Case 2:85-cv-04544-DMG-AGR Document 420-5 Filed 04/23/18 Page 56 of 70 Page ID #:16780 Exhibit 83 REDACTED VERSION OF DOCUMENT FILED UNDER SEAL Exhibit 83 Page 595 Case 2:85-cv-04544-DMG-AGR Document 420-5 Filed 04/23/18 Page 57 of 70 Page ID #:16781 330 C Street, S.W., Washington, DC 20201 I www.acf.hhs.gov April 2, 2018 Via email Re: Flores, et. al., v. Sessions, et al., No. CV 8504544 DMG (C.D. Cal.) Dear Flores Counsel: We have reviewed your letter dated January 16, 2018 regarding the administration of psychotropic medications to unaccompanied alien children (UAC) in the custody of the Office of Refugee Resettlement (ORR) and placed at the Shiloh Residential Treatment Center (Shiloh RTC or Shiloh), including the specific cases that you highlighted and , with ORR. This letter responds to the concerns expressed therein. Shiloh Residential Treatment Center Shiloh RTC is a residential treatment center in Manvel, Texas that cares for children, including UAC in ORR's custody , with a very high level of needs, such as significant mental health problems or violent histories, which require specialized treatment and services. The facility has 44 beds in total, of which 32 are designated for UAC in ORR's custody. As of the date of today's letter, 26 UAC placed by ORR are being housed at Shiloh RTC, which has 4 staff members for every child placed there . Shiloh RTC's program is physically organized in a group of cottages and has a central building where a school is located. Notably, Shiloh RTC is not operated by DayStar Treatment Center (DayStar), which is mentioned in your letter. As of February 2011, Daystar is no longer in operation, and even when it was still in business the licensure of Daystar was completely separate from that of Shiloh. Compliance with Texas State Licensing Standards & ORR Monitoring Visits Shiloh RTC's operations are monitored closely during regular (announced and unannounced) licensing visits and inspections by the State of Texas each year. A licensing visit can cover any topic addressed in the governing Texas Department of Family and Protective Services (TD FPS) Licensing Division's Minimum Standards for General Residential Operations, including most saliently, policy, procedures, and practices concerning the use of psychotropic medication. 1 Shiloh RTC is required to 1 See generally TDFPS ' Minimum Standards for General Residential Operations, available at https://www.dfps.state.tx.us /Child Care/documents/Standards and Regulations/748 GRO.pdf (last visited Exhibit 83 Page 596 Case 2:85-cv-04544-DMG-AGR Document 420-5 Filed 04/23/18 Page 58 of 70 Page ID #:16782 follow strictly any recommendations for corrective action from Texas ' licensure process concerning the care ofUAC and other children who reside and receive treatment services there .2 To ORR ' s knowledge , Texas state licensing officials have not reported any concerns regarding Shiloh RTC ' s compliance with state guidelines concerning the administration of psychotropic medications to UAC in ORR ' s custody. In addition to complying with mandated state licensing requirements in Texas , Shiloh is also accredited by the Joint Commission on the Accreditation of Hospitals and Organizations (JCAHO) , the world recognized leader in the accreditation of health care organizations. Shiloh ' s JCAHO accreditation was just renewed for another three-year period in January 2018. By adhering to JCAHO ' s heightened national standards , which address in relevant part the administration and use of psychotropic medication , Shiloh exceeds Texas state minimum licensing standards. Consistent with JCAHO's standard MM.01 .01.05, Shiloh RTC developed formal monitoring processes, as well as specific written policies and procedures to monitor the use of psychotropic medications. These policies and procedures address the following issues, among others: guidelines for the prescription of emergency psychotropic medication; the use of multiple psychotropic agents in the same class; the use of high-dose pharmacotherapy; the prevention , identification, and management of side effects from the use of psychotropic medication , including tardive dyskinesia. Further , it is Shiloh ' s policy that, in addition to monthly reviews of all their medication orders , on at least a quarterly basis , the board certified child and adolescent psychiatrists who contract with Shiloh to provide psychiatric care for UAC (and other residents) review current prescriptions of psychotropic medications using the best practice guidelines set forth in Texas' Psychotropic Medication Utilization Parameters for Children and Youth in Foster Care.3 Consistent with these guidelines, Shiloh policy requires that psychiatrists treating UAC strive to use no more than four psychotropic medications concurrently, attempt a mono-therapy regimen for identified target symptoms