq.;
ii. forensic services pursuant to 15 M.R.S.A. § 101-B in a residential or hospital setting;
iii. as permitted under applicable law in the case of a person under guardianship, upon the
guardian's informed consent and within the limits of the guardian's authority;
iv. in a residential or hospital setting in a psychiatric emergency, pursuant to procedures as set
out in this Agreement at Section IX(E), and in the "Rights of Recipients of Mental Health
Services"; or
v. in a residential or hospital setting, for individuals who lack capacity to consent to services,
pursuant to the administrative hearing provisions of the "Rights of Recipients of Mental Health
Services."
V. DEVELOPMENT OF A COMPREHENSIVE MENTAL HEALTH SYSTEM
A. General
33. Defendants, the Commissioner and Department of Mental Health and Mental Retardation,
and the Superintendent of AMHI, shall be responsible for the establishment and operation of a
comprehensive mental health system in accordance with the terms and schedule as set out in
this Agreement.
34. Defendants, the Commissioner and Department of Human Services shall:
a. Participate in the design, recruitment, development, funding and review of programs
which are needed for a comprehensive mental health system and which do or will receive

 Departmental funding or be subject to Departmental oversight; and
b. Institute appropriate mechanisms to assure that mental health services receive
maximum federal financial participation.
B. Development Plan
1. General Plan
35. By January 1, 1991, Defendants shall develop a plan detailing efforts they will undertake
in meeting all their obligations under this Agreement. It shall include descriptions of efforts in
developing, funding, maintaining, monitoring and evaluating a comprehensive mental health
system which meets the terms of this Agreement. Said plan shall be submitted to the court,
counsel for the plaintiffs and to the master for his approval in accordance with the procedures
set out at paragraph 293 of this Agreement.
36. The plan shall describe each component of the system, its costs and funding sources,
timelines for development or implementation, and the means whereby its quality and
effectiveness shall be monitored and evaluated on an ongoing basis. For each client service
component of the system, the plan shall additionally: describe the models to be used and the
capacity of the services both in terms of numbers of individuals to be served and the intensity
of services delivered; demonstrate that development plans are based upon class members'
actual needs for the planned services, and enclose supporting data.
37. The plan shall verify with supporting data that in meeting class members' identified needs,
defendants shall not deprive non-class members of services solely because they are not
members of the class.
38. Defendants shall comply with the performance terms and schedule of the plan. The plan
may be revised with the master's approval. Defendants must seek revision of the plan as

 needed to assure that services are developed based upon class members' actual needs.
39. In the quarterly reports which defendants prepare pursuant to paragraph 280 of this
Agreement, defendants shall enclose data demonstrating that the plan for development of a
comprehensive mental health system continues to be based upon class members' actual needs
as reflected in their Individualized Support Plans.
2. Plan for Reduction of AMHI's Census
40. By August 1, 1995, defendants shall reduce the non-forensic census and licensed capacity
at AMHI to 70 persons. No more than 20 of these individuals may be persons requiring
intermediate care facility or skilled nursing facility services. Defendants may additionally
maintain a forensic unit limited to persons admitted pursuant to Title 15 M.R.S.A. Chapter 5,
or who are under sentence to or committed to a State or county correctional facility.
41. Defendants shall meet the reduction of AMHI's population according to the following
schedule:
200 by August 1, 1992
150 by August 1, 1993
100 by August 1, 1994
70 by August 1, 1995
42. The plan required by paragraph 35 of this Agreement, shall include specific references to
how the comprehensive mental health system will achieve required reduction of AMHI's
census and admissions.
43. The plan shall refer to client-specific ISP's and hospital treatment and discharge plans of
all class members hospitalized at AMHI as of the date of this Agreement who have diagnoses
of mental retardation, other developmental disabilities, traumatic brain injury, dementia

 (including Alzheimer's disease or a related disorder) or a primary diagnosis relating to
substance abuse or dependence. For each class member, the plan shall describe the community
services to be developed or used, and timelines for development and discharge.
44. The plan shall refer to client-specific ISP's and hospital treatment and discharge plans for
each individual whose admission to AMHI exceeds 150 days. This portion of the plan shall be
updated quarterly to include additional class members whose admission to AMHI may later
exceed 150 days. For each class member, the plan shall describe the community services to be
developed or used, and shall specify the timelines for development or discharge.
45. To assist the defendants in developing their plan for reduction of AMHI's census, and to
assist the ISP and hospital treatment and discharge teams in developing the client specific plans
required by paragraphs 43 and 44, defendants shall retain a review panel by October 1, 1990,
consisting of two professionals to assess individuals currently hospitalized at AMHI and to
develop recommendations to the teams. One of the professionals shall be chosen by
defendants, the other by counsel for the plaintiffs. Defendants shall retain additional
professionals to perform assessments as needed in individual cases.
46. The recommendations of the panel shall be prepared and submitted to counsel for the
plaintiffs, the master and the individual ISP and hospital treatment and discharge teams by
March 1, 1991. During each successive quarter, the panel shall be reconvened to conduct
assessments of newly-admitted patients and to issue recommendations respecting their
discharge and community support service needs, for as long as the master deems it necessary.
47. On the basis of the panel's recommendations, either party may request revision of the
schedule for reduction of AMHI's census. Said request shall be submitted to the court, the
master and opposing counsel. No revision shall be approved unless the party requesting the

 revision can demonstrate its necessity on the basis of the assessment information, and further,
that the purposes and principles of this Agreement can be achieved with implementation of the
revised terms.
3. Plan for Reduction of AMHI's Admissions
48. The plan required by paragraph 35 of this Agreement shall include descriptions of general
efforts which the defendants will undertake to divert the following persons from admission to
AMHI, to treatment in appropriate settings: persons who are diagnosed as having mental
retardation, other developmental disabilities, traumatic brain injury, dementia (including
Alzheimer's Disease or a related disorder), or a primary diagnosis relating to substance abuse
or dependence. Efforts shall include training of personnel employed in the AMHI admissions
office and in community agencies which routinely refer persons for admission to AMHI.
Training shall include, but not be limited to, the following topics: the identification of persons,
noted above, who are to be considered for diversion from admission to AMHI; determination
of appropriate treatment for said persons; and available treatment programs. Defendants shall
rely upon highly qualified professionals to perform this training.
VI. INDIVIDUALIZED SUPPORT PLANS
49. Class members are entitled to receive an Individualized Support Plan as described below,
which is coordinated and monitored by a community support worker.
A. Delivery System
50. Defendants, Commissioner and Department of Mental Health and Mental Retardation shall
establish, either within the Department or through contracts with private agencies, community
support services which, within reason, are accessible geographically to all class members. The
plan described in Section V(B) above shall also set forth a schedule, on an annualized basis, for

 meeting the needs of class members for community support workers and for ISP's which
conform to the requirements of this Agreement. The needs shall be met as quickly as possible.
In any event, defendants shall assure that all class members who want an ISP or community
support worker shall have them by September 1, 1995.
51. Agencies with which defendants contract shall be required by contract to meet all
applicable sections of this Agreement. Such agencies shall be subject to sanctions for
non-compliance, including, but not limited to, revocation of the contract.
52. Agencies contracted to provide community support services shall be required to cooperate
with defendants in collecting data necessary to the meeting of defendants' obligations under
this Agreement. Such agencies shall also be required to maintain current client records which
chart progress toward achievement of client goals and which meet applicable requirements of
contract, law, regulations and professional standards.
B. Application/Referral for Services.
53. Defendants shall make efforts reasonably calculated to inform class members of their right
to receive the services of a community support worker and other individualized support
services in accordance with an ISP. Such efforts shall include notice to individual class
members whose locations are known and to community and governmental agencies which are
known to serve class members. Class members who decline the services of a community
support worker or an ISP shall be informed that they may apply for these services at any
subsequent time.
54. Class members may apply for the services of a community support worker on their own or
with the assistance of a referring agency. With the class member's consent, the referring
agency may apply for services on the class member's behalf.

 55. A class member who applies for community support services while an inpatient in a
psychiatric facility shall be assigned a community support worker within two working days.
The community support worker shall be responsible for participating at hospital treatment and
discharge planning meetings and for developing an ISP in coordination with the hospital
discharge and treatment plan while the class member is in the facility. Upon the class
member's discharge, the individual's community support worker shall meet with the class
member within four days of discharge, immediately implement the ISP developed during
hospitalization and assure that the individual receives the services identified for delivery.
Within 30 days of discharge, the plan shall be reviewed and revised. This paragraph shall not
be construed so as to prevent the discharge of a patient when a community support worker has
not been assigned in conformity with this section.
56. Class members who apply for services and who are not hospitalized at the time of
application or referral, shall be assigned a community support worker within three working
days of the application. The assigned worker shall meet promptly with the class member and
work to meet the his or her needs until such time that the needs are met or an ISP is developed.
An ISP shall be developed no later than 30 days from the date of application.
57. Upon application for services, all class members shall be notified of their rights under this
Agreement and under the "Rights of Recipients of Mental Health Services" and of their right to
name a designated representative or representatives to assist them, to receive notices of
meetings and to participate at meetings. Class members shall additionally be given
information regarding available advocacy and peer advocacy programs.
C. Individualized Support Plan.
58. An Individualized Support Plan shall be developed and thereafter reviewed and revised no

 less frequently than every 90 days. Plans may be reviewed more frequently as necessary to
address substantial changes in a class member's life, such as hospitalization. The ISP shall be
developed by a team consisting of the class member, the community support worker and other
individuals (including hospital personnel when appropriate) among whom the class member
has authorized the exchange of information and who are needed to ensure that the class
member's needs are adequately assessed and that appropriate recommendations are made.
59. The community support worker shall notify a class member of all ISP meetings and invite
and actively encourage the class member to attend. If a class member does not attend an ISP
meeting, the community support worker shall relay the class member's views on issues to other
members of the team. A class member's guardian, if any, shall also be notified of all ISP
meetings and shall be invited to attend. The class member may invite other persons to ISP
meetings and the community support worker shall encourage the class member to do so.
Notices required by this paragraph shall be given by the community support worker at least ten
days in advance of the meeting date, except that when the meeting is being convened to
address an emergency, notice reasonable for the circumstances shall be required.
60. The community support worker shall notify persons that if they are unable to attend an ISP
meeting they may submit information in writing for consideration at the meeting.
61. ISP's shall be based upon consideration of the class members' housing, financial, social,
recreational, transportation, vocational, educational, general health, dental, emotional, and
psychiatric and/or psychological strengths and needs as well as their potential need for crisis
intervention and resolution services. For those areas in which formal assessment procedures
are available, strengths and needs assessments shall be conducted by appropriately credentialed
professionals, with the class member's consent. Assessments shall be obtained through the

 community resources services and programs described in Section VII. These assessments shall
be updated as frequently as changed circumstances may require, but no less frequently than the
standards of the individual professional discipline dictate in order to assure that the information
is current and reliable. For class members who are inpatients at a psychiatric facility, the
community support worker shall obtain information from the hospital personnel who have
current knowledge of the class member's needs.
62. Services to assist the client in meeting identified needs shall be described. Goals shall be
written for each service. Short-range objectives shall be stated such that their achievement
leads to the attainment of overall goals. Objectives shall be stated in terms which allow
objective measurement of progress and which the class member, to the maximum extent
possible, both understands and adopts.
63. Services shall be based upon the actual needs of the class member rather than on what
services are currently available. If at the time of the meeting, team members know, on the
basis of reliable information that the needed services are unavailable, they shall note them as
"unmet service needs" on the ISP and develop an interim ISP based upon available services
which meet, as nearly as possible, the actual needs of the client. If, after the meeting, and
following diligent efforts to locate the identified services, the community support worker
determines that the services are unavailable, the worker shall reconvene the ISP team for the
purpose of developing an interim ISP as described above. In all cases requiring interim ISPs,
the community support worker shall forward a description of the unmet service needs to the
Commissioner of the Department of Mental Health and Mental Retardation, and defendants
shall use this information to plan for the development of new services in accordance with
Section XV of this Agreement.

 64. An ISP shall include a description of the manner of delivery of each service to be
provided. The manner of delivery shall be one which maximizes the class member's strengths,
independence and integration into the community.
65. Within one week of the meeting, the community support worker shall provide the class
member with a written copy of the ISP. The worker shall notify the class member, by means
the individual shall most likely understand, of the right to file a grievance should he or she
disagree with any aspect of the plan or the assessments upon which the plan is based, or later
be dissatisfied with the plan's implementation.
66. Following development of an ISP, the community support worker is responsible for both
locating the services identified in the plan and for monitoring their delivery to assure that they
are delivered in accordance with the terms of the plan.
67. Because class members have different levels of independence at various times, and
because the identified service needs could be either routinely available or highly specialized
(and more scarce), a community support worker's efforts to achieve location and delivery of
services will vary according to circumstances. At times a simple referral of the class member
to a known resource and subsequent periodic telephone contact with the class member and/or
service provider, may be adequate to assure proper delivery. At other times the community
support worker may need to take a more active role. A more active role may include, but not
be limited to, recruitment of a currently non-existing resource, assisting in providing
transportation, visiting the class member at home, accompanying a class member to
appointments, and actively helping class members to resolve problems.
68. When the community support worker does locate the needed services, he or she shall
include the names of the providers and their performance expectations in the service plan.

