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FOR IMMEDIATE RELEASE

Contact: Dominic Slowey | 781-710-0014
dslowey@sloweymcmanus.com

Disability Law Center Finds Inadequate Access to Treatment,
Mold Contamination, and Unlawful Restraint Practices
at Bridgewater State Hospital Persist

The Disability Law Center (DLC), the Commonwealth’s Protection and Advocacy system, today released a public report regarding its monitoring efforts at Bridgewater State Hospital (BSH) and findings from the latter half of 2023. DLC issued a private, unredacted version of the report on February 29, 2024 to select government officials. The report marks ten years of intensive DLC advocacy to protect the rights of and improve care for individuals involuntarily held in BSH, a Department of Correction (DOC) facility. DLC repeats its urgent call for the Commonwealth to transfer oversight of the BSH population to the Department of Mental Health (DMH) and to construct a new psychiatric hospital.

Covering a range of topics, the report provides updates about recurring unlawful and violent BSH restraint practices, significant mold contamination, and inadequate access to appropriate medical care. In addition, for the first time, the report explores medical expert findings that Medications for Opioid Use Disorder (MOUD) prescribing practices at BSH fail to comport with the medical standard of care and the troubling conditions and limited access to treatment that new admissions to BSH face.

Over the course of this monitoring period, DLC conducted weekly onsite visits, met with individuals held at BSH, met with BSH staff and administrators, reviewed extensive records, regularly corresponded with DOC and its contracted provider, Wellpath, and engaged two highly qualified experts – Gordon Mycology, an expert with 27 years of professional mold and air quality inspection experience, and Dr. Evan Gale, a dual board-certified internal medicine and addiction medicine physician who serves as the Associate Medical Director of the Addiction Consult Team and Director of Inpatient Training of the Addiction Medicine Fellowship at Massachusetts General Hospital.

“It is clear that neither the care that DOC and Wellpath offer, nor the deteriorating prison facility meet the needs of the BSH population. DLC’s monitoring efforts reveal persistent legal violations, abuse, inadequate medical and mental health treatment, and mold contamination at BSH. Transfer of oversight to DMH is long overdue,” stated Tatum A. Pritchard, Director of Litigation of DLC. “Failure to prioritize appropriate, stabilizing care and protect individuals with mental health disabilities at BSH from compounding trauma has real consequences for those individuals, their loved ones, and the Commonwealth’s larger mental health and criminal justice systems.”

“DLC urges the Commonwealth to take action to ensure that all individuals with mental health disabilities who are involuntarily committed for psychiatric evaluation and treatment in our state have access to appropriate services in a therapeutic environment. This cannot be true while BSH remains open,” said Barbara L’Italien, Executive Director of DLC.

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Advocates criticize Municipal Empowerment Act’s approach to public meeting reforms

Proposed legislation fails to guarantee equitable access and undermines the spirit of the Open Meeting Law

FOR IMMEDIATE RELEASE

February 27, 2024

CONTACTS:

Kate Lagreca, klagreca@aclum.org

Geoff Foster, gfoster@commoncause.org

BOSTON – The state’s Joint Committee on Municipalities and Regional Government is scheduled to hold a public hearing today on parts of Governor Healey’s Municipal Empowerment Act S.2571. A coalition of democracy, disability access, and open government advocates expressed strong concerns about the bill’s consequences for access to local government meetings included in sections 2-5. The proposal would make the format of local open meetings completely discretionary instead of maximizing access by guaranteeing hybrid public meetings with both in-person and remote access.

The ACLU of Massachusetts, Boston Center for Independent Living, Disability Law Center, Common Cause Massachusetts,  League of Women Voters of Massachusetts, Massachusetts Newspaper Publishers Association, MASSPIRG, New England First Amendment Coalition, and New England Newspaper & Press Association released the following joint statement in response to the bill:

“The Municipal Empowerment Act falls short on ensuring access to public meetings. It will shut people out of the democratic process by only allowing — and not requiring — municipalities to provide hybrid participation options. Giving every government body complete discretion about how to provide public access to their meetings means people with disabilities or other reasons they can’t attend meetings will be completely shut out when city councils, select boards, or school committees decide to hold meetings exclusively in person.