before prescribing a multiple-therapy regimen, and avoid high-dose pharmacotherapy. The justification for any deviation from these standards must be clearly documented. Peer reviews may also be conducted to review a multiple-therapy regimen. Over and above Shiloh's compliance with Texas State licensing and national JCAHO accreditation requirements , and the facility ' s own policies and procedures , ORR conducts routine Federal monitoring visits and medical reviews , and regularly participates in various treatment meetings concerning UAC placed at Shiloh. Specifically , biannual Federal monitoring visits are conducted by ORR ' s Division of Children ' s Services (DUCS) Monitoring Team, which includes monitoring of March 8, 2018), at page 161 (use of psychotropic medication). These standards require that Texas state licensed residential facilities comply with Texas Administrative Code Chapter 748, Title 40, Social Services and Assistance , Part 19, Department of Family and Protective Services, Division 7, Use of Psychotropic Medication. 2 See Minimum Standards for General Residential Operations , at page v (Introduction) . 3 See Psychotropic Medication Utilization Parameters for Children and Youth in Foster Care (5th Version) (March 2016) , available at https ://www .dfps.state .tx .us/Child Protection/Medical_ Services/ documents /reports/201603_Psychotropic_ Medication _ Utilization _Parameters _for _Foster_ Children .pdf . The Medication Tables therein were updated in July 2016 . This guidance was developed by the Texas Department of Family and Protective Services and the University of Texas at Austin College of Pharmacy with review and input provided by: the Federation of Texas Psychiatry , Texas Pediatric Society, Texas Academy of Family Physicians , the Texas Medical Association , and Rutgers University-Center for Education and Research on Mental Health Therapeutics. Exhibit 83 Page 597 Case 2:85-cv-04544-DMG-AGR Document 420-5 Filed 04/23/18 Page 59 of 70 Page ID #:16783 Shiloh's procedures for documenting medication use and medical treatment ofUAC. ORR's medical team from headquarters has likewise participated in quarterly conference calls regarding residential treatment centers, and has visited Shiloh, in order to monitor the provision of medical care to UAC by reviewing medical procedures and auditing charts. Shiloh also provides a spreadsheet for each UAC placed there which ORR uploads into its patient portal and includes all medications whether prescription, non-prescription or emergency PRN ("as needed"), as well as information about when medications are started or stopped and why, and increases/decreases /adjustments to medications. Additionally, the assigned ORR Federal Field Specialist (FFS), who is trained as a clinical social worker, often participates in weekly treatment team meetings ;it Shiloh where issues concerning medications such as a child's refusal to take medication may be discussed. During periodic medical reviews, the FFS will participate in clinical discussions with the attending psychiatrist and registered nurse for particularly complex cases. The FFS also conducts monthly meetings with Shiloh staff and local General Dynamics Information and Technology (GDIT) Case Coordinators (contracted case management staff who provide recommendations on transfers and release) to discuss specific UAC cases at Shiloh which may include a discussion of UAC's medical treatment and the prescription of medication. Finally, the FFS also conducts quarterly meetings with stakeholders to include ORR headquarter medical staff and the Senior Advisor for Child Well-being and Safety. Among other topics, these quarterly meetings involve a general review by medical doctors of medical treatment and services provided to UAC, including the prescription of psychotropic medications. 4 Informed Consent & UAC Assent Shiloh RTC follows applicable Texas state law concerning informed consent pertaining to the prescription of psychotropic medications to children in state residential treatment facilities. See Texas Administrative CodeĀ§ 748.2253 (use of psychotropic medication). Under these procedures, if a UAC has a viable sponsor, Shiloh's policy is to inform the sponsor about any changes in medications prescribed for a particular child, including starting a new medication or increasing the dose of a current medication. Shiloh ' s policy specifies that informed consent must include an explanation of the following: benefits; risks; side effects; medical consequences of refusing the medication or recommendation for the medication; and contact information for the prescribing physician. However, there are emergency situations in which psychiatrists may prescribe psychotropic medications to UAC without such consent or court authorization when their extreme psychiatric symptoms render them a danger to themselves or others. See Texas Family CodeĀ§ 266.009. Specific Cases: and Turning to the two individual cases mentioned in your letter and -we discuss the specific concerns you highlighted with ORR below. Notably, neither of these cases raised any issues regarding the prescription of psychotropic medication with the Texas state licensing authorities or the JCAHO accreditation process. Rather, both UAC, who exhibited serious mental health symptoms while at Shiloh, were prescribed psychotropic medication in compliance with Texas state law and Shiloh's policies and procedures. 