 69. When the service is to be delivered by an agency funded or licensed by the State, the
community support worker shall execute a written service agreement with the provider. The
service agreement shall describe the service to be provided and any applicable terms as
included in the ISP and shall include the following provisions:
"The provider hereby agrees to the following: (a) that it will not discontinue or otherwise
interrupt services which the provider hereby agrees to deliver to the client and which are
elsewhere described in this agreement, without complying with the following terms:
1. The provider shall first obtain prior written approval from the Department of Mental
Health and Mental Retardation;
2. If written approval is obtained as specified above, and, as a result, services to the client
will be discontinued or otherwise interrupted, the provider shall give thirty days advance
written notice to the client, to the client's guardian, if any, and to the client's community
support worker. If the client poses a threat of imminent harm to persons employed or
served by the provider, the provider shall give notice which is reasonable under the
circumstances;
3. The provider shall give such other notice as may be required by law or regulation; and
4. The provider shall assist the client and the client's community support worker in
obtaining the services from another provider.
(b). The provider further agrees that it shall cooperate with the Department of Mental
Health and Mental Retardation and the Department of Human Services in collecting data
necessary to the Departments' meeting their obligations under the Agreement in Bates, et
al. v. Glover, et al.
(c). The provider further agrees that it shall maintain current client records which chart

 progress toward achievement of goals and which meet applicable requirements of
contracts, law, regulations, and professional standards."
70. In addition to the responsibilities described above, the community support worker shall
have the following duties: participation at hospital discharge planning meetings; monitoring of
services delivered pursuant to the plan in order to assess their continued appropriateness and
effectiveness in meeting class members' needs; appraising progress toward and identifying
impediments to the achievement of class member goals and objectives; promoting ongoing
class member involvement in the review and implementation of their ISP's; attempting to
resolve problems with respect to any component of the ISP; participating in the delivery of
crisis intervention and resolution services as described in Section VII(D) of this Agreement
and providing follow-up services to assure that the crisis is resolved; assisting in the
exploration of lesser restrictive alternatives to hospitalization; for other emergencies which
may arise, assisting in resolving them by mobilizing resources or by intervening directly; and
otherwise providing personalized support to the class member.
71. The ratio of community support workers to clients shall not exceed 1:40. A reasonable
effort will be made to have each community support worker serve clients representing a mix of
needs. Individual clients who present a multiplicity of needs, who have recently required crisis
intervention and resolution services or who have a need for especially intense community
support shall, for purposes of computing the above ratio, be counted as 2.5 clients. In
regulating the number of clients assigned to community support workers, due regard shall be
given to the community support workers' need for training and the demands for record keeping,
travel, and the need for communication with other professionals.
72. The ISP is the principal tool through which class member needs are identified. It is,

 therefore, a critical element in assuring that the comprehensive mental health system is
responsive to class members' actual needs.
73. Not all class members, however, will require or want the active assistance of a community
support worker. Defendants shall not require that class members receive the services of a
community support worker, in order to gain access to other services and resources described in
this Agreement. Defendants shall permit class members to avail themselves of community
services and resources independently, with the help of their friends and family, or with various
levels of intensity of assistance of a community support worker. Class members shall be
encouraged to use the level of supportive assistance appropriate to their circumstances at any
particular time.
74. To assure that the needs of class members who do not receive community support worker
assistance are considered in the design and delivery of comprehensive mental health services,
defendants shall develop a system for the collection of information regarding these individuals
which is informal yet reliable. When soliciting the necessary information from class members,
defendants shall explain that the information is being collected for the sole purpose of planning
services which will meet individually identified needs.
D. AMHI Hospital Treatment and Discharge Plan
75. While class members are admitted to AMHI they shall receive treatment according to a
written individualized treatment and discharge plan, which shall be incorporated into the class
member's ISP as a discrete sub-part.
76. All AMHI patients shall have a preliminary treatment and discharge plan developed within
three working days of admission and a treatment and discharge plan within seven days
thereafter. This plan shall be reviewed and revised as frequently as necessary, but in no case

 less frequently than within 30 days of development, every 60 days thereafter for the first year,
and every 90 days thereafter.
77. The plan shall be developed by an interdisciplinary team which includes the patient, hospital staff representing the disciplines of social
work, psychiatry, psychology, and nursing. Other hospital personnel and other individuals
from the community with whom the patient has authorized the exchange of information and
who are needed to assure that the patient's needs are adequately assessed and that appropriate
recommendations are made shall be included on the team. One of the hospital staff team
members shall be designated as the patient's team coordinator.
78. The patient's team coordinator shall have the same responsibilities with respect to the
development, coordination and monitoring of the hospital treatment and discharge plan as a
community support worker has with respect to an ISP.
79. The hospital treatment and discharge plan shall meet the provisions of paragraphs 61, 64
and 68, with the following modifications:
a. Assessments may be conducted by appropriately credentialed hospital personnel.
b. Complete histories shall be obtained from the patient, community service providers,
and to the extent possible, from other individuals in the community as authorized by the
patient or guardian. Upon learning that a patient has had a prior psychiatric
hospitalization, the team coordinator shall request the patient's consent to the release of the
records of that hospitalization to AMHI. If consent is given, the team coordinator shall,
within two working days, send for copies of the records. These records shall be reviewed
upon arrival and, to the extent of their relevance, shall be considered in the review of the
patient's AMHI treatment and discharge plan.

 c. Goals which must be met in order for the patient to meet discharge criteria shall be
clearly noted. At each review, the team shall assess whether the patient may be safely
discharged.
d. Under no circumstances shall a patient's entitlements, as described below at paragraphs
156, 159 and 162 of this Agreement be left unmet after the dates on which defendants are
required to comply with the provisions of said paragraphs.
e. To facilitate proper performance of the patient team coordinator's monitoring functions,
defendants shall require that hospital chart entries are made and are written in terms of the
patient's individualized goals and objectives.
80. For patients who require but are currently without a community support worker, the
patient coordinator shall, within 48 hours of identification of the need, make a referral, with the
patient's approval, to the appropriate agency for assignment of a community support worker.
Once a community support worker has been assigned, or when a community support worker
has been previously assigned, the patient team coordinator shall be responsible for assuring
that the worker is notified of all future hospital planning meetings, is provided with periodic
progress and other necessary reports, and is apprised of the anticipated discharge date. The
patient's team coordinator is responsible for assuring that information is exchanged between
the AMHI and community planning teams, so that the AMHI treatment and discharge plan and
the ISP are compatible.
81. For patients who decline the services offered by a community support worker, but who
nevertheless will require and accept some post-discharge community services, the patient's
team coordinator is responsible for making necessary contacts with community providers, to
schedule appointments as necessary, to provide information, and otherwise take steps

 necessary to assure that the community services will be available to the patient upon discharge.
82. As soon as possible, but no later than January 1, 1992, all AMHI patients shall have
treatment and discharge plans which conform to the terms of this Agreement.
E. Community Hospital Treatment and Discharge Plans
83. Defendants shall require community hospitals to develop hospital treatment and discharge
plans in coordination with ISP's for all class members whose admissions are funded by the
Department of Mental Health and Mental Retardation. Defendants shall review community
hospitals' individualized treatment and service plans, pursuant to the provisions of paragraphs
282 and 283 of this Agreement, for compliance with the requirements of the "Rights of
Recipients of Mental Health Services".
VII. COMMUNITY RESOURCES, SERVICES AND PROGRAMS
84. There are many generic resources and services in the community for which class members
have a need, but to which their access is limited. Some examples of these resources and
services are health and dental care; independent living accommodations; group and individual
psychotherapy services; substance abuse counseling; transportation; social organizations;
recreational facilities; jobs; and educational institutions. Among the factors limiting class
members' access are attitudes of the public toward persons with mental illness; impairments
which may be associated with mental illness such as diminished organizational skills,
heightened sensitivity to stress, and difficulty with interpersonal relationships; and the
side-effects of long-term institutionalization.
85. In ISP's, class members' needs for generic resources and services shall not be ignored, and
their access to them shall not be presumed. To the maximum extent possible, defendants shall
not use or develop segregated services for any class member, when services otherwise

 available to the general public would be adequate to meet the class member's needs, if
accessible. Instead, community support workers shall diligently work to meet class members'
needs by increasing the accessibility of generic resources and services through efforts in
advocacy, education and support.
86. Other class members may require highly specialized services which either currently are
unavailable or are insufficiently available within the State of Maine. The specialized needs of
these class members shall be considered in their ISP's. These class members may be among
the following:
a. Class members identified for diversion from admission to or discharge from AMHI on
the basis of their diagnoses of mental retardation, other developmental disabilities,
traumatic brain injury, dementia (including Alzheimer's disease or a related
disorder) or a primary diagnosis of substance abuse or dependence;
b. Other individuals who have experienced long term institutionalization, who will be
discharged to the community and who will require specialized services to assist
them in adjusting to community life and avoiding rehospitalization;
c. Other individuals who in the past relied upon hospitalization when lesser restrictive
treatment options would have been more appropriate to meet their needs and who
may need intensive support in adjusting to a community based service system.
87. In funding, developing, recruiting and supporting housing, residential support and other
services to address the needs of the class members described above, defendants shall retain
persons qualified and experienced in the design and delivery of the specific specialty services.
These persons shall identify pre-existing models or design new models for residential and other
support services, and shall advise defendants on staff training and recruitment programs.

 A. Hospitalization
88. Defendants shall make reasonable efforts to fund, develop, recruit and support local
community acute care psychiatric hospitalization options so that class members who require
in-patient psychiatric acute care may receive the necessary hospital services in or reasonably
near their home communities. Defendants shall document their efforts pursuant to this
sub-section by providing the master, on an annual basis, with minutes and outcomes of
meetings with community providers, proposed contracts, recruitment letters, statistics on
community hospitalization costs and patient days, and any agreements entered into with
community hospitals.
89. Defendants shall assure that class member admissions to community hospitals are effected
in accordance with law and shall not fund any community hospitalization which was effected
in violation of law or which was not medically necessary.
90. Defendants shall not fund community hospitals for the treatment of patients unless those
hospitals can assure continuity of treatment during hospitalization and the full protection of the
patients' rights to due process, including the right to a hearing within the time established by
statute for patients admitted pursuant to involuntary procedures. Such assurances shall be
included as a condition of defendants' contracts or agreements for services and payment.
Sanctions for non-compliance with the contracts or agreements, shall include, but not be
limited to revocation of the contracts or agreements.
91. Defendants shall take steps necessary to assure that community hospitals provide quality
care consistent with the terms of this Agreement.
92. To comply with this sub-section on hospitalization, defendants shall meet the applicable
terms and timetables of their plans for development of a comprehensive mental health system

 required by Section V of this Agreement.
B. Housing
93. Defendants shall fund, develop, recruit and support a variety of housing options which can
accommodate varying levels of supportive assistance to clients, depending upon client need.
Some class members will live independently in their own homes, some will require community
support worker assistance in their homes, others will require increased levels of supervision in
their own homes, and yet others will need to live out of home in more restrictive environments
which are fully staff supported.
94. As of the date of this Agreement there are patients at AMHI whose treatment or discharge
plans state that they could live in community settings, but for the lack of available appropriate
housing. Additional AMHI or other hospitalized class members may later be identified as
needing community housing in order to be safely discharged.
95. To comply with this sub-section of the Agreement, defendants shall develop, fund, recruit,
or support sufficient housing to meet the ISP identified housing needs of the class members
referred to above and of class members who are at imminent risk of hospitalization due to lack
of available appropriate housing. Defendants shall develop, fund, recruit and support housing
which is designed to address other individual class members' needs in accordance with
applicable terms and timetables in their plans required by Section V of this Agreement.
96. For purposes of this sub-section, a home is a residential unit where unrelated persons live
together sharing some common space and facilities. It does not include residential
arrangements established through the collaborative efforts of the residents. The housing to be
developed, recruited, newly funded or supported under this Agreement shall be located where
the other community services described in this Agreement are reasonably available. Except for

 hospices, shelters and nursing homes, no homes which exceed an eight person capacity may be
used or developed. This limitation on the use of large homes shall not apply to class members
who choose to live in homes which exceed an eight person capacity, provided the housing is
existing and licensed as of the date of this Agreement and the class member makes an informed
choice to live in the home after having been advised of the provisions of this paragraph.
C. Residential Support Services
97. Defendants shall fund, develop, recruit and support residential support services for
delivery in a variety of home settings, including the client's private home or an agency owned
or operated apartment or home. The services shall be designed to provide the client with the
support and supervision appropriate to his level of independence. The services shall be
flexible so that the support and supervision may be initiated or discontinued, increased or
decreased as the class member's needs change and so that the class member is not required to
move to another setting as his or her needs change.
98. To comply with this sub-section, defendants shall develop, fund, recruit and support
residential support services to meet the ISP identified residential support service needs of all
class members who are hospitalized and who require residential support services in order to be
safely discharged and of all class members who have been identified as being at imminent risk
of hospitalization due to lack of available appropriate residential support services. Defendants
shall develop, fund, recruit or support residential support services for other class members in
accordance with the terms and timetables of their plans required by Section V of this
Agreement.
D. Crisis Intervention and Resolution Services
99. The defendants shall develop crisis intervention and resolution services, either directly or

 through contracts with private agencies. In either instance, defendants shall require that the
services meet the following standards:
a. Services shall be available 24 hours per day, seven days per week.
b. Services shall be delivered by personnel trained in emergency intervention.
c. The trained intervention personnel shall have available to them at all times,
consultation services of a psychologist or a psychiatrist.
d. Services shall include short-term emergency housing for psychiatric crises in a
community-based setting supported by trained staff. The crisis intervention and resolution
services shall be provided directly by the Department of Mental Health and Mental
Retardation or through contracts with private agencies.
e. Crisis intervention and resolution services shall not be operated primarily as screening
or transportation services preliminary to an admission to AMHI or other in-patient
psychiatric facility. The primary purpose of the services is instead to avoid hospitalization
through community-based resolution of crises. Crises cannot always be resolved with one
telephone call, by a single visit or through the provision of temporary housing. The
persons or agencies providing crisis intervention and resolution services may be required
(and must have the capacity) to make multiple contacts with the individuals in crisis.
Additionally, crisis intervention and resolution personnel must follow up on the
individual's circumstances and work closely with the individual's community support
worker after the immediate crisis is resolved.
100. Defendants shall establish sufficient crisis intervention and resolution services to meet
clients' needs. Defendants shall, on a quarterly basis, assess the sufficiency of crisis
intervention and resolution services. If, during any quarter, less than an average of 90% of all