“Last session, the House passed forward-thinking legislation that would have guaranteed hybrid participation by entities under the Open Meeting Law, and together the House and Senate passed a $30 million bond authorization to support municipal IT infrastructure, which Governor Baker vetoed. Passing on the opportunity to build on the Legislature’s earlier efforts, the language in the Municipal Empowerment Act is a major step backwards. It’s time to guarantee the permanent removal of long-standing barriers to participation that particularly impact people with disabilities, caregiving responsibilities, or limited transportation. We look forward to working with the House and Senate to ensure a reasonable guarantee of public access by strengthening the Open Meeting Law for residents of all 351 cities and towns.

“We’re also concerned that a matter of such significant importance is being considered by the Joint Committee on Municipalities and Regional Government instead of the Joint Committee on State Administration and Regulatory Oversight, which has substantial expertise in this area and is able to properly consider the application of the Open Meeting Law to state agencies as well as municipalities. In addition, the language in the bill would undermine the spirit of the Open Meeting Law, because it could result in the level of access to local public meetings varying dramatically from one municipality to the next. The Open Meeting Law has always ensured a statewide standard for public access for all 7 million Bay Staters across all 351 cities and towns.”

Background:

In spring of 2023, the coalition conducted a survey of every city council, select board, and school committee in the state. According to that survey, more than half of those bodies are already conducting fully hybrid or live-streamed meetings. Indeed, hybrid meetings are already standard operating procedure for many government entities in municipalities of every size, from Boston to Gosnold.

• City councils and select boards: 45% of city council and select board meetings are fully hybrid and 17% more are live streamed. In total, 62% are fully hybrid or live streamed.
• School committees: 35% of school committee meetings are fully hybrid and 25% are live streamed. In total, 60% are fully hybrid or live streamed.

The coalition supports a legislative proposal (H.3040/S.2024) that will ensure greater access to open meetings for everyone—particularly for people with disabilities, caregiving responsibilities, or limited transportation—by requiring options for officials and members of the public to attend meetings in person or remotely.

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FOR IMMEDIATE RELEASE

Contact: intake@dlc-ma.org

DLC Report Finds Harmful Lack of Proper Care for Patients at Bear Mountain Nursing Facility in Worcester

Understaffing, overmedicating, and isolating practices plague facility’s long-term patients;

Weak state standards; lackluster enforcement contribute to woeful conditions

BOSTON, MA (January 31, 2024): The Disability Law Center, Inc. (DLC), the Commonwealth’s Protection and Advocacy system, today released an investigative report detailing harmful practices at the Bear Mountain Worcester nursing facility. The report finds the facility, part of a large for-profit healthcare group, demonstrates a detrimental lack of proper patient care. Understaffing, overmedication, and neglect are among the practices of concern highlighted in the report.

The report, the result of a two-year investigation into complaints originating from patients and their families, outlines the worries of those skeptical of the facility’s safekeeping of their loved ones. The federal Nursing Home Reform Act (NHRA) sets standards for ensuring proper care for nursing home residents for a facility to be deemed operable. DLC found many NHRA violations that also constituted abuse or neglect under the statutes that protection and advocacy systems utilize when conducting investigations.

“Our investigation uncovered deeply troubling practices at Bear Mountain’s Worcester facility. The treatment of patients in this facility violates their rights and reflects a wider issue within the industry,” said Nina Loewenstein, lead author of the report and Senior Attorney at DLC. “It’s imperative that immediate action be taken to ensure the safety and well-being of these vulnerable residents.”

In their research, DLC uncovered evidence of a reliance on antipsychotic drugs, questionable schizophrenia diagnoses, isolation, a lack of effective interdisciplinary behavior plans, and minimal engagement with patients in the neuro-behavioral unit. These typically derive from a severe lack of staffing and clinical expertise at facilities, a common issue within the industry, particularly among for-profit providers. The facility lacks any nursing staff who are trained and credentialed in psychiatric nursing, lacks a psychologist, and most importantly, lacks on-site psychiatric and neurological consultations.

Additionally, DLC found that patients have been routinely medicated with multiple antipsychotics and other psychotropic medications, raising compelling questions as to whether this is a consequence of the facility’s understaffing and lack of adequate training and oversight. This practice is prevalent within the neurobehavioral unit, where patients with varying diagnoses, including brain injuries, anxiety, depression, dementia, trauma, and similar behavioral health conditions, reside. The unit comprises two locked floors within Bear Mountain Worcester and is not frequented by other residents.