4 ORR does not, however, employ child and adolescent psychiatrists who would have the training to scrutinize the specific medications prescribed by Shiloh experts . Exhibit 83 Page 598 Case 2:85-cv-04544-DMG-AGR Document 420-5 Filed 04/23/18 Page 60 of 70 Page ID #:16784 was admitted to Shiloh in March 2016 following a psychiatric hospitalization that resulted from his expression of suicidal ideation (jumping from a window of a multi-story building) and threats. He also has a history of severe trauma and has been attacked by gang members, which reportedly put him into a coma for two days and may have resulted in a traumatic brain injury. In the past (2014), says that he actually attempted suicide and shot himself in the head. While placed at Shiloh, he engaged in physically aggressive behavior towards his peers and staff which was unprovoked, and sexually inappropriate behavior with female staff at Shiloh. was prescribed medication by a board-certified child and adolescent psychiatrist who contracted with Shiloh in order to treat his extreme aggressiveness, as well as posttraumatic stress disorder (PTSD) and terrifying nightmares, paranoia, labile mood, and anxiety/depression. Notably, one of the documented goals of family therapy with and his sponsor/mother, which was scheduled for two 45 minute sessions per month, was to understand mental health diagnoses, symptoms, and needs. A goal for mother in therapy was to learn about the psychotropic medication that he was prescribed by his assigned psychiatrist at Shiloh. Further, Service Plan at Shiloh R TC specified that the minor was to be provided medication education in order to ensure that he understood what medications he was prescribed and why. Per this plan, during one medication administration daily, was to be asked to name his medications and state why they were prescribed to him. Following his discharge from Shiloh RTC on 4/12/2016, was transferred directly to NOVA secure facility in order to stabilize his increasingly aggressive and defiant behavior, such as attacking a vulnerable peer and stabbing a staff member with a pencil - incidents which necessitated the administration of PRN psychotropic medication consistent with Texas law in order to calm down. He was not transferred to Yolo secure until more than five months later on 9/25/2016 and spent several months (from June to September 2016) in the interim placed at Mercy RTC in New York. Psychiatric records from NOVA (where was placed from April to June 2016), including a neuropsychological evaluation performed on 5/9/2016 by an independent psychiatrist, indicate that, at the time, although he was initially uncomfortable with the idea of taking medication, believed his medication regimen to be working to improve his emotional state and he wanted to keep taking the same medications. Upon his discharge from NOVA on 6/6/2016, psychiatric records from that facility likewise reflect a recommendation that continue to take his prescribed psychotropic medications. When he arrived at Mercy RTC the next day (6/7/2016), the psychiatrist's progress notes state that he agreed to continue to take his medications. While at Mercy R TC, experienced suicidal ideation and engaged in self harm, actively hallucinated, as well as disclosed intrusive PTSD related memories from his harrowing trip to the United States, which necessitated an increase in the dosage of certain medications, and switching other medications. Following his subsequent placement at Yolo secure in late September 2016, medication logs show that assigned psychiatrist gradually added prescriptions to try new psychotropic medications and reduced the dosage for or eliminated others that had already been taking. It was not until later in November 2016 at Yolo that expressed that he did not want to take most of his medications (with the exception of medications for nightmares and sleeping) because he no Exhibit 83 Page 599 Case 2:85-cv-04544-DMG-AGR Document 420-5 Filed 04/23/18 Page 61 of 70 Page ID #:16785 longer needed them. During a weekly therapy session at Yolo on 11/10/2016 just two days after stopping certain medications psychotropic medications , however, reported to a mental health clinician that he was experiencing more nightmares , sadness , loneliness, and thoughts of harming himself by cutting. Notably, psychiatric records from Mercy RTC where was readmitted in December 2016 show that was prescribed additional psychotropic medications with his consent in order to better stabilize his mood and prevent psychosis, as well as lessen his exhibition of aggressive behavior. When he was transferred to Shiloh RTC in June 2016 on an emergency basis, exhibited several severe mental health symptoms such as psychosis , paranoia , and hyper-suspiciousness. came to Shiloh not long after an acute psychiatric hospitalization in late April 2016 and had a history of bizarre catatonic and seizure-like behavior , and depression. While previously hospitalized , had urinated on himself and attempted to shower with his clothes on. He arrived at Shiloh with several psychotropic medications which had been previously prescribed to him at SW Key Mesa , a staffsecure shelter where he had exhibited oppositional and defiant behaviors, aggression , homicidal threats , and runaway behavior. While placed at Shiloh , engaged in physically and verbally aggressive behavior towards staff and peers , self-injurious behaviors /self-mutilation , as well as inappropriate sexualized behavior; in total he obtained 26 Special Incident Reports (SIRS) while at Shiloh for this behavior. The board-certified psychiatrist who was assigned to at Shiloh gradually made changes to diagnoses based on his observations of him at Shiloh , and changed his medication regimen accordingly. As is permitted by Texas law, also sometimes needed emergency PRN psychotropic medications at Shiloh in order to curb his highly aggressive behavior, and protect him and other minors at the facility. On at least one occasion, asked for such medication in order to help control his extremely volatile mood. Each new medication or dosage change was carefully documented and explained to who never refused to take the medication prescribed and was compliant with his regimen at Shiloh, although he did refuse further medical evaluation later after being transferred to Yolo secure. also agreed to allow his therapist at Shiloh to inform his sponsor mother about his diagnoses and the medications that he was prescribed. The therapist spoke to the mother and provided her with psycho-education about mental illness, and she agreed to take the minor to a psychiatrist in the community to continue his medication if he were released to her upon his discharge from Shiloh. The treating psychiatrist at Shiloh did document side effects that experienced such as weight gain and made further gradual medication changes in order to alleviate such side effects while continuing to treat his serious mental health symptoms effectively. severe psychiatric symptoms such as psychotic behavior improved incrementally throughout his stay at Shiloh and the psychiatrist made different adjustments to his medication regimen up until the time of his discharge to Yolo secure in December 2016. medical records also indicate that he had been successfully treated for pneumonia in the past but that, contrary to your letter, testing did not actually confirm that he had a history of encephalitis . A brain MRI and EEG given to because of prior reports of "seizure-like activit y" were also negative. Exhibit 83 Page 600 Case 2:85-cv-04544-DMG-AGR Document 420-5 Filed 04/23/18 Page 62 of 70 Page ID #:16786 Of note is that records from Yolo secure indicate that physical and verbal aggression with peers and staff persisted after his transfer to that facility in December 2016, and he regularly engaged in disruptive and defiant behavior there. He also expressed suicidal ideation and exhibited sexually inappropriate behavior. In fact, although the assigned consulting psychiatrist ' s progress note from 1/5/ 17 indicated improvement in how felt with a reduction in his medications and stated he reported that he was calm and cooperative with Yolo staff, a psychological evaluation of from March 2017 which details 18 separate SIRS that received since his arrival at Yolo secure which spanned the months of December 2016 through February 2017 seems to suggest otherwise . In that evaluation, the independent licensed clinical psychologist who performed the psychological testing and reviewed various historical medical, psychiatric, and other records concluded that moderate violence risk would likely decrease if he continued to participate in mental health treatment , including taking prescribed psychotropic medications. Finally , we note that the cases you cite are older cases from 2016. There is no evidence that the cases are representative of a widespread problem with the medication practices that exist at facilities where ORR places UAC. James S. De La Cruz Senior Federal Field Specialist Supervisor Office of Office Refugee Resettlement, Division of Children ' s Services Exhibit 83 Page 601