 needs for crisis intervention and resolution services are met, the services shall be deemed
insufficient and defendants shall take immediate corrective action. Defendants shall strive to
improve the delivery of crisis intervention and resolution services, with the goal of meeting all
unmet needs for these services.
E. Vocational Opportunities and Training
101. Defendants shall make reasonable efforts to fund, develop, recruit and support an array of
vocational services to meet plaintiffs' needs as identified in their ISP's. These programs may
include vocational counseling, employment preparation programs which focus upon the
development of work-related skills, supported employment programs, transitional employment
programs, competitive employment referral services, and other programs as meet plaintiffs'
needs.
102. In fulfilling their obligations under this sub-section, defendants shall work cooperatively
with other agencies and departments which operate vocational programs, that clients may
realize the benefits of those programs. To comply with this sub-section on vocational
opportunities and training, defendants shall meet the applicable terms and timetables of their
plans required by Section V of this Agreement.
F. Treatment Options
103. Defendants shall fund, develop, recruit and support an array of treatment services to meet
class members' needs as identified in their ISP's. The services shall include, but not be limited
to: professional assessments; group and individual psychotherapy; psychopharmacological
therapy; occupational therapy; recreation therapy; substance abuse counseling; and sexual and
physical abuse counseling.
104. To comply with this sub-section on treatment, defendants shall develop, fund, recruit and

 support treatment options to meet the ISP identified treatment needs of all class members who
are hospitalized and who require community treatment options in order to be safely discharged
and of all class members who have been identified as being at imminent risk of hospitalization
due to lack of available appropriate treatment options. Defendants shall develop, fund, recruit
and support treatment options for other class members in accordance with terms and timetables
of the plan required by Section V of this Agreement.
G. Recreational/Social/Avocational Opportunities
105. Defendants shall assist class members in the development of leisure skills and shall
endeavor to improve the quality of class members' leisure time by sponsoring programs which
allow class members to utilize, improve, or gain recognition for their avocational talents.
106. To comply with this sub-section on recreational/social/avocational opportunities,
defendants shall meet the applicable terms and timetables of their plans required by Section V
of this Agreement.
H. Transportation
107. Defendants shall make reasonable efforts to identify and resolve transportation problems
which may make services identified in class members' ISP's inaccessible to them. These
efforts shall include, but not be limited to: informal arrangements which meet class members'
needs and the development of written agreements between the Department of Human Services
and agencies charged with providing transportation services for persons entitled to services
under Title XIX of the Social Security Act.
108. To comply with this sub-section on transportation, defendants shall meet the applicable
terms and timetables of their plans required by Section V of this Agreement.
I. Family Support

 109 Defendants shall fund, develop, recruit and support an array of family support services to
include:
a. Education on the terms of this Agreement;
b. Education on available services, and on mental illness from the perspectives of
professionals, other families, and mental health service recipients;
c. Direct support of family groups through the provision of a facilitator at meetings, if
requested;
d. Education on treatment, medications, diagnoses, prognoses, and how to care for
persons with mental illness;
e. Group counseling;
f. Psychoeducational programs; and
g. Respite services for families who provide class members with intense supervision and
assistance. These services shall be made available on a planned basis and shall be
delivered according to models which cause the least disruption to plaintiffs and their
families.
110. Defendants shall also require agencies which provide mental health services to include
among their services the referral of family members with whom the providers have contact to
area family support groups. When referring a family member to a family support group,
agencies shall provide information regarding the group and shall additionally offer to call the
support group to give the family member's name and the means whereby he or she may be
contacted by the support group. Agencies shall periodically reinitiate referrals as appropriate.
111. To comply with this sub-section on family support, defendants shall meet the applicable
terms and timetables of their plans required by Section V of this Agreement.

 VIII. STANDARDS FOR COMMUNITY PROGRAMS
112. This section applies to agencies which are funded or licensed by the Department of
Mental Health and Mental Retardation for the provision of community mental health services.
These agencies shall hereafter be referred to as community mental health agencies. This
section does not apply to the subdivisions or staff of community mental health agencies which
only provide services other than community mental health services.
A. Personnel: Qualifications, Recruitment, Evaluation and Training
1. Qualifications
113. Defendants shall require all agencies providing community mental health services to
maintain a manual which contains up-to-date job descriptions for each mental health service
position. Job descriptions shall clearly define areas of responsibility, including those required
by the terms of this Agreement.
114. Qualifications for each position shall be stated in terms of education and experience.
Appropriate licensure, certification or registration shall be required of all persons who are
subject to such regulation.
2. Recruitment
115. Defendants, through their resource development system, shall assist agencies which
request assistance in recruitment programs. To the extent possible, specific strategies should
include the development of clinical affiliation and internship programs; appointment of
individual staff persons to act as recruitment liaisons in their professional organizations; and
intensive college and university outreach.
116. Defendants shall require community agencies to verify job applicants' licensure,
certification or registration credentials and all other qualifications.

 3. Evaluation
117. Defendants shall require each agency providing community mental health services to
create and implement a performance evaluation protocol for each mental health service
position.
4. Training
118. By November 1, 1990, defendants shall provide copies of this Agreement to all
community mental health agencies and shall conduct presentations for the agencies' staffs to
provide an overview of the Agreement. By February 1, 1991, defendants shall develop a
training program on the terms of this Agreement and on the required specific performance
obligations which agencies and their employees and contract agents must meet in order to
receive future funding or licensing and in order to meet the terms of this Agreement. By July l,
1991, defendants shall deliver said training to the employees and contract agents of all
community mental health agencies. Training shall be scheduled so that agencies do not have to
suspend the delivery of services at any time. Defendants shall make this training program
available to agencies on videotape so that all future new employees and contract agents may
receive the training in orientation.
119. By September 1, 1991, all current employees and contract agents shall receive the full
complement of training and orientation as required for new employees and contract agents as
set out below.
120. All employees of community mental health agencies who perform mental health services
as defined in this Agreement, shall receive orientation training which reinforces the principles
set out at section IV above. The training shall also reinforce the philosophy that the mental
health system is intended to support clients on the basis of their needs, and that agencies and

 employees must, therefore, have the flexibility to recognize and respond to highly
individualized and varying needs, to listen, and to work in concert with other workers in the
community support network and, especially, with the clients themselves.
121. Specific topics in orientation training shall include, but not be limited to, the following:
the terms of this Agreement; the legal and human rights of persons with mental illness;
perspectives and values of consumers of mental health services; identification of, response to,
and reporting of client abuse, neglect, and exploitation; specific job responsibilities of the
trainees; individual community support planning process; mental health services system;
family support services; the role of AMHI in the mental health system; the responsibilities of
various professional and staff positions within the mental health system; the agency mission
and philosophy of community support; principles of staff/patient interaction designed to
facilitate individuals' health, growth and recovery; and client privacy and confidentiality.
Training on the perspectives and values of consumers of mental health services shall be
prepared and delivered by such consumers. Defendants shall recruit and assist them as
necessary.
122. If applicable to the agency, training shall also be provided in physical intervention
techniques.
123. New employees shall not be assigned to duties requiring direct involvement with clients
until they have received most of the above training. Employees will not implement physical
intervention techniques unless they have received the training in this area.
124. Non-medical staff shall additionally be trained in the basics of: identification of adverse
reactions to psychoactive medications; identification of patient illnesses and injury;
preliminary medical emergency care and reporting requirements.

 125. Para-professional staff shall be trained in the basic principles of each of the therapeutic
modalities.
126. Specific training may be waived for any employee whom the agency verifies has recently
received the training through prior employment at another community mental health agency.
127. Professional staff shall be required to meet the continuing education requirements
necessary to maintain their licenses.
128. Agencies shall provide ongoing training opportunities to all staff emphasizing quality
care, including new approaches in the mental health field. Defendants shall take the costs of
training requirements into consideration when contracting with community mental health
agencies.
129. Contract agents and volunteers shall receive orientation and other training applicable to
the specific type of duties they perform, commensurate with the number of hours they provide
services.
B. Other Standards
130. By September 1, 1992, defendants shall draft rules establishing operating standards for
agencies which the defendants have licensed to provide mental health services. The standards
shall be consistent with and designed to assure implementation of the terms and principles of
this Agreement. Said rules shall be submitted to counsel for the plaintiffs and to the master for
his approval in accordance with paragraph 293 of this Agreement. Defendants shall thereafter
promulgate said rules in accordance with the Maine Administrative Procedure Act, 5 M.R.S.A.
§§ 8051 et seq.
131. These rules shall include, but not be limited to, operating standards for community
mental health agencies in the following areas:

 a. Environment;
b. Admission/Acceptance for Services;
c. Discharge/Termination of Services;
d. Individualized support planning;
e. Procedures for the reporting and investigation of allegations of client abuse, neglect and
exploitation;
f. Procedures for the reporting and investigation of client injury, disappearance and death;
g. Staff/client ratios where appropriate;
h. Patient records;
i. Systems for assuring quality of individual services;
j. Use of psychoactive medications and reporting systems;
k. Use of seclusion, restraints and protective devices and reporting systems.
132. Rules governing the use of seclusion, mechanical restraints and protective devices shall
comply with the terms of Section IX(H) of this Agreement. The physicians who order and the
nurses who monitor the implementation of seclusion, restraint and protective devices must be
in the employ of or have on-call arrangements with the agency.
IX. STANDARDS GOVERNING AUGUSTA MENTAL HEALTH INSTITUTE
A. General
133. As to this section of the Agreement governing AMHI, unless otherwise specified,
"defendants" shall mean the Commissioner and Department of Mental Health and Mental
Retardation, and the Superintendent of AMHI.
B. Environment
1. General

 134. All patient living and sleeping areas shall be attractively furnished and designed to
promote privacy, dignity and comfort. All areas, furniture, and bedding shall be kept clean,
odorless, and in good repair. Each patient shall be provided with a secure and readily
accessible storage area of adequate size to accommodate his or her personal belongings.
135. Common areas will have space and equipment sufficient to permit patients to
comfortably socialize, relax, or engage in leisure time activity. To reduce the chance that
patients engaged in activities will intrude upon others not similarly engaged, defendants shall
equip the common areas so that intrinsically incompatible activities are not performed in the
same areas.
136. Each living unit shall have visiting areas to allow patients to meet with visitors in comfort
and privacy. If all designated areas are in use, staff shall make other reasonable arrangements
to assure the patient's and visitor's comfort and privacy.
137. Telephones shall be made available to patients in areas where they may engage in
conversation privately. A sufficient number shall be installed so that by August 1, 1992, one is
available for each seven on-unit staff, and one for each fifteen patients.
2. Health and Safety
138. All patient living and sleeping areas shall meet Maine Department of Human Services
Nursing Home and Hospital Licensing Standards, as applicable, as well as the current Life
Safety Code. Furniture in sleeping areas will at all times be arranged so that patients may
quickly and safely exit in the event of emergency.
139. Defendants shall additionally comply with the following standards:
a. Enclosure of all exposed overhead pipes in patient bedrooms and bathrooms by the date
of entry of the Decree in this matter;

 b. Safe air quality in all patient living and sleeping areas. Smoking areas shall be well
ventilated.
c. Maintenance of temperatures in all patient living and sleeping areas at levels which do
not exceed or fall below that considered safe and comfortable for individuals who are
taking psychotropic medications, or who are medically frail.
d. Immediate removal or abatement of all asbestos which poses a health threat.
140. If renovations are or become necessary in order for defendants to meet the foregoing
environmental standards, they shall submit a plan to the court, the master and counsel for the
plaintiffs describing the renovations they will undertake to meet the standards. The plan shall
include descriptions of the type of renovation to be undertaken; the name of the contractor or
governmental agency which will perform the renovations; the name and title of the AMHI
employee directly responsible for oversight of the renovations; dates of performance and
completion of specific tasks; itemized costs of the renovations; and the specific areas to be
renovated.
141. In planning renovations, defendants shall attempt to minimize overall costs by taking into
consideration AMHI's declining census and admissions and consequent changed uses of the
facility, and by relocating services where possible.
142. Where adequate renovations to meet the above standards either cannot be achieved by the
dates specified in the plan or cannot be achieved without the expenditure of significant
resources, defendants shall discontinue use of the affected areas of AMHI for patient living and
sleeping use.
C. Admissions
1. General