The report also notes that guardians and families of residents have reported widespread, serious infections spreading on site, as well as known rodent infestation and unclean communal spaces. Many residents are unable to report these hazardous conditions themselves.

In response to DLC’s audit, Bear Mountain has agreed to make changes within the facility, including working to certify identified staff on the neurobehavioral unit as certified brain injury specialists through the Brain Injury Association of Massachusetts, as well as conducting a 3-hour Fundamentals of Behavior Management course and an Applied Behavioral Analysis course. Additionally, Bear Mountain is refurbishing its van to facilitate offsite social and community activities, including offering special trips, such as personalized shopping trips, and increasing the number of therapeutic programs offered to residents, related to money management, activities of daily living, hygiene, social skills, and education about healthy eating and exercise.

“The conditions at Bear Mountain have been appalling. It has been a dire situation, and we must hold the Commonwealth accountable for its duty to inspect and ensure proper care in these facilities,” said Barbara L’Italien, Executive Director of DLC, the Commonwealth’s Protection and Advocacy (P&A) system and a nonprofit organization advocating for human rights, empowerment, and justice for people with disabilities.

DLC’s research shows negligence and misconduct are common issues in for-profit healthcare facilities. Their report informs that staffing nursing homes is often a costly endeavor with little return for the investor. Therefore, operating with as few staff as possible is often preferred within the for-profit nursing home sector. Nearly two-thirds of all Massachusetts nursing homes are for-profit.

“Patients and families trusted Bear Mountain to provide proper care, and the facility has failed them time and again,” said Rick Glassman, Director of Advocacy for DLC. “Our research unequivocally shows that the Commonwealth must promptly and carefully examine the negligent or abusive practices at Bear Mountain in Worcester. We are grateful to Bear Mountain for their cooperation in our review and the measures they are taking to improve their facility and we appreciate new state policies to oversee the use of antipsychotics. Our position remains that the Commonwealth is duty-bound to inspect these facilities with an eye towards identifying root causes of deficiencies. Also, the state must impose more rigorous sanctions and corrective action plans when necessary. In this instance, they have not done so.”

DLC’s report includes recommendations that the Commonwealth should take to ensure the well-being of the residents at the facility. These include requiring clinical expertise in psychiatry and neurology; requiring robust multi-disciplinary behavior plans; and limiting enhanced compensation of specialized facilities to those settings which adhere to enhanced standards of care.  The Commonwealth must also ensure the facility is providing training for direct care staff in neurological care and psychotropic medications, as well as human-centered approaches to care and behavioral management; hiring sufficient staff to provide consistent quality care and maintaining basic hygiene; ensuring that residents and legal representatives understand the risks and benefits of medications; and investing in homelike environments and therapeutic spaces with resident involvement and choice. It is also recommended that Bear Mountain restore transportation services to community settings, including shopping and parks, and provide programming to develop activities and skills of daily living and vocational and education counseling.

DLC conducted six site visits from October 2021 until October 2023. During this time, DLC observed the facility’s conditions, reviewed patient records, and interviewed residents and staff, including facility administrators and behavioral health staff from the outside agency providing behavioral health services at Bear Mountain. A psychiatric nurse, a neuropsychiatrist and former nursing home administrator familiar with audits and reviews assisted DLC as experts in assessing the nursing home and final recommendations.

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FOR IMMEDIATE RELEASE:

BOSTON – January 23, 2024 – In a long-awaited victory, incarcerated people who are deaf or hard of hearing will receive life-saving emergency notifications in Massachusetts correctional facilities.

Following eight years of litigation culminating in a trial in August, United States District Court Judge Richard G. Stearns ruled that the Massachusetts Department of Correction’s (DOC) violated the Americans with Disabilities Act and the Rehabilitation Act by failing to provide an effective emergency alarm system and evacuation procedures for people in custody who are deaf or hard of hearing.

“It doesn’t just impact me. It impacts the whole population here. You have elderly people, people with other disabilities, officers – an evacuation procedure that works for all of us sends the message that we all matter,” said Daniel McNair, an incarcerated person and trial witness for the case.

The case is entitled Briggs, et al. v. Department of Correction, et al. The plaintiffs, represented by

Prisoners’ Legal Services of Massachusetts, Disability Law Center, Washington Lawyers’ Committee for Civil Rights and Urban Affairs, and WilmerHale, argued that because many housing units and common areas in DOC facilities rely exclusively on audible alarms, deaf and hard-of-hearing individuals face a significant risk of death or serious injury because of their inability to hear safety announcements and fire alarms. Multiple class members testified at the trial about instances when they were left behind in their cells or did not evacuate promptly during fire drills because they did not hear the alarm.

“This ruling sends a clear message that disability rights do not stop at the prison gates. For far too long, DOC failed to meet its basic legal obligations to ensure equal access to emergency notifications and alarms for deaf and hard-of-hearing prisoners. Today’s decision is an important win for incarcerated people with disabilities,” said Lisa Pirozzolo, Partner at WilmerHale.

“In combination with the wide-ranging 2019 settlement in this case, the Court’s decision makes clear that DOC must provide people who are Deaf or hard-of-hearing access to effective communication, programming, and other services, including life-saving emergency notifications. We are grateful to our clients for their resolve and hope that the ruling serves as a reminder that individuals with disabilities are entitled to reasonable accommodations from all Commonwealth agencies,” said Tatum A. Pritchard, Director of Litigation at the Disability Law Center.

Experts presented by the plaintiffs confirmed that there are many effective means of emergency notification—including visual alarms like strobe lights and tactile alerts—that could serve as appropriate accommodations for deaf and hard-of-hearing people. After years of review and discussion, even DOC officials have acknowledged the “system wide” need for such accommodations.

“We are thrilled that incarcerated deaf and hard-of-hearing people have secured accommodations for their disabilities,” said Kaitlin Banner, Deputy Legal Director at Washington Lawyers’ Committee for Civil Rights and Urban Affairs. “However, it’s disappointing that it required a lawsuit to ensure that people in Massachusetts are guaranteed their right to safety. Massachusetts was not the first state that we’ve fought for access to emergency alarms, but we hope it will be the last state where such a suit is necessary.”

In its ruling, the court ordered the DOC to develop comprehensive policies for each prison to ensure that deaf and hard-of-hearing prisoners can finally receive lifesaving emergency notifications on equal terms with people who do not have disabilities. The court recognized that anything less would subject these incarcerated people to unacceptable risks to their safety and well-being in violation of federal law.

“Deaf and hard-of-hearing prisoners in Massachusetts have been left in their cells during emergencies because DOC has unlawfully refused to provide reasonable accommodations to protect them from dying in a fire. This ruling confirms what we have argued all along – that visual alarms are necessary to protect the health and safety of these individuals and allow them equal access to emergency notifications. I want to thank our clients for their courage and perseverance in this long fight to achieve justice,” said James Pingeon, Litigation Director at Prisoners Legal Services.

The DOC will have until May 16, 2024, to propose a comprehensive policy that provides effective emergency alerts to all deaf and hard of hearing incarcerated people. After plaintiffs have a chance to review and comment, the policy will be submitted to the court for final review and approval.

The alarm system and evacuation plan were the remaining claims not addressed by a comprehensive settlement agreement approved by the court in 2019 in the Briggs litigation. That settlement remedied a wide range of issues faced by incarcerated people with hearing disabilities, including access to hearing aids and sign language interpreters, videophones and captioned telephones, and discrimination in workplace assignments. DOC’s compliance with the terms of that settlement agreement is still being monitored by the court.

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For more information, contact Prisoners’ Legal Services of Massachusetts Communications Director Aaron Steinberg at asteinberg@plsma.org.

FOR IMMEDIATE RELEASE

Contact: Rick Glassman

rglassman@dlc-ma.org

DLC Report Exposes Practice of Diverting Millions Annually of SSA Benefits from Vulnerable Foster Youth in Massachusetts

Investigation reveals systemic issues in DCF’s allocation of Social Security benefits

BOSTON, MA (September 26, 2023): In a comprehensive report released today, Disability Law Center, Inc. (DLC), sheds light on a concerning practice within the Massachusetts Department of Children and Families (DCF) that impacts some of the state’s most vulnerable children and young adults. The report, based on extensive research and data analysis, highlights the diversion of millions of dollars in Social Security Administration (SSA) benefits from children in foster care to the state’s General Fund, potentially robbing these already disadvantaged young adults of a brighter future.

The report can be found below.

The report comes immediately ahead of a hearing today of the Joint Committee on Children, Families, and Persons with Disabilities on legislation (H.157 / S.65) to end this practice and protect the benefits of youth in foster care. DLC will testify at the hearing.