 143. To assure that persons who do not need acute care are not admitted or further
institutionalized and that patients requiring further acute care are not precipitously discharged,
defendants shall develop standardized admission and discharge criteria which are consistent
with law and based upon patient need. These criteria shall be implemented consistently
throughout the State mental health system at all times. The criteria shall provide for the
identification of persons with mental retardation, other developmental disabilities, traumatic
brain injury, dementia (including Alzheimer's Disease or a related disorder), and a primary
diagnosis of substance abuse or dependence, and for referral of these persons to other treatment
settings.
2. Involuntary Admissions
144. Defendants shall require individuals or facilities initiating emergency involuntary
admission to AMHI to transmit to the AMHI admissions office complete records of the
evaluation conducted and of any treatment extended at the time of evaluation. With the
patient's permission, records of any prior treatment extended shall be transmitted to AMHI at
the time of admission.
145. The AMHI admissions office shall, at all times when it is open to admissions, have on
duty or on call a physician to assess a person's need for hospital admission and to decide
whether or not to admit the person. This physician shall: conduct an assessment which
includes a face-to-face interview of the person being proposed for admission; carefully review
the documents arriving with the individual which state the basis for proposed admission;
review other available historical information; interview individuals familiar with the person, as
available; and undertake such further assessment as is professionally required.
146. The defendants shall also require that a community-based support person for each of the

 catchment areas served by AMHI be available to consult with the AMHI admissions office.
Upon the arrival at AMHI of a person proposed for admission (or sooner, if possible), the
AMHI admissions office staff shall immediately contact the appropriate community support or
crisis intervention and resolution worker to ascertain that lesser restrictive alternatives to
AMHI admission have been fully explored.
147. The defendants shall require that all persons, hospitals, or agencies which routinely
initiate emergency applications proposing admission to AMHI are trained as to AMHI's
admission criteria and process.
3. Voluntary Admissions
148. Any patient whose admission is characterized as voluntary shall be continuously
reviewed so that if the patient withdraws his consent to a voluntary admission, the withdrawal
is noted in the record and discharge or involuntary commitment proceedings are initiated. The
superintendent shall require that any voluntary patient whose treatment and discharge plan has
not been reviewed during any six month period by the Maine District Court or pursuant to this
subsection, be examined by two AMHI psychiatrists or psychologists who are not directly
involved in the patient's treatment. If either of these examiners determines that the patient
objects to hospitalization or does not require further hospitalization, the superintendent shall
require that discharge or involuntary commitment proceedings be initiated, whichever is
appropriate given the examination findings.
149. If the examiners determine that the patient is appropriately admitted and does not object
to hospitalization, the superintendent shall retain a psychiatrist or psychologist who is not in
the defendants' employ to examine the patient. If this examiner's findings are consistent with
those of the AMHI examiners, no further review shall be required pursuant to this sub-section

 for another six months. If the examiner finds that the patient objects to hospitalization or does
not require further hospitalization, the superintendent shall require that discharge or
involuntary commitment proceedings be initiated, whichever the superintendent finds to be
appropriate considering all the evaluations.
4. Information to Patients Upon Admission
150. Upon admission, all patients shall be given information summarizing their rights under
this Agreement and the "Rights of Recipients of Mental Health Services." Patients shall also
be advised of their right to name a designated representative or representatives to assist them,
to receive notices of meetings and to participate at meetings. Patients shall additionally be
given information regarding available advocacy and peer advocacy programs.
D. Treatment
151. Treatment at AMHI shall focus upon a patient's strengths, rather than solely addressing
symptoms. Patients are at all times entitled to respect for their individuality and to recognition
that their personalities, needs and aspirations are not determinable on the basis of a psychiatric
label. They shall be treated with dignity; they shall be encouraged and permitted to preserve
the basic rhythm of their lives to the maximum extent possible.
152. Treatment shall be delivered according to an individualized treatment and discharge plan.
153. Every patient shall be given a schedule of therapeutic, rehabilitative and recreational
activities available at AMHI. The schedule shall be updated monthly or more frequently as
necessary. Those activities which would assist the patient in meeting the goals of the treatment
and discharge plan and individually scheduled treatment or rehabilitation sessions shall be
noted on the schedule. The original schedule shall be developed at the patient's first treatment
and discharge planning meeting. Copies of all schedules shall be included in the patient's

 record. Defendants will increase program and activity options so that by January 1, 1993, all
patients will have services which meet their needs as identified in their hospital treatment and
discharge plans. Defendants shall increase leisure activities so that by January 1, 1993,
patients will have opportunity to engage in leisure activities for an additional 20 hours per
week.
154. In exceptional cases, patients may be offered fewer hours of treatment and rehabilitation
than is generally offered other patients, if a physician certifies in writing that such activity
would be medically harmful to the patient. For these patients, the amount of treatment and
rehabilitation which can be tolerated by such patients shall be noted by the physician and shall
be made available. Additionally, such patients shall be provided with such treatment and
encouragement as is required to expand their tolerance for activity, with the goal that the
patient shall receive the minimum treatment and rehabilitation to which all other patients are
entitled under this Agreement.
155. Services to be made available to meet patients' needs, and to be considered at the patient's
treatment planning meeting include, but are not limited to the following:
Group and individual psychotherapy
Psychopharmacological therapy
Social services
Physical therapy
Occupational therapy
Activities of daily living skills training
Recreational therapy
Vocational/Educational programs

 Family support services and education
Substance abuse services
Sexual/physical abuse counseling
Instruction in principles of basic health care,
hygiene and nutrition.
156. Each patient shall be offered individual counseling with a psychiatrist, psychologist,
clinical social worker, psychiatric nurse or a psychiatric physician extender for sessions
totalling at least one hour per week and with one of these individuals or other appropriately
credentialed staff for a minimum of an additional two hours per week.
157. Defendants shall employ the services of an adequate number of nutritionists and
dietitions to assure that all patients' nutritional and dietary needs are individually assessed and
met. The assessments shall take into consideration and accommodate, if reasonably possible,
the patient's wishes.
158. Defendants shall engage independent consultants to assess and recommend treatment
programs for patients who are not responsive to the treatment offered at AMHI.
159. All patients are entitled to receive individualized treatment, to have access to activities
necessary to the achievement of their individualized treatment goals, to receive visitors, to
communicate by telephone and by mail, to exercise daily, to recreate outdoors, and to exercise
their religion. At no time shall these entitlements or basic human rights be treated as privileges
which the patient must earn by meeting certain standards of behavior.
E. Psychoactive Medication
160. Psychoactive medication may be prescribed only by a physician or physician extender
who has examined the patient. The medication may be prescribed only as an integral part of

 the patient's individualized treatment plan or in an emergency.
1. Orders as Part of the Treatment Plan.
161. When psychoactive medications are prescribed as part of the patient's individualized
treatment plan, the plan must state and the patient must be advised of the specific signs,
symptoms or behaviors which the medication is intended to relieve. The patient shall also be
advised of alternative therapies and of precautions, contraindications, and potential adverse
effects of the psychoactive medication. The method for assessing the patient's response to the
medication, including any adverse reactions, shall be stated in objective terms, including, as
applicable, behavioral observations, physical assessments and necessary laboratory tests.
162. All orders for psychoactive medications shall be time limited for a period not to exceed
thirty days, and for a shorter period for controlled drugs and when clinically indicated.
163. When the order expires, or sooner if clinically indicated or if a treatment planning
meeting is scheduled, the physician or physician extender shall examine the patient and review
the patient's record entries charting progress or adverse effects. The physician or physician
extender shall consider reducing or discontinuing some medications, as clinically appropriate,
to assure that the desired therapeutic effects are achieved through the use of minimum dosages
and numbers of medications. Before reducing or discontinuing the medications, the physician
or physician extender must advise the patient as to the anticipated benefits and any known
risks.
164. No physician or physician extender may increase the dosage of specific psychoactive
medications, change the types of medications ordered, or add medications in a patient's
prescribed psychoactive medication regimen without noting in the patient's chart why, in terms
of the patient's responses to the previously prescribed medication, the regimen is being altered.

 The physician or physician extender shall also update the patient's chart, as necessary, to
describe any changes in the method for assessing the patient's response to the medication.
Before entering the order, the physician shall provide the patient with all the information as
required by paragraph 161, above.
2. Emergency Orders
165. An emergency exists when the patient exhibits behavior due to mental illness which
places him or others at risk of imminent bodily injury. Under such circumstances, the
physician or physician extender, upon examining the patient, may declare an emergency and
order the administration of psychoactive medication. At no time may a physician or physician
extender declare an emergency merely because the patient refuses treatment. The order for
emergency medication shall be for a limited period, not to exceed 72 hours. Both the
declaration of emergency and order for administration of medication shall be entered as
medical orders in the patient's record.
166. The physician's or physician extender's notations shall include the following:
a. A description of the behaviors which he has observed, and which created the
emergency;
b. The period, not to exceed 72 hours, during which the medication may be administered;
c. The expected benefits of the order;
d. The specific behaviors or physical responses which staff should monitor and record,
and the means they should use.
167. If, after 72 hours, an emergency continues to exist, an order for continued medication
may be entered, only upon compliance with the foregoing provisions of this sub-section, and
upon authorization of the director of psychiatry or of clinical services and, if the client lacks

 capacity, upon initiation of administrative hearing proceedings described in the "Rights of
Recipients of Mental Health Services."
3. Monitoring.
168. The superintendent shall appoint an individual or team of individuals who shall be
responsible for establishing a data base system for monitoring the use of psychoactive
medications at AMHI and for assuring that the required information is entered. The system
shall be capable of issuing individual patient medication profiles and periodic statistical data.
The reports shall detail the types of medications in use at AMHI, the dosages, duration of use,
and concommitant uses, each in conjunction with reported therapeutic and adverse effects.
The director of clinical services or psychiatry shall review these reports. In no case shall the
prescribing physician be responsible for the review. Following review, the director shall
consult on the case with the prescribing or supervising physician and follow-up with
examinations as necessary on the following patients:
a. Patients for whom either the beneficial or adverse effects of the medications are not
being reported;
b. Patients who are reported as not evidencing any therapeutic effects;
c. Patients who are reported as evidencing significant adverse effects;
d. Patients who are receiving a significant number of medications concomitantly;
e. Patients who are on two or more medications which are known to interact adversely;
f. Patients who are receiving medications in dosages which exceed the manufacturer's
recommendations.
F. General Health Care
169. For the purpose of this sub-section, the term "physician" shall be defined as a licensed

 medical practitioner specializing in the field of primary care medicine.
170. Within 24 hours of admission to AMHI, each patient shall be offered a complete physical
examination, including a pregnancy test for women of child-bearing age when appropriate.
Patients who refuse physical examinations shall be offered such examinations at later dates.
Special attention shall be given to the assessment of medical, nutritional, toxic and
neurological conditions which may otherwise explain the patient's behavior. Special attention
shall also be given to those conditions which may be adversely affected by the use of
psychoactive medication or by any other treatment modality.
171. Medical histories shall be obtained, and, for those patients who are under a physician's
care or who are suspected of having or who are found to have physical health problems,
medical records from community providers shall be requested at the time of the examination,
provided the patient or guardian consents to release of this information.
172. The charts of patients who have specialized medical needs shall be boldly flagged. All
persons having responsibility for direct care of these patients shall be trained to recognize signs
and symptoms of medical problems as identified in the patient's chart by an appropriate
medical professional. They shall additionally be trained to recognize signs and symptoms of
adverse drug reactions, including toxic or allergic reactions, to medications administered
within the hospital. Training shall include instructions on the appropriate preliminary
emergency care which direct care staff shall be required to undertake.
173. No patient shall be denied access to the health care he or she has been receiving in the
community solely because he or she is a patient at AMHI. The defendants shall make every
effort to ensure that the transportation necessary for the patient to keep appointments is
provided. Patients who elect to receive health care services from their community providers

 shall be responsible for the cost of that care.
174. Basic medical care shall be available at AMHI seven days per week, 24-hours per day,
and shall include the services of at least one physician on duty or on-call at all times. Between
the hours of 8:00 a.m. and 4:00 p.m. each weekday, at least one physician will be on duty for
every 75 patients. A physician and the treating psychiatrist shall conduct joint weekly reviews
on the residential units of each patient at AMHI. Clinic staff shall conduct rounds more
frequently as may be necessary to follow-up on the condition of patients receiving clinic
services. Each unit shall have an appropriate and private space in which clinic staff may meet
with patients.
175. All incidents resulting in physical harm to patients, and all complaints or signs of
physical injury, of adverse reactions to medications or of illness shall be immediately reported
to a nurse or physician who shall examine the patient and take appropriate action, including
complying with the provisions of Section IX(J) of this Agreement. When follow-up care or
observation is recommended, the nursing or medical personnel will clearly state in writing their
instructions and their expectations of the individuals providing direct care.
176. Defendants shall develop transfer and referral agreements with area hospitals, clinics, and
specialists to assure that all emergency, surgical, or specialized medical needs of patients can
be met. No patient shall be denied medical care solely by reason of his status as a patient at
AMHI. Defendants will offer training to community health care providers and others, as
needed to facilitate the effective development and implementation of the agreements.
177. Defendants shall meet medical charting requirements consistent with professional
standards.
G. Dental Care

 178. Defendants shall contract for dental services as necessary to assure that all patients may
receive emergency dental examinations and treatment. All patients who have resided at AMHI
for at least six months may additionally receive twice annual examinations, preventive
services, emergency restorative services, and periodontal care.
179. No patient shall be denied access to the dental care he or she has been receiving in the
community solely because he or she is a patient at AMHI. The defendants shall make every
effort to ensure that the transportation necessary for the patient to keep appointments is
provided. Patients who elect to receive dental care from their community providers shall be
responsible for the cost of that care.
H. Seclusion, Restraint and Protective Devices
1. Seclusion.
180. Seclusion means the placement of a patient alone in an isolation room from which he is
denied exit.
181. Seclusion may be employed only when absolutely necessary to protect the patient from
causing physical harm to himself or others, or, if the patient is examined by a physician or
physician extender prior to implementation of seclusion, to prevent further serious disruption
which significantly interferes with other patients' treatment.
182. Seclusion may be used only after less restrictive measures have proven to be
inappropriate or ineffective. Seclusion shall be implemented in accordance with the following
standards:
a. The decision to place a patient in seclusion shall be made by a physician or physician
extender and shall be entered as a medical order in the patient's records. If the physician
or physician extender is not immediately available to examine the patient, the patient may

 be placed in seclusion following an examination by a nurse if the nurse finds that the
patient poses a risk of imminent harm to himself or others. The physician or physician
extender shall personally evaluate the patient within 30 minutes after the patient has been
placed in seclusion. If the evaluation does not take place within 30 minutes, the reasons
for the delay shall be documented in the patient's

chart. This provision applies to all

patients, including those placed in seclusion during the night. Any patient placed in
seclusion shall be kept under constant observation while awaiting an examination by a
physician or physician extender.
b. Staff who place patients in seclusion shall have documented training in the proper
techniques and in less restrictive alternatives to seclusion.
c. As soon as possible, staff should make reasonable efforts to notify the patient's
guardian or designated representative, if any, that the patient has been placed in seclusion,
and the reasons therefor.
d. Each order for initiation or extension of seclusion shall state the time of entry of the
order. It shall state the number of hours the patient may be secluded, not to exceed ten,
and the conditions under which the patient may be sooner released.
e. The need for a patient's continuation in seclusion shall be re-evaluated every 2 hours by
a nurse. The nurse shall examine the patient in person, and unless clinically
contraindicated, shall conduct the examination outside of the seclusion room. The nurse
shall assess the patient to determine whether he or she continues to pose a danger to
himself or others or continues to cause serious disruption of other patients' treatment (for
cases in which a

physician or physician extender has

ordered seclusion for this reason). If the nurse finds danger and that the patient continues

 to require seclusion, seclusion may be continued if the physician's or physician extender's
order has not yet lapsed. Should the patient not need continued seclusion, the nurse shall
release the patient even if the time frame of the original order has not yet elapsed.
f. A special progress record/check sheet shall be maintained for each use of seclusion and
shall include the following documentation:
i. The indication for use of seclusion, i.e. whether a danger to self, others, or serious
disruption of other patients' treatment;
ii. A description of the behaviors which constitute the patient's danger to himself,
others, or serious disruption of other patients' treatment;
iii. A description of less restrictive alternatives used or considered, and a description
of why these alternatives proved ineffective or why they were deemed
inappropriate upon consideration.
g. All orders for the extension of seclusion shall include documentation as for an original
order, but shall additionally state whether the patient was examined outside of the
seclusion room and, if not, the clinical reasons therefor.
h. Every patient placed in seclusion shall be released, unless clinically contraindicated, at
least every two hours to eat, drink, bathe, toilet and to meet any special medical orders.
i. No PRN orders for seclusion may be written and no treatment plan may include its use
as a treatment approach;
j. Patients placed in seclusion shall be given maximum observation and in no instance
shall they be visually monitored less often than every 15 minutes by staff.
k. A description of the patient's behavior as observed shall be noted on the progress
record/check sheet every 15 minutes.