DCF acts as the representative payee for approximately 1,250 children in foster care who are eligible to receive SSA benefits each month, either due to their own disability or based on a parent’s wage-earning record, specifically because their parents have retired, become disabled, or passed away. Instead of passing these funds onto the children or their foster families, or holding them in escrow for when they age-out of the system at age 21, DCF redirects a staggering 90% of these funds – totaling approximately $450,000 to $500,000 a month – into the state’s General Fund. Many of these children are unaware that they are eligible for SSA benefits, further compounding the issue. Annually, around $5.5 million in SSA benefits meant for these vulnerable youth is funneled away for the state’s own use, rather than being allocated for their care and future prospects. The practice disproportionately affects BIPOC and LGBTQ+ youth, who are overrepresented in the foster care system and more likely to experience disability.

The report highlights statistics that underscore the challenges faced by transition-age youth (age 21) in Massachusetts foster care:
40% lack stable housing;

• 74% are not enrolled in post-secondary education;
• 32% have not obtained a high school diploma;
• 46% do not have part- or full-time employment;
• 23% have experienced incarceration; and
• 18% are parents.

“The report we’ve released today underscores a critical point: these SSA benefits, meant to provide a safety net for the most vulnerable among us, are not being directed toward the betterment of foster care services or the well-being of these children. Instead, they are siphoned away, exacerbating the challenges these youth face as they navigate a complex and often unforgiving system,” said Barbara L’Italien, Executive Director of DLC, the Commonwealth’s Protection and Advocacy (P&A) system and a nonprofit organization advocating for human rights, empowerment, and justice for people with disabilities. “The practice not only raises serious ethical concerns but also fails to align with the core principles of justice and equity that should guide our approach to child welfare. It’s high time for a reevaluation of DCF’s policies.”

Rick Glassman, the lead author of the report and DLC’s Director of Advocacy, said the diversion of these funds is not only a public policy issue, it’s a moral one. “The amount of money is meaningless to a state with a $55 billion budget and an approximately $7.2 billion reserve fund. But to a young adult aging out of foster care, it can mean the difference between a transition to independence and life on the streets.”

The report highlights recommendations for reform within DCF to protect vulnerable youth in the foster care system. Similar policies in other states have been subjected to widespread criticism from national media, and as a result many states have adopted or introduced new policies or legislation to help young people conserve these benefits for adulthood.

“We must ensure that young adults, as they age out of foster care here in Massachusetts, have access to the social security benefits to which they are entitled to jumpstart their financial independence as they transition,” said Senator Jo Comerford (D-Northampton). “I am proud to sponsor a bill that would ensure these benefits are protected for youth in foster care, and would require DCF to provide financial literacy training to these individuals. Grateful for my partnership with Representative Tricia Farley-Bouvier, the Disability Law Center, and the Committee for Public Counsel Services.”

Amy Karp, an attorney at the Committee for Public Counsel Services, which represents children and young adults in foster care, said “these bills will protect some of our most vulnerable clients, those who leave DCF without a permanent connection to parents, family or community. If we permit children in foster care to retain the federal benefits to which they are legally entitled, we can change the trajectory of their lives.  No youth should leave foster care to live on the streets.”

Other key recommendations include ending the practice of diverting SSA benefits from these children, safeguarding their assets for future independence, implementing universal screening to determine eligibility for adult SSA benefits, transparently notifying children and their guardians when DCF becomes their representative payee, and proactively seeking responsible family members or supporters to manage benefits where possible.

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Action Alert on Outpatient Commitment: This fall, the legislature’s Judiciary Committee will finish its hearing on the outpatient commitment (IOC) bill, H.164/S.980. If you would like to oppose this, instructions for submitting written testimony are at https://malegislature.gov/Events/Hearings/Detail/4637.  See also https://malegislature.gov/Search/FindMyLegislator

More information is available at https://www.mamh.org/advocacy/take-action/involuntary-outpatient-commitment

Read DLC’s written testimony submitted to the Judiciary Committee:

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DLC submitted written testimony to the legislature about the crisis in continuous skilled nursing, including the inability of families to find nurses to fill allotted hours, and the flaws in the assessment tool which approves only small fragments of time for nursing coverage.