 l. The total amount of time which a patient spends in seclusion may not exceed 24 hours
unless:
i. The patient is given a medical assessment to include at least vital signs, hydration
and nutrition, and assessment and treatment of any injuries;
ii. The patient is examined by the director of psychiatry or clinical services;
iii. The order extending seclusion beyond a total of 24 hours is entered by the
director of psychiatry or clinical services following his examination of the patient
and consultation with the other examiners; and
iv. The patient's guardian, or designated representative, if any, and if available, has
been notified.
m. Records required by the above provisions shall be a part of the patient's permanent
record. Copies shall be forwarded to the medical director, the clinical services director
and the patient advocate.
n. No patient who is mentally retarded may be secluded except in accordance with this
Agreement and applicable regulations promulgated by the Bureau of Mental Retardation
(BMR). Seclusion must be implemented by persons fully familiar with and trained in the
use of the techniques required by the BMR regulations.
o. Seclusion may be ordered on the basis of a patient's self-report, provided the physician
or physician extender otherwise verifies that the patient meets the criteria of paragraph 181
and the decision is otherwise clinically appropriate.
2. Restraint.
183. Restraint is the immobilization of a patient's arms, legs or entire body through the use of
an apparatus which is not a protective device as described in sub-section H(3) below.

 184. Restraint may be employed only when absolutely necessary to protect the patient from
serious physical injury to himself or others and shall impose the least possible restriction
consistent with its purpose. Restraint may be used only after less restrictive measures have
proven to be inappropriate or ineffective. Restraint shall be implemented in accordance with
the following standards:
a. The decision to place a patient in restraint shall be made by a physician or a physician
extender and shall be entered as a medical order in the patient's record. If the physician or
physician extender is not immediately available to examine the patient, the patient may be
placed in restraint following examination by a nurse. A patient placed in restraint shall be
examined by a physician or physician extender within 30 minutes. The reasons for any
delay in this evaluation shall be fully documented in the patient's chart.
b. Patients placed in restraint shall be kept under constant observation.
c. Staff who place patients in restraint shall have documented training in the proper
techniques and in less restrictive alternatives to restraint.
d. As soon as possible, staff should make reasonable efforts to notify the patient's
guardian or designated representative, if any, that the patient has been placed in restraint
and the reasons therefor.
e. Each order for initiation or extension of restraint shall state the time of entry of the
order. It shall state

the number of hours the patient may

be restrained, not to exceed six, and the conditions under which the patient may be sooner
released.
f. The need for a patient's continuation in restraint shall be re-evaluated every two hours
by a nurse. The nurse shall examine the patient in person and, unless clinically

 contraindicated, shall conduct the examination while the patient is free from restraint. If
the nurse finds that the patient continues to pose a danger to himself or others and
continues to require restraint, restraint use may be continued if the physician's or physician
extender's order has not yet lapsed. Should the patient not need continued restraint, the
patient shall be released even if the time frame of the original order has not yet lapsed.
The patient shall be examined by a physician or physician extender every six hours.
g. A special progress/check sheet record shall be maintained for each use of restraint and
shall include the following documentation:
i. The indication for use of restraint, i.e., whether a danger to self or others;
ii. A description of the behaviors which constitute the patient's danger to himself or
others;
iii. A description of less restrictive alternatives used or considered, and a description
of why these alternatives proved ineffective or why they were deemed
inappropriate upon consideration.
h. All orders for the extension of restraint shall include documentation as for an original
order, but shall additionally state whether the patient was examined free of restraint, and,
if not, the clinical reasons therefor.
i. Every patient placed in restraint shall be frequently monitored and released as necessary
to eat, drink, bathe, toilet, and to meet any special medical orders. Patients in restraint
shall have each extremity released, sequentially, no less frequently than every fifteen
minutes.
j. No P.R.N. orders for restraint may be written and no treatment plan may include its use
as a treatment approach.

 k. A description of the patient's behavior as observed shall be noted every fifteen minutes
on the progress record/check sheet.
l. The total amount of time which a patient spends in restraint may not exceed 24 hours
unless:
i. The patient is given a medical assessment to include at least vital signs, hydration
and nutrition, and an assessment and treatment of any injuries;
ii. The order extending restraint beyond a total of 24 hours is entered by the director
of psychiatry or of clinical services following his examination of the patient and
consultation with the other examiners.
iii. The patient's guardian, if any, and if available, has been notified.
m. Records required by the above provisions shall be made a part of the patient's
permanent record. Copies shall be forwarded to the medical director, the clinical services
director and the patient advocate.
n. No patient who is mentally retarded may be restrained except in accordance with this
Agreement and with applicable regulations promulgated by the Bureau of Mental
Retardation (BMR) as implemented by persons fully familiar with and trained in the use of
the techniques required by the BMR regulations.
3. Protective Devices.
185. Protective devices which are used for medical reasons to ensure a patient's safety and
comfort, to provide patient's stability during medical procedures, facilitate medical
(non-psychiatric) treatment or safeguard health in the treatment of a health-related problem are
exempt from the operation of the foregoing procedures governing the use of restraints. The
following procedures for use of protective devices may never be used, however, as a substitute

 for those governing restraint or seclusion.
186. Examples of some protective devices are: bed-padding or bolsters to maintain a patient's
body alignment; devices for the immobilization of fractures; devices to permit the safe
administration of intravenous solutions or to prevent their removal; protective equipment, such
as mitts, to prevent the aggravation of a medical condition through scratching, rubbing or
digging; helmets to protect the head from falls due to unsteadiness, seizures or self-injurious
behavior; geriatric chairs, seat belts, or vest restraints to prevent ambulation when it is
medically contraindicated or to permit a patient, who for medical reasons could not do so
unassisted, to remain in a seated position.
187. The use of protective devices shall be subject to the following:
a. The decision to use a protective device shall be made by a physician who has examined
the patient prior to its use. The decision shall be entered as a medical order in the patient's
record.
b. When ordering use of a protective device, the physician shall select the device which
interferes with the patient's free movement and ability to interact with his environment to
the least degree necessary to achieve the medical purpose for which the device is ordered.
c. Staff who use protective devices shall have documented training in their application.
d. The need for the use of a protective device shall be re-evaluated bi-weekly by a
physician who examines the patient. Orders for devices which immobilize patients shall
be re-evaluated daily. If the physician determines that continued use of the protective
device is clinically indicated, further use may be ordered. The order for extension of use
shall be entered as a medical order in the patient's record.
e. Protective devices which hamper a patient's free movement, such as mitts, geriatric

 chairs or vest restraints, shall be removed every two hours, so that the patient may be
permitted free movement, unless the physician's order indicates that removal would
interfere with the patient's health care. The physician shall indicate in his order the level
of staff supervision and assistance necessary during the patient's periods of free
movement. Where protective devices have been routinely used, the patient's treatment
plan will address ways of reducing or eliminating their use.
f. A special progress record/check sheet shall be maintained for each use of protective
devices which hamper a patient's free movement. These check sheets shall be used to
document the patient's release from the device every two hours and shall include a
description of the patient's condition as observed during the period of free movement.
g. Every patient to whom a protective device has been applied shall be frequently
monitored and assisted as necessary to meet personal needs and to participate in treatment
and activities.
4. Safety Review.
188. The restraint and protective devices used at AMHI and the techniques used for placing
individuals into restraint or seclusion shall be examined at least semi-annually by an
independent consultant knowledgeable and experienced in the use of seclusion and restraint.
No new type of device or technique may be introduced for use without such an examination.
The consultant shall examine the devices and techniques to assure that they are safe and
humane. Should the consultant find that any device or technique used at AMHI is unsafe or
unnecessarily compromises a patient's comfort or dignity, AMHI shall immediately
discontinue its use.
5. Reports.

 189. Defendants shall prepare monthly reports on the use of seclusion, restraint and protective
devices and shall submit copies to the master and counsel for the plaintiffs. These reports shall
state the patient's name, age and sex; the reason for the order; the patient's unit; the name of the
physician entering the order; the patient's principal diagnosis; whether seclusion, restraint or a
protective device was ordered; the type of apparatus or device used, if applicable; and the time
and duration of its use. The defendants shall analyze the data in terms of trends relating to
rates of admission; census; units of use; physicians entering the orders; patients' diagnoses, age
and sex; and other relevant variables.
190. Defendants shall develop and implement training programs, and take such other steps as
are necessary to eliminate all inappropriate uses of seclusion, restraint or protective devices,
and to reduce the overall use of seclusion and restraint.
191. If, on the basis of the foregoing analyses, defendants determine that any use of seclusion,
restraint or protective devices was negligently or abusively ordered or implemented,
defendants shall immediately initiate an investigation pursuant to Section IX(I).
I. Patient Abuse, Neglect and Exploitation
192. All staff shall be required to report instances of patient abuse, neglect and exploitation
immediately. Reports shall be made to the superintendent with a copy to the patient advocate.
The superintendent shall notify the patient's guardian or designated representative and forward
all reports to the Bureau of Elder and Adult Services or the Division of Child and Family
Services of the Department of Human Services, as appropriate.
193. All reports shall be immediately and thoroughly investigated. Results of investigations
shall be in writing and shall be made available to the patient and the patient's guardian or
designated representatives.

 194. Subject to the State personnel grievance procedures, all AMHI employees shall be:
a. Relieved of duties involving direct patient care during the pendency of an investigation
of an allegation of patient abuse, neglect or exploitation, unless the superintendent finds,
after diligent review of the available information, that there are no grounds to suggest any
probability that the employee poses a risk of harm to patients;
b. Terminated from employment upon a finding of sexual abuse of a patient, physical
abuse resulting in serious injury to or death of the patient, serious neglect or serious
exploitation. Upon a finding of lesser misconduct, the employee shall be subject to
imposition of progressive discipline, including suspension and termination.
195. No employee who is terminated from employment as a result of disciplinary action for
patient abuse, neglect, or exploitation shall be employed in any capacity, at any time, at any
state institution operated by the Department of Mental Health and Mental Retardation.
196. Each employee, before being hired, shall be informed of these provisions and shall be
required to sign a statement that he understands the provisions and will abide by them.
197. All allegations and findings of patient abuse, neglect and exploitation shall be collected
and analyzed in terms of trends relating to rates of admission, census, units of incidence, job
descriptions and prior training of staff involved, and other relevant variables. On the basis of
these analyses, defendants shall develop and implement training programs and shall take other
steps as are necessary to reduce future incidents.
J. Patient Injury and Death
198. All incidents of serious injury to a patient and all incidents of patient disappearance or
death shall be immediately reported to the superintendent with a copy to the patient advocate.
The superintendent shall immediately notify the patient's guardian or designated representative,

 if any, and shall forward all reports of death, disappearance or serious injury to the
commissioner.
199. Upon receipt of these reports, the superintendent shall immediately initiate a review.
Reviews of death and serious injury shall be conducted by independent professionals
(including non-medical experts when appropriate) who are qualified and experienced in the
assessment of the quality of the type of care and treatment which was rendered or should have
been rendered in each case. Panels reviewing patient deaths shall not include persons who are
employed by the defendants, provided that the defendants may appoint panels consisting of
State employees for the purpose of conducting death reviews concurrently with the outside
panels.
200. Results of reviews shall be in writing and shall be made available to the master. Specific
findings shall be collected and analyzed under the process developed in accordance with
sub-section IX(I) above. On the basis of the analyses, defendants shall develop and implement
training programs and shall take other steps as are necessary to reduce future incidents of
death, disappearance or injury.
201. If it appears, at any time during or following a review initiated pursuant to this
sub-section, that a patient's serious injury, disappearance or death resulted from employee
abuse or neglect, the superintendent shall initiate proceedings in conformity with sub-section I
of this Sectionnt.
K. Staff/Patient Ratios
202. Defendants shall hire and retain staff at AMHI sufficient to carry out the requirements of
this Agreement. The overall staff/patient ratio shall be maintained at a minimum of 2:1.
Minimum ratios for the staff listed below shall be as follows:

 a. General medicine physicians-1:75 during the hours 8:00 a.m. to 4:00 p.m., weekdays,
and one physician on duty or on call for the hospital during all other hours;
b. Psychiatrists-1:25 from 8:00 a.m. to 4:00 p.m. weekdays and one on duty or on-call
during all other hours;
c. Psychologists-1:25 from 8:00 a.m. to 4:00 p.m. weekdays;
d. Nursing-1:20 from 8:00 a.m. to 4:00 p.m., during the day shift seven days per week,
one assigned per unit during all other hours;
e. Social Workers-1:15 from 8:00 a.m. to 4:00 p.m., weekdays;
f. Mental Health Workers-1:6 during the day shift seven days per week and 1:8 all other
hours;
g. Recreational/Occupational Therapists/Aides-1:8 overall. Defendants shall schedule
working hours on the basis of identified needs of patients, taking into consideration their
need for a full range of recreational and community activities or weekdays, evenings,
weekends and holidays.
203. The above ratios shall be fully met by September 1, 1992. In planning to meet these
staff/patient ratios, defendants may take into consideration reduction in the patient population.
204. For purposes of calculating compliance with the above staffing ratios, only the following
employees may be counted: those present and on duty; and those who have completed at least
90% of their orientation training. While performing staff development, quality assurance or
similar duties, employees shall not be counted for purposes of calculating compliance with
staffing ratios.
L. Personnel: Qualifications, Recruitment, Evaluation and Training
1. Qualifications.
205. Defendants shall maintain a manual which contains up-to-date job descriptions for each

 position at AMHI. Job descriptions shall clearly define areas of responsibility, including those
required by the terms of this Agreement.
206. Qualifications for each position shall be stated in terms of education and experience.
Appropriate licensure, certification or registration shall be required of all persons performing
duties at AMHI who, if they performed similar duties in the community, would be subject to
such regulation.
207. Defendants shall develop and implement standards for the credentialing of mental health
workers.
2. Recruitment.
208. Defendants shall develop a program for recruiting professionals. As needed, this
program shall have nationwide application. Specific strategies should include the development
of clinical affiliation and internship programs; appointment of individual staff persons to act as
recruitment liaisons in their professional organizations; and intensive college and university
outreach.
209. Defendants shall annually review salaries for licensed, certified and registered AMHI
professionals and recommend salary adjustments as needed to attract and retain qualified
professionals.
210. All applicants for positions at AMHI shall be carefully screened. Licensure, certification
or registration credentials and all other qualifications shall be verified.
3. Evaluation.
211. Defendants shall establish a task-based competency evaluation protocol for each staff
position at AMHI. Supervisors will be responsible for annually evaluating their subordinates
on the basis of the protocol. In respect to employees who are found to be deficient in the

 performance of their duties, defendants shall pursue all appropriate corrective measures
available under law, regulation or contract. Corrective measures include, but are not limited to,
required additional training, extension of probation, reassignment to other duties, or, where the
deficiencies are serious or the employee has failed to respond to prior corrective measures,
termination of employment.
212. In addition to the evaluation process, supervisors shall investigate complaints brought to
their attention of deficient performance respecting employees under their supervision.
4. Training.
213.

By October 1, 1990, defendants shall provide copies of this Agreement to all AMHI

employees and shall conduct presentations to employees for the purpose of providing an
overview of the Agreement. By June 1, 1991, defendants shall conduct training on the terms
of the Agreement and on the required specific performance obligations each employee must
meet to comply with its terms. By September 1, 1991, all current employees shall receive the
full complement of training and orientation as required for new employees as set out below.
214. AMHI employees shall receive orientation training of a minimum of 120 hours in the
following areas:
a. The terms of this Agreement; patients' legal and human rights; perspectives and values of
consumers of mental health services; identification of, response to, and reporting of
patient abuse, neglect, and exploitation; fire protection; AMHI’s mission and
philosophy of care; principles of staff/patient interaction designed to facilitate patients’
health, growth and recovery; patient privacy and confidentiality; and specific job
responsibilities of the trainees. Training on the perspectives and values of consumers
of mental health services shall be prepared and delivered by such consumers.

 Defendants shall recruit and assist them as necessary.
b. The treatment and discharge planning process; mental health services system; family

support services; AMHI organization and the responsibilities of various departments,
professions and staff positions; physical intervention techniques; implementation of
seclusion and restraint; specialized patient observation procedures (i.e. close, constant,
1:1 observation, etc.);
c. The basics of: identification of adverse reactions to psychoactive medications;
identification of patient illnesses and injury, preliminary emergency medical care and
reporting requirements;
d. The basic principles of each of the therapeutic modalities; cardio-pulmonary
resuscitation.
Topics required to be included in employee orientation are as outlined in Attachment A.
215. New employees shall not be assigned to duties requiring direct care of patients until they
have received 90% of the orientation training. Employees will not implement seclusion,
restraint or utilize physical intervention techniques or carry out specialized observation
procedures unless they have received the training in these areas.
216. Professional staff shall be required to meet the continuing education requirements
necessary to maintain their licenses, registration or certification, and shall be encouraged to
participate in interdisciplinary training offered at AMHI. Additionally, all nursing and medical
staff shall be required to receive 10 hours of training each year in the psychiatric aspects of
their treatment responsibilities and all psychiatrists shall be required to receive at least 10
hours in the non-psychiatric aspects.
217. Defendants shall provide ongoing training opportunities to all staff emphasizing quality

 care, including new approaches in the mental health field.
218. The consultants whom defendants have otherwise retained to design individualized
programs for patients pursuant to paragraph 158 above, shall be retained to train staff in the
delivery of the individualized programs.
219. Defendants shall document the training each employee has received in his or her
personnel file.
M. Patient Records
220. Patient records shall be maintained under the supervision of a qualified, credentialed
medical records professional.
221. Entries in records shall be legible, dated, signed, and followed by a legible notation of the
name of the person making the entry and his or her signature.
222. Information in the records shall be sufficiently detailed and coordinated to assure that
persons involved in the patient's care and treatment may readily determine the patient's
medical, psychiatric, and social status, as well as the patient's progress in all areas addressed in
the treatment plan. In addition to reports, entries and documents which are required by specific
provisions of this Agreement, patient records shall include the following information:
a. Patient identification data;
b. Reports of assessments: as completed upon admission, as updated and as completed by
consultants;
c. Treatment and discharge plans and treatment schedules;
d. Physicians' orders;
e. Notes of patient progress under the treatment plan;
f. Documents regarding competency, guardianship, admission status and grievance

 decisions;
g. Records from other treating sources, documenting history;
h. Check sheets;
i. Reports of all diagnostic tests and procedures; and
j. Discharge summary.
223. This information shall be made available to persons responsible for the patient's care and
treatment. The records shall be organized to maximize the delivery of coordinated care and
treatment and so that entries by persons of the various disciplines or areas of care and treatment
may be readily cross-referenced.
X. STANDARDS GOVERNING TREATMENT OF MINORS
224. Defendants shall immediately undertake such action as is necessary to assure that by
September 1, 1992, defendants will discontinue operation of the Adolescent Treatment Unit.
Thereafter, defendants will no longer admit any person to AMHI who is less than 18 years old
except pursuant to Title 15, chapter 5.
225. From the date of this Agreement until August 1, 1992, defendants may admit individuals
to the Adolescent Treatment Unit who are between the ages of 13 and 18 and who meet the
criteria for admission under emergency procedures as set out at 34-B M.R.S.A. § 3863. Under
no circumstances are individuals under the age of 18 to be treated on the same unit as adults.
226. While the Adolescent Treatment Unit remains in operation, its census shall not exceed 12
patients. It shall meet all the standards of Section IX of this Agreement, including Section K
governing "Staff/Patient Ratios," except that ratios for the positions listed below shall be as
follows:
Child Psychiatrist: 1:15 during the day shift on weekdays;

 Certified Educational Psychologist: 1:12 during the day shift on weekdays;
Nurses (RN, LPN): 1:5 during the day shift on weekdays, at least one on the unit during all
other hours;
Mental health workers: 1:3 during the day shift on weekdays and 1:4 during all other
hours;
Teachers: 1:12 during the day shift on weekdays;
227. The Adolescent Treatment Unit shall additionally meet the following standards:
a. The Adolescent Treatment Unit must designate a professional to be on duty or on call
at all times, to consult with admissions office personnel for the purpose of screening
individuals being proposed for admission to the Adolescent Treatment Unit. This
individual must be trained and experienced in the treatment and diagnosis of childhood
mental illnesses, and must also be familiar with the then current census of the unit as well
as general characteristics and treatment needs of the unit's patients. This individual will be
responsible for advising the admissions office personnel whether the adolescent being
proposed for admission may safely and appropriately be admitted.
b. The Adolescent Treatment Unit shall include an area, separate from the leisure activity
area, which is conducive to study and equipped with age appropriate library materials.
The unit shall include an activity area with age appropriate equipment. A broad array of
activities shall be available to adolescent patients and shall be designed to enhance the
patients' social, intellectual, physical, and emotional development.
c. All dental care services, as set out at Section IX(G) of this Agreement shall be available
to adolescents regardless of the length of their hospital admission.
d. Psychotropic medications may only be prescribed under the direction of a Board

 eligible or certified child psychiatrist.
e. Family therapy shall be offered to the parents and/or custodians of each patient and
shall be available for a minimum of one hour per week.
f. The procedures governing seclusion of adult patients shall be followed in the
Adolescent Treatment Unit, except as modified below:
i. Seclusion may be employed only when absolutely necessary to protect the patient
from causing physical harm to himself or others;
ii. Patients placed in seclusion shall be monitored no less frequently than every five
minutes by a designated staff person;
iii. The primary focus of the person doing 1:1 or five minute checks will be to make
contact with the patient, to listen to the patient and to assess the patient's ability to
establish self control and follow staff direction; and
iv. A description of the patient's behavior as observed will be noted on the progress
record/check sheet every five minutes.
g. Defendants are responsible for assuring that all patients on the Adolescent Treatment
Unit receive educational services during their hospitalization, regardless of whether the
adolescent is restricted to the unit or is permitted to attend school in the community.
Within one working day of an adolescent's admission, defendants shall contact the
responsible school unit to arrange educational services.
h. Defendants shall designate a staff person or persons on the unit to monitor educational
programs to assure that the children are receiving the educational services, in terms of
individualization, substance, location and duration, to which they are entitled. The staff
person or persons shall be familiar with the provisions of the Education of the

 Handicapped Act, 20 U.S.C.S. § 1401-1485; the regulations adopted pursuant to that Act,
34 C.F.R. Part 300; the education regulations adopted pursuant to Section 504 of the
Rehabilitation Act of 1973; and Maine law and regulations governing education of
exceptional children, 20-A M.R.S.A. §§ 7201 et seq. and Special Education Regulations,
Chapter 101.
i. When defendants believe that a patient is not receiving the educational services to
which he or she is entitled, they shall notify the adolescent's parent or guardian or
surrogate parent appointed by the Department of Educational and Cultural Services, for
the purpose of attempting resolution with the responsible school unit. If further remedy
available under the foregoing laws and regulations needs to be pursued, defendants shall
assist the parent, guardian or surrogate parent in pursuing those remedies and shall refer
them to available legal and advocacy assistance.
j. Defendants shall retain consultants or employ individuals qualified to perform
neuropsychological evaluations, and educational and developmental assessments, when
required for any patient. These consultants or employees shall also be qualified and
experienced in making recommendations for individualized educational programs.
k. In developing the adolescent's treatment and discharge plan, defendants shall comply
with the provisions of Section VI of this Agreement, but shall additionally consider the
child's educational, and other developmental needs, and shall make recommendations for
services, both at AMHI and upon discharge, which meet these needs.
228. Professional and direct care staff employed on the Adolescent Treatment Unit shall
receive training as required by Section IX(L) of this Agreement, and shall additionally receive
training in the following areas:

 a. Principles of treatment in accordance with childhood and adolescent and developmental
psychology;
b. Principles of treatment of the sexually or physically abused adolescent;
c. Educational rights.
229. Only those employees who have received training in the above areas shall be assigned for
duty on the Adolescent Treatment Unit.
230. When it is apparent that a patient in the Adolescent Unit will soon be ready for discharge
and no known community resources are available, Defendant Commissioner of Mental Health
and Mental Retardation, and, in the case of a child in State custody, the Commissioner of
Human Services, shall be notified for the purpose of immediately mobilizing all resources
necessary to effect a timely discharge.
231. Defendants shall file monthly reports with the master and counsel for the plaintiffs on
any actions taken pursuant to the foregoing paragraph.
232. If, after the date of this Agreement, defendants determine that discontinuation of AMHI
services to adolescents will place mentally ill adolescents at serious risk of harm, they may
submit a request to the master to allow them to continue operation of the Adolescent Treatment
Unit.
233. Any requests for continuation of operation of the Adolescent Treatment Unit shall be
submitted with a written report which contains the following:
a. A statement of the need for continuation of AMHI services to adolescents with
supporting facts;
b. A description of all steps which defendants have taken since the date of this Agreement
to develop or utilize alternative resources for the treatment of adolescents;

 c. A description of the adolescents whom the defendants have admitted since the date of
this Agreement. Descriptions for each adolescent shall include: age, diagnosis, presenting
problems upon admission, custodial status, and crisis intervention and lesser restrictive
alternatives explored prior to admission;
d. A description of the treatment services rendered to adolescents admitted to AMHI since
the date of this Agreement, the length of their inpatient stays, and a description of the
community programs to which they were discharged;
e. A description of the treatment programs which defendants intend to offer in the future,
anticipated length of in-patient stays, and the community programs currently available to
adolescents upon discharge and those which defendants intend to develop;
f. Summaries of all agreements or established working relationships, between the AMHI
Adolescent Treatment Unit and other governmental or community agencies, which are
used to effect discharge and community support plans. Where agreements are in writing,
defendants shall submit copies to the master;
g. Job descriptions of all staff to be employed on the Adolescent Treatment Unit, with
notations as to the positions currently filled;
h. Copies of all AMHI policies and procedures which are or shall be exclusively
applicable to the Adolescent Treatment Unit; and
i. A statement of the period of time for which the defendants are requesting continued
operation of the Adolescent Treatment Unit.
234. For those adolescents who were admitted to the Adolescent Treatment Unit following the
date of this Agreement and who were in the custody of the Department of Human Services
during any period of their hospitalization, defendant Commissioner of the Department of

 Human Services shall submit a report to the master describing the steps he has taken since the
date of this Agreement to develop or utilize alternative resources to meet the needs of children
in the custody of the Department of Human Services.
235. Defendants shall supplement the information required by these reports as may be
requested by the master. The master shall act upon defendants' request for permission to
continue operation of the Adolescent Treatment Unit in conformity with the procedures set out
in Section XVII below.
XI. STANDARDS GOVERNING TREATMENT OF NURSING HOME PATIENTS
236. Defendants may treat persons requiring nursing home care at AMHI.
237. By September 1, 1991, these patients must, at all times, be treated on distinct units at
AMHI which meet all state and federal regulations governing the operation of nursing homes.
By August 1, 1995, the combined licensed capacity of these units shall not exceed 20 persons.
Defendants must maintain licenses issued by the Department of Human Services to operate
each entity as a nursing unit. Additionally, defendants must maintain proper certification from
the Health Care Finance Administration of the United States Department of Health and Human
Services pursuant to Title XVIII and Title XIX of the Social Security Act, as applicable. At no
time after August 1, 1995 may defendants apply for or operate the nursing home units under a
waiver of or grandfather provision in respect to any of the state and federal licensing and
certification requirements.
238. By September 1, 1992, no patient may be admitted to a nursing home unit of AMHI
unless the patient meets the admission criteria of the institute as well as the admission criteria
of the laws and regulations governing operation of nursing homes. By September 1, 1995, no
patient may reside in a nursing home unit of AMHI unless the patient meets the admission

 criteria of the institute as well as the admission criteria of the laws and regulations governing
operation of nursing homes. No patient who may be diverted appropriately to another setting
for treatment, as required by Section V(B)(3) of this Agreement, may be admitted to a nursing
home unit of AMHI.
239. All sections of this Agreement, including Section IX(K) governing Staff/Patient ratios,
shall apply to the nursing home units except that ratios for the position listed below shall be as
follows:
Nurses (RN, LPN), 1:10 during the day shift seven days per week; 1:20 during all other hours.
240. In meeting the requirements of Section IX(D) of this Agreement, defendants shall not
exempt any nursing home patient from treatment solely by reason of the patient's age.
Exemptions must be based upon documented medical conditions and the terms of paragraph
153 must be met.
241. Discharge to lesser restrictive treatment settings, including home-based services, or
discharge to nursing homes closer to the patient's home community or the communities of
involved friends or family shall be explored actively for all patients. When the treatment and
discharge team determines that a patient could be discharged to a lesser restrictive treatment
setting, or would benefit from discharge to a nursing home in another community, or when a
voluntarily admitted patient requests such a discharge, the patient's team coordinator shall
immediately attempt to locate the necessary services or treatment setting. If, after diligent
efforts, the patient's team coordinator is unable to locate the necessary resources, the
coordinator shall forward a description and location of the unmet service or treatment settings
to the commissioner, and defendants shall use this information to plan for the development of
new services in accordance with Section XV of this Agreement.

 242. Models for the provision of community services to class members who currently reside
on nursing home units at AMHI and who will be discharged or diverted from admission shall
be described in the plan required by Section V of this Agreement. The models shall include
pre-existing nursing homes and other residential settings, as appropriate. Defendants shall
provide or fund supplementary psychiatric, psychiatric nursing, and other services to these
homes as necessary to meet class members' needs.
243. Staff employed on the nursing home units shall receive the training as required by
Section IX(L) of this Agreement, and shall additionally receive training in the following areas:
Feeding techniques;
Care of persons who are bed-ridden or who are frail, including special techniques to lift
and transfer patients; position patients in bed; maintain patient privacy; maintain
patient hygiene.
Adverse reactions to medications common to geriatric patients;
Principles of nursing and psychiatric treatment and care of geriatric patients;
Recognition of conditions common among geriatric patients which may be mistakenly
identified as symptoms of mental illness.
244. Only those employees who have received training in the above areas shall be assigned for
duty in the nursing home units.
245. By January 1, 1991, defendants shall retain a nationally recognized consultant, approved
by the master and counsel for the plaintiffs, to develop a training program and principles of
psychiatric treatment and care of geriatric patients. Said consultant shall be a psychiatrist
specializing and experienced in geriatric psychiatry.
246. The consultant whom defendants retain to develop the training program referred to above

 shall additionally review the records of all nursing home patients and examine the patients as
needed. The consultant shall specifically review treatment programs, laboratory protocols,
medical care, the use of psychoactive medications, defendants' reports of evidence of tardive
dyskinesia and extra pyramidal symptoms, defendants' use of restraint and protective devices,
and any other matters within the consultant's expertise. To assist defendants in complying with
the provisions of this Agreement, the consultant shall issue a report which includes his findings
and recommendations for the revision of individual treatment programs and medical care and
for overall revision of AMHI practices, policies and procedures in the nursing home units. The
report shall be submitted to the defendants and the master and counsel for the plaintiffs.
Within 90 days thereafter, defendants shall submit a plan to the master in response to the
consultant's recommendations. On the basis of the consultant's report, the master and counsel
for the parties will identify any patients not previously identified as requiring the development
of housing in accordance with Section VII(B) above.
247. By January 1, 1993, defendants shall recruit, employ or contract with a psychiatrist who
is specially trained and experienced in psychiatric treatment and care of geriatric patients to
serve on an on-going basis as a consulting psychiatrist for the nursing home units. Defendants
shall also contract for the services of a neurologist and a physician specializing in geriatric
medicine to meet the individual patient neurological consultation and general medical care
needs of AMHI patients residing on nursing home units.
248. Should the defendants plan to continue use of the Greenlaw building for the treatment of
patients, they shall make necessary structural alterations to assure the following:
a. All patients' bedroom areas shall have walls which extend from floor to ceiling;
b. No patient shall be required to share a bedroom with more than one other patient;

 c. All patient bedroom areas shall have access to natural lighting and ventilation;
d. Distinct dining and activity areas shall be maintained.
249. By January 1, 1993, defendants shall submit a plan and schedule to the master and
counsel for the plaintiffs for the above structural alterations, or in the alternative, for
development of new nursing home units. If new nursing home units are to be developed,
defendants shall demonstrate that in selecting locations for the new units, defendants gave
specific consideration to the home communities of the patients, or of their friends or families.
XII. STANDARDS GOVERNING TREATMENT OF FORENSIC PATIENTS
250. The terms of this Agreement governing standards at AMHI shall apply to the Forensic
Treatment Unit and to persons who become class members by reason of an admission to the
Forensic Treatment Unit of AMHI except that the discharge and release of forensic patients
from AMHI shall be governed by 15 M.R.S.A., Chapter 5. The terms of this Agreement shall
not apply to any class member while he or she is incarcerated in a correctional facility.
251. By January 1, 1992, defendants shall submit a plan to counsel for the plaintiffs and to the
master for his approval, outlining treatment of juvenile forensic patients after the Adolescent
Treatment Unit is closed. Said plan shall describe measures the defendants will take to treat
and protect juvenile forensic patients, giving particular attention to the need for separating
juveniles from adults.
XIII. PUBLIC EDUCATION
252. Defendants shall develop, fund and support a variety of public education programs
designed to educate the public regarding mental illness, the myths and stigma associated with
it, and the rights of consumers of mental health services and their families. Programs shall
include those targeted to assist members of individual communities or employees of public

 service agencies to interact with persons with mental illness without prejudice and to foster the
full integration of persons with mental illness into their home communities. Groups to which
the public education programs shall be offered may include, but not be limited to, schools,
libraries, area agencies on aging, general assistance offices, shelters, governmental agencies,
civic organizations and law enforcement agencies.
XIV. DEPARTMENT OF HUMAN SERVICES PUBLIC WARDS AND ADULT
PROTECTIVE SERVICES
253. For purposes of this section, "public wards" refers to wards of the Defendant Department
of Human Services.
254. Defendant Department of Human Services shall provide casework services to its class
member public wards. Services shall include the active monitoring of all ISP's or hospital
treatment and discharge plans and attendance at all planning meetings.
255. When caseworkers are contacted for the giving of necessary consent to decisions, they
shall seek the information necessary to the giving of an informed decision which will be in the
ward's best interest and which will maximize the ward's independence consistent with the
ward's current circumstances. Before authorizing treatment, the Department of Human
Services will seek the counsel or opinion of an independent professional when the risks
associated with the proposed medical order or procedure are great, or when the proposed
medical order or procedure limits the ward's independence and the prognosis for improvement
as a result of implementing a proposed medical order or procedure is poor or guarded.
256. Caseworkers shall visit all class member public wards at least twice monthly.
257. By January 1, 1992, active caseloads for caseworkers assigned to class member public
wards shall not exceed 25 cases.
258. Caseworkers shall advise class member public wards of their right to name a designated

 representative or representatives and the availability of advocacy and peer advocacy assistance.
259. Caseworkers shall additionally advise class member public wards at least annually of
their right to petition the Probate Court for termination of guardianship. The advice shall be
given both orally and in writing and shall include information on the application and hearing
procedure and on the availability of legal assistance.
260. By October 1, 1990, defendants shall provide copies of this Agreement to all DHS adult
protective service and guardianship workers and shall conduct presentations to employees for
the purpose of providing an overview of the Agreement. By June 1, 1991, defendants shall
conduct training on the terms of the Agreement and on the required specific performance
obligations each employee must meet to comply with its terms.
261. By September 1, 1991, all Department of Human Services employees who are assigned
to work with class members shall receive the full complement of orientation training on the
following: the terms of this Agreement; class members' legal and human rights; perspectives
and values of consumers of mental health services; identification of, response to, and reporting
of abuse, neglect and exploitation; individual treatment and discharge planning process; ISP
process; and the mental health services system. All new employees or all workers newly
assigned to work with class members shall be required to receive this training and to complete
90% of the training before undertaking to work directly with class members. Training on the
perspectives and values of consumers of mental health services shall be conducted by such
consumers. Defendant Department of Mental Health and Mental Retardation shall assist them
as necessary.
XV. PLANNING, BUDGETING AND RESOURCE DEVELOPMENT
262. The Department of Mental Health and Mental Retardation shall develop a centralized

 system for the planning, budgeting and development of resources to meet class members'
needs.
263. Class members' needs shall be determined by information obtained from ISP's and
hospital treatment and discharge plans. Defendants shall require that all AMHI treatment team
coordinators and all community support workers submit reports describing plaintiffs' current
unmet service needs and their projected future service needs. Defendants shall additionally
collect information from concerned family members and citizens through the use of public
forums. The Department of Mental Health and Mental Retardation shall issue semi-annual
reports of the information collected and shall forward these reports to the Commissioner of the
Department of Human Services and to the master and counsel for the plaintiffs. Defendants
shall use this information in the preparation of budget requests and in the planning and
development of resources, so that the actual needs of the class members dictate resource
development.
264. Persons responsible for administration of the resource planning and development system
shall keep apprised of all programs and services available within the State and of their
effectiveness in meeting class members' identified needs. This information shall be circulated
to AMHI patient team coordinators and to community support workers on a quarterly basis for
their use in the ISP planning process.
265. Resources developed shall be based upon current knowledge in the mental health field.
All resources shall be designed to maximize clients' strengths and independence and to
integrate clients fully into the mainstream of community life.
266. Defendants shall acquire and maintain the capacity to develop necessary resources on a
local level. When developing resources, defendants may elect to contract with area agencies or

 individuals for development and administration or, defendants themselves may develop the
resources and administer them directly or through contracts.
267. Defendants will establish liaisons with professional associations to assist in the
recruitment of qualified professionals for positions of employment, training or consultation at
AMHI and in the community.
XVI. MISCELLANEOUS
A. Budgets
268. The defendants shall prepare budget requests which are calculated to meet the terms of
this Agreement. The defendants shall additionally take all necessary steps and exert good faith
efforts to obtain adequate funding from the Legislature. A copy of all portions of the
governor's budget applicable to this Agreement shall be sent to the master and counsel for the
plaintiffs when the budget is sent to the Legislature, and a copy of the final budget approved by
the Legislature shall be sent to the master and counsel for the plaintiffs immediately following
approval of the budget. This paragraph shall apply to any supplemental budget requests. The
terms of this paragraph shall not be construed so as to limit the rights of the plaintiffs to seek
further relief pursuant to paragraph 12 of this Agreement, subject to any defenses that the
defendants might have to such relief.
B. Capacity
269. Defendants shall establish and implement a protocol for assuring that all treatment is
delivered by means consistent with the determination of a patient's clinical and judicial
capacity. The protocol shall require that clinical determinations of incapacity are reviewed
every sixty days. Because patients may be requested by different persons to consent to a
variety of forms of treatment or procedures, the protocol shall be designed to assure that

 determinations as to patients' capacity to consent are cross-referenced and are consistent.
270. Where inconsistent determinations as to a patient's capacity to consent have been made,
the clinical services director, or a physician or psychologist whom he appoints and who is not
directly treating the patient, shall examine the patient, make a determination as to the patient's
capacity to consent, and enter his findings in the patient's record.
271. A class member who is determined to be incapacitated shall be treated in conformity with
procedures established under the "Rights of Recipients of Mental Health Services."
C. Defendant's Designees
272. In various provisions of this Agreement, the individual named defendants or specific
professionals are required to perform certain tasks. The parties agree that the individual
defendants may delegate their required tasks or those of the named professionals to
subordinates, but that individual defendants shall have responsibility for assuring that the
required tasks have been completed.
D. Attorney's Fees
273. Nothing in this Agreement shall operate so as to bar plaintiffs' counsel from filing
motions with the Court seeking approval of the payment of reasonable attorneys' fees and costs
incurred in the oversight, enforcement or implementation of this Agreement. Defendants
reserve the right to object to any said motions.
XVII. QUALITY ASSURANCE, INTERNAL MONITORING, REPORTING
AND IMPLEMENTATION:
274. Defendants shall take all necessary action to insure substantial compliance with each of
the provisions of this Agreement by September 1, 1995, and to thereafter maintain compliance.
275. Defendants shall be responsible for assuring the quality of services required by this
Agreement and for monitoring and evaluating all mental health services, programs and other

 systems required to carry out the terms of this Agreement. In meeting this responsibility,
defendants shall:
A. Licensing
276. Defendant Department of Mental Health and Mental Retardation shall develop licensing
standards for all agencies and facilities providing mental health services. The standards shall
be consistent with the terms of this Agreement, and shall cover all its terms. Standards shall
govern both practices and policies and licensing reviews shall be conducted in a manner to
assure compliance with both.
B. Contracts
277. Defendant Department of Mental Health and Mental Retardation's contracts with
agencies for the provision of mental health services shall require the individuals or agencies to
accept referrals of all class members. Once the interdisciplinary team determines that the class
member requires specific services, no agency under contract with the defendants may refuse
those services except when, in the case of a residential facility, there are no vacancies, and in
the case of other services, the extension of services would cause the agency to exceed
pre-established staff/client ratios. Services may be terminated against the recommendations of
the interdisciplinary team only upon the agency's compliance with the contract terms required
by paragraph 69 above, with notice to the client of his right to grieve the decision.
278. All contracts referred to above shall be written in terms of the specific performance
expected of the mental health service agency or individual. Such terms shall be consistent with
the terms of this Agreement. The Commissioner and Department of Mental Health and Mental
Retardation shall be responsible for monitoring compliance with the terms of the contracts by
reviewing both policies of the agency and actual practices.