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FOR IMMEDIATE RELEASE

August 1, 2023

Contact:
Tatum A. Pritchard
Director of Litigation
Disability Law Center
617-315-4612
tpritchard@dlc-ma.org

Disability Law Center Again Recommends Transfer of Oversight of Bridgewater State Hospital to the Department of Mental Health Due to Continuing Health and Safety Risks and Rights Violations

Boston, MA – The Disability Law Center (DLC) has issued its July 2023 report detailing findings and recommendations from its intensive monitoring activities at Bridgewater State Hospital (BSH), including the Bridgewater Annex Units at Old Colony Correctional Center.

DLC covers an array of topics in the report, all of which indicate that health and safety risks and serious rights violations abound at the Department of Correction (DOC) facility run by contractor Wellpath, despite recent reform efforts. For example, DLC finds that: incomplete efforts to address the presence of mold and stifling conditions in housing unit cells leave BSH Persons Served at risk; BSH Persons Served continue to be subjected to violent interventions and illegal chemical and physical restraint and seclusion practices; and access to medical care for many BSH Persons Served remains inadequate. In examining continuity of care issues for current and former Persons Served, DLC discusses impediments to timely and successful transfers to DMH facilities and Mental Health Watch practices in several county correctional facilities.

After almost a decade of monitoring, DLC again urgently calls on the Commonwealth to transfer oversight of the BSH population to the Department of Mental Health (DMH) and to construct a new psychiatric hospital. While DLC offers several interim recommendations to address immediate needs and interests of Persons Served, the report emphasizes that protecting the health, safety, and rights of those with complex mental health needs and disabilities who are involuntarily committed to BSH can only be accomplished with a transfer of power and closure of the infamous facility.

”DLC’s long-term monitoring efforts, supported by Line Item #8900-0001, provide critical insight into the conditions and treatment offered to individuals with complex mental health needs behind the walls of Bridgewater State Hospital. DLC welcomes the bond money now appropriated by the Governor to complete a study of the development a new hospital and urges the state to prioritize the overdue shift from a correctional model to a therapeutic mental health approach overseen by the Department of Mental Health.” Barbara A L’Italien, Executive Director, DLC.

As Massachusetts’ designated Protection and Advocacy, DLC is authorized under federal law to investigate incidents of abuse, neglect, and death of individuals with disabilities throughout the Commonwealth. Line Item #8900-0001 of the FY 2023 Budget provides DLC funding and enhanced legislative authority to monitor the efficacy of service delivery reforms, physical plant, and continuity of care at BSH.

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FOR IMMEDIATE RELEASE

May 8, 2023

Contact:
Tatum A. Pritchard
Director of Litigation
Disability Law Center
617-315-4612
tpritchard@dlc-ma.org

Disability Law Center Investigation Finds Neglect in Cancer-Related Death of an Individual Involuntarily Committed to Lemuel Shattuck Hospital

Boston, MA – The Disability Law Center (DLC) issued a public report today outlining findings of neglect and recommendations concerning the death from cancer of an individual with mental health disabilities who was involuntarily committed to the Metro Boston Mental Health Units at the Lemuel Shattuck Hospital (LSH). As the designated Protection and Advocacy agency for Massachusetts, DLC is authorized under federal law to investigate incidents of abuse, neglect, and death of individuals with disabilities throughout the Commonwealth.

The report discusses the experience of Mr. Harris (a pseudonym), a Black man from Boston diagnosed with schizoaffective disorder, who developed a cancerous lesion on his nose that was not properly diagnosed or treated for more than a year and a half while he was inpatient at LSH. As part of the investigation, DLC’s medical expert concluded that Mr. Harris would have had a high chance of survival had his cancer been treated promptly at or soon after his initial presentation. Unfortunately, LSH provided Mr. Harris medical treatment that failed to comport with the standard of care in a several ways, including by failing to diagnose through biopsy and appropriately treat his lesion; failing to ensure that Mr. Harris received a timely surgical referral to remove the lesion; and failing to obtain informed consent for Mr. Harris’ treatments from his legal guardian, despite medical records indicating that Mr. Harris did not have the ability to provide such consent.

DLC provided LSH, the Department of Public Health, and the Department of Mental Health its initial findings and recommendations for corrective action in 2022. DLC also gave these entities an advance copy of the public report prior to its release. In response to DLC’s findings, LSH conducted a thorough review and ultimately implemented key changes aimed at improving care for LSH patients, including: requiring LSH dermatology staff to photograph skin lesions and wounds for the medical record; requiring biopsies on “all conditions identified as ‘lesion,’ ‘growth’ [or] ‘suspicion of skin malignancy’ prior to initiating treatment; and developing new formal processes and practices to ensure better communication between LSH providers.

DLC recognizes the importance of the corrective action LSH has taken and the many changes in LSH administration since the time of Mr. Harris’ death but believes that more must be done to address the lack of or unequal access to quality medical care that people with mental health disabilities experience every day in our Commonwealth. ”Mr. Harris’ death is a tragic example of what can happen when a health care system fails to be attentive and accommodate the medical needs of a vulnerable individual – an example made worse by the fact that he was institutionalized at LSH to protect him from harm based on to the severity of his mental health disability,” stated Barbara L’Italien, Executive Director of the Disability Law Center.  As discussed in the report, it is well-established that many individuals with mental health disabilities experience poor health outcomes and unequal access to health care. Compounding these experiences are the institutional racism in U.S. health care delivery systems and pervasive health disparities for communities of color, women, people who identify as LGBTQIA+, people with Limited English Proficiency, people with low incomes, and people with other disabilities. While the Commonwealth continues to make efforts to improve health equity, barriers persist and must be dismantled, especially in public hospitals like LSH.

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FOR IMMEDIATE RELEASE

February 1, 2023

Contact:
Tatum A. Pritchard
Director of Litigation
Disability Law Center
617-315-4612
tpritchard@dlc-ma.org

Disability Law Center Finds Continuing Systemic Rights Violations and Health and Safety Risks at Bridgewater State Hospital

Boston, MA – The Disability Law Center (DLC) has issued our January 2023 public report summarizing findings and recommendations arising out of intensive monitoring efforts at Bridgewater State Hospital (BSH) from July 2022 through December 2022. The report examines both continuing and new concerns discovered during this reporting period related to facility conditions and BSH policies and practices that negatively impact the rights, health, and safety of BSH Persons Served.

Among the topics discussed is the continuing widespread presence of mold growth throughout BSH, as confirmed by DLC’s expert, despite the costly mold remediation and asbestos abatement efforts the Department of Correction undertook in response to DLC’s 2022 reports. The presence of environmental toxins, in combination with sanitation issues, vermin infestation, recurring power outages, and ineffective heat mitigation efforts during the summer months, put Persons Served at risk. In addition, systemic violations of Massachusetts law regarding chemical and physical restraint and seclusion persist at BSH, resulting in foreseeable physical and psychological harm to Persons Served. Likewise, inadequate language access for individuals with Limited English Proficiency and many impediments to successful continuity of care following discharge from BSH remain unchanged.

DLC’s report also raises two new issues related to treatment of BSH Persons Served. First, information DLC gathered during this reporting period indicates that access to treatment for individuals with substance use disorder is insufficient and BSH providers may be inappropriately tapering and terminating access to Medication Assisted Treatment. Second, DLC presents serious concerns about BSH’s introduction of an “atypical antipsychotic” taken via inhalation as a treatment option for Persons Served, despite the medication’s association with increased risk of bronchospasm and contradictions for people with respiratory conditions and aging individuals with dementia.

In the report, DLC provides sweeping recommendations for addressing the issues examined. Ultimately, however, in keeping with past reports, DLC concludes that protecting PS – people with complex mental health needs who are forced to submit to evaluation and treatment at BSH – requires that the Commonwealth transfer oversight of the population to the Department of Mental Health and commit to building a new hospital.

”DLC’s intensive, long-term monitoring efforts, made possible through the support and expanded authority granted by Line Item #8900-0001, provide unique and critical insight into the treatment of people with complex mental health needs at Bridgewater State Hospital. With the new administration comes a renewed request to prioritize the overdue shift from a correctional model to a therapeutic mental health approach overseen by the Department of Mental Health.” Barbara A L’Italien, Executive Director, DLC.

As the designated Protection and Advocacy agency for Massachusetts, DLC is authorized under federal law to investigate incidents of abuse, neglect, and death of individuals with disabilities throughout the Commonwealth. Line Item #8900-0001 of the FY 2023 Budget provides DLC funding and enhanced legislative authority to monitor the efficacy of service delivery reforms, physical plant, and continuity of care at BSH.

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Read the Report