 C. Quality Assurance and Internal Monitoring
279. By September 1, 1991, Defendants shall design a comprehensive system of internal
monitoring, evaluation and quality assurance for all areas covered by this Agreement. Critical
data shall be collected and reported through an electronic data base system. As part of this
system, defendants shall perform an annual random statistically significant review of class
members residing both at AMHI and in the community to measure defendants' compliance
with this Agreement in meeting individual class members' needs and in protecting their rights
under this Agreement.
D. Progress Reports
280. Defendants shall prepare quarterly reports on their progress in meeting and thereafter
complying with the terms of this Agreement. These reports shall make specific reference to
the headings and structure of this Agreement, and will contain a brief description of efforts
made and progress achieved. Defendants shall note the areas where compliance has not been
achieved, provide a brief explanation of the reasons for their non-compliance, and a description
of the efforts they will be undertaking during the forthcoming quarter to come into compliance.
For those areas in which defendants claim to have achieved compliance with the terms of this
Agreement, they shall attach copies of their most recent internal monitoring, evaluation and
quality assurance report. Quarterly progress reports shall be submitted to the master and
counsel for the plaintiffs for approval by the master in accordance with the procedures set out
in Section XVII below. Defendants shall send copies to oversight bodies, including the
Commission on Mental Health, Office of Advocacy, the agency for the protection and
advocacy of mentally ill individuals established pursuant to 42 U.S.C. §§ 10801 et seq., the
Joint Standing Committee on Human Resources and, if requested, to the Probate Courts.

 281. Defendants Commissioner and Department of Human Services shall be responsible for
assuring that each class member public ward is provided all the benefits of this Agreement. On
a quarterly basis, they shall prepare and issue a report regarding each such ward identifying the
treatment plan for that period, the steps taken to comply with the treatment plan, any obstacles
identified in achieving the stated goals, and plans for overcoming such obstacles, if any. These
reports shall be submitted to the master and counsel for the plaintiffs.
E. Enforcement of Regulations
282. Defendants shall take administrative action necessary to assure that the regulations
entitled "Rights of Recipients of Mental Health Services" and "Rights of Recipients of Services
who are Children in Need of Treatment", as may be amended, are applied to all facilities
providing in-patient psychiatric services and to all agencies or facilities providing in-patient,
residential or outpatient mental health services which are licensed, funded or contracted by
either the Department of Mental Health and Mental Retardation or the Department of Human
Services.
283. Staff from the Department of Mental Health and Mental Retardation's Office of Quality
Assurance and Licensing shall participate in DHS licensing surveys of the aforementioned
facilities for the purpose of monitoring compliance with the "Rights of Recipients of Mental
Health Services," the "Rights of Recipients of Services who are Children in Need of
Treatment," and the standards of this Agreement. The Department of Mental Health and
Mental Retardation shall prepare reports of its findings. Said reports shall not contain client
names or other client-identifying information. These reports shall be submitted to the
Commissioner of the Department of Human Services, the Commissioner of the Department of
Mental Health and Mental Retardation, the Office of Advocacy, the master and counsel for the

 plaintiffs, and the agency for the protection and advocacy for mentally ill individuals
designated pursuant to 42 U.S.C. § 10801 et seq.
XVIII. MONITORING AND ENFORCEMENT ROLE OF THE MASTER
284. The parties agree to the appointment of a Master to monitor the implementation of this
Agreement. The Master shall serve as an officer of the Court and shall serve solely the Court
and the interests of justice. The Master shall serve for a fixed term to be set by the Court in its
Order Appointing or Renewing the Appointment of the Master, but in any event, the term of
the Master shall terminate no later than the date of the Court's order pursuant to paragraph 13
of the Consent Decree.
285. The Master shall commence his duties as soon as practicable, but no later than 45 days
from the date of his appointment.
286. The Master shall not be subject to dismissal except for good cause. Either party may
petition the Court for dismissal or replacement of the Master or renewal of the term of
appointment of the Master upon thirty days notice to the court and opposing counsel.
287. Upon resignation, disability, termination for cause or expiration of term of the Master,
the parties shall consult one another in an effort to reach agreement about the replacement or
appointment of the Master.
288. If the parties are unable to reach agreement as to the person to be replaced or appointed to
the Master's position, they shall each submit a list of three nominees to the Court, along with
supporting curriculum vitae. These lists shall be supplied within 21 days of the date of any
order issued by the Court approving the replacement or renewal of the term of the Master.
Each party will then have 15 days to comment on the list of candidates nominated by the
opposing party. The Court shall thereafter promptly issue an order for the appointment of the

 Master from the lists of nominees presented.
289. Defendants shall pay the salary and expenses of the Master and shall pay for necessary
clerical and professional support. In addition, the Master shall be reimbursed for reasonable
and necessary expenses incurred in the discharge of his duties and responsibilities under this
Agreement. Such expenses include, but are not limited to, fees and expenses of expert
consultants, travel expenses, transcriptions and photocopy fees, and office and clerical
expenses. The compensation and expenses for the Master shall be subject to approval by the
Court. Within 45 days of the date of this Agreement, and on each subsequent anniversary, the
parties shall submit a proposed annual budget to the Court, including the proposed rate of
compensation for the Court's approval. In subsequent years, the parties shall consult with the
Master regarding his budgetary needs. As necessary, the Master may submit supplemental
amended budget requests to the Court for its approval after the parties have had an opportunity
to comment. Unless and until the Master's budget is directly appropriated to the Judicial
Department, the defendants shall deposit the amount of the approved budget or supplemental
amended budget into an established court-supervised escrow account.
290. The Master shall have only those duties and responsibilities specified herein. In general,
the Master has the duty and responsibility to monitor the implementation of all terms of this
Agreement, to attempt to resolve disputes arising between the parties and to make
recommendations that will facilitate the goals and objectives of this Agreement.
291. The Master shall, in consultation with counsel for all parties, develop a process to
evaluate and measure the Defendants' compliance with the terms and principles of this
Agreement.
292. It is the duty of the Master to review all reports that the Defendants are required to

 prepare by this Agreement. In addition to these reports, the Master may require the Defendants
to file reports or respond to written questions relating to any matter covered by this Agreement.
All reports submitted to the Master shall be made available to all parties to this action, subject
to the right of defendants to seek an order restricting disclosure to counsel of documents
defined at 32 M.R.S.A. § 3296 and 24 M.R.S.A. § 2510(3).
293. This Agreement requires the Master's approval of certain plans or reports prior to
defendants implementing their terms. This Agreement also requires the Master's approval of
certain draft regulations prior to their promulgation under the Maine Administrative Procedure
Act. When reviewing such plans, reports or draft regulations, the Master shall solicit responses
from counsel for the parties and shall thereafter issue a written opinion approving or
disapproving the plan, report or draft regulations within 30 days. Any party aggrieved by the
Master's decision may invoke the procedures set out at paragraphs 294 through 297 of this
section.
294. Either party may submit any dispute concerning this Agreement to the Master, who shall
attempt to informally mediate and resolve the dispute. The Master may make use of such
informal dispute resolution processes as he deems necessary, which may include, but are not
limited to, informal suggestions or recommendations and compulsory conferences of the
parties.
295. If these informal attempts fail to resolve the dispute, either party may submit a written
request to the Master for specified relief and for a recommended decision. A copy of this
request shall be filed by the petitioner with the Court and served upon opposing counsel. The
Master shall issue and file a written recommended decision supported by written findings of
fact with the Court within 21 days from the date of receipt of the written request and shall

 serve counsel of record with copies of the decision. The recommended decision shall become
final and binding upon the parties unless either party files an objection to the recommended
decision and a request for hearing on the matter in controversy with the Court within 21 days
from the date of the issuance of the decision. The Court shall then promptly convene a
conference of counsel in an attempt to expedite the scheduling of the hearing.
296. Although the parties shall be afforded a de novo hearing, the Master's written
recommendations and findings may be introduced into evidence by either party and the Master
may be called to testify as a witness by either party or by the Court.
297. The parties may, by written agreement made in advance, agree to submit any dispute to
the Master for adjudicative resolution. If the parties proceed under this section the Master shall
schedule an evidentiary hearing wherein they may submit such evidence and testimony as are
permitted by the Maine Rules of Evidence. The Master shall issue his written decision,
including findings of fact and conclusions of law within 21 days of the completion of the
hearing. The decision of the Master shall become final and binding upon the parties unless
either party files an objection to the decision and supporting memorandum of law with the
Court within 21 days of the date of the issuance of the Master's decision. The responding party
will then have 14 days to prepare an opposing memorandum. The Superior Court shall apply
an appellate standard of review when considering any matter submitted for its review under
this section.
298. The Master also has the authority to make recommendations sua sponte with regard to
implementation of this Agreement if: (1) the Master believes that the Defendants are not in
compliance with the Agreement; (2) this judgment is accompanied by written findings of fact
which indicate the source for the evidence upon which each finding is based; and (3) the

 recommendations are consistent with and can be implemented within the framework of the
Agreement. Such recommendations will include, where necessary, timetables for
implementation of steps or measures necessary to bring the Defendants into compliance.
These recommendations will become final and binding upon the parties unless either party
invokes the procedures set out at paragraphs 294 through 297.
299. The Master shall submit a written report to the Court and the parties every six months
detailing the progress achieved by the Defendants with implementing the terms of this
Agreement. Each report shall include a description of all disputes and interpretive questions
which have been addressed and resolved by the Master in the preceding six-month period. The
report shall highlight all instances of Defendants' compliance and non-compliance with the
Agreement within the six-month period and shall include specific recommendations as to how
to facilitate Defendants' full and timely compliance with the provisions, goals and objectives of
this Agreement. All recommendations made by the Master shall be supported by specific
findings and shall reference the documentary evidence relied upon by the Master in rendering
his recommendation. Prior to filing the report, the Master shall submit a proposed draft to the
parties for comment. The specific recommendations contained in the report shall become final
and binding upon the parties unless either party invokes the procedures set out at paragraphs
294 through 297. The Master shall take appropriate measures to prevent the disclosure of
confidential information to the general public. Nothing in this paragraph shall prohibit the
Master from submitting additional reports or comments to the Court or the parties at any other
time.
300. For the purpose of gathering relevant information and prior to submitting the report
required by paragraph 299 above, the Master shall solicit public comment from class members,

 relatives of class members and their guardians, client advocacy groups, the Office of
Advocacy, community service providers, Defendants' employees or other necessary persons,
regarding the progress achieved by the Defendants in implementing this Agreement. The
requirements of this section may be satisfied by holding a publicized public meeting, by
soliciting written comments, by a combination of the above or by any other methods of
gathering input and information that the Master deems necessary and appropriate.
301. Copies of the final report shall be furnished to the counsel for the plaintiffs, chairpersons
of appropriate committees of the Legislature, the Office of Advocacy, and the protection and
advocacy program established pursuant to 42 U.S.C. §§ 10801 et seq. In addition, a copy shall
be supplied to any member of the public who makes a request for the report, provided that
reasonable photocopy and mailing fees may be charged to cover the costs of public
disbursement of the report.
302. The Master shall have access to all facilities, records, documents, information, programs,
residential settings and persons affected by or involved in the implementation of this
Agreement. The Master shall have the authority to conduct inquiries and consult with
professionals to assist in finding facts relevant to implementation of this Agreement.
XIX. ENFORCEMENT
303. The parties agree that the terms of this Agreement may be specifically enforced directly
by the Court upon written motion of the parties, with notice to opposing counsel; provided that,
the Court may require the parties to mediate their dispute before the Master pursuant to the
provisions of paragraph 294 above prior to proceeding to a hearing on the parties' motion.
During any time where a Master is not serving or has not been appointed, the parties shall
make reasonable attempts to informally resolve all disputes prior to their application to the

 Court.
Consented to by the undersigned:
FOR THE PLAINTIFFS:

FOR THE DEFENDANTS:

Date:
Richard M. Goldman

Robert W. Glover

Date:
Helen M. Bailey

Linda Breslin

Date
Neville Woodruff

Rollin Ives

Date:
Peter Darvin

Date:
Robert Marks

Date:
Helen Hershkoff

Date:
John A. Powell

Date:

Date:

Date: