williams v rauner...court monitor fy2018 compliance assessment annual report to the court gail p....

WilliamsvRAUNER

CaseNo.05-C4673(N.D.Ill.)

CourtMonitorFY2018ComplianceAssessmentAnnualReporttotheCourt

GailP.Hutchings,MPACourtMonitor

November2,2018

Case: 1:05-cv-04673 Document #: 494 Filed: 11/05/18 of 96 PageID #:8075

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TableofContentsExecutiveSummary………………………………………………………………………………………….……PageiiiSectionI:Introduction.……………………………………………………………………………………..……Page1SectionII:OverviewofFY2018ComplianceAssessmentFindings………………………..Page10SectionIII:DiversionforWilliamsClassMembers……………………………………….……….Page23SectionIV:OutreachtoWilliamsClassMembers………………………………………….……..Page31SectionV:EvaluationofClassMembersforTransitionAppropriateness…….….…..Page40SectionVI:ServicePlanningforWilliamsClassMembers………….……………………..…Page47SectionVII:TransitionActivitiestoSupportClassMembers…..……….…….……………Page56SectionVIII:Community-BasedServicesandHousingCapacityDevelopment.…...Page69SectionIX:AdministrativeRequirements……………………….….……………….….….….……Page74SectionX:ImplementationPlanning……………………………….…..…………..…………………Page81Conclusion..………………………………………………………………………………………………………...Page88


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ExecutiveSummaryThisreportisintendedtoprovideJudgeJoanLefkow,SeniorUnitedStatesDistrictJudge,NorthernDistrictofIllinois,andtheWilliamsConsentDecreePartieswiththeCourtMonitor’sthoroughassessmentontheDefendants’(andotherswhenrelevant)fiscalyear2018performanceunderWilliamv.Rauner(CaseNo.05C4673),specificallycompliancewiththeobligationsoftheWilliamsConsentDecree.Withinthisreport,theCourtMonitorendeavorstoprovidetheCourtwithafairandneutralassessmentoftheDefendants’performancerelativeto50requirementsintheConsentDecree,aswellastheCourtMonitor’sperformancerelativetotwoadditionalrequirements.ThisisthepresentCourtMonitor’sfirstreporttotheCourtunderWilliamsv.Rauner.InJuneof1999,theUnitedStatesSupremeCourtruledinfavoroftwowomenwhowereunnecessarilyconfinedtoaGeorgiapsychiatrichospitalandheldinthegroundbreakingOlmsteadv.L.C.,527U.S.581(1999)thatunnecessarysegregationandconfinementofpeoplewithdisabilitiesviolatestheAmericanswithDisabilitiesAct,creatingalegalpathwayandrecoursetochallengesystemsthatinappropriatelyrelyoninstitutionalcareanddonotpermitpeopletochoosetoliveintheleastrestrictivesettingappropriatetotheirneeds.Approximatelysixyearslater,inAugustof2005,twopeoplewithmentalillnessesresidinginInstitutesforMentalDiseases(IMDs)1filedalawsuitallegingthattheStateofIllinoiswasinviolationofTitleIIoftheAmericanwithDisabilitiesActandSection504oftheRehabilitationAct.Thelawsuitcontendedthatthepersonswithmentalillnesswereneedlesslysegregatedininstitutionalsettingsanddeniedtheopportunitytoreceiveservicesinmoreintegratedcommunity-basedsettings.InSeptemberof2010,theWilliamsv.QuinnConsentDecreewasfiled,whichspecifiedtheState’sobligationstoaffordClassMemberstherightstoliveinthemostintegratedsettingspossible,throughconcertedeffortstodivertindividualsfrominappropriateplacementinto,andtransitioneligibleindividualsoutof,the24privately-ownedWilliamsfacilitiesacrossIllinois.TheWilliamsConsentDecreehas61distinctrequirements.Ofthose,11requirementsareeitherduplicatedrequirements,arenotrelevanttothecomplianceperiod,orapplytotheCourtMonitor.Theremaining50requirementsrelatetospecificobligationsfortheDefendantsonly,focusedoncomplianceacrossseveralinterlockingdomains,includingdiversion,outreach,evaluation,serviceplanning,transitions,communityservicesandhousingdevelopment,administration,andimplementationplanning.Figure1summarizestheCourtMonitor’scompliancedeterminationsrelativetoallConsentDecreerequirements.Ofthe50distinctrequirementsapplicabletoFY2018,theDefendantsareincompliancewith11requirements(22%),inpartialcompliancewith10requirements(20%),andout-of-compliancewith29requirements(58%).1ThetermsInstitutesofMentalDiseases(IMDs)andSpecializedMentalHealthRehabilitationFacilities(SMHRFs),


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Figure2illustratescompliancedeterminationsrelativetoeachdomain,aggregatingtothetotalnumberofrequirementsfallingwithineachcompliancecategory.Withinthisreport,thereisadedicatedsectionforeachofthecompliancedomainslistedbelow,whichincludestheCourtMonitor’srationaleforeachcomplianceassessmentrating.

Figure2.SynopsisofFY2018ComplianceAssessmentsforWilliamsConsentDecreeRequirements

Total#and%byDomain-FY18Requirements

ComplianceAssessmentRatingsbyDomain

Diversion-RelatedComplianceAssessmentRatings InCompliance PartialCompliance Out-of-Compliance

2(100%) 0(0%) 0(0%) 2(100%) Outreach-RelatedComplianceAssessmentRatings

InCompliance PartialCompliance Out-of-Compliance3(100%) 1(33%) 2(67%) 0(0%)

Evaluation-RelatedComplianceAssessmentRatings Incompliance Partialcompliance Out-of-compliance

7(100%) 2(29%) 2(28%) 3(43%) ServicePlanning-RelatedComplianceAssessmentRatings InCompliance PartialCompliance Out-of-Compliance

9(100%) 0(0%) 3(33%) 6(67%) Transition-RelatedComplianceAssessmentRatings InCompliance PartialCompliance Out-of-Compliance

7(100%) 1(14%) 2(29%) 4(57%) Community-BasedServices&HousingComplianceAssessmentRatings


Administrative-RelatedComplianceAssessmentRatings InCompliance PartialCompliance Out-of-Compliance

7(100%) 6(86%) 1(14%) 0(0%) ImplementationPlanning-RelatedComplianceAssessmentRatings InCompliance PartialCompliance Out-of-Compliance

13(100%) 1(8%) 0(0%) 12(92%)

InCompliance:11(22%)

PartialCompliance:10(20%)

Out-of-Compliance:29(58%)

Figure1.Defendants'CompliancewithWilliamsConsentDecreeRequirements (TotalRequirements=50)


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DespitesubstantialFY2018under-performance,theDefendantshaveahistoryofnear-compliancewithtransitionrequirements,achievinggreaterthan90%oftransitionsforfiveofsevenyearsofConsentDecreeimplementation.Further,theDefendantshave–overthepastsevenyears–developedseveralprocesses/systemsthathaveproveneffectiveanddurable.Theseinclude,butarenotlimitedto,anoutreachinfrastructure,mechanismstofacilitatehighpercentagesofClassMemberstransitioningintoPermanentSupportiveHousing(theConsentDecree-requiredhousingoption),evaluationeffortsthatreachasignificantproportionofClassMembers,andaspecializedclinicalteamtoreviewproviderdecisionstooverturnordelayrecommendedtransitionsforclinical,medical,financialandotherreasons.Itisalsoimportanttorecognizethatto-date,theDefendantshavetransitionedmorethan2,300ClassMembers,andqualityoflifedatarevealsthattheirliveshavesignificantlyimproved.TheDefendantsconductanevaluationofClassMemberswhohavetransitionedsincethebeginningoftheWilliamsConsentDecree,surveyingthematpre-transition,6monthsaftertransition,12monthsaftertransition,and18monthsaftertransition.Theoutcomesofthisevaluationareunequivocal:onaverage,ClassMembersself-reportbetteraccesstocare,qualityofcare,satisfactionwiththeircare,socialconnectedness,andtreatmentplanparticipationaftertheyhavetransitionedoutofWilliamsfacilities.Ofnote,ratesofClassMembersatisfactionwithtreatmentandservicesaveraged66.4%priortotransition,andjumpedto89.6%at6monthspost-transition,and90.1%at12monthspost-transition.2Behindthesefiguresarerealpeople,suchasDebra,3oneoftheoriginalWilliamsClassMembers.Debra’sstoryprovidesasalientexampleofhowtransitioningoutofaWilliamsfacilitycandrasticallyimproveClassMembers’qualityoflife,increasetheirparticipationinthecommunity,andsupporttherealizationoftheirpotentialwhichbenefitsthebroadercommunity.InAugustof2018,theCourtMonitorlearnedthatDebraremainslivinginthecommunity.Sheistacklinganumberofpersonalchallenges,includingswitchingtoanewpsychiatrist,managingherauditoryhallucinations,andattemptingtoquitsmoking.Debraattendsweeklytherapy,participatesinaweeklyartclass,andregularlyvisitsalocalcommunitycenterforpeersupportandsocialization.DebraservesasanAmbassadorintheWilliamsprogram,sharinghertransitionstorytobuildconnections,fosterhope,andmodeltootherClassMembersconsideringtransitioningthatasuccessfultransitionandlifeinthecommunityis,infact,possible.Unfortunately,asignificantportionofDebra’scohortoforiginalClassMembersisnotlivinginthecommunity.Dataregardingthedispositionoftheoriginal4,169ClassMembers(asofJune30,2018)revealsthatnearlyeightyearsafterConsentDecreeimplementation,1,613(39%)remaininWilliamsfacilities,657(16%)aredeceased,and763(18%)arenowresidinginothernursingfacilities.Anadditional180ClassMembers2WilliamsvRaunerConsentDecree.WilliamsSemi-AnnualReport14.July1,2017–June30,2018.SubmittedSeptember13,2018.3ThisClassMember’snamehasbeenreplacedwithapseudonymtopreserveheranonymityandconfidentiality.


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arenolongerintheClassastheyarenotonMedicaid.Eightyearslater,ofthe4,169originalClassMembers,only602(14.5%)havebeentransitionedtothecommunityundertheWilliamsprogramandanadditional354(8.5%)havebeentransitionedthroughnon-Williamsprograms.Despiteyearsofnear-compliancewithWilliamstransitionrequirements,aserioustrendhasbegunthatrequiresimmediateattentionandchange.AsdisplayedinFigure3,infiscalyears2012to2017,theDefendantsaveragedaperformanceoutcomeforClassMemberstransitionsof92.5%.Fortheassessmentperiodcoveredbythisreport,FY2018,theDefendants’performancepercentagedecreasedto79%.AsoftheendofthefirstquarterofFY2019,theDefendantsperformancehassignificantlydroppedevenmorewithonly41achievedtransitionsoutofthe1004required.WhiletheDefendantshavetheremainderofFY2019toincreasethenumberandrateoftransitions,ifthecurrentrateremainsconstantfortherestofFY2019,onecanexpectaperformanceoutcomeofonly41%,anall-timelowmarkduringtheentiretyoftheWilliamsprogramwithseriousconsequencesforClassMembersnowandinthefuture.

Figure3.ClassMemberTransitions:FiscalYears2012–2018FiscalYear(FY) #TransitionsRequiredbyFY #TransitionsAchievedbyFY5 Performance%62012 256 26378 103%92013 384 354 92%2014 423 320 76%2015 390 374 96%2016 400 374 94%2017 400 377 94%2018 400 315 79%TheDefendants’majordomainsofnon-compliance–describedinmoredetailthroughoutthisreport-arerelatedtobarriersatthehighestlevelofWilliamsfunctioning.TheseissuesrepresentareasinwhichtheDefendantspossessinherentstrengths,capital,andresourcescapableofreversingunderperformance,andunlesspromptlyaddressed,willresultintheprogram’scontinueddecline.Theseissuesinclude:

4Atotalof400transitionsarerequiredduringFY2019;the100figureusedhererepresentsone-quarterofthefiscalyear’srequiredtransitionstoapplycontexttothenumberoftransitionsachievedduringthefirstquarter.5147ClassMemberswereduplicateswhosignedmorethanoneleaseinmorethanonefiscalyear.Thisfiguredoesnotincludethose147ClassMembers(DMHdata,August15,2018).6Ibid.7TheDefendantsreported294transitions,however,thisnumberincluded31ClassMembersweretransitionedoutsideoftheWilliamsprogram;thisfiguredoesnotincludethesetransitions(DMHdatafromAugust15,2018).8DatareportedforFY12includedtransitionsthroughNovemberof2012,thusexceedingthefiscalyearby5months.ItisunclearifandhowmanyofthosetransitionswerealsoreportedinFY13transitiondata(DMHdatafromAugust15,2018).9DatareportedforFY12includedtransitionsthroughNovemberof2012,thusexceedingthefiscalyearby5months.ItisunclearifandhowmanyofthosetransitionswerealsoreportedinFY13transitiondata(DMHdatafromAugust15,2018).


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§ Absenthigh-levelleadershipwithauthorityandaccountability.Achangeindirectiontoreversethedownwardtrendoftransitionsandotherareasofnon-compliancewillrequirestronger,proactiveleadership,resultinginaclearlyarticulatedvisiontocomplywithandeventuallyexittheDecree,asenseofurgency,acommitmenttosystems-levelchange,andagilesystemsandproviderdevelopment.Withoutthisnewforce,theDefendantswilllikelyremainintheinertiathathasresultedinsixconsecutiveyearsofnon-compliancerelativetotransitionrequirementsandothercriticaltermsoftheDecree.

§ Inadequateactionregardingstate-andsystem-widediversion.TheConsentDecreeobligatestheDefendantstohaveredesigneditsnursingfacilityscreeningprocessbyJuneof2016,resultinginacontrolledfrontdoortothesystem.Twoyearsafterthisduedate,diversioneffortsremainedlimitedtoasmallpilotandthenursingfacilityscreeningprocessremainsmateriallybroken,resultingininappropriateadmissionsintoWilliamsfacilitiesandagrowingWilliamsClasssize.

§ Lackofdata-drivendecisionmaking.AgreatdealofClassMember-leveldataexistsandisavailabletotheDefendantsforuseininformingrequisiteproviderandsystems-levelinvestments,neededprocessimprovements,andotheractionsanddecisionstosupportgreatercomplianceandattainmentofnumerictransitionrequirementsandtoalleviatetheon-goinginfringementofClassMembers’rights.ThereexistsnocoherentWilliams-wideuseofsuchdataanddecision-makingaboutprogrammaticplanningandimplementation.

§ Insufficientprovidertype,quantity,andcapacitytoaddresssignificantandrecurringbarriers.TheDefendantsassertthatthecurrentWilliamsClassismoremedicallyandpsychiatricallycomplex,renderingthemmoredifficulttotransition.Regardlessofthisclaim’sveracity,theDefendantsmustdevelopnewservicesandsupportsthatmatchClassMemberintensityofneed.Variousevidence-basedandpromisingservicesandsupports–suchasbenefitsacquisitionsupportforthosewithlowornoincomesorenhancedAssertiveCommunityTreatmentteamsthatserveindividualswithmedicalcomplexities–couldhelppropeltheDefendantsintocompliance.TheDefendantsshowlittleseriousconsiderationorattemptsatimplementingahostofbestpractices,todate,largelyignoringproviderfeedback,formerandcurrentCourtMonitorandotherexpertrecommendations,andothersuccessfulstateandlocalgovernmenteffortstotransitioninstitutionalizedpopulations.

Inthisreport,theCourtMonitorhasprovidedcontextualdatatoassisttheCourtandthePartiesinunderstandingthefullscopeanddetailofobservedcomplianceissues.Inaddition,specificrecommendationsareofferedfortheDefendants’considerationtoachieveorenhancecompliance,andassuch,advancethecivilrightsofpeoplewithpsychiatricdisabilities,whilefacilitatingtheirfullparticipationin,contributionto,and,infact,enrichmentofcommunitylife.GailP.Hutchings,MPACourtMonitorWilliamsv.RaunerNovember2,2018


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SectionI.Introduction—BackgroundandContextThisreportpresentstheCourtMonitor’sassessmentratingsandrelevantdiscussionsoftheDefendants’complianceunderWilliamsv.Rauner(CaseNo.05C4673;UnitedStatesDistrictCourtfortheNorthernDistrictofIllinois–EasternDivision)basedontheassessmentperiodoffiscalyear2018.Thereport’sbasesforassessmentofcomplianceincludetheoriginalWilliamsConsentDecreerequirements.ThereportisissuedinfulfillmentoftheConsentDecree’srequirementfortheCourtMonitorto,“Within60daysaftertheendofeachyearofservice,theMonitorwillreporttotheCourtandthePartiesregardingnoncompliancewiththeDecree.Suchreportsshallincludetheinformationnecessary,intheMonitor’sprofessionaljudgment,fortheCourtandthePlaintiffstoevaluateDefendants’complianceornon-compliancewiththetermsoftheDecree.TheMonitormayfileadditionalreportsasnecessary.ReportsoftheMonitorshallbeservedonallParties.”10JudgeLefkowappointedGailP.Hutchings,MPA,asCourtMonitorforWilliamsv.RauneronSeptember29,201711;thisisherfirstWilliamsConsentDecreecomplianceassessmentreporttotheCourt.12ComplianceAssessmentPeriod.TheperiodofcomplianceassessmentcoveredbythisreportisJuly1,2017toJune30,2018,otherwisereferredtoasfiscalyear2018orFY2018.Othersignificantdevelopmentsthatoccurredpriortoorsubsequenttothattimeframearementionedwhendeemedrelevanttoreaders’understandingofcontext,trends,andthelike.CaseinBrief.TheWilliamsConsentDecreewasfiledonSeptember29,2010.13In2005,PlaintiffsbroughtsuitintheUnitedStatesDistrictCourt,NorthernDistrictofIllinois,allegingviolationsofTitleIIoftheAmericanswithDisabilitiesAct(ADA)andSection504oftheRehabilitationActbysegregatingandinstitutionalizingadultswithmentalillnessesin24Williamsfacilities,alsoInstitutionsforMentalDiseases(IMDs),locatedacrossIllinoisandfailingtoprovideopportunitiesforthoseindividualstoliveandreceiveservicesinthemostintegratedsettingappropriatetotheirneeds.ThelawsuitnamedfiveDefendantsinIllinoisstategovernment,includingtheGovernor,SecretaryoftheIllinoisDepartmentofHumanServices,theDirectoroftheDivisionofMentalHealthoftheIllinoisDepartmentofHumanServices,theDirectoroftheIllinoisDepartmentofHealthcareandFamilyServices,andanyoftheirsuccessors.14TheDefendantsdidnot

10Williamsv.Quinn,CaseNo.05C4673,UnitedStatesDistrictCourtfortheNorthernDistrictofIllinois,EasternDivision.FiledSeptember29,2010.Pg.21.11JudgeLefkowappointedMs.HutchingstoalsoserveasCourtMonitorforColbertv.Rauner(CaseNo.07C4737)onSeptember26,2017.12TheworkandcontributionsofJakeBowling,MSW,tothecomplianceassessmentreportaregratefullyacknowledged.13Williamsv.RaunerwastransferredfromJudgeWilliamT.HarttoJudgeJoanLefkowonSeptember8,2017.14Williamsv.Blagojevich,CaseNo.05C4673,UnitedStatesDistrictCourtfortheNorthernDistrictofIllinois,EasternDivision.FiledAugust15,2005.Pg.7.


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admittoviolationsandaConsentDecreewasagreeduponbytheParties15andenteredbytheCourtonSeptember10,2010.TheDivisionofMentalHealthintheDepartmentofHumanServiceswasvestedastheleadimplementationagencyfortheConsentDecreesincetheonsetoftheprogram’simplementation.TheConsentDecreedefinesWilliamsClassMembersas,“AllIllinoisresidentswhoareeighteen(18)yearsofageorolderandwho:(a)haveaMentalIllness;(b)areinstitutionalizedinaprivatelyownedInstitutionforMentalDiseases;16and(c)withappropriatesupportsandservicesmaybeabletoliveinanintegratedcommunitysetting.17TheConsentDecreeenumeratesspecificrequirementsplacedontheDefendants,sometime-limitedandothersongoing,pertainingtoactivitiesnecessitatedbytheConsentDecree,whichincludediversion,outreach,evaluations,serviceplans,community-basedserviceandhousingcapacitydevelopment,transitions,implementationplanning,andadministrativerequirements.TheConsentDecreeidentifiestheprocesstohireaCourtMonitor,specifieshisorherduties,grantstohimorherspecificpowers,andstatesobligationsforcompliancetorequeststhatarerelevanttothefulfillmentoftheCourtMonitor’sduties.TheConsentDecreealsonamesspecificinstancesinwhichthePlaintiffsandtheCourtMonitoraretobeinvolvedinvariousprocessesandstatesthattheCourtwillmakefinaldeterminationsonmattersthatthePartiescannotagreeupon.VariouscourtordersfiledbeforetheendoftheFY2018complianceassessmentperiodthathaveimpactedrequirementsundertheConsentDecreehavebeenrecordedandinclude,butarenotlimitedto:§ WilliamsConsentDecreeOrder,enteredonSeptember29,2010;§ TheinitialImplementationPlan,approvedonJuly29,2011;§ TheOrderbytheHonorableWilliamT.HartappointingDennisJones,MSW,MBA,as

CourtMonitor,signedonNovember1,2010;§ TheOrdertosubstituteBruceRaunerforPatQuinnasnamedDefendant

(Governor),signedonJanuary29,2015;§ ThecasereassignedtotheHonorableJoanH.Lefkowforallfurtherproceedings,

September8,2017;and,§ TheOrderbytheHonorableJoanH.LefkowappointingGailHutchings,MPA,as

CourtMonitor,signedonSeptember26,2017.

15TheoriginalPartiestoWilliamsv.QuinnincludeClassCounsel(AmericansCivilLibertiesUnionofIllinois;KirklandandEllis,EquipforEquality,andBazelonCenterforMentalHealthLaw)andDefendants(GovernoroftheStateofIllinois,theSecretaryoftheIllinoisDepartmentofHumanServices,theDirectoroftheDivisionofMentalHealthoftheIllinoisDepartmentofHumanServices,theDirectoroftheIllinoisDepartmentofPublicHealth,theDirectoroftheIllinoisDepartmentofHealthcareandFamilyServices).16ThetermsInstitutesofMentalDiseases(IMDs)representsaFederalclassification(pursuanttoMedicaidregulations)assignedtohospitals,nursingfacilities,orotherinstitutionsthateachhavemorethan16beds,serveadults,andwheremorethan50%ofitsresidentshavediagnosesofseriousmentalillness.17Williamsv.Quinn,Case1:05-cv-04673;Docket#326,Filed3/15/10;Page2of23.


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ConversionofWilliamsfacilitiesfromIMDstoSMHRFs.Ofthe24Williamsfacilities(seetextbox)namedintheConsentDecree,astheresultoflegislationpassedin2013,21arenowreferredtoasSpecializedMentalHealthRehabilitationFacilities,orSMHRFs,twoareseekingSMHRFstatusbutstilloperateaslong-termcarefacilities,andonerecentlyannounceditsclosureinFall2018.18AllarestillInstitutesofMentalDisease(IMDs).TheCourtMonitorisunclearabouttherationaleforre-classifyingthesefacilitiesasSMHRFsfromnursingfacilities.Inhersitevisitstofiverandomly-selectedWilliamsfacilities(acknowledgingthatthisrepresentsalimitednumber/sampleofWilliamsfacilities),theCourtMonitorwasgravelyconcernedabouttheapparentlackofactivetreatmentandotherconditionswithinthesefacilities.(MoredetailregardingobservedconditionswithinSMHRFsisprovidedinSectionV).

TheformerCourtMonitoralsohadconcernsabouttheappropriatenessandoversightoftheSMHRFstotheextentthatherequestedthestatetoengageaqualifiedconsultingfirmtoexplorethemeritsofmovingfiscalcontrolofSMHRFsfromtheDepartmentofHealthcareandFamilyServices(HFS)totheDepartmentofHumanServices’(DHS)DivisionofMentalHealth(DMH)andwhethersuchatransfermightenhancecomplianceundertheWilliamsConsentDecree.InFebruaryof2018,BakerTillysubmittedtheFiscalResponsibilityTransferAssessment,19informallyreferredtoasthefeasibilitystudy.TheconsultantssuggestedthatitwouldbetoocostlytotransferSMHRFfiscaloversightfromHFStoDHS/DMH.Whilethetransferoffiscalcontrolwasnotrecommended,thefirmofferedseveralotherimportantrecommendationstostrengthenfiscalandoperationalefficiencyofSMHRFsandtheiroversight.TherecommendationsaddressedissuesthatcontinuetothwartConsentDecreecomplianceincluding:improvingcommunicationandcoordinationwithManagedCareOrganizations(MCOs)throughstrongercasemanagementprocedures,contractingwithanon-DMHentityforutilizationmanagementtoauthorizecareandpaymentwithinSMHRFs,andimplementingaco-ledoversightstructurebetweenDMHandHFS.DespitecommitmentsfromtheDefendantstoconsidertheserecommendationsandmultiplerequestsfromtheCourtMonitortobeapprisedofsuchdeliberationsandtheir

18MonroePavilionsubmittednoticeofclosuretotheIllinoisDepartmentofPublicHealtheffectiveNovember10,2018,thusreducingthenumberoffacilitiescoveredundertheWilliamsConsentDecreefrom24to23.19FiscalResponsibilityTransferAssessment.BakerTilly.SubmittedFebruary2018.

DefiningTerms.ThetermsInstitutesofMentalDiseases(IMDs)andSpecializedMentalHealthRehabilitationFacilities(SMHRFs),whileoftenusedinterchangeably,denotedifferentthings.AnIMDisaFederalclassification(pursuanttoMedicaidregulations)assignedtohospitals,nursingfacilities,orotherinstitutionsthateachhavemorethan16beds,serveadults,andwheremorethan50%ofitsresidentshavediagnosesofseriousmentalillness.UnderthetermsoftheSpecializedMentalHealthRehabilitationActof2013,aSMHRFisoneofthe24facilitiespreviouslycategorizedaslong-termcarefacilitiesthatwerere-classifiedasSpecializedMentalHealthRehabilitationFacilities.ManyusethesetwotermsinterchangeablyinWilliams-relatedprogramdocumentationanddiscussions.Forthepurposesofthisreport,theterminologyusedtorefertothese24facilitiescollectivelyis“Williamsfacilities.”


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outcome(s),nofurtherinformationhasbeenprovidedandtherecommendationsappeartohavegoneignoredwithnocommitmentsordiscernableactions.SizeofWilliamsClass:FY2012–FY2018.DeterminationofthetotalsizeofthecurrentWilliamsMemberClassentailscountingtwosubgroups:thoseresidinginWilliamsfacilities/IMDsandhavenotleftpursuanttotheWilliamsConsentDecreeprocessandthosewhohavebeentransitionedoutofthesefacilitiesundertheConsentDecreeimplementationintocommunity-basedhousingandservicessettings.20Thefirstsub-group–thoseresidinginWilliamsfacilities-isreferredtoasthecensus.21

Figure4providesdataonthetotalcensusofthe24Williamsfacilitiesperfiscalyear-endbetween2012and2018.Forthecomplianceassessmentperiod,IllinoisDepartmentofHealthcareandFamilyServicesdataindicatesafacilitystatuscensustotalof3,808residents(reportedasofthefirstdayofFY2018),22adecreaseof282residentsor6.9%sinceFY2012.Thesecondsub-groupofthecurrentClassentailsthenumberofClassMemberstransitionedintothecommunitythroughtheWilliamsprogram.AlsoindicatedinFigure4,asoftheendoftheFY2018complianceassessmentperiodandsincethebeginningofFY2012,theDefendantshavetransitionedatotalof2,23823ClassMembers.

Figure4.WilliamsClassSize:FY2012toFY2017andNumberandPercentageofClassMembersTransitionedbyYear

FiscalYear24

24Williams’FacilitiesCensus

Year-to-Year%Change(FacilityCensusOnly)

NumberofTransitionedClassMembers

%OfTransitionedClassMembersbasedonTotalClassSize(FacilityCensusOnly)

2012 4090 (Baseline) 26325,26 6.4%2013 4058 -0.8% 354 8.7%2014 3852 -5.1% 321 8.3%2015 3830 -0.6% 374 9.8%2016 3776 -1.4% 374 9.9%2017 3776 0.0% 377 10%2018 3808 +0.8% 315 8.3%20Athirdsub-groupofWilliamsClassMembersincludesthosewholeftWilliamsfacilities(IMDs),butdidnotdosoundertheWilliamsprogram.TheseindividualsarenotconsideredtobepartofthecurrentClasssize(Plaintiffs’responselettertoCourtMonitorDraftReport,October16,2018).21HFSIMDcensusincludesMedicaid-eligibleresidentsforthetimeperiod.22TheClassMembercensusrepresentsapoint-in-timefigurethatvariesovertime;thecensuscountincreasesthroughouttheyearduetoadmissionsanddecreasesduetotransitions,deaths,andotherdischarges.23147ClassMemberswereduplicateswhosignedmorethanoneleaseinmorethanonefiscalyear.Thisfiguredoesnotincludethose147ClassMembers(DMHdatafromAugust15,2018).24Thecensusisthetotalnumberofresidentsasofthefirstdayofthefiscalyear(e.g.FY2012figurewasbasedoncensusasofJuly1,2011).25TheDefendantsreported294transitions,however,thisnumberincluded31ClassMemberstransitionedoutsideoftheWilliamsprogram;thisfiguredoesnotincludethesetransitions(DMHdatafromAugust15,2018).26DatareportedforFY12includedtransitionsthroughNov.2012,exceedingthefiscalyearby5months.ItisunclearifandhowmanyofthosetransitionswerealsoreportedinFY13transitiondata(DMHdatafromAugust15,2018).


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OftheoriginalClass,1,613ClassMembers(39%)stillremaininWilliamsfacilities,657(16%)aredeceased,and763(18%)arenowresidinginothernursingfacilities.Anadditional180ClassMembersarenolongerClass-eligible,astheyarenotonMedicaid.Further,ofthe4,16927originalClassMembers,only602(14.5%)havebeentransitionedundertheWilliamsprogram.Williams’FacilitiesResidentCensusTrendsAnalysis.WhilenotaspecificrequirementundertheConsentDecree,onecanexaminetheWilliams’facilitiesresidentcensusdatatodeterminetrendswithintimeframesasanindicationofprogressrelatedtothestate’seffortstowardoveralllong-termcaresystemsrebalancingeffortsthatespousesmovingawayfrominstitutionalcaretocommunitycare.BasedonHFSdatareportedabove,betweenFY2012andFY2018,thetotalresidentcensusoftheWilliamsfacilitiesdeclinedbyatotalof282residents,representingadownwardchangeof6.9%.Averagedbyyear,thisisanannualchangeof1.2%.Duringthesametimeframe,thenumberofClassMemberstransitionedannuallytothecommunityasapercentageoftheportionoftheClasssizecomprisedbyClassMembersinWilliamsfacilitiesrangedfrom6.4%to10%.

OnepotentialcauseforthisslowdownwardtrendinWilliamsfacilitiescensusisanuncontrolledsystemfrontdoorissue,specificallyasitrelatestotheinappropriateadmissionofpeoplewithseriousmentalillnessintoWilliamsfacilities/IMDsandotherinstitutions.TheDefendantsobligationtoinstitutetheneededprocessestoavoidinappropriateIMDplacements—throughtheredesignofnursingfacility-screeningprocesses,knownasPre-AdmissionScreeningandResidentReview(PASRR)—isclearintheConsentDecree.MoredetailonthisissueasitspecificallyrelatestoIllinois’apparentlyflawedscreeningprocessiscontainedinSectionIIofthisreport.Notonlyistheimportanceofeffectivediversionprogramsconsistentwiththebestpracticesofhighqualityhealth/mentalhealthsystems,butitisalsoanintegralstrategytoassisttheDefendantsincomplyingwithandexitingtheDecree.TheDecreerequiredtheDefendantstoinstituteastatewidediversionprogramtodivertadultswithseriousmentalillnessfromunnecessaryWilliamsfacilitiesadmissionsbyJune2016.However,whiletheyhaveimplementedadiversionpilotprogram—andafterpressurefromtheCourtMonitorandPlaintiffsagreedtoscaletheprogramto22morehospitalsinFY2019—theyhaveresistedimplementationofafullstatewidediversionprogram,onethattheConsentDecreerequirestoresultin,“noindividualwithMentalIllnesswhoseServicePlanprovidesforplacementinCommunity-BasedSettings[being]…housedorofferedplacementinanIMDatpublicexpenseunless…heorshedeclines”theopportunitytotransition.28InOctoberof2018,theDefendantsrevealedthattherequiredstatewidediversionprogramwouldnotbeexpandedinFY2019,duetostatecontractingandprocurementissues,furtherdelayingcompliance.

27ThenumberdiffersslightlyfromtheoriginalcensusdatareportedinFigure4becauseHFSprovidedanupdatednumberinOctober18,2018tocorrectapreviousformulaerror.28WilliamsConsentDecree,SectionVI.


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NumberofTransitionsbyYear:Requiredvs.Achieved.Figure5depictsthenumberofannualCourt-requiredtransitionsofClassMembersfromWilliamsfacilitiestocommunity-basedsettingsversusthosetransitionsachievedbyyearsincethebeginningoftheConsentDecree’simplementation.29BetweenFY2012andFY2018,atotalof2,238ClassMembershavebeentransitioned,withtheDefendantsonly(potentially)exceedingtransitionrequirementsinoneoutofthesevenyearsofWilliamsimplementation.Forthisreport’speriodofcomplianceassessment,FY2018,theDefendantstransitionedatotalof315ClassMembersoutoftherequired400,resultinginaperformancerateof79%,theirsecond-worstperformanceperiodsincetheDecree’scommencementandasteepdeclinefromprioryears’performance.

Figure5.ClassMemberTransitions:FiscalYears2012–2018FiscalYear(FY) #Transitions

RequiredbyFY#Transitions

AchievedbyFY30PerformancePercentage31

2012 256 2633233 103%342013 384 354 92%2014 423 320 76%2015 390 374 96%2016 400 374 94%2017 400 377 94%2018 400 315 79%Notably,whileoutsideofthecomplianceassessmentperiodforthisreport,dataforFY2019compliancewithtransitionrequirementsisavailableforthefirstquarterofthefiscalyear(July1,2018toSeptember30,2018).Thisdataisrelevanttothisreportasitdemonstratesthecontinuingandconcerningdownwardtrendintransitionperformance.TheWilliamsFY2019ImplementationPlanrequired400transitionsandasofSeptember30,2018(25%intothefiscalyear),andonly41(or10%)oftherequiredtransitionshavebeenachieved.WhiletheDefendantshavetheremainderofFY2019toincreasetransitionnumbersandrates,ifthiscurrentrateremainsconstant,only40%oftherequiredtransitionswillbemetbyfiscalyear’send.Transitionperformanceforfiveofthepastsevenyearsresultedingreaterthan90%compliance;thusthedramaticdecreasesinFY2018andto-dateinFY2019aretroubling.ThesenegativeoutcomesundoubtedlyrequireathoroughreexaminationandsignificantchangestothecurrentresourcesandprocessesusedtotransitionWilliamsClassMembers.

29DataprovidedbyIllinoisDivisionofMentalHealth,8-15-18.30147ClassMemberswereduplicateswhosignedmorethanoneleaseinmorethanonefiscalyear.Thisfiguredoesnotincludethose147ClassMembers(DMHdatafromAugust15,2018).31Ibid.32TheDefendantsreported294transitions,however,thisnumberincluded31ClassMemberstransitionedoutsideoftheWilliamsprogram;thisfiguredoesnotincludethesetransitions(DMHdatafromAugust15,2018).33DatareportedforFY12includedtransitionsthroughNovemberof2012,thusexceedingthefiscalyearby5months.ItisunclearifandhowmanyofthosetransitionswerealsoreportedinFY13transitiondata(DMHdatafromAugust15,2018).34Again,datareportedforFY12includedtransitionsthroughNovemberof2012,thusexceedingthefiscalyearby5months.ItisunclearifandhowmanyofthosetransitionswerealsoreportedinFY13transitiondata(DMHdatafromAugust15,2018).


7

ClassMemberDemographics.ThefollowingoffersasnapshotofClassMemberdemographics(i.e.,race,gender,age),retrievedfromregistrationdatacapturedbytheMentalHealthCollaborativeforAccessandChoice,whichservesastheAdministrativeServicesOrganizationfortheWilliamprogram.ThisdatareflectsthoseClassMembersapprovedfortransitionandassignedtotransitionentitiesandwhoseinformationisenteredintoadatabaseasapartoftheirinitialregistrationprocess.35Demographiccharacteristicsof4,136ClassMembersinclude:§ Race:1,914(57.4%)areBlack,1,984(48%)areWhite,129(3.1%)areclassifiedas

“race/ethnicitynotavailable,”433areAsian(1.6%),andtheremaining43ClassMembers(1%)areAmericanIndian/AlaskaNative,reportmorethanonerace,orareNativeHawaiianorotherPacificIslander,respectively.36

§ Gender:2,708(65.5%)aremaleand1,428(34.5%)arefemale;§ Age:340(8.2%)areage65andolder,2,242(54.2%)areage45-64,1,452(35.1%)are

age25-44,97(2.3%)are21to24,andfive(.1%)areage18-20.§ HistoryofMentalHealthTreatment:45.4%ofClassMembershaveahistoryof

continuoustreatmentformentalhealthproblems,63.3%haveahistoryofcontinuousresidentialtreatmentduetomentalillness,60.3%haveahistoryoflivinginmultipleresidentialsettings,and74.3%haveahistoryofreceivingoutpatientmentalhealthservices.37

§ Diagnoses:Data38showthat66.8%haveaprimarydiagnosisofschizophreniaandotherpsychoticdisorders,30.1%arediagnosedwithbipolarandmooddisorders,andtheremainderofdiagnosesincludeanxietyandstressdisorders,disordersofchildhoodoradolescence,andothermentaldisorders.39

WilliamsProgramBudgetedvs.ActualExpenditures.TheWilliamsprogramisallocatedamultimillion-dollarbudgettocoverstaffcosts,contractors(e.g.,organizationsthatprovideoutreach,evaluation,andtransitionservices),evaluationandqualityimprovementsupport,andotherkeyprogramactivities.Itisimportanttonotethatthisbudgetdoesnotincludecostsformainstreamresourcesthat—whileavailabletoandusedbysomeWilliamsClassMembers—arenotexclusivelydevelopedordesignatedforthem,suchassomeMedicaidspending,housingsubsidies,community-basedbehavioralhealthservices,healthcare,andhousingservicesdevelopedorpaidforoutsideofConsentDecreeimplementationactivities.

35ThisdatareflectsallWilliamsClassMemberswhowereregisteredbytransitionagenciessinceConsentDecreeinceptioninOctober2011.36Thesumofthesepercentagesexceeds100%becausesomeClassMembershaveself-reportedmorethanonerace/ethnicitycategory.37Thesecategoriesarenotmutuallyexclusive.38ThisdataisreportedasInternationalClassificationofDiseases(ICD)10diagnoses.39ThetotalnumberofICD-10frequenciesequals3,544.ThisislessthantheoverallnumberofClassMembersinthedatabase(4,136)becausesomeindividualshaveICD-9scoresinstead.


8

InFY2018,theannualWilliamsprogrambudgetwascloseto$44.8million.40InFY2018,approximately$37.841wasspent,constituting84%budgetexpenditureversusallocationrate.InFY2017,onlyabout$36.2millionwasactuallyexpendedoutofabudgetof$42.4million,representing85%ofthebudget.42ThesefiscalyearsandassociatedspendingratesarepartofamultiyearpatternofunderspendingwithintheallocatedWilliamsprogrambudget.ThisfiscaldataindicatesthatwhiletheDefendantswereunabletomeettransitionrequirementsinFY2017andFY2018,inadditiontofacingalargenumberofout-of-complianceassessmentsandrelatedissuesasreflectedinthisreport,theyareinexplicablyleavingsignificantresourcesunspentthatcouldsupportcomplianceinanumberofareas,rangingfrominvestinginthedevelopmentofadditionalcommunity-basedproviderandhousingcapacitytothedesignandimplementationofarobustnursingfacilitydiversionprogram.ComplianceAssessmentApproach.TheCourtMonitorendeavoredtouseastraightforwardandtransparentapproachtoplanandcarryoutthecomplianceassessmentapproachunderWilliamsforFY2018.DuringtheCourtMonitor’sfirstLargePartiesMeetinginDecember2017andinatleastsixsubsequentmeetingsandwrittendocuments,thePartieswereinformedthatcomplianceassessmentwouldbeconductedforeachrequiredelementintheoriginalConsentDecreeasupdatedbyanysubsequentCourtdocumentsimpactingthoserequirements(i.e.,ImplementationPlans).ThestatedexpectationwasthattheDefendantswoulddemonstratecomplianceundereachcontemporaryrequirementwithdata(inallpossiblecircumstances)andrelevantinformationthatprovidesneededcontextforafairandneutralcomplianceassessment.TheCourtMonitormetwithDHS,includingDMH,staffinFebruary2018todiscussfeedbackonSemi-AnnualComplianceReport13,whichwassubmittedinDecemberof2017,andexpectationsforfuturereports.DuringbothMayandJuly2018,theCourtMonitorprovidedtheDefendants,viatheDHS/DMHprojectleadandDHScounsel,withaspreadsheetthatlistedeachrequiredWilliamscomplianceelementbasedontheoriginalConsentDecreeandsubsequentdocumentsthatupdatedorotherwiseamendedcompliancerequirements.TheDefendantsagreedtousetheCourtMonitor-providedframeworkfortherequiredSemi-AnnualComplianceReports.InFebruaryandJuly,respectively,theDefendantssubmittedtherequiredSemi-AnnualCompliancereports;thefirstreportcoveredthereportingperiodofJuly1toDecember31,2017,andthesecondcoveredJanuary1toJune30,2018.Foreachreport,theCourtMonitorconductedananalysisofrequiredversussubmittedinformationneededtoassesscomplianceandprovidedtheDefendantswithtwoadditionalopportunitiestosubmitthemissingdataandinformation.Insomeinstances,theDefendantsultimately

40ExactamountbudgetedforFY2018was$44,792,900.DHSdataprovidedOctober5,2018.41AsofOctober5,2018,DHSreported$37,757,912.30wasspentduringFY2018andnotedthatadditionalexpenditurescouldstillresultbeforethefiscalyearisclosedout.42TheFY2017Budgetwas$42,392,900and$36,167,630wasspent(DHSdataprovidedonOctober5,2018).


9

providedtherequireddataandinformationandforotherstheydidnot.Relevantsectionsinthisreportreflectbothcircumstances.ComplianceAssessmentReportDevelopmentProcess.TheCourtMonitorandherstaffrelieduponavarietyofinformationanddatasourcesindevelopingthereport,includinginformationprovidedbythePartiesduringmonthlyLargePartiesMeetingsandotheradhocmeetings;CourtStatusHearings;Semi-AnnualComplianceReports;WilliamsImplementationPlansandAmendments;variousreportsanddocumentsissuedbythestateanditscontractors;otherdataandinformationreportedbythestate;IllinoisStatestatutes,policies,andadministrativerules;informationprovidedbythePlaintiffsandkeyinformants(e.g.,ClassMembers,outreach,service,andhousingprovideragencystaff,Ombudsman);andobservationsandinformationderivedfrominterviews,medicalandotherrecordsreviews,andmaterialsfromtheCourtMonitor’ssitevisitstoarandomlyselectedsampleofWilliamsfacilitieslocatedacrossIllinoisinJune2018.TheCourtMonitorhasnotauditedorotherwiseindependentlyverifiedreporteddataprovidedbythestateorothersources.Toensurethereport’sdataandotherfactualcontentaccuracy,adraftversionofthereportwassharedwiththeDefendantsandthePlaintiffs(Parties)onOctober8,2018andtheywereprovidedanopportunitytoidentifyfactualerrorsoromissions.TheDefendantsandthePlaintiffsprovidedseparatewrittenresponses.ThefinalreportincorporateschangesorcommentstotheextentthattheCourtMonitoragreedthatcorrectionswerejustifiedandappropriate.


10

SectionII.OverviewofFY2018ComplianceAssessmentFindings

TheWilliamsConsentDecreecontains50specificnumeric-,process-,andquality-relatedrequirementsoftheDefendantsthatarefocusedondesigning,developing,andimplementingaprogramthatfacilitatesandoperationalizesopportunitiesforeligibleClassMemberswithseriousmentalillnesstore-enterthecommunityfromunnecessaryconfinementinthe24Williamsfacilities(InstitutesofMentalDisease).TheserequirementsspanmultipledomainsoftheDefendants’obligationspursuanttotheWilliamsConsentDecree,includingdiversion,outreach,evaluation,serviceplanning,transitionsupport,expansionordevelopmentofcommunity-basedhousingandservices,implementationplanning,andadministrativesupport.TwoadditionalConsentDecreerequirementsfocusontheCourtMonitor’sdutiesandthePartiesandCourtMonitor’sinvolvementinvariousplanningandreportingaspects.Thefollowingfivesectionsofthisreportaddresstheindividualdomainsofdiversion,outreach,evaluation,serviceplanning,andtransitionsupport,respectively,andreflectthestep-by-stepsequencebywhichaClassMembermightinterfacewithWilliamsprogramprocesses(seeFigure6).Followingthesesections,threeadditionalsectionsfocusonthedomainsofexpansionofcommunity-basedservicesandhousing,implementationplanning,andadministrationandreporting.Withineachdomain,thespecificrequirementsrelativetothatdomainasdictatedbytheConsentDecreearelistedinsequentialorderastheyalignwiththeprocessitself;thus,theymaynotreflecttheorderofthecompliancerequirement(s)astheyappearedinsourcedocuments(i.e.ConsentDecree).Finally,theCourtMonitorsoughttonotassessandreportcomplianceonduplicatedrequirements,whichlikelyworkedtobenefittheDefendants.Figure6.SequenceofBasicWilliamsProcessesbyDomain

TheindividualcompliancedomainsillustratedinFigure6includethesubsequentelementsintheirdedicatedsections:

1. AdescriptionofhowthedomainrelatestooverallConsentDecreecompliance.2. AcomplianceassessmentratingsgridthatdepictstheCourtMonitor’sassessment

ofwhethertheDefendants(orothers,whenrelevant)achievedcompliancewith

AdministrativeSupport

Outreach Evaluation ServicePlan TransitionDiversion

Services&Housing

Development

ImplementationPlanning


11

specificrequirementsassociatedwiththatdomainduringtheFY2018assessmentperiod.EachcompliancecriterioncorrelatestotheConsentDecree.

3. RelevantdataandinformationusedbytheCourtMonitortoreachthecompliancedeterminationandassessmentratingwithadditionalnarrativeandanalysis.

4. RecommendationsofferedbytheCourtMonitorforconsiderationonactionsand/oractivitiesintendedtoassisttheDefendantswithachievingorstrengtheningcompliancewithrequirementsrelevanttothedomain.

Forthereport’spurposes,oneofthreecomplianceassessmentdeterminations(incompliance,partialcompliance,out-of-compliance)wasassignedtoeachWilliamsConsentDecreerequirementthatisapplicabletothecomplianceassessmentperiodofFY2018.ConsentDecreelanguageorprovisionsthatdonotapplytothereportingperiod,reflectCourtMonitororClassCounselobligations,orrepresentrepeatlanguage,arecodedassuch.Figure7displaysthecomplianceassessmentdeterminationcategoriesusedbytheCourtMonitorandtheirdefinitionofuseinthereport.

SomerequirementsundertheWilliamsConsentDecreeareclearlynumeric/quantitativeinnature(e.g.,numberofrequiredClassMembertransitions),whileothersrequiretheCourtMonitor’sevaluationandcompliancedeterminationbasedonthebestavailabledataandthe“CourtMonitor’sprofessionaljudgment.”44Inbothcircumstances,data

43ThemajorityofrequirementsapplytotheDefendants.ComplianceoccasionsthatinvolveothersamongthePartiesand/ortheCourtMonitorareidentifiedassuch.44WilliamsConsentDecree,SectionIX.

Figure7.CourtMonitorComplianceAssessmentRatingCategoriesandDefinitionsComplianceAssessmentRatingCategory

Definition

Legend

InCompliance TheDefendants’43performancewassubstantiallyinaccordancewiththecriterion,requirement,orobligation.

Green

PartialCompliance

TheDefendantshavemetsomeaspectsorpartsandhavenotmetsomeaspectsorpartsofthecriterion,requirement,orobligation.Fornumericrequirements,theCourtMonitorgenerallyassignedthisratingininstanceswheretheDefendantsachievedmorethan50%compliancebalancedwithwhethertheDefendantshadasystemorprocessinplacerelativetothespecificrequirement.

Yellow

Out-of-Compliance

TheDefendantseitherfailedtocomplywiththerequirementorfailedtodemonstratecompliancewiththestandard.

Red

OtherCategories:NotRelevanttoReportingPeriod

TheDefendantswerenotrequiredtodemonstratecompliance,astherequirementisapplicableonlybeforeoraftertheFY2018assessmentperiod.

RequirementofCourtMonitor

RequirementsreflectobligationsoftheCourtMonitor.

RepeatedLanguage

Requirementshavealreadybeenrepresentedandrated(eitherseparatelyorwithinotherrequirements)anddoublecountingwouldskewtheoverallcompliancedetermination.


12

andinformationisprovided,withsourcecitation,tosupportorjustifytheCourtMonitor’scomplianceassessmentdeterminations.Figure8showsthat,amongthe50distinctrequirementsapplicabletotheDefendantsinFY2018,theDefendantswereassessedasincompliancewith11requirements(22%),inpartialcompliancewith10requirements(20%)andout-of-compliancewith29requirements(58%).

Figure9reflectstherequirementsfromtheConsentDecree,dividedintotheeightcompliancedomainslistedaboveandprovidestheCourtMonitor’sFY2018complianceassessmentratingforeach.

InCompliance:11(22%)

PartialCompliance:10(20%)

Out-of-Compliance:29

(58%)

Figure8.Defendants'CompliancewithWilliamsConsentDecreeRequirements (TotalRequirements=50)

Figure9.FY2018ComplianceAssessmentRatingsforWilliamsConsentDecreeRequirements

FY2018ComplianceAssessmentRatingsforDiversion-RelatedRequirements

Req.# Source/Citation WilliamsConsentDecreeRequirementLanguage ComplianceRating

1 WilliamsConsentDecreeVI(8)(A)

Withinone(1)yearoffinalizationoftheImplementationPlan,noindividualwithMentalIllnessshallbeadmittedtoanIMDwithoutaprescreeninghavingfirstbeenconductedthroughthePASRRProcessandaninitialServicePlancompleted.DefendantswillensurethatthePASRRProcess:identifiesandassessesindividualswhomaybeappropriateforplacementinaCommunity-Basedsetting;identifiesCommunity-BasedServicesthatwouldfacilitatethatplacement;andensuresthatapprovedadmissionstoIMDsareonlyforthoseIMDsthatcanprovidetreatmentconsistentwiththeindividual'sinitialServicePlanandconsistentwiththegoaloftransitiontoaCommunity-BasedSetting.

Out-of-Compliance


13

2WilliamsConsentDecreeVI(8)(B)

Afterthefirstfive(5)yearsfollowingthefinalizationoftheImplementationPlan,noindividualwithMentalIllnesswhoseServicePlanprovidesforplacementinCommunity-BasedsettingsshallbehousedorofferedplacementinanIMDatpublicexpenseunless,afterbeingfullyinformed,heorshedeclinestheopportunitytoreceiveservicesinaCommunity-BasedSetting.

Out-of-Compliance

FY2018ComplianceAssessmentRatingsforOutreach-RelatedRequirements

3 WilliamsConsentDecreeVII(10)

DefendantsshallensurethatClassMembershavetheopportunitytoreceivecompleteandaccurateinformationregardingtheirrightstoliveinCommunity-BasedSettingsand/orreceiveCommunity-BasedServices,andtheavailableoptionsandopportunitiesfordoingso.

RepeatedLanguage

4WilliamsConsentDecreeVI(6)(C)

Defendantsshallensure,asprovidedintheImplementationPlan,thatallClassMembersshallbeinformedaboutCommunity-BasedSettings,includingPermanentSupportiveHousing,andCommunity-BasedServicesavailabletoassistindividualsinthesesettings,andthefinancialsupportClassMembersmayreceiveinthesesettings.

PartialCompliance

5 WilliamsConsentDecreeVI(9)(C)

ClassMembersshallnotbesubjectedtoanyformofretaliationinresponsetoanyoptionselectednorshalltheybepressuredtorefrainfromexploringappropriatealternativestoIMDs.

PartialCompliance


AllcostsforoutreachshallbebornebyDefendants. InCompliance

FY2018ComplianceAssessmentRatingsforEvaluation-RelatedRequirements


QualifiedProfessionalsshallinformClassMembersoftheiroptionspursuanttosubparagraphs6(a),6(d),and7(b)ofthisDecree.

InCompliance

8WilliamsConsentDecreeVI(6)(A)

Withintwo(2)yearsofthefinalizationoftheImplementationPlandescribedbelow,everyClassMemberwillreceiveanindependent,professionallyappropriateandperson-centeredEvaluationofhisorherpreferences,strengthsandneedsinordertodeterminetheCommunity-BasedServicesrequiredforhimorhertoliveinPSHoranotherappropriateCommunity-BasedSetting.

NotRelevanttoReporting

Period


Inadditiontoprovidingthisinformation,DefendantsshallensurethattheQualifiedProfessionalsconductingtheEvaluationsengageresidentswhoexpressconcernsaboutleavingtheIMDwithappropriatefrequency.

PartialCompliance

10WilliamsConsentDecreeVI(6)(B)

AnyClassMemberhastherighttodeclinetotakepartinsuchEvaluation.AnyClassMemberwhohasdeclinedtobeevaluatedhastherighttoreceiveanEvaluationanytimethereafteronrequest.

Out-of-Compliance


DefendantsshallensurethatEvaluationsareconductedbyQualifiedProfessionalsasdefinedinthisDecree.

InCompliance

12WilliamsConsentDecreeVI(6)(D)

AfterthesecondyearfollowingfinalizationoftheImplementationPlan,theEvaluationsdescribedinSubsection6(a)shallbeconductedannually.

PartialCompliance


14


AspartofeachClassMember'sannualEvaluation,thereasonsforanyClassMember'soppositiontomovingoutofanIMDtoaCommunity-BasedSettingwillbefullyexploredandappropriatelyaddressedasdescribedinSectionVII.

Out-of-Compliance


AnyClassMemberwhohasreceivedanEvaluationbuthasdeclinedtomovetoaCommunity-BasedSettingmayrequesttobereassessedfortransitiontoaCommunity-BasedSettinganytimethereafter.

Out-of-Compliance

FY2018ComplianceAssessmentRatingsforServicePlan-RelatedRequirements

15WilliamsConsentDecreeVI(7)(C)

TheServicePlanshallbedevelopedbyaQualifiedProfessionalinconjunctionwiththeClassMemberandhisorherlegalrepresentative.TheQualifiedProfessionalalsoshallconsultwithotherappropriatepeopleoftheClassMember'schoosing.

PartialCompliance


EachServicePlanshallfocusontheClassMember'spersonalvision,preferences,strengthsandneedsinhome,communityandworkenvironmentsandshallreflectthevalueofsupportingtheindividualwithrelationships,productivework,participationincommunitylife,andpersonaldecision-making.

Out-of-Compliance


BasedontheresultsoftheEvaluationsdescribedabove,DefendantsshallpromptlydevelopServicePlansspecifictoeachClassMemberwhoisassessedasappropriatefortransitiontoaCommunity-BasedSetting.

Out-of-Compliance

18 WilliamsConsentDecreeVI(7)(F)

TheServicePlanshallbecompletedwithinsufficienttimetoprovideappropriateandsufficienttransitionsforClassMembersinaccordancewiththebenchmarkssetforthintheDecree.

Out-of-Compliance

19 WilliamsConsentDecreeVI(7)(B)

ForeachClassMemberwhodoesnotopposemovingtoCommunity-BasedSetting,theServicePlanshall,ataminimum,describetheCommunity-BasedServicestheClassMemberrequiresinaCommunity-BasedSetting,andatimetableforcompletingthetransition.

Out-of-Compliance


ThoseClassMembersnottransitioningfromIMDstopermanentsupportivehousingwillhaveongoingreassessmentswithtreatmentobjectivestopreparethemforsubsequenttransitiontothemostintegratedsettingappropriate,includingPSH.

Out-of-Compliance


EachServicePlanshallbeperiodicallyupdatedtoreflectanychangesinneedsandpreferencesoftheClassMember,includinghisorherdesiretomovetoaCommunity-BasedSettingafterdecliningtodoso,andshallincorporateserviceswhereappropriatetoassistinacquisitionofbasicinstrumentalactivitiesofdailylivingskillsandillnessself-management.AcquisitionofsuchskillsshallnotbeaprerequisitefortransitioningoutoftheIMD.

Out-of-Compliance


15


IftherehasbeenadeterminationthataClassMemberisnotcurrentlyappropriateforPSH,theServicePlanshallspecifywhatservicestheClassMemberneedsthatcouldnotbeprovidedinPSHandshalldescribetheCommunity-BasedServicestheClassMemberneedstoliveinanotherCommunity-BasedSettingthatisthemostintegratedsettingappropriate.

PartialCompliance

23WilliamsConsentDecreeVI(7)(E)

TheServicePlanshallnotbelimitedbythecurrentavailabilityofCommunity-BasedServicesandSettings;provided,however,thatnothinginthissubparagraphobligatesDefendantstoprovideanytypeofCommunity-BasedServicebeyondthetypesofCommunity-BasedServicesincludedintheStatePlanandRule132.

PartialCompliance

FY2018ComplianceAssessmentRatingsforTransition-RelatedRequirements


PSHwillbeconsideredthemostintegratedsettingappropriateforClassMembersexceptthat,(1)foranyClassMembers(i)whohaveseveredementiaorotherseverecognitiveimpairmentsrequiringsuchahighlevelofstaffingtoassistwithactivitiesofdailylivingorself-caremanagementthattheycannoteffectivelybeservedinPSH,(ii)whohavemedicalneedsrequiringahighlevelofskillednursingcarethatmaynotsafelybeprovidedinPSH,or(iii)whopresentanimminentdangertothemselvesorothers,theevaluatorwilldeterminethemostintegratedsettingappropriate,whichmaybePSHoranothersetting,and(2)nothinginthisparagraphshallpreventClassMemberswhocanandwishtolivewithfamilyorfriendsorinotherindependenthousingthatisnotconnectedwithaserviceproviderfromdoingso.

PartialCompliance


ClassMemberswhomovetoaCommunity-BasedSettingwillhaveaccesstoallappropriateCommunity-BasedServices,includingbutnotlimitedtoreasonablemeasurestoensurethattheirhousingremainsavailableintheeventthattheyaretemporarilyplacedinahospitalorothertreatmentfacility.

PartialCompliance


Withinfive(5)yearsofthefinalizationoftheImplementationPlan,allClassMemberswhohavebeenassessedasappropriateforlivinginaCommunity-BasedSettingwillbeofferedtheopportunitytomovetoaCommunity-BasedSetting.

Out-of-Compliance

27WilliamsConsentDecreeVIII(15)

IntheeventthatanyIMDseekstodischargeanyClassMemberbeforeappropriatehousingisavailable,includingbutnotlimitedtocircumstancesinwhichanIMDdecidestoclose,Defendantswillensurethatthoseindividualsarenotleftwithoutappropriatehousingoptionsbasedontheirpreferences,strengths,andneeds.

Out-of-Compliance


16

28 WilliamsConsentDecreeVI(8)(G)

BytheendofthefifthyearafterthefinalizationoftheImplementationPlan,Defendantswillhave:(1)offeredplacementtoonehundredpercent(100%)ofallindividualswhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting;and(2)developedthecorrespondingnumberofPSHunitsorotherCommunity-BasedSettingssufficientfortheseindividuals.Forpurposesofthissubparagraph,theseindividualsincludethetotalof(1)allClassMembersasoftheendofthefourthyearafterthefinalizationoftheImplementationPlanwhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting,and(2)allformerClassMemberswhohavealreadytransitionedfromtheIMDtoaCommunity-BasedSettingortoanothercommunitysettingsincethefinalizationoftheImplementationPlan.

Out-of-Compliance

29 WilliamsConsentDecreeVI(8)(G)

ForpurposesofthisDecree,PSHincludesscattered-sitehousingasawellasapartmentsclusteredinasinglebuilding,butnomorethan25%oftheunitsinonebuildingwithmorethan4unitsmaybeusedtoservePSHclientsknowntohavementalillness.Forbuildingswith2to4units,nomorethan50%oftheunitsmaybeusedtoservePSHclientsknowntohavementalillness.However,duringfirst5yearsafterfinalizationoftheIP,upto75classmembersmaybeplacedinbuildingswheremorethan25%oftheunitsservePSHclientsknowntohaveMIifthosebuildingswereusedtoservePSHclientspriortoMarch1,2010.Afterfirst5yearsfollowingthefinalizationoftheIP,allclassmembersservedinPSHshallbeofferedtheopportunitytoresideinbuildingsthatcomplywith25%or50%unitslimitsetforthaboveinthissubparagraph.

InCompliance

30 WilliamsConsentDecreeVI(8)(H)

AftertheendofthefifthyearfollowingfinalizationoftheImplementationPlan,ClassMemberswhoareassessedasappropriateforlivinginaCommunity-BasedSetting,whodonotopposetransitiontoaCommunity-BasedSettingandwhoseServicePlansprovideforplacementinCommunity-BasedSettingsshallbeofferedtheopportunitytomovetothosesettingsandshallreceiveappropriateservicesconsistentwiththeServicePlanwithinonehundredandtwenty(120)daysofthedateoftheServicePlan.

Out-of-Compliance


BytheendofthefirstyearafterthefinalizationoftheImplementationPlan,Defendantswillhave:(1)offeredplacementinaCommunity-BasedSettingtoaminimumof256ClassMemberswhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting;and(2)developed256PSHunitsforthebenefitofClassMembers.


Period


17


BytheendofthesecondyearafterthefinalizationoftheImplementationPlan,Defendantswillhave:(1)offeredplacementinaCommunity-BasedSettingtoaminimumof640ClassMembers(includingthe256referencedinsubparagraph8cabove)whoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting;and(2)developed640PSHunitsforthebenefitofClassMembers.


Period

33 WilliamsConsentDecreeVI(8)(E)

BytheendofthethirdyearafterthefinalizationoftheImplementationPlan,Defendantswillhave(1)offeredplacementtoatleastfortypercent(40%)ofallindividualswhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSettings;and(2)developedthecorrespondingnumberofPSHunitsorotherCommunity-BasedSettingssufficientfortheseindividuals.Forpurposesofthissubparagraph,theseindividualsincludethetotalof(1)allClassMembersasoftheendofthesecondyearafterthefinalizationoftheImplementationPlanwhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting,and(2)allformerClassMemberswhohavealreadytransitionedfromtheIMDtoaCommunity-BasedSettingortoanothercommunitysettingsincefinalizationoftheImplementationPlan.


Period

34WilliamsConsentDecreeVI(8)(F)

BytheendofthefourthyearafterthefinalizationoftheImplementationPlan,Defendantswillhave(1)offeredplacementtoatleastseventypercent(70%)ofallindividualswhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting;and(2)developedthecorrespondingnumberofPSHunitsorotherCommunity-BasedSettingssufficientfortheseindividuals.Forpurposesofthissubparagraph,theseindividualsincludethetotalof(1)allClassMembersasoftheendofthethirdyearafterthefinalizationoftheImplementationPlanwhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting,and(2)allformerClassMemberswhohavealreadytransitionedfromtheIMDtoaCommunity-BasedSettingortoanothercommunitysettingsincefinalizationoftheImplementationPlan.


Period


18

35 WilliamsConsentDecreeX(21)

Withinsixty(60)daysofApprovaloftheDecree,DefendantsshalloffereachoftheNamedPlaintiffstheopportunitytoreceiveappropriateservicesinthemostintegratedsettingappropriatetohisorherneedsandwishes,includingPSH.ProvisionofservicestotheNamedPlaintiffspursuanttothisparagraphshallnotbeusedtodetermineanyotherindividual'seligibilityforservicesunderthetermsoftheDecree.


Period

FY2018ComplianceAssessmentRatingsforCommunity-BasedServices&HousingRequirements

36WilliamsConsent

DecreeV(5)

Defendantsshallensuretheavailabilityofservices,supports,andotherresourcesofsufficientquality,scopeandvarietytomeettheirobligationsundertheDecreeandtheImplementationPlan.

Out-of-Compliance

37WilliamsConsent

DecreeV(5)

Defendantsshallimplementsufficientmeasures,consistentwiththepreferences,strengths,andneedsofClassMembers,toprovideCommunity-BasedSettingsandCommunity-BasedServicespursuanttotheDecree.

Out-of-Compliance

FY2018ComplianceAssessmentRatingsforAdministrative-RelatedRequirements

38 WilliamsConsentDecreeIX(16)

TheCourtwillappointanindependentandimpartialMonitorwhoisknowledgeableconcerningthemanagementandoversightofprogramsservingindividualswithMentalIllnesses.ThePartieswillattempttoagreeontheselectionofaMonitortoproposetotheCourt.IfthePartiesareunabletoreachagreement,eachpartywillnominateonepersontoserveasMonitorandtheCourtwillselecttheMonitor.Withintwenty-one(21)daysofApprovaloftheDecree,thePartiesshallsubmittheirjointrecommendationorseparatenominationsforaMonitortotheCourt.IntheeventtheMonitorresignsorotherwisebecomesunavailable,theprocessdescribedabovewillbeusedtoselectareplacement.

InCompliance

39WilliamsConsentDecreeIX(18)

TheMonitorshallreviewandevaluateDefendants'compliancewiththetermsoftheDecree.Notlessthaneverysix(6)months,DefendantsshallprovidetheMonitorandPlaintiffswithadetailedreportcontainingdataandinformationsufficienttoevaluateDefendants'compliancewiththeDecreeandDefendants'progresstowardachievingcompliance,withthePartiesandMonitoragreeinginadvanceofthefirstreportofthedataandinformationthatmustbeincludedinsuchreport.

PartialCompliance


DefendantswillnotrefuseanyrequestbytheMonitorfordocumentsorotherinformationthatarereasonablyrelatedtotheMonitor'sreviewandevaluationofDefendants'compliancewiththeDecree,andDefendantswill,uponreasonablenotice,permitconfidentialinterviewsofDefendants'stafforconsultants,excepttheirattorneys.

InCompliance


19


TheMonitorwillhaveaccesstoallClassMembersandtheirrecordsandfiles,aswellastothoseserviceproviders,facilities,buildingandpremisesthatserve,orareotherwisepertinentto,ClassMembers,wheresuchaccessisreasonablyrelatedtotheMonitor'sreviewandevaluationofDefendants'compliancewiththeDecree.

InCompliance


TheDefendantsshallcomplywithPlaintiffs'requestsforinformationthatarereasonablyrelatedtoDefendants'compliancewiththeDecree,includingwithoutlimitationrequestsforrecordsorotherrelevantdocumentspertinenttoimplementationoftheDecreeortoClassMembers.PlaintiffsshallalsobepermittedtoreviewtheinformationprovidedtotheMonitor.AllinformationprovidedtotheMonitorand/orPlaintiffspursuanttotheDecreeshallbesubjecttotheProtectiveOrder.

InCompliance


DefendantsshallcompensatetheMonitorandhisorherstaffandconsultantsattheirusualandcustomaryratesubjecttoapprovalbythecourt.DefendantsshallreimburseallreasonableexpensesoftheMonitorandtheMonitor'sstaff,consistentwithguidelinessetforthinthe"Governor'sTravelControlBoardTravelGuideforStateEmployees."DefendantsmayseekrelieffromtheCourtifDefendantsbelievethatanyoftheMonitor'schargesisinappropriateorunreasonable.

InCompliance

44 WilliamsConsentDecreeXII(24)

ThecostofallnoticeshereunderorotherwiseorderedbytheCourtshallbebornebytheDefendants.

InCompliance


TheMonitor'sdutiesincludeevaluatingDefendants'compliancewiththeDecree,identifyingactualandpotentialareasofnon-compliancewiththeDecree,mediatingdisputesbetweentheParties,andbringingissuesandrecommendationsfortheirresolutiontotheCourt.Within60daysaftertheendofeachyearofservice,theMonitorwillreporttotheCourtandthePartiesregardingcompliancewiththeDecree.Suchreportsshallincludetheinformationnecessary,intheMonitor'sprofessionaljudgment,fortheCourtandPlaintiffstoevaluatetheDefendants'complianceornon-compliancewiththetermsoftheDecree.TheMonitormayfileadditionalreportsasnecessary.ReportsoftheMonitorshallbeservedonallParties.

CourtMonitorRequirements

—InCompliance


20


IntheeventthattheMonitorfindsDefendantsnotincompliancewiththeDecree,theMonitorshallpromptlymeetandconferwiththePartiesinanefforttoagreeonstepsnecessarytoachievecompliance.IntheeventthatPlaintiffsbelievethatDefendantsarenotcomplyingwiththetermsoftheDecree,PlaintiffsshallnotifytheMonitorandDefendantsofDefendants'potentialnon-compliance.TheMonitorthenshallreviewthePlaintiffs'claimsofactualorpotentialnon-complianceand,astheMonitordeemsappropriateinhisorherprofessionaljudgment,meetandconferwithDefendantsandPlaintiffsinanefforttoagreeonstepsnecessarytoachievecompliancewiththeDecree.IftheMonitorandPartiesagree,suchstepsshallbememorializedinwriting,filedwiththeCourt,andincorporatedinto,andbecomeenforceableaspartof,theDecree.IntheeventthattheMonitorisunabletoreachagreementwithDefendantsandPlaintiffs,theMonitororeitherPartymayseekappropriaterelieffromtheCourt.IntheeventthatPlaintiffsbelievethatDefendantsarenotincompliancewiththeDecreeandthattheMonitorhasnotrequestedappropriaterelieffromtheCourt,PlaintiffsmayseekrelieffromtheCourt.TheMonitorwillnotcommunicatewiththeCourtwithoutadvancenoticetotheParties.

CourtMonitorandPlaintiffs’Requirements

—InCompliance

47WilliamsConsentDecreeXI(22)

Infullsettlementofallattorneys'feesincurredtodateinconnectionwiththelitigation,Defendantsshallpay,subjecttocourtreviewandapproval,$1,990,000.00toClassCounsel.Infullsettlementofallout-of-pocketcostsandexpenses(nottoincludeattorneys'fees)incurredtodatebyClassCounsel,DefendantsshallpaytoClassCounselsuchcostsandexpensesincurredbyClassCounselthroughandincludingtheApprovaloftheDecreeandanyappealthereof.SuchamountsshallbedistributedtoClassCounselinthemannersetforthinwritteninstructionsprovidedbyClassCounsel.Furthermore,suchamountshallbesetforthinaJudgmentOrdertobeenteredbytheCourt.Defendantsshallcompleteandsubmitallpaperworknecessaryforpaymentofsuchamounts,plusapplicablestatutorypost-judgmentinterest,withinfive(5)businessdaysafterexpirationofthetimetoappealthefeeawardwithoutthefilingofaNoticetoAppealoraftertheissuanceofthemandatebythehighestreviewingcourt,whicheverislater.


Period

FY2018ComplianceAssessmentRatingsforImplementationPlan-RelatedRequirements

48WilliamsConsentDecreeVII(10)

TheImplementationPlanshalldescribemethodsbywhichsuchinformationwillbedisseminated,theprocessbywhichClassMembersmayrequestservices,andthemannerinwhichDefendantswillmaintaincurrentrecordsoftheserequests.

Out-of-Compliance


21


TheImplementationPlanshalldescribemethodsforengagingresidents,includingwhereappropriate,providingreasonableopportunitiesforresidentstovisitandobserveCommunity-BasedSettings.

Out-of-Compliance


Defendants,withtheinputoftheMonitorandPlaintiffs,shallcreateandimplementanImplementationPlantoaccomplishtheobligationsandobjectivessetforthintheDecree.

Out-of-Compliance

51 WilliamsConsentDecreeVIII(11)

TheImplementationPlanmust,ataminimum:a)Establishspecifictasks,timetables,goals,programs,plans,strategies,andprotocolstoassurethatDefendantsfulfilltherequirementsoftheDecree.

Out-of-Compliance


TheImplementationPlanmust,ataminimum:b)Describethehiring,trainingandsupervisionofthepersonnelnecessarytoimplementtheDecree.

Out-of-Compliance


TheImplementationPlanmust,ataminimum:c)DescribetheactivitiesrequiredtodevelopCommunity-BasedServicesandCommunity-BasedSettings,includinginter-agencyagreements,requestsforproposalsandotheractionsnecessarytoimplementtheDecree.

Out-of-Compliance


TheImplementationPlanmust,ataminimum:d)Identify,basedoninformationknownatthetimetheImplementationPlanisfinalizedandupdatedonaregularbasis,anyservicesorsupportsanticipatedorrequiredinServicePlansformulatedpursuanttotheDecreethatarenotcurrentlyavailableintheappropriatequantity,qualityorgeographiclocation.

Out-of-Compliance


TheImplementationPlanmust,ataminimum:e)Identify,basedoninformationknownatthetimetheImplementationPlanisfinalizedandupdatedonaregularbasis,anyservicesandsupportswhich,basedondemographicandotherdata,areexpectedtoberequiredwithinoneyeartomeettheobligationsoftheDecree.

Out-of-Compliance


TheImplementationPlanmust,ataminimum:f)IdentifyanynecessarychangestoregulationsthatgovernIMDsinordertostrengthenandclarifyrequirementsforservicestopersonswithMentalIllnessandtoprovideforeffectiveoversightandenforcementofallregulationsandlaws.

Out-of-Compliance


TheImplementationPlanmust,ataminimum:g)DescribethemethodsbywhichDefendantsshallensurecompliancewiththeirobligationsunderParagraph6(Evaluations)ofthisDecree.

Out-of-Compliance


TheImplementationPlanmust,ataminimum:h)DescribethemechanismsbywhichDefendantsshallensurecompliancewiththeirobligationsunderParagraph10(Outreach)ofthisDecree.

Out-of-Compliance


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TheImplementationPlanshallbeupdatedandamendedannually,oratsuchearlierintervalsasDefendantsdeemnecessaryorappropriate.TheMonitorandPlaintiffsmayreviewandcommentuponanysuchupdatesoramendments.IntheeventtheMonitororPlaintiffsdisagreewiththeDefendants'proposedupdatesoramendments,themattermaybesubmittedtotheCourtforresolution.

Out-of-Compliance


TheImplementationPlan,andallamendmentsorupdatesthereto,shallbeincorporatedinto,andbecomeenforceableaspartoftheDecree.

InCompliance


Within135daysofApprovaloftheDecree,DefendantsshallprovidetheMonitorandPlaintiffswithadraftImplementationPlan.TheMonitorandPlaintiffswillparticipateindevelopingandfinalizingtheImplementationPlan,whichshallbefinalizedwithinnine(9)monthsfollowingApprovaloftheDecree.IntheeventtheMonitororPlaintiffsdisagreewiththeDefendants'proposedImplementationPlan,themattermaybesubmittedtotheCourtforresolution.


Period


23

SectionIII.DiversionofWilliamsClassMembersAgreatdealofattentioninimplementingOlmstead-relatedConsentDecreesandotherlikeprogramscentersondownstreameffortstotransitionpeoplewithpsychiatricandotherdisabilitiesoutofinstitutionsandintothecommunitytocomplywiththeirrightstoliveintheleastrestrictivesettingappropriatetotheirneedsandtorestoretheirabilitytolivedignifiedandfulllivesintheircommunityofchoice.However,aproportionateamountofattentionmustbeaffordedtoupstream,diversion-focusedeffortsandactivities,includingthedevelopmentofassessmentprocedurestoidentifythosewhoareinappropriateforadmissionintoinstitutionsandhowtheycaninsteadaccessadequatecommunity-basedservicesandhousingresourcesthusprovidingalternativestoinstitutionalization.Moreover,effectivediversionrequirespartnershipswithentitiesthatmightotherwiserefertoinstitutionstoensuretheirabilitytopromptlyandefficientlyidentifyandconnectindividualstocommunity-basedservices.Onthesystems-level,diversioneffortscancreatemacro-levelcostsavings,45andprovideacomplianceandexitpathfromConsentDecrees.Moreimportantly,ontheindividuallevel,appropriatediversioncanpreventpeoplefrombeingtrappedinrestrictivesystemsandsettingsthatviolatetheirrights,erodepersonalfreedoms,jeopardizequalityoflife,andunderminethetruepromiseandpotentialofpeoplewithdisabilities.WithintheWilliamsConsentDecreetherearetwodistinctrequirementsrelatedtodiversion.ThefirstrequirementobligatestheDefendantstodesignandimplementascreeningandserviceplanningprocessthateffectivelydivertsindividualswithseriousmentalillnessfromWilliamsfacilitiesandlinksthemtoserviceandhousingalternativesinthecommunity-basedsystem.ThefederallymandatedPre-AdmissionScreeningandResidentReview(PASRR)processisnamedasthemechanismtosupporttheseConsentDecree-requiredfunctions.PASRRisafederalrequirementintendedtoensurethatindividualswithdisabilitiesarenotinappropriatelyplacedinnursingfacilitiesforlong-termcare,andrequiringtheevaluationofnursingfacilityapplicantswithseriousmentalillnessand/orintellectualdisabilityforthemostappropriatesettingfortheirneeds(i.e.,inthecommunity,anursingfacility,acutecaresetting).PursuanttotheWilliamsConsentDecree,theDefendantsaretousethePASRRprocesstoidentifythoseindividualswhoareinappropriateforadmissiontoWilliamsfacilities,supportdevelopmentofaninitialserviceplanthatoutlinesneededcommunity-basedservicesandhousing,andidentifyandreferindividualswhowouldotherwisebecomeWilliamsClassMemberstoappropriatecommunity-basedservices.Underthisprocess,ifaplacementinaWilliamsfacilityiswarranted,admissionsshouldbeapprovedonlyifthatfacilitycanprovidetreatmentandservicesconsistentwiththepreviouslyreferencedinitialserviceplanandfocusedonfacilitatingeventualre-entryintothecommunity.46

45Retrievedfrom:www.healthaffairs.org/doi/full/10.1377/hlthaff.2009.0877.46WilliamsConsentDecree,SectionVI.


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Theseconddiversion-relatedrequirementintheWilliamsConsentDecreedemandsthatfiveyearsaftertheinitialImplementationPlan(createdinJune2011)theDefendantshaveasysteminplacetopreventplacementofanyindividualwithmentalillnessintoaWilliamsfacility(i.e.,IMD)atthepublicexpenseandofferplacementinacommunitysettingthatisthemostintegratedsettingappropriate,unlessheorsherefusestoreceiveservicesinthatcommunity-basedsetting.Thismeansthat,asofJune2016,theConsentDecreerequiredtheDefendantstohaveaworkingstatewidediversionprogramtopreventinappropriateadmissionsintoWilliamsfacilitiesofpeoplewithseriousmentalillnesswhocouldandwishtoliveinacommunitysetting,thusofferingasystemwithacontrolledfrontdoor.FromMarchtoAugust2017,theDefendantsinitiatedasix-monthpilotprogramin14hospitalsfocusedonlinkingPASRRagents(whoareoftenembeddedinacutecarehospitalsandwhoreferpatientsinthehospital’spsychiatricunitsdirectlytoWilliamsfacilities)withcommunitymentalhealthcenters(CMHCs)toassesswhetherhospitalpatientswhootherwisewouldbelikelytobeadmittedtoaWilliamsfacilitycanandshouldbedivertedtocommunitybasedservices.ThepilotprogramsetouttostudyhowmanyadultswithmentalillnesscouldbeassessedandappropriatelydivertedfrominappropriateadmissiontoaWilliamsfacility,theeffectivenessoftheprocessesbeingtestedtopromoteandsupportdiversion,andprogramcostsforservicesandhousingnecessarytosupportsuccessfuldiversion.Duringthepilot,theDefendantsaimedtoincreaselinkagestoMedicaid-billablecommunity-basedservices,decreaserelianceoninpatientservices,lessenthelengthsofstayandre-admissionsratesforinpatientservices,formulaterecommendationsforspecificcommunity-basedservicesneededfordivertedindividuals,andprovideemergencyfundingresourcestosupportretentioninthecommunity.DuringthecomplianceassessmentperiodofFY2018,793individualswerereferredtoCMHCreviewersthroughtheDiversionPilotProjectand88(9%)weredivertedintocommunity-basedsettings.Ofthe793referrals,236individuals(36%)refusedcommunity-basedservicesand134(17%)weredeemedineligibleduetonothavingaMedicaidpayersourceorseriousmentalillness.Whiledataindicatesthatonly9%oftheoverallnumberofpatientsreferredwasdiverted,itisimportanttokeepinmindthatwhensubtractingthosewhowerenotinterestedoreligible,amongthoseremaining,21%werediverted.Thedispositionof38%ofthe793individualsreferredtoCMHCreviewersisunclearduetomissing/incompletedatafromtheDefendantsintheWilliamsSemi-AnnualReport14.Duringthisreportingperiod,theDefendantsalsostatedthattheyexecutedFY2019contractextensionswithcurrentCMHCcontractors,exploredexpansiontootherareasofthestate,drafted(butdidnotrelease)aRequestforInformationtosolicitpotentialcontractorsforgeographicexpansion,andexploredrestructuringofpaymentapproachestoincorporateincentive-basedpayments.


25

DespitethepromisingoutcomesofthisDiversionPilotProject,theDefendantswereveryreluctanttoendthepilotphaseandscaletheprojecttothebroader,statewidesystem,asrequiredbytheConsentDecree.TheCourtMonitorandPlaintiffspressuredtheDefendantstoconcludethepilotandexpandthediversionprogramstatewide.TheDefendants—intheirFY2019ImplementationPlan—committedtoexpandingtheDiversionProjectto22additionalhospitalsinphasesbetweenSeptember2018andMarch2019.Whilethiswouldnotrepresentafullstatewide/system-widediversionprogram,theDefendantsstatedthattheexpansionwouldaddress87%ofadmissionstoWilliamsfacilities;thus,itsignifiesimportantforwardmovementandprogresstowardcompliancewiththediversionrequirement.However,duringthefinalizationofthisreport,uponinquiryregardingthestatusoftheexpansion,theDefendantsnotifiedthePlaintiffsandtheCourtMonitorthat,duetocontractingissues,theynolongerexpecttoexpandthediversionprogramduringFY2019.Diversion-RelatedComplianceRequirements:ComplianceAssessmentsforFY2018AsdisplayedinFigure10,theDefendantsarefoundout-of-complianceforbothdiversion-relatedrequirementsintheWilliamsConsentDecree.ThiscomplianceassessmentratingwasassignedbecausetheDefendantsdidnotensurethatthePASRRprocessincorporatedConsentDecree-requiredelements(seebelowforfurtherdetailonthispoint)andtheydidnotensurethatanyindividualwithmentalillnesswasnotneedlesslyconfinedtoaWilliamsfacilitywithintheConsentDecree’sdirectedtimeframe.TheendofFY2018markedsevenyearsintotheConsentDecree’simplementationandtwoyearsaftertheConsentDecree-mandateddeadlineofJune2016forthestatewidediversionprogram.Yet,theDefendantsdidnotimplementacomprehensive,system-wideefforttocontrolthefrontdoorofthesystemtodivertpotentialfutureClassMembersfromWilliamsfacilitieswhenappropriate.Figure11containsthetextofeachdiversion-relatedrequirementintheWilliamsConsentDecree,alongwiththeCourtMonitor’scompliancerating.

Figure10.SynopsisofFY2018ComplianceAssessmentsforDiversion-RelatedWilliamsConsentDecreeRequirements

Total#CurrentRequirementsin

Domain

ComplianceAssessmentRating



26

Figure11.FY2018ComplianceAssessmentRatingsforDiversion-RelatedWilliamsConsentDecreeRequirements

Req.# Source/Citation WilliamsConsentDecreeRequirementLanguageCompliance

Rating


Withinone(1)yearoffinalizationoftheImplementationPlan,noindividualwithMentalIllnessshallbeadmittedtoanIMDwithoutaprescreeninghavingfirstbeenconductedthroughthePASRRProcessandaninitialServicePlancompleted.DefendantswillensurethatthePASRRProcess:identifiesandassessesindividualswhomaybeappropriateforplacementinaCommunity-Basedsetting;identifiesCommunity-BasedServicesthatwouldfacilitatethatplacement;andensuresthatapprovedadmissionstoIMDsareonlyforthoseIMDsthatcanprovidetreatmentconsistentwiththeindividual'sinitialServicePlanandconsistentwiththegoaloftransitiontoaCommunity-BasedSetting.

Out-of-Compliance


Afterthefirstfive(5)yearsfollowingthefinalizationoftheImplementationPlan,noindividualwithMentalIllnesswhoseServicePlanprovidesforplacementinCommunity-BasedsettingsshallbehousedorofferedplacementinanIMDatpublicexpenseunless,afterbeingfullyinformed,heorshedeclinestheopportunitytoreceiveservicesinaCommunity-BasedSetting.

Out-of-Compliance

Out-of-ComplianceRatingsRequirement1:InsteadofdesigningamultipartPASRRprocessthatsupportsdiversionthroughaccurateassessment,serviceplandevelopment,andpromptreferraltocommunity-basedsettings,theDefendantsreliedonIllinois’current,inadequate,andoftenbrokenPASRRprocess.Initscurrentform,itappearsthatPASRRagenciesmerelyscreenapplicantsforappropriatenessforWilliamsfacilitiesandnursingfacilityplacement,anddonothavetheresponsibilityorscopetoconductserviceplanningorgeneratereferralstocommunity-basedorganizations.WhiletheDefendantsarguethattheirPASRRprocessisadherenttofederallaw,aclaimnotyetacceptedbytheCourtMonitor,itisclearthatthePASRRprocess—evenifcompliantwithfederalrules—doesnotcompleteConsentDecree-requiredfunctionsandiswroughtwithseveralissues,including:§ DuringtheCourtMonitor’ssitevisitstofiveWilliamsfacilitiesinJuneof2018,

facilitydirectorsandstaffindicatedthatthePASRRsystemisbroken,withhospitalsoftencoordinatingPASRRscreeningsasatechnicalityafterreferraldecisionstoWilliamsfacilitieshadalreadybeenmade,facilityadmissionsproceedingwithoutPASRRscreens,andseriousquestionsaboutaccuracyofsuchscreenings(includinginstanceswherethereviewerdidnotdetectmentalillnessdespiteextensivehistoryofmentalillnessinothermedicalrecords).


27

§ TheDepartmentofHealthcareandFamilyServices(HFS)—inaJune2018lettertotheCourtMonitorrespondingtoPASRR-relatedconcernscitedbytheCourtMonitorundertheColbertConsentDecree—acknowledgedtheneedfor“major[mentalhealth]PASRRchanges.”TheystatedthatIllinoisneedsaconcertedeffort,“toupgrade/updatethedesignandtheoperationofMHPASRRprocesses,linkages,anddatasystems,”andthatthestatereceivestechnicalassistancein“improvingandredesigningitssystem.”Thisredesign,theywrote,mustresultintheestablishmentofa,“feasible,sustainable,ongoingstatewidesystemtoensureappropriatediversion,rapidcommunityreintegrationwherepossibleand,transitionafteramorelengthystay.”47

§ OutsideofDiversionPilotProjectsettings,thecurrentPASRRprocessdoesnotcompletetheinitialserviceplan,butinsteadmakes“serviceneedrecommendationsforindividuals”;thiscircumventsacriticalfunctionofaConsentDecree-compliantPASRRprocess:thatClassMembersreceiveanindividualizedplanatthetimeofscreening.Forthosebeingdiverted,thisplancoordinatescommunity-basedsupportsandservicesdesignedtopreventinstitutionalizationandfacilitateretentioninthecommunity;forthoseapprovedforadmissionintoaWilliamsfacility,thisplanaimstoshortenlengthsofstayandultimatelypreparetheClassMemberforcommunityre-entrybyindicatingthetypesofservicesafacilitycanprovidethatbestsuitstheClassMember’sneeds.

Requirement2:TheaforementionedissuescompromisedtheDefendants’complianceforthisrequirement,focusedonre-engineeringaPASRRsystemthatwouldpreventanypersonwithamentalillnessappropriateforcommunity-basedsettingsfromenteringaWilliamsfacilityunlessheorshedesiredtolivethere.Thiswastobeachieved“afterthefirstfiveyears”oftheInitialImplementationPlan,whichwasfiledinJune2011;thusthedeadlinewasJune2016.ItisimportanttonotethatwhiletheDefendantsareout-of-compliancewiththesetwodiversion-relatedrequirements,theDiversionPilotProjectdataoutcomesdemonstratesthatifresourcesareproperlyappliedandthePASRRprocessincludesserviceplanningandpromptconnectiontocommunity-basedservices,individualswhootherwisemayinappropriatelybecomeWilliamsClassMemberscanbedivertedfromWilliamsfacilities.CourtMonitorRecommendationsforAchievingorEnhancingCompliancewithDiversion-RelatedRequirementsTheDefendantsmustcomeintofullcompliancebyimplementingasystem-widediversionprogramthroughapplyingconcertedeffortstoaddressanuncontrolledfrontdoortothesystemthatresultsincontinuedover-relianceoninstitutionalsettings(includingWilliamsfacilities),inabilitytobendcostcurves,andaconstantflowofinappropriatelynewClassMembersthusaddingtotheClasssizeandthwartingthe47IllinoisDepartmentofHealthcareandFamilyServicesLetter,Responseto“KeyObservationsandConcernsRegardingNursingFacilityPreadmissionScreeningProcesses(PASRRandOBRA)andImpactonColbertClassMembers.”June19,2018.


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spiritandintentionoftheWilliamsConsentDecreespecificallyandOlmstead-complianceoverall.Broadlyspeaking,continuedavoidanceofdecisiveandsystem-wideactionregardingdiversionwilllikelyresultinaninabilitytoexittheConsentDecree.TheCourtMonitoroffersthefollowingrecommendationsfortheDefendants’considerationrelativetothisdomain.1. Immediatelycomplywiththerequirementforasystem-widediversionprogram.

TheWilliamsConsentDecreeclearlyincludesarequirementthatfiveyearsfollowingthebeginningofimplementation,astatewideprogramtodivertinappropriateadmissionsofadultswithseriousmentalillnesstoWilliamsfacilitiesbeinplaceandfunctioning.Assuch,theDefendantsshouldutilizebudgetresourcestoimmediatelyimplementasystem-widediversionprogramthatnotonlyengageshospitalsbutalsoothertypesofsettingsfromwhichavoidableadmissionsmightoccursuchascommunity-basedprovidersorsettings,shelters,orfamilyhomes.TheDefendantscommitmenttosignificantlyincreasethediversionprogram’sscopeandcapacityinFY2019—movingitfromapilotactivitytoanongoingprogram—holdsgreatpromise,notonlytowardfullerrequirementcompliancebutalsoinofferingaconcertedefforttoavoidthenegativeconsequencesonClassMembersandthefinancialburdenofavoidableadmissionstoWilliamsfacilitiesandotherinstitutions,suchasthenursingfacilitiesthatfallundertheColbertConsentDecree.However,recentnoticefromtheDefendantsthattheexpansioncommitmentwillnotoccurduringFY2019continuestohinderimportant,needed,andrequireddiversionefforts.ThiswillconstituteyetanotheryearofdelayintherequiredstatewidediversionrequirementandjeopardizescompliancewithaspecificFY2019complianceelement.TheDefendantsarestronglyencouragedtoimmediatelydedicatethesufficientresources,oversight,andmanagement,includingthedatacollectionandreportingnecessary,forappropriatestatewidediversionstosucceed.2. Createandimplementadata-drivencommunity-basedservicesandhousing

capacityplantosupportdiversionstatewide.SectionVIIIdescribestheWilliamsConsentDecreerequirementsforthedevelopmentofcommunity-basedservicesandhousing,aswellastheDefendants’performancerelativetothoserequirements.OnemajorweaknesswiththeWilliamsprogramthatimpactscomplianceisthelackofaclearlinkbetweendataonClassMemberservicesneedsandhousingandthedevelopmentofadata-drivenservicesandhousingcapacityexpansionplan.Tosupportdiversion,theDefendantsshouldbothenhancetheirabilitytoutilizeClassMember-leveldatatosupportdevelopmentofservicesandhousingfordivertingClassMembersandcreateamulti-yearservicesandhousingdevelopmentplan.Fordiversioneffortstosucceed,entitiesandindividualsthatreferClassMemberstoWilliamsfacilities,includinghospitals,grouphomes,andfamilymembers,mustbeawareofandhaveaccesstoconcretecommunity-basedalternativestoWilliams


29

facilities.Thisshouldincludeavailablepermanentsupportivehousingunits,crisisstabilizationandpeerrespiteresources,outpatientbehavioralhealthservicesavailableonthesame-day,48financialandbenefitsassistance,andotherresourcestofacilitateandsupportcommunityplacementandtenure.Animportantcomponentofadata-drivencommunity-basedhousingandservicesplanshouldincludecommunity-basedcrisisresponseservicestoaddresstheacknowledgedinadequatecrisissysteminIllinois.Community-basedcrisisservices–suchaspeer-runrespite,mobilecrisisteams,andcrisisstep-downservices–canhelpcommunitymembersavoidunnecessaryinterfacewithemergencydepartmentsandhospitalpsychiatricdepartments,whichincreaseriskforWilliamsfacilities’placement.3. Alignincentivesanddisincentivestopromotegreateruseofcommunity-based

servicesandhousing.

Thefactremainsthat,currently,itiseasierandfastertogetapersonwithseriousmentalillnessadmittedintoaWilliamsfacilitythanitistogethimorherintoacommunity-basedsetting,admissionappropriatenessnotwithstanding.Assuch,inadditiontoexpandingcommunity-basedresources,theDefendantsshouldconsidertheimplementationoffinancialandotherincentivesanddisincentivesdesignedtoencourageappropriatereferralstocommunity-basedsettingsanddiscourageinstitutionalization.Alignmentofincentivesanddisincentivesmightinclude:§ Arigoroussecond-levelreviewsystemthatusesmanagedcareprinciplestoensure

theappropriatenessofreferraltoWilliamsfacilities;§ Trainingandexpectationsettingforhospitaldischargeplannerstomakesurethey

areawareoftheirresponsibilitytoavoidinappropriatereferralstoWilliamsfacilitiesandareawareofcommunity-basedalternativessuchasdiversionprograms;

§ Designingfinancialbonusesandpenaltiesassociatedwithadmissions;§ Collectionandanalysisofadmissions-relatedperformancemeasureswithasetof

regularlyreviewedandremediationactions;and,§ Risk-andvalue-basedarrangementswithpayers,includingMedicaidManagedCare

Organizations(MCOs)andproviderscenteredonavoidingand/orreducingunnecessaryhospitalizationandinstitutionalization.

4. RedesignthePASRRprocesstoincludeConsentDecree-requiredinitialservice

planningcomponent.TheWilliamsConsentDecreeisclear:PASRRmustnotsingularlyfocusontheeligibilityscreeningfunction.Instead,PASRRmustincludeaserviceplanningfunctionthateitherdeterminestheappropriatefrequencyandamountsofcommunity-basedservicesforthosedeemedinappropriateforadmissiontoWilliamsfacilitiesorrecommendsservices

48TenYearsIn:SameDayAccessisNowtheExpectation.MTMServices.NationalCouncilConference2014.


30

toafacilitythatcanreducelengthofstayandprepareanindividualforrapidcommunityre-entry.Initscurrentform,PASRRdoesneither,andwithintheDiversionPilotProject,whereserviceplanningdidoccurinpartnershipwithCMHCs,outcomesforpeopleweresignificantat21%ofhospitalpatientswhowerebothinterestedandeligiblefordiversionbeingdiverted.CompliancewiththetermsoftheDecreewillrequirearedesignedandeffectivePASRRsystemthatfullycomportswithFederallawandtheConsentDecree.495. EngageManagedCareOrganizationstosupportdiversionactivities.

Thestate-fundedMedicaidManagedCareOrganizations(MCOs)intheIllinoissystemarenotablyabsentfromdiversioneffortsforClassMembers,aswellasfromothersignificantWilliamsprocesses.ClassMembersareMedicaidbeneficiariesand,traditionally,MedicaidMCOsprovideabroadoversightandaccountabilityroleandoftenalsoadirectservicedeliveryroletoensurethattheirbeneficiariesareprovidedpreventativecareandmedicalandbehavioralhealthtreatmentsandsupportstoavoidtheonsetorexacerbationofillnessesandtoensurethatenrolleesarenotunnecessarilyengagedinexpensiveservicesforwhichtheMCOassumesfinancialrisk.TheFiscalResponsibilityTransferAssessment(feasibilitystudy),submittedinFebruaryof2018,containsseveralrecommendationsonhowtheDefendantscanrealizeandoptimizetheroleofMCOsrelativetoadmissionintoWilliamsfacilities/SMHRFs.50TheDefendantsareencouragedtogivedueconsiderationtotheserecommendations.TobetterunderstandtheDefendants’positionregardingtheMCOs'rolesandresponsibilitiesasrelateddirectlytoClassMembers,theCourtMonitormetwithseniorHFSofficialsinSeptember2018.AseparatemeetingbetweentheCourtMonitorandMCOexecutiveswillbearrangedforinFY2019.Likewise,theDefendantsarestronglyencouragedtodevelopadeeperunderstandingabouthowMCOsmight—throughtheirstaff,resources,andprotocolssuchasutilizationreviewprocesses—significantlycontributetodiversionefforts.WhilethisrecommendationspecificallyaddresseshowMCOsmightsupportdiversionefforts,MCOengagementacrossalldomainsofConsentDecreecomplianceiswarrantedandstronglyrecommended.

49“PASRRRedesign”isincludedintheDefendants’FY2019ImplementationPlan,butasofthesubmissionofthisreport,noreportofsignificantprogresshasbeenmadeinsupportofsuchredesign.50FiscalResponsibilityTransferAssessment.BakerTilly.SubmittedFebruary2018.


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SectionIV.OutreachtoWilliamsClassMembersAsrequiredbytheWilliamsConsentDecree,theDefendantsmustdesignandimplementanoutreachprogramthatidentifiesClassMembers,informsthemoftheirrightsundertheConsentDecree,andprovidescompleteandaccurateinformationonthetypesofservices,supports,andhousingthatcanhelpthemtransitiontoandlivesuccessfullyinthecommunity.51AneffectiveoutreachandengagementprogramisthefoundationofallthesubsequentWilliamsprocessesasitrepresentsthefirstinterfacebetweenstaffandClassMembers.Itistheinitial—andperhapsmostimportant—opportunitytoexplaintheprogram,buildrelationshipsandconnectionswithClassMembers,andaddressClassMembers’fearsandconcernsaboutcommunitylife.TheWilliamsprogramdesignedandbrandedanoutreachinitiative,MovingOn,whichutilizesoutreachstafffromtheNationalAllianceforMentalIllness(NAMI).ThegoalofoutreachactivitiesistoprovideinformationtoClassMemberabouttheirrightsandresponsibilitiespursuanttotheWilliamsConsentDecree,promotetheavailabilityofcommunity-basedsupportsandservices,andconnectinterestedClassMemberswithevaluationstoassesstheirreadinessandappropriatenessforcommunitylife.ThefollowingoutreacheffortscomprisetheMovingOnprogram:§ OutreachfromNAMI.NAMIoutreachstaffengagesinseveralcoreoutreachand

educationalfunctionsthatsetthestagefortransition.Theseinclude:distributingpromotionalmaterialsabouttheprogram;conductingprivateinterviewswithClassMemberswhoexpressinterestintransitioningtothecommunity;conveningquarterlygroupmeetingstoprovideinformationonClassMemberrightsandresponsibilities;facilitatingcallsbetweentransitionedClassMembersandinstitutionalizedClassMemberstogeneratehopeandinterestintransition;respondingtoClassMemberswhowishtoundergoevaluationsandobtainingconsentsforspecializedtesting,ifneeded(e.g.,neuropsychologicaloroccupationaltherapy);troubleshootingissuesbetweenClassMembers,transitionagencies,Williamsfacilities,andDMH;andsupportingdecisionappealsrelatedtoClassMembers’transitionappropriateness.

§ OutreachfromNAMIAmbassadors.FourteenNAMIAmbassadors—hiredindividualswhohavediagnosesofseriousmentalillness,similartoClassMembers,andsuccessfullytransitionedfrominstitutionalliving(e.g.,innursingorWilliamsfacilities)tothecommunity—regularlyvisitWilliamsfacilitiestobuildconnectionswithClassMembersandsharetheirownexperiencesregardingtransitiontothecommunitypost-institutionalization.

TheDefendantssubmitteddataontheactivitiesandoutcomesofbothWilliamsoutreachentities,butdataontheNAMIAmbassadorprogramcoveredonlythesecondhalfofthefiscalyear.Thus,itisdifficulttoascertainwhethertheDefendantsreached51WilliamsConsentDecree,SectionVII.


32

eachClassMember,theextentofoverlapbetweenoutreachentitiesregardingthenumberofengagedClassMembers,andtheircompliancerelativetoanumberofotheroutreach-relatedrequirements.FY2018dataonoutreach-relatedactivitiesinclude:§ TheWilliamsprogramusestheHFScensuscountofallWilliamsfacilities’residents

asofJuly1,2017(firstdayofFY2018)astheproxynumberfortheasegmentofthetotalClasssize(notincludingClassMemberswhoweretransitioned);thisnumberwas3,808individuals.

§ DuringFY2018,NAMIoutreachworkersengaged828ClassMembers(22%oftheClass).Ofthose,597ClassMembers(72%)engagedinafollow-upmeetingwithanoutreachworker,andtheremaining28%(231ClassMembers)refusedtoengageorentertainoutreachattempts.TheDefendantsassertthatmanyotheroutreachencountersoccurattheindividualandgroupClassMember-levelsbutdonottrackorcollectdataassociatedwiththeseoutreachefforts.52

§ NAMIAmbassadorsinterfacedwith1,105ClassMembersinthesecondhalfofFY2018,53withapproximatelyhalfofthoseinteractionsconductedthroughcommunitymeetingsandtheotherhalfconductedthroughindividualinterviewswithClassMembersabouttheMovingOnprogram.

§ TheDefendantsindicatedthatClassMembersrefusedengagementforavarietyofreasons,including:theirlevelofcomfortwithintheirWilliamsfacilitysetting,nodesiretoleave,perceptionthattheyaretooilltoleave,andconcernswiththeWilliamsprocess.

§ Duringthereportingperiod,therewere6,311repeatedcontactsbetweenoutreachworkersandClassMembers,butbecausethisdatadoesnotidentifyunduplicatedcounts,thenumberofindividualClassMemberscontactedisunknown.

Outreach-RelatedComplianceRequirements:ComplianceAssessmentsforFY2018ReachingClassMembersresidinginWilliamsfacilitiesduringtheinitialoutreachphase,anddoingsoeffectively,isfoundationaltotheDefendants’successfulcompliance,andnotonlywithintheoutreachdomain.OutreachoutcomesdirectlyimpactcompliancewiththeConsentDecree’srequirementsforthenumbersoftransitionedClassMembersbecausetheoutreachphasemostoftendeterminestheindividuals’eligibilityanddesireforfurtherprogramparticipation(i.e.,transitionprocessevaluationsandrecommendations).TherearefourspecificrequirementsintheWilliamsConsentDecreerelatedtooutreachefforts,withtworequirementsoverlapping.WhilethereisnospecificnumericrequirementforthenumberofClassMemberswhoshouldreceiveoutreach,theConsentDecreesetsforthavisionthatallClassMembersreceiveregularandfrequent

52Defendants’letterinresponsetotheCourtMonitor’sdraftreport:October19,2018.53ContactdatafortheNAMIAmbassadorProgramwasnotprovidedforthefirsthalfofFY2018intheDefendants’Semi-AnnualComplianceReport13.


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outreach,and,aspreviouslystated,theWilliamsfacilities’censusisusedastheproxyindicatorforthatportionofthetotalClasssize.Additionally,theConsentDecreerequiresthecompletenessandaccuracyofinformationsharedduringtheoutreachprocessandoutlinestheinformationtobesharedduringClassMemberoutreach(e.g.,availablecommunitysupportsandservices,transitioncostassistance,homeaccessibilityassistance).Finally,theConsentDecreerequirestheDefendantscoveralloutreach-relatedcostsandputintoplacemeasurestoprotectClassMembersfromanyretaliation.

Figure12.SynopsisofFY2018ComplianceAssessmentsforOutreach-RelatedRequirements

Total#ofCurrentRequirements



Overall,asshowninFigures12and13,theCourtMonitor’sFY2018complianceassessmentfindstheDefendantsincompliancewithoneofthethreeoutreach-relatedrequirementsandinpartialcompliancewiththeremainingtworequirements.

Figure13.FY2018ComplianceAssessmentRatingsforOutreach-RelatedWilliamsConsentDecreeRequirements


3Williams

ConsentDecreeVII(10)

DefendantsshallensurethatClassMembershavetheopportunitytoreceivecompleteandaccurateinformationregardingtheirrightstoliveinCommunity-BasedSettingsand/orreceiveCommunity-BasedServices,andtheavailableoptionsandopportunitiesfordoingso.

RepeatedLanguage

4Williams

ConsentDecreeVI(6)(C)

Defendantsshallensure,asprovidedintheImplementationPlan,thatallClassMembersshallbeinformedaboutCommunity-BasedSettings,includingPermanentSupportiveHousing,andCommunity-BasedServicesavailabletoassistindividualsinthesesettings,andthefinancialsupportClassMembersmayreceiveinthesesettings.

PartialCompliance

5Williams


ClassMembersshallnotbesubjectedtoanyformofretaliationinresponsetoanyoptionselectednorshalltheybepressuredtorefrainfromexploringappropriatealternativestoIMDs.

PartialCompliance

6Williams


AllcostsforoutreachshallbebornebyDefendants. InCompliance


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InComplianceRatingsRequirement6:TheCourtMonitorfindstheDefendantsincompliancewiththerequirementtobearallcostsforoutreachservicessinceIllinoisstategovernmenthasincurredallinitialandongoingcostsassociatedwiththeWilliamsoutreachprogram.PartialComplianceRatingsTheCourtMonitorfindstheDefendantsonlypartiallycompliantineachoftheremainingtworequirementswithintheoutreachdomain,perthefollowing:Requirement4:NAMIoutreachworkersconductedoutreachto828(22%)oftheeligibleClass)andNAMIAmbassadorshadcontactwith1,105(29%)ofeligibleClassMembers.Whilethetwofiguresaggregateto51%ofallClassMembersinWilliamsfacilities,itisdifficulttofullyassesscomplianceforthefollowingreasons:§ ItisproblematictocalculatetheactualnumberofClassMemberswhoreceived

outreachbecausesomeClassMembersmayhavebeendoubleortriple-counted(countedbyeachoutreachentity).

§ ItisalsochallengingtoassesscompliancerelativetothisrequirementwithoutNAMIAmbassadordataforthefirsthalfofthefiscalyear(datawasprovidedonlyforthesecondhalfofthefiscalyearandthustheirreachovertheentirefiscalyearwaspresumablybroader).

§ TheConsentDecreelacksspecificitynecessarytofullyassesscompliancewiththisrequirementasthereisnofrequencyrequirementforoutreach(e.g.monthly,quarterly,orannually).

ForFY2018,theCourtMonitorisutilizingtheproxyindicatorofClasssize(3,808)asthebaselineforthenumberofClassMembersrequiringoutreach.Evenifasmanyas25%oftheClassisdeductedfromthisdenominatortoreflectthosewhoareintheprocessofevaluationortransition,thecollectiveeffortsofNAMIoutreachandAmbassadorswouldonlyhavereached68%ofthoseremaining2,856ClassMembers.Forthesereasons,theCourtMonitorassignedacomplianceratingofpartialcompliance.TheDefendantsstatetheyhaveseveralmeasuresinplacetoensurethatinformationconveyedtoClassMembersiscompleteandaccurate,includingextensivetraining,programmaterials(e.g.,fliers,brochures,videos),andongoingadministrativemeetingsbetweenoutreachentitiesandtheDivisionofMentalHealth(DMH).WhilethesedemonstratetheDefendants’intenttoconveyaccurateinformation,originallytheDefendantsdidnotprovideanydataorinformationtodemonstrateactualClassMembers’receiptofcompleteandaccurateinformation(e.g.,numberandpercentageofClassMemberswhosignedaninformedconsentdocument).Inarecentlettersentto


35

theCourtMonitorbytheDefendants,54theythenindicatedthat828ClassMemberssigned“lettersofconsent/verification/interest”inFY2018.GiventhattheseinformedconsentproceduresonlyreachedasmallpercentageofClassMembers(22%),theCourtMonitorgavearatingofpartialcomplianceforthisrequirement.Requirement5:WhileDefendantsindicatedintheirSemi-AnnualComplianceReportsthattheycommunicatedtoWilliamsfacilitydirectorsandstafftheconsequencesofretaliationagainstClassMembers,theydidnotprovideanydatatodocumentthenumberofallegationsofretaliationstowardClassMembersandtheoutcomesoftheclaims(e.g.,substantiated,unsubstantiated).Theyalsodidnotindicate:(1)howandwhenthesecommunicationsoccurred;(2)howoftentheyarerepeatedtoensurethatnewstaffaremadeaware;and(3)anydirect-to-ClassMembereffortstoinformthemoftheirrightsandrecourseiftheyexperienceretaliation.Therefore,theCourtMonitorgavetheDefendantsaratingofpartialcomplianceforthisrequirement.CourtMonitorRecommendationsforAchievingorEnhancingCompliancewithOutreach-RelatedRequirementsBeyondtheexplicitrequirementsoftheConsentDecree,theCourtMonitorhasconcernsabouttheeffectivenessandcomprehensivenessoftheWilliamsoutreachprogram.TheDefendants’performancedatarevealsalowrateofClassMemberengagementinoutreach,whichlikelyunderminesandcontributestotheDefendants’non-compliancewiththeirrequirementsforthenumbersofClassMemberstobetransitioned.TheCourtMonitoroffersthefollowingrecommendationstohelptheDefendantsimproveoutreacheffortsandresultsandtobringthemintofullcompliancewithalloutreach-relatedrequirements.1. Establish,implement,andmonitoranewpolicyfocusedonthetimingand

frequencyofoutreachandre-engagementactivities.ClassMemberslivinginWilliamsfacilitiesmayhaveconcernsandfearsaboutlivinginthecommunity.Thisisunderstandable;individualswhohavebeeninstitutionalizedoftenexperienceanerosionofpreviouslymasteredskills,lowself-efficacyandconfidence,alackoffinancialresources,andotherbarriersthatmightcompromisetheirconfidenceincommunityre-entry.Assuch,itisimportantthatwhenaClassMembersays“no,”outreachworkersviewthisasanopportunitytobuildrapport/trust,provideadditionaleducation,andutilizemotivationalinterviewingprinciplestoenhancewillingnesstotransitionandaddressfearsandconcerns.Thisiterativeprocessmightrequiremultipleengagementsfromthesameoutreachindividualorteam.Assuch,theDefendantsshouldconsideranoutreachprotocolcenteredonassertiveengagementandre-engagementprinciplesandcomprisedofthefollowingcomponents:

54Defendants’writtenresponsetodraftreport:October19,2018.


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§ Aclearexpectationthattheoutreachroleisnotmerelyfocusedonidentifyingthosewhoarereadyfortransition,butsupportingClassMembersintheoftenslowreadinessprocesstoincreasetheirefficacyexpectation;

§ Clearguidelinesforhowoftenanoutreachworkerorevaluatorshouldre-engageaClassMember(e.g.,monthly,semimonthly,quarterly)tooptimallysupportClassMembersthroughthisprocess;

§ Datacollectionrequirementstosupportreportingandaccountabilityforassertiveengagementandre-engagement;and

§ CoordinationwithWilliamsfacilitystaffandotherevaluation-andtransition-relatedentitiestosupportteam-basedapproachestoenhancingreadinessthroughskillbuilding,habilitation,connectiontobenefits/financialassistance,andoccupationaltherapy.

2. Develop(orenhance)aninformedconsentprocessthatensuresClassMemberunderstandingandprovidesclearrecourseforretaliation.

TheDefendantsstatethattheyhaveanextensivetrainingprogramandsetofpromotionalmaterials/resourcestoconveycompleteandaccurateinformationtoClassMembers.However,itiscriticalthattheyensurethatClassMemberreceiptofinformationmeetsthestandardsoftheConsentDecree.Namely,dothetoolsandstrategiesutilizedbytheDefendantsresultinClassMembers’fullyunderstandingtheirrightsandresponsibilitiesundertheConsentDecree?Toensurethis,theDefendantsmightconsideraninformedconsentprotocol,similartothoseusedinresearchstudies,wheretheoutreachworkerusesasimple,writtendocumenttoexplainkeycomponentsoftheWilliamsprogram,providinganopportunityfortheClassMembertoreflectbackthekeycomponentsoftheprogram.Defendantsarerecommendedtoreviewtheircurrent“letterofconsent/verification/interest”anddetermineifrevisionsareneededtoachievethisobjective.SimilartotheapproachusedbytheDefendantstotrackbothattemptedandcompletedevaluations,informedconsentletterscanbecomeatooltohelptrackoutreachattemptsandsignifyClassMemberunderstanding.ThisinformedconsentprocessshouldincludeclearguidanceforwhataClassMembershoulddoifheorshefeelsthatWilliamsfacilities’staff,transitionstaff,guardians,familymembers,orotherstakeholdersareretaliatingagainsthimorherforconsideringtransition.Existingresources,includingtheWilliamsWarmLine,couldbepromotedasamechanismtoreportandrequestassistanceifanyWilliamsfacilityemployee,guardian,familymember,orotherstakeholderperpetratesthreats,intimidation,orretaliationduringaClassMember’sinterfacewiththeWilliamsprogram.WhilethecontractorresponsiblefortheWarmLineisnolongertakinglivecalls,ClassMembersandotherswhocallthehotlinearenowredirectedtocontactDMHdirectly.InFY2018,callswerereceivedfromClassMembersrequestingtransitionandappealstatusupdates,lodgingcomplaintsagainstagencies,andrequestingevaluations.Finally,theWilliamsprogramshoulddevelopapolicystatementregardingretaliationanditsconsequencesthatis


37

regularlysharedwithfacilityadministratorsandallstaffwhocomeintocontactwithClassMembers.

3. Streamlineoutreacheffortstominimizeduplicationofeffort,promoteteam-based

approaches,establishclearworkflows,andholdcontractorsaccountabletoestablishedperformancemetrics.

TheDefendantshaveamultiprongedoutreachstrategy,whichincludesNAMIoutreachworkersandNAMIAmbassadors.Sincemanyplayersengageinoutreachefforts,itisrecommendedthattheDefendants:§ OrganizeoutreachactivitiestoensurethateveryClassMemberisengaged—

sometimesthroughmultipleoutreachattempts.Ideally,ClassMembersreceivefrequentcontactfromthesameteamorindividual,tosupportrapportandtrustbuilding;

§ Developuniversaloutreach-relatedperformancemeasuresandregularlyanalyzeentity-specificandaggregateddata(acrossallentities)todemonstrateperformancerelativetoConsentDecreerequirements;

§ DesignorredesignworkflowstoensurethattheyareclearandreduceClassMemberandnursingfacilitystaffconfusionandfrustrationduetoduplicationofeffort,lackofroleclarity,andawkwardtransitionsbetweenoutreachandevaluation;

§ Provideopportunitiesforoutreachentitiestodiscussbottlenecks,strengthencollaboration/coordination,andotherWilliamsfacility-specificissues;and

§ Createcommunicationandcoordinationworkflowstoensureinformationsharingbetweenvariousentities.

4. Trainoutreachstaffinactiveengagementbestpractices,includingmotivational

interviewing,warmhand-offs,andothers,andrequiretheiruse.Thereisasubstantialevidencebaseofprovenoutreachandengagementstrategiesshowntoreducerefusalorattritionratesandincreaseserviceparticipationamongvulnerablepopulations.TheDefendantsareencouragedtoexploretheuseorbroaderuseofsuchstrategies.ThiscouldbecompletedinpartnershipwiththemultidisciplinaryteamofnineWilliamsQualityMonitorswho“maintainresponsibilityformonitoringthequalityofcare,qualityoflife,communityintegrationandqualityofservicesprovidedtoClassMembers.”55Strategiesinclude:§ MotivationalInterviewing.Theevidence-basedpracticeofmotivational

interviewingisapatient-centeredmethodforenhancingintrinsicmotivationtochangehealthbehaviorbyexploringandresolvingambivalence.Undera

55WilliamsvRaunerConsentDecree.WilliamsSemi-AnnualReport14.July1,2017–June30,2018.SubmittedSeptember13,2018.


38

motivationalinterviewingframework,aninitialdeclineor“no”mightbeseenasanopportunitytoexploreaClassMembers’ambivalence,fear,resistance,orlackofunderstanding,andthenunearthorenhanceintrinsicmotivation.OnerecommendationistorequireongoingtrainingofallWilliamsoutreachandevaluationstaffonapplyingmotivationalinterviewing.Inaddition,thestaffshouldberegularlyevaluated,throughanestablishedqualityassessmentprogram,forfidelitytothepracticeandforanyneededskillsimprovement.Additionally,itisrecommendedthatWilliamsoutreachprocessesbeassessedtoensurethatmultipleoutreachandengagementopportunitiesareprovidedtoClassMemberswhoindicatepossibleinterest,butexpressconcernsabouttransitioning—beforerecordingthemasdecliningoutreachorevaluation.ClassMemberswhoarefullyeducatedabouttheirtransitionrights,opportunities,andtheresourcesthatwillbemadeavailabletothembutmakeinformeddecisionstodeclineparticipationinthetransitionconsiderationprocess,shouldhavethosedecisionsrespected.ClassMembersunderlegalguardianshipstatusandthosewithfamilyconnectionsmaypresentinstanceswhereguardiansandfamilymemberswouldalsobenefitfromWilliamsoutreachandengagement,includingmotivationalinterviewing.

§ WarmHand-OffsandPre-DischargeCommunityVisits.Atermcoinedintheintegratedprimaryandbehavioralhealthcarearena,awarmhand-offreferstoareferralpracticewhereinthemedicalproviderintroducesthepatienttothebehavioralhealthconsultantinreal-timetoultimatelysupportateam-basedandintegratedapproachtoaddressoften-interrelatedmedicalandbehavioralhealthconditions.AppliedinthecontextoftheWilliamsoutreachprogram,outreachstaffcouldfacilitateanin-personintroductionbetweentheClassMemberandthetransitionevaluator,reinforcingpreviousconversations/interestsandassistinginrapportdevelopmentbetweentheClassMemberandevaluator.Similarly,forClassMembersrecommendedfortransitionandinwhichyetanotherprofessionalwouldbeintroducedintotheprocess,thewarmhand-offprocesswouldberepeatedtocreateamoreseamlessexperience.Additionally,peersupportstaffcanhelpClassMembertransitionthroughuseofpre-dischargecommunityvisitsdesignedtoincreasetheClassMember’scomfort-levelinenteringthecommunityandallowthemlow-pressureopportunitiestovisithousingunits,viewserviceproviderfacilities,interactwithstaff,exploreneighborhoods,andincrementallygainfamiliaritywiththeircommunitiesofchoice.SomeofthesearedoneundertheWilliamsprogram,butnotuniformlyorcomprehensively.

§ ActiveEngagement,IncludingGuardianandFamilyEngagement.Activeengagementisasetofstrategiesbetweenaproviderandaclientthatincludemaintainingfrequentcontact,ensuringpromptinitialresponsestoclients,quickfollow-up,andadditionalfollow-upsifnoresponseisreceived.Activeengagementalsofocusesonbuildingrelationshipswithfamiliesandguardians,usingcommunicationmethodstobuildhopeandtrust(e.g.,verbalencouragement,meetingpeoplewheretheyare,beingsupportiveandnon-punitiveorjudgmental),andofferingmaterialandconcretesupport.


39

§ LinguisticandCulturalCompetence.ItiscriticalthatoutreachstaffreceivetraininginlinguisticandculturalcompetencetoappropriatelyengagediverseClassMembers.Inadditiontoensuringthatoutreachworkerswhospeakthesamelanguage(s)orinterpretersareavailableforClassMembers,trainingshouldincludehowtoeffectivelyoutreachtoindividualswithdisabilitieswhomayhavecommunicationchallenges(e.g.,staffskilledincommunicationmethodssuchasAmericanSignLanguage).


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SectionV.EvaluationofClassMembersforTransitionAppropriatenessEveryClassMemberhasthelegalrighttoliveintheleastrestrictivesettingappropriatetohisorherneedsand,wherepossible,toparticipatefullyincommunitylife.ItiscriticalthattheDefendantscreateandimplementanevaluationprocessthataccuratelyassessesaClassMember’smedicalandpsychiatriccircumstancesandhisorherabilitytoperformactivitiesofdailyliving(ADLs)todeterminewhetherthepersonisappropriatefortransitionintothecommunity.ADLstypicallyincludekeylifetasksthatindividualsmustmanagetobesafeandindependentsuchaseating,bathing,grooming,dressing,toileting,andtransferring.PertheWilliamsConsentDecree,aqualifiedprofessionalistoconductaperson-centeredevaluationforeveryClassMemberwhoagreestosuchandtheevaluationsaretoidentifytheirpreferences,strengths,andneedsandresultinadeterminationoftheappropriatenessofrecommendingtransitiontocommunitylivingornot.Iftransitionisrecommended,thetypesofcommunity-basedservicesandhousing,withadefaultpreferenceofpermanentsupportedhousing(unlessspecificcircumstancesexist)56necessarytosupportsuccessfulcommunitytenurearetobeincludedintheserviceplan,whichistheendresultoftheevaluationprocess.UndertheWilliamsConsentDecree,LutheranSocialServicesofIllinois(LSSI)andMetropolitanFamilyServices(MFS)provideevaluations,witheachemployingsevenfull-timequalifiedprofessionalsduringFY2018.TheWilliamsConsentDecreeincludesspecificrequirementsfortheprovisionofevaluations,including:§ Evaluationsmustbeconductedbyqualifiedprofessionals;§ ClassMembersmusthavetherighttodeclineevaluationsand,afterdeclining,can

requestandreceiveanevaluationatalatertime;§ Evaluationsmustbeconductedannually,providingthoseClassMemberswhowere

notrecommendedfortransitionorwhoelectednottomovepost-evaluationfuturere-evaluationopportunities;

§ Duringtheannualevaluationprocess,qualifiedprofessionalsmustexploreandaddressanyClassMemberoppositiontomovingoutofaWilliamsfacility;and

§ ClassMemberswhodeclinetomoveafteranevaluationcanrequestare-evaluation.

56PermanentsupportivehousingwillbeconsideredthemostintegratedsettingappropriateforClassMembersexceptthat,(1)foranyClassMembers(i)whohaveseveredementiaorotherseverecognitiveimpairmentsrequiringsuchahighlevelofstaffingtoassistwithactivitiesofdailylivingorself-caremanagementthattheycannoteffectivelybeservedinpermanentsupportivehousing,(ii)whohavemedicalneedsrequiringahighlevelofskillednursingcarethatmaynotsafelybeprovidedinpermanentsupportivehousing,or(iii)whopresentanimminentdangertothemselvesorothers(WilliamsConsentDecree,SectionVI)


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Figure14delineatesthenumberofClassMemberswhowereeligibleforandultimatelyparticipatedinevaluation-relatedprocessesduringFY2018,includingthoseofferedevaluationsandwhoreceivedevaluationsandannualre-evaluations.DMHreportedthatqualifiedprofessionalsofferedevaluationsto99%ofallClassMembersintheWilliamsfacilities,resultingin34%ofClassMembersreceivingcompletedevaluations.Ofthosewhowereeligibleforannualre-evaluations(havingalreadyreceivedanevaluationinthepreviousfiscalyear),82.5%receivedthere-evaluationand49%receivedthere-evaluationwithin60daysoftheduedateoftheirre-evaluation.

Figure14.FY2018DataonEvaluation-RelatedRequirementsandOutcomesEvaluationActivity NumberofEligibleClass

Members(UnduplicatedCount)

NumberofClassMembersWhoImpactedByEvaluationActivity(UnduplicatedCount)

PercentageofActualClassMembers(Eligiblevs.Received)

OfferedanEvaluation 3,808 3,78557 99%CompletedanEvaluation 3,808 1,283 34%CompletedanAnnual(Re-)Evaluation58

3,113 2,571 82.5%

TimelyCompletionofAnnual(Re-)Evaluation59

3,113 1,52660 49%

Evaluation-RelatedComplianceRequirements:ComplianceAssessmentforFY2018AspresentedinFigures15and16,theWilliamsConsentDecreecontainsatotalofsevencompliancerequirementsrelativetoClassMemberevaluations(relevanttothisreportingperiod),whichincludeprocess-orientedrequirements(e.g.,frequencyandtimelinessofevaluationsandre-evaluations);content-relatedrequirements(e.g.,evaluationstoexploreClassMemberoppositiontomovingintothecommunity);andnumericrequirementsregardingcompletedevaluations.Figure15providesasynopsisofthecomplianceassessmentratingsforFY2018undertheevaluation-relateddomainofrequirementsandshowsthattheDefendantsareassessedtobeincompliancewithtwoofthesevenrequirements,areinpartialcompliancewithtworequirements,andareout-of-compliancewiththeremainingthreerequirements.

57DataprovidedinphonecommunicationwithDMHonNovember1,2018.58Thisfigurerepresentsthosewhoareeligibleforanannualevaluation(sometimesreferredtoas“re-evaluations”or“evaluationupdates”)duringFY2018.ThisrepresentsClassMemberswhoreceivedanevaluationandwerenotrecommendedortheyreceivedanevaluation,wererecommended,andelectedtostayintheWilliamsfacility.59TheDefendantsdefinetimelycompletionas60daysaftertheanniversaryofthepastyear’sevaluation.60TheDefendantsassertthatthisfiguremaybehigherthanreportedbecauseofadataentrylag.TheDefendantswereofferedtwoadditionalopportunitiesthroughSeptember13,2018tosubmitupdateddatabutdidnotdoso.


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Figure15.SynopsisofFY2018ComplianceAssessmentsfor Evaluation-RelatedRequirementsTotal#CurrentRequirements


Incompliance Partialcompliance Out-of-compliance7(100%) 2(29%) 2(28%) 3(43%)

Figure16.FY2018ComplianceAssessmentRatingsforEvaluation-Related

WilliamsConsentDecreeRequirements


7Williams


QualifiedProfessionalsshallinformClassMembersoftheiroptionspursuanttosubparagraphs6(a),6(d),and7(b)ofthisDecree.

InCompliance

8Williams

ConsentDecreeVI(6)(A)

Withintwo(2)yearsofthefinalizationoftheImplementationPlandescribedbelow,everyClassMemberwillreceiveanindependent,professionallyappropriateandperson-centeredEvaluationofhisorherpreferences,strengthsandneedsinordertodeterminetheCommunity-BasedServicesrequiredforhimorhertoliveinPSHoranotherappropriateCommunity-BasedSetting.


Period

9Williams


Inadditiontoprovidingthisinformation,DefendantsshallensurethattheQualifiedProfessionalsconductingtheEvaluationsengageresidentswhoexpressconcernsaboutleavingtheIMDwithappropriatefrequency.

PartialCompliance

10Williams

ConsentDecreeVI(6)(B)

AnyClassMemberhastherighttodeclinetotakepartinsuchEvaluation.AnyClassMemberwhohasdeclinedtobeevaluatedhastherighttoreceiveanEvaluationanytimethereafteronrequest.

Out-of-Compliance

11Williams


DefendantsshallensurethatEvaluationsareconductedbyQualifiedProfessionalsasdefinedinthisDecree.

InCompliance

12Williams

ConsentDecreeVI(6)(D)

AfterthesecondyearfollowingfinalizationoftheImplementationPlan,theEvaluationsdescribedinSubsection6(a)shallbeconductedannually.

PartialCompliance

13Williams


AspartofeachClassMember'sannualEvaluation,thereasonsforanyClassMember'soppositiontomovingoutofanIMDtoaCommunity-BasedSettingwillbefullyexploredandappropriatelyaddressedasdescribedinSectionVII.

Out-of-Compliance

14Williams


AnyClassMemberwhohasreceivedanEvaluationbuthasdeclinedtomovetoaCommunity-BasedSettingmayrequesttobereassessedfortransitiontoaCommunity-BasedSettinganytimethereafter.

Out-of-Compliance


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InComplianceRatingsRequirement7:TheDefendantsarerequiredtoinformClassMembersoftheirrightstoanevaluation,and–accordingtodatasubmittedbytheDefendantsinanOctober2018letter61-weresuccessfulinreaching3,785unduplicatedClassMembers,comprising99%oftheWilliamsfacilities’censusof3,808.Requirement11:Further,theDefendantshaveattestedthatqualifiedprofessionalsconductallevaluations.QualifiedprofessionalsaredefinedintheConsentDecreeas“personswhoareappropriatelylicensed,credentialed,trainedandemployedbyaPASRRAgency.”62WhileonlyoneofthetwoevaluationagenciesisalsoaPASRRAgency,theDefendantsattesttotheclinicallicensureandfunctionalappropriatenessofthecurrentevaluators.TheCourtMonitor,inherprofessionaljudgment,findsthatthisdefinitionalissuedoesnotrisetothelevelofanout-of-complianceratingandthusassignedanincompliancerating.PartialComplianceRatingsRequirement9:DefendantsarerequiredtoensurethatqualifiedprofessionalsengageClassMemberswhomayfearmovingintothecommunityorhaveconcernsaboutprogramprocessesoverallatan“appropriatefrequency.”Whenprovidedanopportunitytoreviewthisreportindraftform,theDefendants’responsewasemphaticaboutaseparationofdutiesbetweenoutreachstaffandevaluationstaff,assertingthatthesefunctionsaremutuallyexclusiveanddatarelativetothesefunctionsshouldnotbesynthesizedtoreachorinformcompliancedeterminations.However,forthisrequirementthatrelatesdirectlytoevaluators’responsibilitiestoengageClassMemberswhoexpressconcernsabouttransitioning,theDefendantssharedataonthecontactsbetweenoutreachstaff,Ambassadors,andevaluatorstomakethecasethatcollectively,theiroutreachandevaluationprogramsmakerepeatedcontactstoClassMembers,duringwhichClassMemberscouldraiseconcernsabouttransitionandhavethoseconcernsaddressedorengaged.WhilethereappearstobenocurrentprotocoltocapturethenumberofClassMemberswhoexpressfearsorconcernsabouttransitioningandtheredoesnotappeartobeanypolicyinplacethatdefines“appropriatefrequency”oroutlinesanassociatedprocessrequirementregardingthefrequencyofClassMemberengagementiftheyexpressconcernsregardingtransitions,itisreasonabletoassumethattheconstellationofWilliamscontractors(includingoutreach,evaluation,andtransitionagencies)supportedClassMemberswhoexpressedconcernsabouttransitioning.Giventhis,theCourtMonitorassignedaratingofpartialcompliancerelativetothisrequirement.

61Defendants’writtenresponsetodraftreport:October19,2018.62WilliamsConsentDecree,SectionVI.


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Requirement12:TheDefendantsdataindicatedthatduringFY2018,3,113ClassMemberswereeligibleforre-evaluations,representingthoseClassMemberswhoreceivedanevaluationinFY2017butwerenotapprovedfortransition.Ofthose,2,571receivedre-evaluations(constituting82.5%ofthosewhowererequiredtoreceivere-evaluations)and1,526receivedtimelyre-evaluations.Giventhisoutcome,theDefendantsarefoundinpartialcompliancewiththisrequirementforFY2018.Out-of-ComplianceRatingsTherearethreerequirementsundertheevaluationdomaininwhichtheDefendantsareassessedtobeout-of-complianceduringtheFY2018complianceperiod,including:Requirement13:TheDefendantsarerequiredtofullyexploreandappropriatelyaddressreasonsthatClassMembersopposetransitioning[emphasesadded].TheDefendantscollectdataregardingreasonsforClassMemberoppositiontotransitioning,rangingfromaClassMembers’contentmentwithresidenceinthefacility,tofamily/guardianconcerns,toaperceptionthathisorhermedicalconcernsaretooserioustolivesuccessfullyinthecommunity.However,theDefendantsdidnotprovideanydataorotherinformationtoindicatethatissuessuchasthese—onceraisedbyClassMembers—aresubsequently“appropriatelyaddressed.”ThismightbedemonstratedthroughdatasuchasthenumberofClassMemberswhoraisedsuchconcerns,howmanyofthosewererespondedto,andtheoutcomeastoiftheresponseresultedintheClassMemberagreeingtoparticipateintheevaluationprocessornot.Lackingdemonstrabledataorprocessinformationattestingtocompliancewiththisrequirement,theDefendantsareassessedasout-of-complianceforFY2018.Requirements10and14:TheDefendantswereunabletoprovidedatatodemonstratethatthoseClassMemberswhorequestare-evaluation(eitherafterinitiallydeclininganevaluationofferorafterundergoingtheevaluationprocessandbeingrecommendedtotransitionbutdecidingnotto)actuallyreceivere-evaluationsthereafter.Despitearequestforthisdata,theDefendantsinsteadprovideddatatoindicatethat66%ofClassMemberswhoconsistentlyrefusedevaluationspriortoFY2018werere-approachedforanannualevaluation.WhilethisdemonstratesthattheDefendantsre-engagedClassMemberswhoinitiallyrefusedevaluationstoofferthemre-evaluations,itdoesnotprovidethenumberofthosewhorequestedre-evaluations(afteraninitialrefusaloradecisiontonottransition)andwhetherthoseClassMembersactuallyreceivedthere-evaluation.Defendantsareassessedasout-of-complianceonthisrequirementforFY2018.


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CourtMonitorRecommendationsforAchievingorEnhancingCompliancewithEvaluation-RelatedRequirementsTheCourtMonitoroffersthefollowingrecommendations,designedtocorrectissuesrelatedtofrequencyofevaluationsandre-evaluationsandaddtomorerobusteffortstoaddressClassMemberreluctanceoroppositiontoparticipatingintheevaluationprocessasitisnecessarytobeconsideredfortransitiontothecommunity.1. Correctissuesrelatedtothefrequencyofevaluations.

Complianceissuesrelatedtotheevaluationdomainareprimarilyprocess-orientedinnatureandcanberesolvedbydevelopingandimplementingclearperformancestandardsforcontractorswhoareresponsibleforconductingevaluations(e.g.,ResidentReviewers),usingmetricsandotherdatareportingandanalysestomonitorcompliancewiththeseprocessandoutcomerequirementsamongcontractors.First,theDefendantsshouldconsidercreatingaclearprotocolthataddressesthetimelinessandfrequencyrequirementsforevaluationandre-evaluationefforts,sharetheserequirementswiththeevaluationcontractors,andmakethempartofthecontractualrequirements.Elementscoveredintheprotocolshouldincludethenumbersandpercentagesofrequiredversusaccomplishedevaluations,including:annualevaluationupdates,outreachtoClassMemberswithinanappropriatefrequency,timelycompletionofevaluationsandre-evaluations,andtimelycompletionofserviceplans.Inadditiontospecifiedcontractlanguage,thismaybeconveyedandmonitoredusinggraphicssuchasaprocessmapthatindicatesthesequence,timing,andfrequencyofparticularactivitiesandadatadashboardthatindicatesrequirementsversusoutcomes.Second,theDefendantsshouldexploreregular,perhapsweekly,useofadatasystembyqualityassurancestafftoreviewwhethercontractorscomportwiththeevaluationrequirementsandtakecorrectiveactionsdirectlywithcontractors,ifnecessary.Thismayrequireimplementationofarelatedrecommendation:buildingadatainfrastructureinwhichcontractorscollectandinputreal-timedatasotheDefendantscanimmediatelyidentifyandactuponissues.Finally,ifnotalreadydeveloped,theDefendantsshouldconsideranoutcome-basedorpay-for-performancepaymentstructuretoincentivizecontractoragencycompliancewithprocess-relatedConsentDecreerequirements.Thisshouldapplytotimelycompletionofevaluations,re-evaluations,andserviceplans.


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2. StrengthenabilitytoidentifyandreportonClassMemberoppositiontoevaluationsandotherreasonsforincompleteevaluations.

ThenumberofClassMembersforwhomevaluationswereattemptedbutnotcompletedishigh(66%).Theuniverseofdataandreasonsforthishasnotbeenprovided;however,itisreasonabletoassumethatatleastsomeofthisisduetoClassMemberopposition.Understandingandexploringwhytheydeclinetoparticipateisalinchpinstepinthetransitionprocess.ClassMembersmayinitiallydeclineparticipationintheevaluationprocessforseveralreasons,includingmedicalorpsychiatrichealthissuesorconcerns;acceptanceofcurrentlivingsituationintheWilliamsfacility;self-efficacy;strainedfamilyrelationshipsorlackoffamily/guardiansupport(orapprovalwhenlegallyrequired);lackoftrustorrapportwithoutreachstafforevaluators;fearsormisconceptionsabouttheprogram’sgoals;andmisunderstandingsorapprehensionsaboutwhatservices,supports,andhousingwillbeprovidedaftercommunitytransition.Assuch,theDefendantsshouldconsiderimplementingmechanismstobetterunderstandreasonsforoppositiontoevaluationandreportonthesereasons.3. ImplementClassMemberandsystems-levelinterventionstoaddressreasonsfor

ClassMemberoppositiontooutreach,evaluation,andtransition.

TheConsentDecreemandatesthattheDefendantsnotonlyunderstandreasonsforClassMemberoppositiontoevaluationparticipation,butalsoaddressthesereasonsappropriately.TheDefendantscancreateandimplementbothsystems-levelandClassMember-levelsolutionstocommonbarrierstoengagingClassMembersinvariousWilliamsprocessessuchas:§ UsingoccupationaltherapiststoimproveClassMembersskillswithActivitiesofDaily

Living(ADLs)suchaslaundryandcooking;§ EducatingClassMembersabouttheavailabilityofwrap-aroundmedicalservices

suchasthatprovidedbynurseswhoarepartofAssertiveCommunityTreatmentteamsandcanaddressmedicalneedsinthecommunityforthoseClassMemberswhobelievestheyare“tooill”toliveinthecommunity;

§ ImplementingaguardianengagementprogramtodiscussandaddressconcernsaboutlifeinthecommunityforClassMembers;

§ Strengtheningtheuseofmotivationalinterviewingtoaddressfearsandresolveambivalence;and

§ Usingbenefitsspecialiststoallayfearsaboutlackofincome,includingavailabilityoffinancialassistance,healthinsurancecoverage,employmentopportunities,andspecializedbenefitsprogramsforpeoplewithdisabilitiessuchasTrialWorkPeriodorTickettoWorkprogramsthroughtheSocialSecurityAdministration.


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SectionVI.ServicePlanningforWilliamsClassMembersServiceplanningistheprocessbywhichWilliamsprogramstaffpartnerwithClassMemberstodevelopaperson-centeredserviceplan.Serviceplansarerequiredtocontainthevision,preferences,communitysupportandserviceneeds,andgoalsoftheClassMemberfocusedonattaining(andmaintaining)successfultransitiontothecommunity.TheircompletionisrequiredforbothClassMemberswhohavebeenrecommendedfortransition—focusedontheservicesandsupportsthatwillfacilitatetransitionandcommunitylife—andthosewhoarenotrecommendedfortransition—centeredongoalsandservicesdesignedtopreparethemfortransitionatalatertime.TheDefendants’FY2018Semi-AnnualComplianceReportsoutlinedelementsoftheWilliamsprogram’sserviceplanningapproach,whichrequiresthatobjectivesandserviceinterventionsarebasedupontheClassMember’sneeds,vision,andgoals,andoutlinestheirrightstodeveloptheserviceplanwithhisorherlegalrepresentative.Inaddition,thefollowingConsentDecreerequirementsapplytoserviceplans:§ Serviceplansmustbecompletedbyqualifiedprofessionalsandinclude,ifdesired,a

legalrepresentativeorotherpersonoftheClassMember’schoosing;§ ForClassMembersassessedasappropriatefortransition,theserviceplansmust

includethecommunity-basedservicesneededbytheClassMembers,aswellasatimetableforcompletingtransition;

§ ForClassMemberstransitionedintonon-permanentsupportivehousingsettings,theserviceplanmustjustifynon-permanentsupportivehousingplacement,andincludecommunity-basedservicesthatcansupportthemostintegratedsettingpossibleandappropriate;

§ ForClassMembersnotapprovedfortransition,serviceplansmustincludetreatmentobjectivestoprepareClassMembersforsubsequenttransitiontopermanentsupportivehousingorothercommunity-basedoptionsandshouldbeperiodicallyupdated,reflectiveofthechangingneedsandpreferencesofaninstitutionalizedClassMemberandinclusiveofservicesthatsupporttheacquisitionoflivingskillsandillnessself-management;

§ Allserviceplansmustbecompletedpromptlyandinsufficienttimetosupporttransitions;and

§ Serviceplanscannotbelimitedtowhattheserviceandhousingsystemcurrentlyhasavailable;serviceplansshouldincludeanyservicethatiscurrentlyprovidedundertheStateMedicaidPlanandRule132.

ServicePlan-RelatedComplianceRequirements:ComplianceAssessmentforFY2018SimilartootherWilliamsConsentDecreedomains,compliancerequirementsforserviceplansincludeprocess-relatedfactors(e.g.,timelinessandfrequencyofserviceplancompletion)andcontent-relatedfactors(e.g.,whetheraserviceplanreflectsaClass


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Member’svision,preferences,andneeds).Toassesscomplianceinthisarea,theCourtMonitorrevieweddataprovidedintheDefendants’FY2018Semi-AnnualComplianceReports.

Figure17.SynopsisofFY2018ComplianceAssessmentsforServicePlan-RelatedRequirements

Total#CurrentRequirements


InCompliance PartialCompliance Out-of-Compliance9(100%) (0%) 3(33%) 6(67%)

AsdisplayedinFigures17and18,theWilliamsConsentDecreecontainsninerequirementspertainingtoserviceplans.TheCourtMonitorassessedtheDefendantsaspartiallycompliantforthreerequirementsandout-of-compliancefortheothersixrequirements.Themajordeficiencyresultinginnon-compliancefortheentireserviceplandomainisthattheDefendants,despitesevenyearsofprogramimplementation,havenotdevelopedandimplementedamethodologytotrackandreportonthecontent-andprocess-relatedcompliancerequirementsrelatedtoserviceplanningortomonitorthequalityandimplementationofserviceplancomponents.Absentthenecessaryactivity,andoutcomedataandreporting,theDefendantscouldnotanddidnotdemonstratefullcomplianceinanyofthisdomain’sareas.

Figure18.FY2018ComplianceAssessmentRatingsforServicePlan-RelatedWilliamsConsentDecree

Req.#Source/Citation

WilliamsConsentDecreeRequirementLanguage

CourtMonitorFY2018ComplianceAssessmentRating

15

WilliamsConsentDecreeVI(7)(C)

TheServicePlanshallbedevelopedbyaQualifiedProfessionalinconjunctionwiththeClassMemberandhisorherlegalrepresentative.TheQualifiedProfessionalalsoshallconsultwithotherappropriatepeopleoftheClassMember'schoosing.

PartialCompliance

16

WilliamsConsentDecreeVI(7)(D)

EachServicePlanshallfocusontheClassMember'spersonalvision,preferences,strengthsandneedsinhome,communityandworkenvironmentsandshallreflectthevalueofsupportingtheindividualwithrelationships,productivework,participationincommunitylife,andpersonaldecision-making.

Out-of-Compliance

17

WilliamsConsentDecreeVI(7)(A)

BasedontheresultsoftheEvaluationsdescribedabove,DefendantsshallpromptlydevelopServicePlansspecifictoeachClassMemberwhoisassessedasappropriatefortransitiontoaCommunity-BasedSetting.

Out-of-Compliance

18

WilliamsConsentDecreeVI(7)(F)

TheServicePlanshallbecompletedwithinsufficienttimetoprovideappropriateandsufficienttransitionsforClassMembersinaccordancewiththebenchmarkssetforthintheDecree.

Out-of-Compliance


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19

WilliamsConsentDecreeVI(7)(B)

ForeachClassMemberwhodoesnotopposemovingtoCommunity-BasedSetting,theServicePlanshall,ataminimum,describetheCommunity-BasedServicestheClassMemberrequiresinaCommunity-BasedSetting,andatimetableforcompletingthetransition.

Out-of-Compliance

20


ThoseClassMembersnottransitioningfromIMDstoPermanentSupportiveHousingwillhaveongoingreassessmentswithtreatmentobjectivestopreparethemforsubsequenttransitiontothemostintegratedsettingappropriate,includingPSH.

Out-of-Compliance

21


EachServicePlanshallbeperiodicallyupdatedtoreflectanychangesinneedsandpreferencesoftheClassMember,includinghisorherdesiretomovetoaCommunity-BasedSettingafterdecliningtodoso,andshallincorporateserviceswhereappropriatetoassistinacquisitionofbasicinstrumentalactivitiesofdailylivingskillsandillnessself-management.AcquisitionofsuchskillsshallnotbeaprerequisitefortransitioningoutoftheIMD.

Out-of-Compliance

22


IftherehasbeenadeterminationthataClassMemberisnotcurrentlyappropriateforPSH,theServicePlanshallspecifywhatservicestheClassMemberneedsthatcouldnotbeprovidedinPSHandshalldescribetheCommunity-BasedServicestheClassMemberneedstoliveinanotherCommunity-BasedSettingthatisthemostintegratedsettingappropriate.

PartialCompliance

23

WilliamsConsentDecreeVI(7)(E)

TheServicePlanshallnotbelimitedbythecurrentavailabilityofCommunity-BasedServicesandSettings;provided,however,thatnothinginthissubparagraphobligatesDefendantstoprovideanytypeofCommunity-BasedServicebeyondthetypesofCommunity-BasedServicesincludedintheStatePlanandRule132.

PartialCompliance

PartialComplianceRatingsTheDefendantsarefoundinpartialcomplianceduringFY2018forthreeoftheserviceplan-relatedrequirements:§ Requirement22:TheDefendantsweretoindicate—throughtheserviceplanning

process—whichservicescouldnotbeprovidedinconcertwithpermanentsupportivehousingbutcanbeprovidedwithresidencyinanotherappropriatesettingthatislessintegrated(e.g.SupportedResidentialSetting).Ofthe194ClassMemberswhoweretransitionedduringthesecondhalfofFY2018,21(11%)wenttoasupervisedresidentialsetting(non-permanentsupportivehousing).WhileserviceplanningstaffdidcaptureservicesneededbytheseClassMembers,manyoftheseservices—suchasAssertiveCommunityTreatment,nursingservices,andoutpatientsubstanceuseservices—canandareprovidedtoClassMembersresidinginpermanentsupportivehousingandthusarenotappropriatereasoningorjustificationsforanon-permanentsupportivehousingreferral.TheDefendantswere


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foundinpartialcompliancebecausetheservicestheylistintheserviceplansforthoseClassMemberstransitionedtonon-permanentsupportivehousingsettingsareservicescommonlyprovidedinconcertwiththoseprovidedinpermanentsupportivehousing.

§ Requirement23:TheDefendantsindicatedthattherewere25ClassMemberswhowereunabletotransitionduetothelackofaserviceintheirchosengeographicalareaduringFY2018.Ofthose25,threeClassMembersidentifiedasecondgeographicpreference.Whilethisdataisuseful,particularlyasitidentifiesClassMemberswhosetransitiondidnotoccurbecauseofserviceunavailabilityinhisorhercommunityofchoice,itdoesnotindicatehowmanyClassMemberseventuallytransitionedduringFY2018butwereforcedtolocateinacommunitynotoftheirfirstpreferenceonaccountoflackingservicesorhousing.ThelackofdataandanalysisunderthisrequirementfurtherexemplifiestheDefendants’resistancetoidentifying,quantifying,andsupplyingneededservicesandhousingasrequiredbytheConsentDecreeandcouldbesubstantiallyenhancedbyexaminingserviceplans.TheDefendantswerefoundinpartialcomplianceforthisrequirement.TheDefendantsdidstatethatadditionaldataonoutcomesforindividualsunabletoobtainserviceswouldbegatheredduringFY2019forfuturereports.

§ Requirement15:WhiletheDefendantsindicatethattheywouldhonoraClassMember’spreferencetoincludealegalrepresentativeorotherindividualintheserviceplanningprocessandwouldreferaClassMemberwhoappearedtobecognitivelycompromisedforaspecializedassessment,thereisneitherevidenceoftheexistenceofaprocessorconcertedefforttoeducateClassMembersregardingtheirrighttoincludeotherindividualsinhisorherserviceplanningprocessnordataorotherinformationprovidedbytheDefendantstoreporttheextenttowhichClassMembersincludedotherrepresentativesintheserviceplanningprocessduringFY2018.BecausetheinitialpartofthissamerequirementrequirestheDefendantstohaveserviceplansdevelopedbyqualifiedprofessionals,andtheDefendantsstatedthatoccurredduringFY2018,theassessmentratingfortheentirerequirementispartialcompliance.

Out-of-ComplianceRatingsForthesixremainingrequirementsundertheservice-planningdomain,theDefendantsarefoundout-of-compliance,basedonthefollowingdataandreasoning:Requirement16:TheDefendantsindicatedthatateamofQualityMonitorsreviewed315serviceplansandrequestedrevisionsiftherewere“deficiencies”;theydidnot,however,trackandreportthenumberofrequestedrevisionsortheextenttowhichserviceplanningstaffarecompliantwiththespecificrequirementsforeachserviceplan.ThelackofdataandreportingunderminescomplianceevidenceandassessmentandleadstotheFY2018ratingofout-of-compliance.Whilethestate’scontractedAdministrativeServiceOrganization(MentalHealthCollaborativeforAccessandChoice)collectsinformationaboutserviceplanscompletedbyCMHCs,theDefendantsdidnot


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presentthefindingsofthatdataviatheirtwoFY2018semi-annualreports.TheCourtMonitorrequested(twice)specificdatatodemonstratethatserviceplanscontainedtherequiredelementsof“personalvision,preferences,strengthsandneedsinhome,communityandworkenvironmentsandshallreflectthevalueofsupportingtheindividualwithrelationships,productivework,participationincommunitylife,andpersonaldecision-making.”63ThisrequirementalsoreflectstheWilliamsConsentDecree’sfocusontheimportanceofworkenvironmentsandproductiveemploymentinaClassMember’sjourneytowardfullparticipationincommunitylife.EmploymentnotonlyprovidesfinancialresourcestotheClassMember(tosupportacquisitionandretentionofhousingandotherbasicneeds),butcanalsodeeplyenrichaClassMember’slifeandcatalyzepersonalempowermentthroughskill-building,socialconnections,meaning/purpose,andstructure.Despitethecriticalimportanceofemployment,activitiesandoutcomesinthisarea–throughtheWilliamsprogram–areextremelyweak.Only507ClassMembershaveenrolledinIndividualizedPlacementandSupport(IPS)employmentprogramssincetheoutsetoftheDecree’simplementationmorethansevenyearsago.Amongthe381IPSparticipantswhohavebeendischargedfromtheemploymentprogram,281(or74%)haveneverworked,andonly69ClassMembers–or18%-haveworkedmorethan90days.OfthosecurrentlyintheIPSprogram(143ClassMembers),93havenotworked(65%),and50arecurrentlyworking(35%).Toputthisintoperspective,2,251ClassMembershavetransitionedintothecommunitysincethebeginningoftheWilliamsConsentDecree,yetonly150ClassMembers–or6.7%-haveworkedasaresultoftheWilliamsemploymentprogramsandonly105(4.7%)ofthemworkedformorethan90days.64Similarly,underthestate’semploymentassistanceprogramadministeredbyDivisionofRehabilitationServices,dataindicatesthatonlyfivereferralshavebeenmadeofClassMembersinthepastsevenyears,andzeroClassMembershavebeenplacedinemployment.Requirements17and18:Regardingthepromptnessofdevelopingserviceplans,theDefendantsassertthatthetimelinessofserviceplanningis“nolongerviewedasapotentialissueimpedingaClassMember’stransition”andthatcontractoragenciesareempoweredtodeterminethebesttimingforserviceplancreation.65ThisisnotinaccordancewiththeConsentDecree’scleartermsofpromptandtimelyserviceplan

63WilliamsConsentDecree,SectionVI.64ThesefiguresonlycaptureClassMemberswhoreceiveIPSSupportedEmploymentservicesthroughspecificWilliams-contractedCMHCs.Assuch,additionalWilliamsClassMembersmayreceiveemploymentsupportfromotherCMHCsormaybeworkingoutsideoftheseparticularprograms.Further,afteraClassMemberisstablyemployed,workingactivitiesarenolongertrackedinthisIPSdatasystem.65WilliamsvRaunerConsentDecree.WilliamsSemi-AnnualReport14.July1,2017–June30,2018.SubmittedSeptember13,2018.


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development.Failuretodemonstratecomplianceviadataorotherinformationleadstoanassessmentofout-of-complianceinFY2018forbothoftheserequirements.Requirements19and20:OnceagaintheDefendantsreportedthattheydonotcollectdataregardingwhetherserviceplansincludetherequiredelementsofneededcommunity-basedservicesandatimetablefortransitioncompletions.TheDefendantsalsodidnotsubmitdatatosupportcompliancewiththerequirementthatserviceplansidentifiedtreatmentobjectivestoprepareindividualswhoaretransitionedtonon-permanentsupportivehousingsettings(e.g.,supervisedlivingfacilities)forpermanentsupportivehousinglater.Requirement21:TheDefendantsindicatedthattheyhavenodatabasetocollectdataregardingperiodicserviceplanupdatesforthosewhoarereferredtoCMHCsorwhoarenotrecommendedfortransition.Absentanydataorotherevidenceofcompliancewiththisrequirement,theDefendantsareassessedasout-of-complianceforFY2018.Requirement21obligatestheDefendantsto,“incorporateserviceswhereappropriatetoassistinacquisitionofbasicinstrumentalactivitiesofdailylivingskillsandillnessself-management.”66IntheCourtMonitor’svisitstoarandomselectionoffiveWilliamsfacilitiesinJuneof2018,onedynamicwasclear:shesawnoevidenceofactivetreatmentduringherhours-longvisitstoeachofthefiveWilliamsfacilities.Duringthesesitevisits,theCourtMonitorobservedthatmostWilliamsfacilitiesresidentswereeitherintheirbeds(eventhoughvisitsoccurredduringtheday)andnotengagedinanyindividualorgroupactivityortreatment(e.g.occupationaltherapy,individualcounseling,casemanagement,groupsforskill-building,angermanagement,substanceuserecovery,illnessself-management,etc.)orsmokingtobaccoindesignatedsmokingareas.While22outof24oftheseresidencesarenowclassifiedasSpecializedMentalHealthRehabilitationFacilities,itseemsthatverylittletreatmentorrehabilitationisoccurringinthesefacilities,oratleastnotinthosefacilitiesshevisited.TheCourtMonitorfearsthatresidenceinthesefacilitiesmayhinderrecoveryandcausesomeClassMemberstoloseconcretelivingskillsandconfidenceasopposedtogainlivingskillsandconfidence,inpreparationtotransitionbackintothecommunity.Additionally,theCourtMonitorwascompelledtoreporttwoofthefiveWilliamsfacilitiesshevisitedtotheIllinoisDepartmentofPublicHealth(DPH)forconcernsrelatedtothecleanlinessofresidentsandpremisesandlackofactivetreatment.DPH,afterinvestigation,statedtheyhadnofindingstocorroboratetheCourtMonitor’sobservations.

66WilliamsConsentDecree,SectionVI.


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CourtMonitorRecommendationsforAchievingCompliancewithServicePlan-RelatedRequirements1. Implementastrategytocomplywitheachserviceplanrequirement,includinga

methodologytocollectandreportdatanecessarytodemonstratecomplianceregardingserviceplantimeliness,frequency,completeness,andquality.

TheDefendantsidentifiedseveralareasrelatingtothetimeliness,frequency,andqualityofserviceplanswheredataisnotcurrentlycollectedandthuscouldnotbereported.TheConsentDecreeincludesaclearobligationfortheDefendantstomonitoranddemonstratecompliancewithserviceplanningaspects.Theirfailuretodosohasnotonlyledtoout-of-complianceratingsformostofthisdomain’srequirements,butalsoprecludedprogrammanagersandassessorsfromthebenefitofinformationandinsightssuchdatacouldhaveprovidedtotheserviceplanningprocessandoutcomes.Improvingthisprocesswillhelpidentifystrengthsandweaknesses,addressqualitydeviationsamongthecontractorswhodevelopserviceplans,andaddressbarrierstotimelinessandtheimpactthishasonClassMembertransitions.Assuch,theDefendantsshouldconsiderdevelopingamethodologytocollect,analyze,andreportdataassessingtheinclusionofrequiredcontentandthetimelinessofcompletingserviceplans.Thiscouldbeexecutedinseveralways,including:

§ RequiringmonthlyreportsonanumberofkeyperformanceindicatorsfromWilliams

contractagenciesthatdevelopserviceplans;§ Requiringthedirectinputofdataintoatrackingsystem(e.g.,enhancementtothe

trackingsystemsusedtogenerateperformanceandoutcomereports);§ EnhancingtheUniversityofIllinoisinChicagoCollegeofNursing’squalityassurance

roletoprovidedeeperandwiderassessmentinquiriesandmakerecommendationsforimprovementsacrosstheserviceplanningcompliancedomain;and

§ Enhancingtheroleofthestate’scontractedAdministrativeServiceOrganizationtocollectcompliance-relatedinformation.

Trackingprocessmeasuresrequiresprojectanddatamanagementsophistication,whichincludesthedevelopmentofperformancemeasures/indicators;databasedevelopmentanduse;datacollection,entry,cleansing,andanalysisprotocols;trainingforprovidersonprocessmeasuresanddatasubmissionrequirements;dataanalysisandreporting;andaqualityassessmentandimprovementprocess.Ideally,suchneededimprovementswouldtakeplacegloballyacrosstheWilliamsprogram.TheDefendantsareencouragedtore-examineandgivemeaningfulconsiderationtotherecommendationsprovidedintheApril2017ConsultantsReportissuedunderColbertvs.Rauner67asendorsedbythepriorCourtMonitorinhisSpecialReporttotheCourtsubmittedinMay2017.68The67ColbertConsentDecree,ReporttotheCourtMonitor:RecommendationsforSystemandProcessImprovements.Retrievedfrom:www.aclu-il.org/sites/default/files/field_documents/court_monitors_special_report.pdf.68Colbertv.Rauner,SpecialReporttotheCourt.May12,2017.Retrievedfrom:www.aclu-il.org/sites/default/files/field_documents/court_monitors_special_report.pdf


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formerCourtMonitorencouragedWilliamsprogramstafftoalsoconsidertherecommendationsprovidedtosupportstrongerperformanceundertheColbertprogram,yetthereisnoevidencethatthishasoccurredasofthewritingofthisreport.OnerecommendationintheConsultants’reports,endorsedbythepriorCourtMonitor,wastodeveloparobustdataenterpriseprogramthatcapturesperformancerelativetothenumeric-,process-,andquality-orientedindicatorsacrossrequiredactivityandreportingdomains. 2. Ensureclearlinesofresponsibilityforserviceplancompletionandtreatmentand

skillsdevelopmentinterventionsandactivitiestherein.

Thecrucialstepofassigningresponsibilityforwhoshouldensurethatthevariousclinicaltreatmentsandskillsdevelopmentdocumentedinserviceplansareactuallyimplementedappearstobelacking.DuringtheCourtMonitorsvisitstovariousWilliamsfacilitiesinJuneof2018mostoftheadministratorsandstaffintervieweddidnotknowwhowasresponsibleforkeepingtheserviceplans,wheretheycouldbefound,whethertheywereimplementedand/orrevisedperiodically,andsoon.Thisidentifiesanotablegapinthetransitionprocessthatshouldbeaddressedimmediately.3. Addressprovider-relatedissuespertainingtoserviceplandevelopment.AstheleadagencyforWilliamsimplementation,itisimportantthatDMHaddresscontractoragency-relatedissuesthatmayleadtonon-compliancewithserviceplanningrequirements.Theseareasinclude:§ Williamscontractoragencies’potentialunwillingnesstoprovideprojectedtransition

timelinesbecauseofconcernthattheywillbeheldaccountablefortimeframes;§ Potentialoverlapbetweendevelopmentandcontentofcommunitymentalhealth

centertreatmentplansandWilliamsserviceplans,andrelatedproviderfrustrationwithinefficienciesandduplicationofeffort;

§ CMHCsrequeststodiscontinuereferralsandassignmentforClassMemberswithnoincomesfortransitionservicesandDMHpolicystatescannotbetransitionedwithoutincome;

§ Provideragencycapacityissuesrelatedtoconductingserviceplanupdatesevery180daysforthoseClassMemberspreviouslynotrecommendedfortransition;and

§ Lackofjustificationforplacementinnon-permanentsupportivehousingsettingsandpotentiallackofunderstandingaboutthearrayofservicesthatcanbeprovidedtoClassMembersinpermanentsupportivehousingtopromotehousingretentionandcommunitytenure.

TheseoverallneedstoimprovecompliancewithserviceplanrequirementsshouldbeaddressedinthenextrequiredImplementationPlanandtheactivitiesthatensuetoachievecomplianceinthisdomainshouldtaketherecommendationsofferedaboveintodeepconsideration.


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4. Utilizeservice-planningimplementationasanopportunitytoenhanceinstrumentallivingskillsandprepareClassMembersforsuccessfulcommunitylivinginpermanentsupportivehousing.

TheWilliamsConsentDecreelanguageisconsistentwiththeresearch:mostpeoplewithseriousmentalillnesscananddothriveinpermanentsupportivehousingsettings,iftheysochoose.WhileothertypesofhousingsettingsmaybeappropriateforClassMembersinlimitedcircumstancesandduration,theConsentDecreeincludesaclearpreferenceforpermanentsupportivehousingbyincludingonlythreespecificsituationsthatcanbeusedtoplaceClassMembersinnon-permanentsupportivehousing.Evenfurtherattestingtothepermanentsupportivehousingpreference,theConsentDecreerequiresserviceplanstoincludegoals,strategies,andservicesforindividualsreferredtonon-permanentsupportivehousingsettingsthatfocusonpreparingthemforeventualpermanentsupportivehousingplacement.Clinically,preparingpeopleforpermanentsupportivehousingrequiresprogramstofocusonhabilitation69,rehabilitation,andskillbuilding,inadditiontotheprovisionofclinicalandmedicalsupports.ThatmeansthatwhetheraClassMemberisnotrecommendedfortransitionandremainsinaWilliamsfacilityorisrecommendedfortransitionbutreferredtoanon-permanentsupportivehousingsetting,thefocusofthatperson’sserviceplanshouldbetheacquisitionoftheskillsnecessarytoeventuallyliveinpermanentsupportivehousing,andthenservicesshouldensue.FulladherenceunderWilliamstothepermanentsupportivehousingrequirement,unlessoneormoreofthestatedcaveatsexist,mightrepresentaphilosophicalshiftforsomestateagencystaffandproviders,aswellasoperationalandclinicalshiftsforserviceproviders(e.g.,Williamsfacilitiesandtransitionalhousingproviders).Itisunderstandable,yetnotacceptable,thatbecauseIllinoislackstherangeandsupplyofcommunity-basedservicesneededforClassMemberstosuccessfullytransitionandremaininthecommunity(i.e.,crisisservices,assertivecommunitytreatmentteamsavailable24/7;substanceusetreatment,independenthousingunitswithonsiteaccessto24/7medicalstaff,primarycareservices,transportation)someprogrammanagersandprovidersavoidtransitioningClassMembers.However,theappropriateresponsetothisdilemmaisnottocontinuetoinappropriatelyinstitutionalizeClassMembersinWilliamsandotherfacilities,itis,asrequiredbytheConsentDecree,tobuildandsustainthetypesofservices,supportsandhousingneededbyClassMemberswho,withthem,cansuccessfullyliveinthecommunity.

69Habilitationincludescognitive,social,finemotor,grossmotor,orotherskillsthatcontributetomobility,communication,andperformanceofactivitiesofdailylivingandenhancequalityoflife.


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SectionVII.TransitionActivitiestoSupportClassMembersThisreport’sprecedingsectionsthatfocusondiversion,outreach,evaluation,andserviceplanningentailactivitiesdesignedtodetermineClassMembereligibilityandappropriatenessforcommunitytransitionandthen,whenindicated,prepareClassMembersfortransitionfromWilliamsfacilitiesintothecommunity.SuccessfultransitionofappropriateClassMembersisthecentralintentoftheConsentDecree.TheDefendants’abilitytomeetthespecificnumerictransitionrequirementsundertheConsentDecreeisoftenviewedasoneofthemostimportant,oratleastthemostvisible,indicatorofcompliance.SuccessorfailuretoachievethenumberofrequiredtransitionssignalstheDefendant’sabilitytoeffectivelyreachandidentifyappropriateClassMembers,prepareforandeffectuatetransitions,and,atthesystems-level,moveinthedirectionofrebalancingthementalhealthservicessystemawayfrominstitution-basedandrestrictivecaresettingstowardcommunity-basedservices,supports,andhousing. DuringFY2018,tosupporttransitionandcommunity-basedsupportsandservices,theDefendantscontractedwitheight“fullarrayserviceCommunityMentalHealthCenters(CMHCs),”toofferafullarrayofMedicaidbillableservices(includingAssertiveCommunityTreatmentandCommunitySupportTeamservices)alongwithothernon-billablementalhealthservices.TheDefendantsalsocontractedwitheightotherorganizations,called“transition-onlyCMHCs,”thatprovideserviceswithintheircertificationsbutdonotofferAssertiveCommunityTreatmentorCommunitySupportTeamservices.InFY2018,theDefendantsassignedtransitiontargetstotheeightfullarrayserviceCMHCs;thesetargetstotaledthenumberofrequiredtransitionsforFY2018—400ClassMembers.DatahighlightsprovidedbytheDefendantsintheirFY2018Semi-AnnualReports(13and14)70include:§ InFY2018,theDefendantseffectuated315transitions,representing79%oftheir

totaltransitionrequirementof400;§ 177ofthe315FY2018transitionsrepresentClassMembersapprovedfortransition

duringthatsamefiscalyear,andtheremaining138transitionsrepresentClassMemberapprovedfortransitioninthepreviousfiscalyear(FY2017);

§ InFY2018,therewere1,038ClassMemberswhowereapprovedfortransitionthroughtheevaluationprocess;

§ Ofthe1,038ClassMemberswhowereapprovedfortransitionthroughtheevaluationprocessinFY2018,177(17%)weretransitioned.

§ Theremaining861ClassMemberswerenottransitionedbecausetheywereplacedonholdsforlegal,financial,medical,orpsychiatricreasons(212,or25%),werein

70WilliamsvRaunerConsentDecree.WilliamsSemi-AnnualReport13.SubmittedDecember2017.WilliamsvRaunerConsentDecree.WilliamsSemi-AnnualReport14.SubmittedSeptember13,2018.


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thehousingsearchprocess(30,or3%),beingreviewedbytheClinicalCaseReviewPanel(38,or4%),wereunabletobelocated(111,or13%);declinedtotransition(134or15%);orwereinthepipelineforfuturetransition(336or39%);

§ InthesecondhalfofFY2018,89%ofallClassMemberswhotransitionedenteredtheirownlease-heldapartments(permanentsupportedhousing);71and

§ Theaveragelengthoftime(indays)fromClassMemberassessmenttotransitionis164days(5.5months)andtheaveragelengthoftime(indays)fromassignmenttoaCMHCtotransitionis94days(3.1months).

Transition-RelatedComplianceRequirements:ComplianceAssessmentforFY2018TheWilliamsConsentDecreecontains12compliancestandardspertainingtothetransitiondomain.Fiveofthe12requirementsrepresenthistoricalrequirementsandarenotrelevanttothisreportingperiod,whichleavessevenrequirementsthatarerelevanttotheFY2018performanceperiod.Underthisdomain,theDefendantsarerequiredtoprovideanyClassMemberapprovedthroughtheevaluationprocessanopportunitytotransitiontocommunity-basedservicesandpermanentsupportivehousing;supportClassMemberswhoaredischargedfromWilliamsfacilitiespriortotheiragreed-upontransitiondatetoensurethattheydonotloseaccesstoservicesandhousingduetoearlydischarge;providepermanentsupportivehousingtoalltransitioningClassMemberswhodonotmeetspecificexclusionarycriteria;andimplementmeasurestoprotectClassMembersfromevictionduringhospitalization. Figure19.SynopsisofFY2018ComplianceAssessmentsfor

Transition-RelatedRequirementsTotal#CurrentRequirements



AsindicatedbyFigures19and20,forthecurrentrequirementsunderthetransitiondomainforFY2018,theDefendantsareassessedasincompliancewithonerequirement,inpartialcompliancewithtworequirements,andout-of-compliancewithfourrequirements.

71TheDefendantsdidnotsubmitdataonhousingsettingbytypeforClassMemberswhotransitionedduringthefirsthalfofFY2018.


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Figure20.FY2018ComplianceAssessmentRatingsforTransition-RelatedWilliamsConsentDecreeRequirements

Req.# Source/Citation


CourtMonitorFY2018

ComplianceAssessment

Rating

24


PSHwillbeconsideredthemostintegratedsettingappropriateforClassMembersexceptthat,(1)foranyClassMembers(i)whohaveseveredementiaorotherseverecognitiveimpairmentsrequiringsuchahighlevelofstaffingtoassistwithactivitiesofdailylivingorself-caremanagementthattheycannoteffectivelybeservedinPSH,(ii)whohavemedicalneedsrequiringahighlevelofskillednursingcarethatmaynotsafelybeprovidedinPSH,or(iii)whopresentandangertothemselvesorothers,theevaluatorwilldeterminethemostintegratedsettingappropriate,whichmaybePSHoranothersetting,and(2)nothinginthisparagraphshallpreventClassMemberswhocanandwishtolivewithfamilyorfriendsorinotherindependenthousingthatisnotconnectedwithaserviceproviderfromdoingso.

PartialCompliance

25


ClassMemberswhomovetoaCommunity-BasedSettingwillhaveaccesstoallappropriateCommunity-BasedServices,includingbutnotlimitedtoreasonablemeasurestoensurethattheirhousingremainsavailableintheeventthattheyaretemporarilyplacedinahospitalorothertreatmentfacility.

PartialCompliance

26


Withinfive(5)yearsofthefinalizationoftheImplementationPlan,allClassMemberswhohavebeenassessedasappropriateforlivinginaCommunity-BasedSettingwillbeofferedtheopportunitytomovetoaCommunity-BasedSetting.

Out-of-Compliance

27

WilliamsConsentDecreeVIII(15)

IntheeventthatanyIMDseekstodischargeanyClassMemberbeforeappropriatehousingisavailable,includingbutnotlimitedtocircumstancesinwhichanIMDdecidestoclose,Defendantswillensurethatthoseindividualsarenotleftwithoutappropriatehousingoptionsbasedontheirpreferences,strengths,andneeds.

Out-of-Compliance

28

WilliamsConsentDecreeVI(8)(G)

BytheendofthefifthyearafterthefinalizationoftheImplementationPlan,Defendantswillhave:(1)offeredplacementtoonehundredpercent(100%)ofallindividualswhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting;and(2)developedthecorrespondingnumberofPSHunitsorotherCommunity-BasedSettingssufficientfortheseindividuals.Forpurposesofthissubparagraph,theseindividualsincludethetotalof(1)allClassMembersasoftheendofthefourthyearafterthefinalizationoftheImplementationPlanwhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting,and(2)allformerClassMemberswhohavealreadytransitionedfromtheIMDtoaCommunity-BasedSettingortoanothercommunitysettingsincethefinalizationoftheImplementationPlan.

Out-of-Compliance


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29

WilliamsConsentDecreeVI(8)(G)

ForpurposesofthisDecree,PSHincludesscattered-sitehousingasawellasapartmentsclusteredinasinglebuilding,butnomorethan25%oftheunitsinonebuildingwithmorethan4unitsmaybeusedtoservePSHclientsknowntohavementalillness.Forbuildingswith2to4units,nomorethan50%oftheunitsmaybeusedtoservePSHclientsknowntohavementalillness.However,duringfirst5yearsafterfinalizationoftheIP,upto75classmembersmaybeplacedinbuildingswheremorethan25%oftheunitsservePSHclientsknowntohaveMIifthosebuildingswereusedtoservePSHclientspriortoMarch1,2010.Afterfirst5yearsfollowingthefinalizationoftheIP,allclassmembersservedinPSHshallbeofferedtheopportunitytoresideinbuildingsthatcomplywith25%or50%unitslimitsetforthaboveinthissubparagraph.

InCompliance

30

WilliamsConsentDecreeVI(8)(H)

AftertheendofthefifthyearfollowingfinalizationoftheImplementationPlan,ClassMemberswhoareassessedasappropriateforlivinginaCommunity-BasedSetting,whodonotopposetransitiontoaCommunity-BasedSettingandwhoseServicePlansprovideforplacementinCommunity-BasedSettingsshallbeofferedtheopportunitytomovetothosesettingsandshallreceiveappropriateservicesconsistentwiththeServicePlanwithinonehundredandtwenty(120)daysofthedateoftheServicePlan.

Out-of-Compliance

31

WilliamsConsentDecreeVI(8)(C)

BytheendofthefirstyearafterthefinalizationoftheImplementationPlan,Defendantswillhave:(1)offeredplacementinaCommunity-BasedSettingtoaminimumof256ClassMemberswhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting;and(2)developed256PSHunitsforthebenefitofClassMembers.

NotRelevanttoReportingPeriod

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WilliamsConsentDecreeVI(8)(D)

BytheendofthesecondyearafterthefinalizationoftheImplementationPlan,Defendantswillhave:(1)offeredplacementinaCommunity-BasedSettingtoaminimumof640ClassMembers(includingthe256referencedinsubparagraph8cabove)whoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting;and(2)developed640PSHunitsforthebenefitofClassMembers.


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WilliamsConsentDecreeVI(8)(E).

BytheendofthethirdyearafterthefinalizationoftheImplementationPlan,Defendantswillhave(1)offeredplacementtoatleastfortypercent(40%)ofallindividualswhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSettings;and(2)developedthecorrespondingnumberofPSHunitsorotherCommunity-BasedSettingssufficientfortheseindividuals.Forpurposesofthissubparagraph,theseindividualsincludethetotalof(1)allClassMembersasoftheendofthesecondyearafterthefinalizationoftheImplementationPlanwhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting,and(2)allformerClassMemberswhohavealreadytransitionedfromtheIMDtoaCommunity-BasedSettingortoanothercommunitysettingsincefinalizationoftheImplementationPlan.



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34

WilliamsConsentDecreeVI(8)(F)

BytheendofthefourthyearafterthefinalizationoftheImplementationPlan,Defendantswillhave(1)offeredplacementtoatleastseventypercent(70%)ofallindividualswhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting;and(2)developedthecorrespondingnumberofPSHunitsorotherCommunity-BasedSettingssufficientfortheseindividuals.Forpurposesofthissubparagraph,theseindividualsincludethetotalof(1)allClassMembersasoftheendofthethirdyearafterthefinalizationoftheImplementationPlanwhoareassessedasappropriateforlivinginaCommunity-BasedSettingandwhodonotopposemovingtoaCommunity-BasedSetting,and(2)allformerClassMemberswhohavealreadytransitionedfromtheIMDtoaCommunity-BasedSettingortoanothercommunitysettingsincefinalizationoftheImplementationPlan.


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WilliamsConsentDecreeX(21)

Withinsixty(60)daysofApprovaloftheDecree,DefendantsshalloffereachoftheNamedPlaintiffstheopportunitytoreceiveappropriateservicesinthemostintegratedsettingappropriatetohisorherneedsandwishes,includingPSH.ProvisionofservicestotheNamedPlaintiffspursuanttothisparagraphshallnotbeusedtodetermineanyotherindividual'seligibilityforservicesunderthetermsoftheDecree.


InComplianceRatingRequirement29:TheDefendantsarefoundincompliancewithensuringthatClassMembersresideinpermanentsupportivehousingsettingswherelessthanaquarteroftheresidentsconstitutepeoplewithdisabilities.Becauseprivatelandlordscannotrevealthedisabilitystatusofresidents,anothermethodmustbeusedtoascertaincompliance.TheDefendantshavestatedthattheymonitorthenumberofClassMemberswithleasestoresideunderacommonrooftoensurethatthe25%limitisfollowed,areasonableproxyindicatorforcompliance.DMHdataforFY2018ofClassMembersresidinginlease-heldunitsindicatedthat76%ofthebuildingshadwithonlyoneClassMemberinresidenceandlessthan6%hadmorethanfiveClassMembersinresidence.72Itappears,basedonthedata,thatthe25%rulewasadheredtoandthustheratingofincompliancewasgiven.PartialComplianceRatingsRequirement24:DatafromthesecondhalfofFY201873signalsthattheDefendantslargelyandappropriatelyrelyonpermanentsupportivehousingasthehousingtypefortransitionedClassMembers.TheWilliamsConsentDecreeestablishesthreescenarioswheretheDefendantscanreferaClassMembertoasettingotherthanpermanentsupportivehousing.TheseincludeaClassMemberwithadiagnosisofDementiaorotherprogressivecognitivedisorders,atriskforharmtoselforothers,orwithmedical72WilliamsvRaunerConsentDecree.WilliamsSemi-AnnualReport14.SubmittedSeptember13,2018.73TheDefendantsprovideddataonlyforthesecondhalfofthefiscalyear.


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needsrequiring24-hourcare.Additionally,aClassMembercanchoosetoliveinanon-permanentsupportivehousingsetting.TheDefendantsareassignedapartialcomplianceratingpursuanttothisrequirementbecausetheyreferred11%oftransitionedClassMembers(duringthesecondhalfofFY2018)toSupervisedResidentialSettings—non-permanentsupportivehousingsettings—whiletheseClassMembersdidnotmeetthespecificpermanentsupportivehousingexclusionarycriteriaenshrinedintheDecree.Moreover,theDefendantsattestthatthereisnocurrentmethodologyinplacetoensurethatthosereferredtonon-permanentsupportivehousingsettingsmeetsthosespecificcriteria.Requirement25:TheDefendantsarefoundinpartialcompliancewiththetwo-partrequirementofensuringthattransitioningClassMembershaveaccesstocommunity-basedsettingsandareabletoremainintheirhousingiftheyaretemporarilyplacedinahospitalorothertreatmentfacility.Relativetothefirstpartoftherequirement—obligatingtheDefendantstodevelopappropriatecommunity-basedservicesforClassMemberstransitioningintothecommunity—theCourtMonitorassignedtheratingofpartialcompliancebecauseoftheDefendants’admissionthatthereremaingapsinservices,andtheDefendants’inactionrelatedtoMultiyearProviderGrowthPlan.WilliamsandColbertproviderssubmittedtotheDefendantsaMultiyearProviderGrowthPlanonFebruary28,2018,expressingthedesireforan“environmentoffeedbackinwhichprovidervoiceisheard”andnotingthatCMHCswouldnotmeet“numbersdemandedbytheconsentdecree(sic)unlesssignificantreinvestmentintocommunitymentalhealthisprovided.”74BytheendofFY2018,allactivitiesassociatedwiththeMultiyearProviderGrowthPlanwereprocess-orientedinnature,andintheirFY2019ImplementationPlan,theDefendantsplannedactionswerealsoonlyprocess-oriented,includingsemi-annualmeetingswithWilliamsCMHCsregardingtheMultiyearGrowthPlanrecommendationsandimplementationstatus;theintentiontocontinue“executiveleveldiscussions”to“explorefeasibilitieswithotherareasidentifiedinthisPlan”;andtheconveningofdiscussionswithCMHCsregardingseveralissuesincludedintheplan,suchastransportationreimbursement,alignmentofdocumentationrequirements,andneuropsychologicalassessments.75WithinFY2018andevento-date,theDefendantshavereportednoconcreteactionsbasedontheMultiyearGrowthPlanthathaveresultedintheexpansionofprovidercapacity.Additionally,inJanuaryof2017,theIllinoisHousingTaskForcereleasedareportoutliningactivitiesandrecommendationsnecessarytoaddressunmethousingneeds,includingthosenecessarytocomplywithOlmstead-relatedinitiativesinIllinois,includingtheWilliams(andColbert)ConsentDecrees.76Thereportprovidedinformationonthe,“currentinventoryandunmetneed,compar[ing][permanentsupportivehousing]versusinstitutionalcosts,identify[ing]potentialresourcestocreatePSH,and74Multi-YearGrowthPlan,ExecutiveSummary,February2018.75FY19WilliamsImplementationPlan,DHSFinalDraft(June27,2018).762017SupportiveHousingWorkingGroup,IllinoisHousingTaskForce.January2017.


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propos[ing]productiongoalsaswellasstrategiestoimprovePSH.”TheTaskForceestimatednumberofPSHunitsneededforWilliamsClassMemberswas1,647unitsperyear.ItisdifficultfortheCourtMonitortoascertaintheextenttowhichasufficientnumberofhousingunitshasbeendevelopedspecificallyforWilliamsClassMemberssincemuchofthehousing-relateddataandinformationpresentedatLargePartiesandothermeetingsspansoveralleffortstoexpandaffordablehousing.ThesecondpartofthisrequirementregardstheabilityfortheDefendantstohelpClassMembersmaintaintheirhousingandavoidevictioniftheyfindthemselvestemporarilyplacedinothersettings,suchasinpatientpsychiatricorsubstanceusetreatment.InFY2018,theDefendantsreportthat65ClassMemberslefttheirhousingunitsformedicalorpsychiatrictreatmentand,ofthose,all65wereabletomaintaintheirunitsbecauseoftheDefendants’policyofpayingforthreemonthsofrentforClassMembersinthosecircumstances.Theprimaryareaofnon-complianceinthetransitiondomainisthenumericrequirementof400ClassMembertransitionsduringFY2018.WhilethenumerictransitionrequirementforFY2018isnotcodifiedintheConsentDecreeitself,eachyear,thePartiesidentifyatransitionrequirementduringtheimplementationplanningprocess.AsindicatedinFigure21,theDefendantswerenotcompliantwiththeirtransitionrequirementof400ClassMembertransitionsinFY2018,effectuatingonly315(79%)transitions.Asstatedpreviously,theDefendantsreliedoneightCMHCcontractorstoprovide“fullservice”transitionservicesandanothereightCMHCstoprovidelimitedtransitionservices.ThefirsteightCMHCswereassignedtoachievethetotalnumberoftransitionsrequiredforFY2018,whiletheotherswereviewedasprovidingsupplementaltransitions.Infact,datasubmittedbytheDefendantsinSemi-AnnualReport14revealedthatofthe315transitionsachievedduringFY2018,97%wereaccomplishedbytheeightfullserviceCMHCs,with3%completedbytheothers.Importantly,withintheeightfullserviceCMHCs,theDefendantsreliedontwoofthemtoproduce230(57.5%)oftherequired400transitions.Oneoftheseagenciesmetitsrequirementexactly,transitioning70ClassMembers.Thesecondagency,however,onlyachieved83ofits160transitions(or52%).WhilefiveoftheeightfullserviceCMHCsmetorexceededtheirassignednumberoftransitionsrequiredforFY2018,becausethissingleproviderwasassignedsuchalargepercentageofneededtransitions(40%)anddidnotmeetthetarget,thatdifferencealoneimpactedDefendantscompliancenegatively.ThisindicatesthattheDefendants’inabilitytoreachtransitionrequirementsmayrelatetoplanningmisjudgmentsandmiscalculationsregardingexpectedprovidercapacityandperformanceandover-relianceandassignmentofalargeproportionoftransition

Figure21.FY2018TransitionComplianceRequirementvs.Outcome:WilliamsClassMemberTransitions

Transitions#Required #Achieved

400 315(79%)


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responsibilitiestoasingleproviderorganization.77Whileoutsideofthetimeframeofthereport’sassessment,FY2019datathusfarindicatesasimilarpatternoftheDefendantsover-relianceononeortwoCMHCproviders;thiscoupledwithunderperformanceandotherfactorsishavingsimilarconsequencesfortheDefendant’stransitionoutcomesbeingfarbelowtargetsthusfarinthecurrentfiscalyear.Out-of-ComplianceRatingsRequirements26and28:TheDefendants,bythefifthyearoftheinitialImplementationPlan(producedinJuneof2011),wererequiredtotransition100%ofClassMembersapprovedthroughtheevaluationprocess,havingdevelopedasufficientnumberofcommunity-basedservicesandpermanentsupportivehousingunits.Inshort,theDefendantsarenowherenearmeetingthisrequirement.Outofthe1,038ClassMembersapprovedfortransitionthroughtheevaluationprocess,only315transitionsoccurredduringFY2018,and138ofthose315ClassMembersrepresentClassMemberswhowereapprovedfortransitioninthepreviousfiscalyear.LagsandcarryovernumbershaveandwillbeexpectedtorepeatinfutureyearsyetthefundamentalissueremainsthatasignificantlylowernumberofClassMemberswhowererecommendedtotransitionactuallytransitioned.ForthoseClassMemberswhoareinitiallyrecommendedtotransitionthroughtheevaluationprocessbutsubsequentlyarenottransitioned,therearemultiplereasons.Thisincludesthe“ComplexitiesAffectingSeamlessTransition”designationandprocess–alsoknownastheCASTlist.ThisdesignationoccurswhenClassMembersareinitiallyrecommendedfortransitionthroughtheevaluationprocess,butduringeitherthepre-referralprocess(betweenevaluationandreferraltotheCMHCtransitionagencies)orpost-referraltotransitionentities(afteratransitionentityisworkingwithaClassMember),theClassMemberisplacedona“hold”forreasonssuchasnoincome;excessincomeresultinginspend-downobligations;servicesnotavailableinadesiredlocation;CMHCcapacityissuesatinthedesiredlocation;Medicaidpendingstatus;inabilitytogatheridentificationdocuments;andmedicaland/orpsychiatriccomplexities(orurgentneeds/risksintheseareas).UndertheCASTlist/processthatDefendantshavebeenusing,ifthetransitionagency(CMHC)believesthataClassMember,originallyrecommendedfortransitionbytheResidentReview(evaluation)process,hasbecomeunabletotransition,theycanprovideclinicaldocumentationandotherinformationtotheDMHClinicalCaseReviewPanel(CCRP).Onaregularbasis,theCCRPreviewsthisinformationandthendeterminestoeithersupportoroverturntheprovider’sdecisionaboutaClassMember’stransitionappropriateness.InFY2018,250ClassMembers(or29%ofremainingClassMemberswhowereinitiallyrecommendedthroughtheevaluationprocessandnottransitionedto77TheCourtMonitorhasnotyetfullyinvestigatedreasonsforthisinstanceofmajorunderperformance.Assuch,thisobservationisnotdesignedtocriticizeorattributeblametoprovidersregardingperformancetowardtransitiontargets.


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thecommunity)wereplacedontheCASTlist,wereintheCCRPreviewprocess,orplacedonanothertypeofhold.78ReasonsforplacementontheCASTincludeissuesrelatedtomentalhealth,medicationmanagementneeds,medical/diabetes-relatedcomplications,generalmedicalneeds,financialneeds,andhousing-relatedissues.AccordingtodatafromDMH,nearly90%ofthe141ClassMembersonCASTweretherebecausenoincome,8%wereplacedonCASTduetohousing-relatedissues,andtheremainingduetomentalhealthissues.79Another109ClassMemberswerealsoplacedonnon-CASTholds,withdataindicatingthatthemostcommonreasonsfortheseholdswerementalhealth,housing,andfunding.80,81PlacingDefendantsontheCASTlist—oronanyothertypeofhold—shouldbereservedforthoseinveryspecificcircumstancessuchasapsychiatriccrisisormedicalconcern.Otherwise,CASTunderminescompliancetorequirements26and28andlikelypreventstheDefendantsfrommeetingtransitionrequirements.SeveralotherCAST-relatedissuesmustbeaddressed,whichinclude:§ AllClassMembersontheCASTlistwereatonetimeapprovedfortransitionthrough

theevaluationprocess.Itisunclearwhetherdiscrepanciesbetweenthedeterminationmadeduringtheevaluationprocesslieintransitionproviders’disagreementswithassessmentofClassMembers’readinesstotransitionand/orothershortcomingswiththeevaluationprocess;theirinabilityorunwillingnesstoservevulnerableindividualswithcomplexandmyriadpsychiatricandmedicalneeds;alackofadequatecommunity-basedservices,supports,andhousing;inadequatepaymentorreimbursementratestobuildandsustaincommunity-basedcapacityfortransitioningClassMembers;oraconfluenceofthesefactors.Sometransitionprovidershavenotedthattheywouldliketoconductoutreachandevaluationfunctionsthemselves,insteadofrelyingonthestate-contractedResidentReviewAgencies,statingthattheycanmoreappropriatelyidentifytransitionsuitableClassMembersandmoreaccuratelyassesstheirtransitionreadiness.However,theCourtMonitorandDefendantshaveconcernsaboutthemeritsofhavingthesameentityconductoutreach,evaluation,andtransitionfunctions,asthismaypresentconflictsofinterest.

§ ManyofthecircumstancesthatmayjustifyaClassMember’splacementontheCASTlistarecommonchallengesamongClassMembers(and,ingeneral,Medicaid-eligibleindividualswithphysicaland/orpsychiatricdisabilities)suchaslowincomes,medicalorpsychiatriccomplexities,anduninsuredstatus.AfteryearsofchargewithimplementingtheDecree,theDefendantscanandshouldbeexpectedtoutilizeacogentapproachbasedondataaboutClassMembers’needsandsuccessfactorstoidentify,plan,fund,andotherwiseensurethatadequatecommunity-basedservices,

78DataprovidedbyDMHasofJuly9,2018.79Ibid.80Ibid.81ItisunclearhowtheseholdsdifferfromCAST-relatedholds,astherearesimilar/samecategoriesinboth(e.g.mentalhealth,medical,housing).


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supports,andhousingexist.ThishasbeeninthepastandremainsafundamentaldeficitoftheWilliamsprogramanddirectlyimpedestheDefendantscompliancewithanumberofrequirements,including—mostnotably—failuretoachievethenumberofrequiredClassMembertransitions.

TheDefendantsarealsoout-of-complianceforFY2018withtheremainingtworequirementsunderthisdomain,including:§ Requirement27:TheConsentDecreeincludesatermtoensurethatthoseClass

MemberswhoaredischargedfromWilliamsfacilitiesamidsttheirtransitionprocessreceivetargetedassistancetocontinuetheirtransitiondespiteearlydischarge.InFY2018,74ClassMembersreceivedaNoticeofInvoluntaryTransferorDischargefromoneofthe24Williamsfacilities.Reasonsfortheinvoluntarydischargeincludephysicalsafetyofothers(62%),medicalreasons(24%),late/non-payment(9%),reasonnotprovided(3%),orphysicalsafety(1%).WhileitisinformativetoknowthenumberofClassMemberssubjectedtounplanneddischargeduringFY2018andthereasonsforsuch,theDefendantsdidnotprovideanydatatodemonstratewhoamongtheseClassMemberswerealreadyinthetransitionprocessand/orwhethertherewasanyinterventiontoprovidecommunity-basedhousingorservicestothem,despitetheirunplanneddischargefromtheWilliamsfacility.Becauseofthis,theDefendantsareout-of-complianceforthisrequirement.

§ Requirement30:TheConsentDecreeobligatestheDefendantstocompletetransitionswithin120daysofserviceplandevelopment.Forthesecondhalfofthefiscalyear,82morethanhalfofallClassMemberswhoweretransitioned(99of194)werenottransitioneduntilgreaterthan120daysfromassignmenttoaCMHC(theproxydateforserviceplandevelopment).TheDefendantsnotethattransitiondelaysareconsequenttoClassMemberissuessuchaspoorcredithistory,evictionhistory,criminalbackground,medicalcomplexities,andotherissues.

CourtMonitorRecommendationsforAchievingorEnhancingCompliancewithTransition-RelatedRequirementsToachievetherequirednumberofClassMembertransitions,theDefendantsareencouragedtorefertotherecommendationsofferedineachoftheothersectionsofthisreport,particularlySectionVIII.AdditionalrecommendationsthattheDefendantsmightexploretoenhanceperformanceandincreasecomplianceinfutureyearsareofferedbelow.

82TheDefendantsdidnotprovidedatarelativetothisrequirementforthefirsthalfofFY2018.


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1. Identifyandaddressbarrierstotimelyandsuccessfultransitions.Whiletransitioncertainlyentailsacomplex,multistepprocess—andthereareneithernationalnorotherestablishedbenchmarksforthesetimeframes—atfacevalue,theDefendants’averageofmorethanfivemonths(164days)betweenarecommendationandtransitionappearslengthy.TheDefendantsareencouragedtodevelopstrategiestoincreasetransitiontimeliness,perhapsreplicatingbestpracticesinrapidhousingandservicelinkagessuchasHousingFirstandRapidRe-Housingproviders.Areasforinquiryandexaminationinclude:§ WhatwerethebarrierstotimelytransitionsofClassMembers?Whichbarriers

createdasignificantgapbetweenClassMembersrecommendedfortransitionandthosewhotransitioned?

§ ForClassMembersreferredtotransitionagencycontractorsbutnotultimatelytransitioned,whatservicesandsupportsarenecessarilytofacilitatetransitionandlifeinthecommunity?

§ WhatstepsarecurrentlymissingthatshouldbeputintoplacetobetterprepareandpositionaClassMemberfortransition(e.g.,occupationaltherapy,earlierinquiriesintocriminaljusticeinvolvementandcredithistory)?

2. ResolvediscrepanciesbetweenevaluationresultsandsubsequentCASTlistingsanddeterminations.

TheDefendants’FY2018Semi-AnnualReportsmadenoeffortstodescribethediscrepanciesbetweenevaluationresultsandsubsequentCASTdeterminations.ThisincludeswhetherandhowtheevaluationprocesscanbeimprovedtobetterandmoreaccuratelyassessaClassMember’sappropriatenessandreadinessfortransition.TheCourtMonitorbelievesthatcommitment,leadership,funding,andimplementationofappropriatecommunity-basedservicesandsupportscanresolveatleastsomebarriersthatresultinClassMembersbeingplacedontheCASTlist.TheDefendantsshouldutilizethedatafromtheCASTlistanddiscussionswithWilliamsevaluatorsandtransitionagency/community-providercontractorstounderstandwhetherdiscrepanciescanbeattributedtoevaluationprocessflawsand,ifso,todevisewaystosuccessfullyaddressthem.3. AddressCASTbarriersthroughdata-drivendevelopmentofcommunitysupports,

services,andhousing.Inthementalhealthfield,peoplewhoneedandusetreatmentandservicesoftenexperiencemultiplebarrierstorecoveryandfullparticipationincommunitylife,includingnoincome,medicalandpsychiatriccomplexities,substanceusedisorders,lackofhealthinsurancecoverage,andstigma,amongothers.Thiscreatesanimperativeforsystemstodesignservicesandhousingtoaddressthesebarriersandtopromotethesocialwelfare,stability,andlifeinthecommunityforindividualswithpsychiatric


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disabilities.Usingdatafromthe“CAST”list,theDefendantsarerecommendedtoconsiderthefollowing:§ AddressingthecircumstancesofClassMemberswithnoincomebythoroughly

exploringtheireligibilityforentitlementprogramssuchasthefederalSSI/SSDIOutreach,Access,andRecovery(SOAR)thatfeaturesstafftrainedandskilledatexpeditingandincreasingthelikelihoodofsuccessfulSSI/SSDIinitialapplicationsandappeals;benefitsspecialistsprograms;andincreasedemploymentservices;83,84

§ ResolvingClassMembers’Medicaidpendingstatusthroughuseofbenefitsspecialists,insurancenavigators,andthoroughexplorationandpotentialadoptionofapresumptiveeligibilityprogramforchildlessadults,whicharecurrentlyinplaceinIndiana,Montana,NewHampshire,NewJersey,andOhio85;and

§ Attendingtothelackofaccesstoservicesandhousing,aswellasthetreatmentofpsychiatricandmedicalcomplexities,throughdata-drivenexpansionofcommunity-basedservicesandhousing(seeSectionVIIIfordetail).

4. AddressSpecificOut-of-ComplianceAreasInthethreeareasreferencedabove(Requirements24,27,and30),itissuggestedthattheDefendantsexplorethefollowingrecommendationstocomeintocompliance: § IncreaseTimelinessofTransitions.TheDefendantsindicatethattransitionsarenot

currentlycompletedinatimelymanner,withnearlyhalfexceedingtheConsentDecree-establishedtimeframeof120days.Assuch,theyshouldconsiderstrategiestoaddresstransitionstimeliness,includingdesigningpoliciesandproceduresthatproactivelyassessandaddressbarriersknowntocreatelagsintransition(e.g.,housinglocation,benefitsacquisition,Medicaiddeterminationsorreauthorizations).

§ OnlyExcludeClassMembersfromPermanentSupportiveHousingBasedonChoiceorConsentDecree-ApprovedConditions.PursuanttoRequirement24,theDefendantsshouldconsiderinvestingtimeandattentiontodevelopingamethodologytoindicatewhetherthoseClassMembersnotreferredtopermanentsupportivehousingorprivateresidencesmeetthethreeconditionslistedaboveorhavechosentoliveinadifferenttypeofresidentialsetting.Theyshouldoutlinestepstodevelopthemethodology,trackthisdata,andultimatelydemonstratecompliance.IftheDefendantsdonotcurrentlyhaveamethodologytodemonstratewhetherClassMemberswhoarenotreferredtopermanentsupportivehousingorprivateresidencesreceiveperiodicre-evaluationswithtreatmentobjectivesfocusedonpermanentsupportivehousingreadiness(otherthanthosewithconfirmed

83TheDefendantscommitintheFY2019ImplementationPlantodevote$14,000toaSOARcontractortoexpediteSSI/SSDIbenefitsapplicationsforClassMembers.TheCourtMonitoracknowledgesthatalimitednumberofClassMembersmaynotbeeligibleforSSIorSSDIbecausetheydonothaveaqualifyingdisability(includingthosewhohaveaprimarydiagnosisofsubstanceusedisorder).84IntheDefendants’writtenresponsetotheCourtMonitor’sdraftreport(October19,2018),theDefendantsindicatethat131wereassignedtoCASTfinancialholdsfromthebeginningofFY18todate.85KaiserFamilyFoundation,PresumptiveEligibilityinMedicaidandCHIPasofJanuary1,2018.


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diagnosesofDementiaorotherprogressivecognitivedisordersorthosewhohavechosenadifferentlivingarrangement),theyshouldconsiderdevelopingthemethodology,trackingthedata,andultimatelydemonstratingcompliance.Finally,ifDefendantsfindanoverrelianceonnon-permanentsupportivehousingsettingsduetoevaluationerrorsorlackofcommunitycapacity,SectionVIIIprovidesrecommendationstosupportbroaderdevelopmentofpermanentsupportivehousing.

§ DevelopMechanismstoSupportInvoluntarilyDischargedClassMembers.Asreferencedabove,theDefendants—intheirsemi-annualreports—didnotindicateanyeffortstosupportClassMemberswhoweredischargedfromWilliamsfacilitiespriortoaplannedtransitiondate.Assuch,theDefendantsshouldcreateacollaborativeprocesstoensureWilliamsfacilitiesactivelyengageandinvolveWilliamsprovideragencieswhenanunplanneddischargeoccurs,andcoordinateeffortstoworkwiththeClassMember’snewresidence(whetheranotherIMD,nursingfacility,hospital,orotherresidentialoption)tocontinuetheirtransition.86

Attheveryminimum,theDefendantsshouldprovidetheseClassMemberswithawrittenstatementdetailingthetransitionservicesandlinkagestocommunity-basedhousingandservicesavailabletothem,aswellascontactinformationforappropriateprovidersdesignatedtoassisttheClassMemberpost-discharge.TheClassMembershouldsignthedocumentandasevidenceofattemptedcompliancewiththerequirement,theDefendantsshouldreportthenumberofClassMemberswhowereprovidedwiththisinformation,thenumberprovidedwithtransitionassistancebeforeorafterdischarge,wheretheyweredischargedto,andiftheyultimatelytransitionedtothecommunity.

86WilliamsConsentDecree,SectionVIII.


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SectionVIII.Community-BasedServicesandHousingCapacityDevelopmentTheconsequencesofbehavioralhealthanddisabilitysystems’lackofsufficientcommunity-basedsupports,services,andhousingforpeoplewithdisabilitiesareoftenthepredicateofOlmsteadcases.Lackofcommunity-basedserviceproviderandhousingcapacitycreatesdependencyoninstitutionallevelsofcareforpeoplewithdisabilitiesandtheirfamilies.TheWilliamsDefendantsarenoexceptiontothisdynamic,withahistoricallackofstrategicinvestmentincommunity-basedservicesandhousingprovidersandstatebudgetimpedimentsthathavedestabilizedthecommunity-basedmentalhealthsystem.TheWilliamsConsentDecreeprovidesaclearimperativeandpathtoexpandcommunity-basedservicesandhousingthatarenecessarytosuccessfullytransitionappropriateClassMembersfromWilliamsfacilitiestocommunityliving.ItrequiresthatDefendantsdevelopandimplementservicesandsupportsintheappropriatequantityandqualitytocreateasystemthatfullysupportsdiversionandtransition.87Ofnote,undertheColbertConsentDecree,thepreviousCourtMonitor,DennisJones,MBA,MSW,authorizedanindependentconsultanttodevelopasetofrecommendationstosupportthedevelopmentofcommunitycapacityandto,“determinethecurrentbarrierstotheDefendants'developmentofCommunityCapacityrequiredtoachievecompliancewiththeConsentDecreeandtheCNP[CostNeutralPlan]andtotransitiongreaternumbersofClassMemberstoCommunity-BasedSettingsinthefuture.”88TheConsultantsdeliveredtheirreport89totheformerCourtMonitorinApril2017.90WhilethisactivitytookplaceundertheColbertConsentDecree,Mr.Jones—inhisMay2017SpecialReporttotheCourt91onthetopic—notedthatthefindingsandrecommendationsfromtheConsultant’sreport,“representathoughtfulandcomprehensiveframeworkfornotonlyColbertbutalsorelatedeffortsfortheWilliamsConsentDecree.”92

87WilliamsConsentDecree,SectionV.88ColbertCostNeutralPlan,Page6.89ColbertConsentDecree,ReporttotheCourtMonitor:RecommendationsforSystemandProcessImprovements.Retrievedfrom:www.aclu-il.org/sites/default/files/field_documents/court_monitors_special_report.pdf.90Disclosure:TheConsultingteamwasledbyGailP.Hutchings,MPA,PresidentandCEOoftheBehavioralHealthPolicyCollaborative,andcurrentCourtMonitorunderbothWilliamsv.RaunerandColbertv.Rauner.91SpecialReporttotheCourt,DennisR.Jones,MSW,MBA,May12,2017.92Ibid.


70

CommunityServicesandHousingDevelopment-RelatedComplianceRequirements:ComplianceAssessmentforFY2018TheWilliamsConsentDecreehastwodistinctrequirementsforthedevelopmentofcommunity-basedservicesandhousingcapacity,whichcloselyrelatetothetransitiondomainrequirements.Theseincludefurnishingservicesandhousingoftheappropriatescope,variety,andqualitytomeettermsoftheDecreeandimplementingsufficientmeasurestodevelopcommunity-basedsupportsandservicesalignedwithClassMemberpreferences,needs,andstrengths.

Figure22.SynopsisofFY2018ComplianceAssessmentsforCommunity-BasedServicesandHousingCapacity-RelatedRequirements




AsdisplayedinFigures22and23,assessmentratingsofout-of-complianceweredeterminedforbothrequirementsinthisdomain.Figure23.FY2018ComplianceAssessmentRatingsforCommunity-BasedServicesand

HousingCapacity-RelatedWilliamsConsentDecreeRequirements

Req.#

Source/Citation


CourtMonitorFY2018


Rating

36

WilliamsConsentDecreeV(5)

Defendantsshallensuretheavailabilityofservices,supports,andotherresourcesofsufficientquality,scopeandvarietytomeettheirobligationsundertheDecreeandtheImplementationPlan.

Out-of-Compliance

37

WilliamsConsentDecreeV(5)

Defendantsshallimplementsufficientmeasures,consistentwiththepreferences,strengths,andneedsofClassMembers,toprovideCommunity-BasedSettingsandCommunity-BasedServicespursuanttotheDecree.

Out-of-Compliance

Out-of-ComplianceRatingsRequirements36and37:Theseinterlockingrequirements—bothcenteredondevelopingsufficientserviceproviderandhousingcapacitytosupportClassMembertransitions—allstemfromoneclearandconsistentdeficiency:theabsenceofadata-drivenproviderandhousingcapacitydevelopmentplan.ThisissuetracesbacktotheFY2018AbbreviatedImplementationPlan,whichdoesnotcomplywiththerequirementto,“describetheactivitiesrequiredtodevelopCommunity-BasedServices,transitioncosts,homeaccessibilityadaptationcosts/housingassistance,includinginter-agencyagreements,requestsforproposals,mechanismsforhousingassistance,andother


71

actionsnecessarytoimplementtheDecree,”orto,“identify,basedoninformationknownatthetimetheIP[ImplementationPlan]isfinalizedandupdatedonaregularbasis,anyservicesorsupportsanticipatedorrequiredinServicePlansformulatedpursuanttotheDecreethatarenotcurrentlyavailableintheappropriatequantity,quality,orgeographiclocation.”93ThereisnoindicationintheDefendants’FY2018Semi-AnnualReportsorfromtheCourtMonitor’sdirectinquirytotheDefendantsthattheyutilizedatafromserviceplansoranyothersourcetoinformandactupondevelopmentofcommunity-basedservicesandhousing.TheDefendantshaveaccesstorobustdatasets(e.g.,services/housingneedsindicatedinClassMembers’serviceplans;dataanddatatrendsaboutbarrierstotransitionforthoseClassMembersontheCASTlist;Medicaidclaimsdataidentifyingservicebilling;performancedataofcurrentWilliamsoutreach,evaluation,transition,services,housingcontractors;andmanyothers).Despitethis,noevidenceremainsthattheDefendantsutilizeClassMember-,program-,orsystem-leveldatatodeterminewhatspecific,numericinvestment(s)areneededtosupporttherequirednumberoftransitions.Additionally,theDefendantscontinuedtomaintainaCASTlistandindicatedthattheywereunabletotransitionClassMembersduetolackofsufficientcommunity-basedservices(includingservicesthatcansupportacquisitionoffinancialbenefitsforClassMembers)and/orneededhousing;thisrelatestotheprovisionofneededservicesintheClassMembers’desiredlocations.Therealitiesofinsufficientcommunity-basedservices,supports,andhousinghaveresultedindelayedordeniedtransitions.TheonuslieswiththeDefendantstoquicklyidentify,address,andresolvetheseissuestoensureadequatecapacityexiststotransitionandsustainClassMembersinthecommunity.Informedandgenuineeffortstoidentifyandquantifymissingorinadequateservicesorsupportswithinthestate’sMedicaid-eligibleservicepackage,pertheConsentDecree,arenecessarytodrivetheDefendant’splanningandaction,andfullcompliance.CourtMonitorRecommendationsforAchievingCompliancewithCommunityServicesandHousingDevelopment-RelatedRequirementsTheDefendantsneedtoquicklyanddecidedlymoveintocompliancewitheachoftherequirementsunderthisdomainoftheWilliamsConsentDecree.TheDefendantsarestronglyrecommendedtodevelopacomprehensive,multi-yearcommunityproviderandhousingcapacityassessmentanddevelopmentplanthatusesdatatoinform,specifyandquantifythetypesandnumbersofservices,supports,housingunitsthatareneededtoeffectivelytransitionandmaintainClassMembersinthecommunityandthefinancial/monetarycommitmentsthatareassociatedwithmeetingthesecapacityfulfillmentorenhancementneeds.ThefollowingspecificrecommendationsareofferedtoassisttheDefendantsinattainingcomplianceinthisimportantdomain.

93WilliamsConsentDecree,Page22.


72

1. Developadata-drivencommunityproviderandhousingcapacityplan.SeveralsetsofClassMember-leveldataexistthatcanhelpidentifyandprojectareasandamountsofneededdevelopmentofcommunityserviceproviderandhousingcapacity.DespitetheDefendants’accesstoexistingdatasets,theDefendants’semi-annualcompliancereports,ImplementationPlans,andrelevantinformationofWilliamsevaluatorsandserviceandhousingproviders,aswellasdiscussionswiththeDefendants,reveallittleevidencethattheDefendantsutilizeClassMember-,program-,andsystem-leveldatatodeterminethespecifictypesandnumbersofservices,supports,andhousinginvestment(s)neededtosupportandsustainrequiredClassMembertransitions.AsrequiredintheConsentDecree,theDefendantsshouldutilizedataabouttheservices“anticipatedorrequired”inserviceplanstoformulatetheappropriate“quantity,quality,orgeographiclocation”forserviceandhousingexpansions.94Further,theDefendantshouldusetheCASTlisttoenhanceacommunityserviceproviderbaseskilledattransitioningandotherwiseservingClassMemberswithcomplexneeds.Finally,aspreviouslynoted,thesetofrecommendationstosupportthedevelopmentofcommunitycapacityundertheColbertConsentDecree,whichtheformerCourtMonitorindicatedcouldalsoserveasaroadmapforcommunity-basedhousingandservicecapacitydevelopmentundertheWilliamsConsentDecree,canbeutilizedtosupportservicesandhousingexpansion.TheDefendantsmightalsoconsider(re)examiningandimplementingthemanyrecommendationsmadebyprovidersintheMulti-YearProviderGrowthPlantheysubmittedtotheDefendants.95Additionally,theDefendantsshouldconveneproviders,includingclinicalleadersandexecutives,andevaluatorsregularlytoidentifysystemsandprocessbarriers,proposesolutions,sharestateresponsesandactionsteps,trackresults,andidentifyandwidenapplicationofsuccessfulsolutions.2. Expandevidence-basedandsupplementalservicestosupporttransitionand

successfulcommunitylife.

AsofferedintheformerCourtMonitor’sSpecialReporttotheCourtonMay2017(submittedundertheColbertConsentDecreebutstatedasgermanetotheWilliamsConsentDecree),thereremainseveralactionsthattheDefendantscanimmediatelyimplementtobuildcommunityhousingandprovidercapacity,including:§ ClearlyarticulatingandimplementingastrategytooptimizetheMedicaidmanaged

careprogram,the(thenpendingandnowapproved)Medicaid1115waiver

94WilliamsConsentDecree,SectionVII.95ProviderMulti-YearGrowthPlanwassubmittedonFebruary28,2018toDMHandIDoA.


73

program,96andotherbehavioralhealthtransformationplanstoexpandandfinanceserviceprovidercapacityinneededareas;

§ Providingsupportiveemployment,supportiveeducation,andincomegenerationsupport,whichareimportantservicestosupportrecoveryandcommunitylife;

§ AnalyzingthenumberofAssertiveCommunityTreatmentandCommunitySupportTeamsneededtosupportClassMembersandpromptlyreleasingfundingbidopportunitiesforqualifiedcommunityserviceproviders;

§ Forgingandexpandingpartnershipswithcityandcountyhealth,behavioralhealth,housingandotheragencies,asClassMembersareormaybecomeresidentsofthosejurisdictionsandshouldbeaffordedthesameservicesandresourcesasotherresidentswholiveinthesecommunities;

§ Implementingcrisisservices,suchascrisiscenters,peer-runrespites,crisisapartments,andmobilecrisisteams;and

§ Buildingapeersupport/recoverynetwork,includingrecoverycenters,mobilepeersupportteams,wholehealthpeers(trainedtoaddresschronichealthconditions),peerwarmlineandcrisishotlines,andotherparaprofessionalbestpractices.

3. CreatenewservicestomatchClassMemberintensityofneed.TheDefendantsandsometransitionprovidersrepeatedlyassertthatmanyoftheClassMemberswhohavenotyetbeentransitionedaremorepsychiatricallyandmedicallycomplexthanthoseinpreviousyearsandcannotbesafelyoradequatelyservedinthecommunitygiventhecurrentlyavailabletypeandqualityofservices,contributingtoasteepdeclineintransitionperformance.WhiletheCourtMonitorandPlaintiffshaverequestedandawaitdatatosupportthisassertion,iftrue,theDefendantsmustendtheirpolicyofallowinginitialorcontinuingunneededinstitutionalizationandinsteaddevelopnew,enhancedcommunity-basedservicesthatmatchClassMembers’intensityofneed,if24-hourcareisnotneeded.Thereareprogramsacrossthecountrythathavesucceededinmovinginstitutionalizedpopulations–includingthemostclinicallycomplex-intothecommunity.Forinstance,PhiladelphiaimplementedhighlyeffectiveHousingFirstandAssertiveCommunityTreatment(ACT)programs,includingenhanced-ACTprogramsthataddresstheneedsofspecializedsub-populationsofpeoplewithmentalillness(e.g.veterans,co-occurringsubstanceusedisorders)andaprogramthatcoordinatesdirectlywithhomehealthaidestoassistindividualswithcomplexmedicalandpsychiatricneeds.IdentifyingandinvestigatingmodelprogramsfromotherstatesandcommunitiescanbeameaningfulactivitytoassisttheDefendantswithreplicatingandapplyingbestpractices. 96EffectiveJuly1,2018,theBetterCareIllinoisWaiver,anew1115waivergrantedunderthefederalMedicaidprogram,enablesIllinoistopilotordemonstrateasetofhigh-prioritybenefitsincluding,butnotlimitedto,supportivehousingservices,supportedemployment,transitionservicesforjustice-involvedindividuals,substanceusedisordercasemanagement,withdrawalmanagement,andrecoverycoaching.


74

SectionIX.AdministrativeRequirementsAlargescale,multi-agencyinitiativesuchastheWilliamsConsentDecreeimplementationprogramrequiresstrategic,operational,andbusinesspracticesophisticationtoeffectivelymanageboththeactivitiesthatsupportcomplianceandthesurroundingactivitiesthatunderpincompliance.UndertheConsentDecree,thereare10compliancestandardsthatrelatetoeitherone-timeorongoingadministrativefunctions.Theseadministrativerequirementsfocusonthetimelyandresponsivesubmissionofreports,data,andinformationrequestedbythePlaintiffsandtheCourtMonitor,aswellastheselectionandpaymentofaCourtMonitor.Eightofthe10requirementsapplytotheDefendantsonly(withonenotrelevanttothisreportingperiod)andofthetworemainingrequirements,oneappliestoaCourtMonitorobligationandtheothertoajointobligationoftheCourtMonitorandthePlaintiffs.AdministrativeComplianceRequirements:ComplianceAssessmentforFY2018AsindicatedinFigures24and25,fortheFY2018complianceperiod,theDefendantsareassessedasincompliancewithsixofthesevencurrentrequirementsundertheadministrativedomainandinpartialcompliancewiththeoneremainingrequirement.TheothertworequirementspertainingonlytotheCourtMonitorandtheCourtMonitorandthePlaintiffs,respectively,wereincomplianceforFY2018,butwerenotincludedinthetallyofDefendants’complianceratings.

Figure24.SynopsisofFY2018ComplianceAssessmentsforAdministrative-RelatedRequirements





75

Figure25.FY2018ComplianceAssessmentRatingsforAdministrative-RelatedWilliamsConsentDecreeRequirements

Req.#

Source/Citation


CourtMonitorFY2018


Rating

38

WilliamsConsentDecreeIX(16)

TheCourtwillappointanindependentandimpartialMonitorwhoisknowledgeableconcerningthemanagementandoversightofprogramsservingindividualswithMentalIllnesses.ThePartieswillattempttoagreeontheselectionofaMonitortoproposetotheCourt.IfthePartiesareunabletoreachagreement,eachpartywillnominateonepersontoserveasMonitorandtheCourtwillselecttheMonitor.Withintwenty-one(21)daysofApprovaloftheDecree,thePartiesshallsubmittheirjointrecommendationorseparatenominationsforaMonitortotheCourt.IntheeventtheMonitorresignsorotherwisebecomesunavailable,theprocessdescribedabovewillbeusedtoselectareplacement.

InCompliance

39


TheMonitorshallreviewandevaluateDefendants'compliancewiththetermsoftheDecree.Notlessthaneverysix(6)months,DefendantsshallprovidetheMonitorandPlaintiffswithadetailedreportcontainingdataandinformationsufficienttoevaluateDefendants'compliancewiththeDecreeandDefendants'progresstowardachievingcompliance,withthePartiesandMonitoragreeinginadvanceofthefirstreportofthedataandinformationthatmustbeincludedinsuchreport.

PartialCompliance

40


DefendantswillnotrefuseanyrequestbytheMonitorfordocumentsorotherinformationthatarereasonablyrelatedtotheMonitor'sreviewandevaluationofDefendants'compliancewiththeDecree,andDefendantswill,uponreasonablenotice,permitconfidentialinterviewsofDefendants'stafforconsultants,excepttheirattorneys.

InCompliance

41


TheMonitorwillhaveaccesstoallClassMembersandtheirrecordsandfiles,aswellastothoseserviceproviders,facilities,buildingandpremisesthatserve,orareotherwisepertinentto,ClassMembers,wheresuchaccessisreasonablyrelatedtotheMonitor'sreviewandevaluationofDefendants'compliancewiththeDecree.

InCompliance

42


TheDefendantsshallcomplywithPlaintiffs'requestsforinformationthatarereasonablyrelatedtoDefendants'compliancewiththeDecree,includingwithoutlimitationrequestsforrecordsorotherrelevantdocumentspertinenttoimplementationoftheDecreeortoClassMembers.PlaintiffsshallalsobepermittedtoreviewtheinformationprovidedtotheMonitor.AllinformationprovidedtotheMonitorand/orPlaintiffspursuanttotheDecreeshallbesubjecttotheProtectiveOrder.

InCompliance


76

43


DefendantsshallcompensatetheMonitorandhisorherstaffandconsultantsattheirusualandcustomaryratesubjecttoapprovalbythecourt.DefendantsshallreimburseallreasonableexpensesoftheMonitorandtheMonitor'sstaff,consistentwithguidelinessetforthinthe"Governor'sTravelControlBoardTravelGuideforStateEmployees."DefendantsmayseekrelieffromtheCourtifDefendantsbelievethatanyoftheMonitor'schargesisinappropriateorunreasonable.

InCompliance

44

WilliamsConsentDecreeXII(24)

ThecostofallnoticeshereunderorotherwiseorderedbytheCourtshallbebornebytheDefendants.

InCompliance

45


TheMonitor'sdutiesincludeevaluatingDefendants'compliancewiththeDecree,identifyingactualandpotentialareasofnon-compliancewiththeDecree,mediatingdisputesbetweentheParties,andbringingissuesandrecommendationsfortheirresolutiontotheCourt.Within60daysaftertheendofeachyearofservice,theMonitorwillreporttotheCourtandthePartiesregardingcompliancewiththeDecree.Suchreportsshallincludetheinformationnecessary,intheMonitor'sprofessionaljudgment,fortheCourtandPlaintiffstoevaluatetheDefendants'complianceornon-compliancewiththetermsoftheDecree.TheMonitormayfileadditionalreportsasnecessary.ReportsoftheMonitorshallbeservedonallParties.

CourtMonitorRequirement

—InCompliance

46


IntheeventthattheMonitorfindsDefendantsnotincompliancewiththeDecree,theMonitorshallpromptlymeetandconferwiththePartiesinanefforttoagreeonstepsnecessarytoachievecompliance.IntheeventthatPlaintiffsbelievethatDefendantsarenotcomplyingwiththetermsoftheDecree,PlaintiffsshallnotifytheMonitorandDefendantsofDefendants'potentialnon-compliance.TheMonitorthenshallreviewthePlaintiffs'claimsofactualorpotentialnon-complianceand,astheMonitordeemsappropriateinhisorherprofessionaljudgment,meetandconferwithDefendantsandPlaintiffsinanefforttoagreeonstepsnecessarytoachievecompliancewiththeDecree.IftheMonitorandPartiesagree,suchstepsshallbememorializedinwriting,filedwiththeCourt,andincorporatedinto,andbecomeenforceableaspartof,theDecree.IntheeventthattheMonitorisunabletoreachagreementwithDefendantsandPlaintiffs,theMonitororeitherPartymayseekappropriaterelieffromtheCourt.IntheeventthatPlaintiffsbelievethatDefendantsarenotincompliancewiththeDecreeandthattheMonitorhasnotrequestedappropriaterelieffromtheCourt,PlaintiffsmayseekrelieffromtheCourt.TheMonitorwillnotcommunicatewiththeCourtwithoutadvancenoticetotheParties.

CourtMonitorandPlaintiffs’Requirements

—InCompliance


77

47

WilliamsConsentDecreeXI(22)

Infullsettlementofallattorneys'feesincurredtodateinconnectionwiththelitigation,Defendantsshallpay,subjecttocourtreviewandapproval,$1,990,000.00toClassCounsel.Infullsettlementofallout-of-pocketcostsandexpenses(nottoincludeattorneys'fees)incurredtodatebyClassCounsel,DefendantsshallpaytoClassCounselsuchcostsandexpensesincurredbyClassCounselthroughandincludingtheApprovaloftheDecreeandanyappealthereof.SuchamountsshallbedistributedtoClassCounselinthemannersetforthinwritteninstructionsprovidedbyClassCounsel.Furthermore,suchamountshallbesetforthinaJudgmentOrdertobeenteredbytheCourt.Defendantsshallcompleteandsubmitallpaperworknecessaryforpaymentofsuchamounts,plusapplicablestatutorypost-judgmentinterest,withinfive(5)businessdaysafterexpirationofthetimetoappealthefeeawardwithoutthefilingofaNoticetoAppealoraftertheissuanceofthemandatebythehighestreviewingcourt,whicheverislater.


Period

InComplianceRatings§ Requirement38:TheConsentDecreeoutlinestheprocessbywhichthePartiesand

CourtshallselectaCourtMonitor.DuringtheFY2018reportingperiod,formerCourtMonitorDennisJones,MBA,MSW,whohadservedsincetheDecree’sinception,announcedhisretirement.ThePartiesfollowedtheprocessoutlinedintheWilliamsConsentDecreeandattemptedtoagreeonarecommendationtotheCourtforanewCourtMonitorandresultedintheParties’filingseparatemotionsnominatingdifferentcandidates.JudgeLefkowchoseGailP.Hutchings,MPA,andappointedherastheWilliams(andColbert)CourtMonitoronSeptember26,2017.TheDefendantswereincompliancewiththeFY2018requirement.

§ Requirement43:Thistwo-partrequirementobligatestheDefendantstopaytheCourtMonitorandhisorherstafftheircustomaryrates.AftertheDefendantsrefusedtoadheretotherequirementregardingpayingtheCourtMonitorhercustomaryrate,theJudge’sinterventionwassoughtandsheissuedarulingontheMonitor’scompensationrate.TheJudge’sdecisiononthismatterenabledtheDefendantstobeassessedasincompliancewiththefirstpartofRequirement44.97Regardingstaffing,inFY2018,theCourtMonitorrequestedguidancefromtheDefendants,DHSandDMHspecifically,astheCourtMonitor’scontractisissuedunderthoseentities,abouttheuseofsubcontractorstoassistwithperformanceoftheCourtMonitor’sdutiesundertheWilliamsConsentDecreeandtoberetainedandpaidwithintheoriginalFY2018budgetintheCourtMonitor’scontract.ThisrequestwentvirtuallyunansweredalongwithrefusalstoprovidetheCourtMonitorwiththename(s)ofappropriatecontractstafftowhichtospeak.AfterraisingthisconcernwiththeDeputyAttorneyGeneral,hereportedthattheDefendantsfinallyagreedtopayfortheCourtMonitor’suseofsubcontractors.ThematterisnowconsideredresolvedwiththeendingresultofpaymentsbeingissuedforCourt

97JudgeLefkowissueddecisiontopaytheCourtMonitor’srateonNovember8,2017.


78

Monitorinvoicesthatincludecostsforsubcontractorservices.TheDefendantswereultimatelydeterminedtobeincomplianceduringtheassessmentperiod.

§ Requirements40and41:TheCourtMonitor’sdutyistorequestrelevantdataandinformationneededtomonitorandassesscomplianceanddevelopacomprehensiveanddetailedunderstandingofIllinois’mentalhealthandhousingsystemsandtheWilliamsprogram.TheDefendantsarerequiredtorespondtoreasonablerequestsforinformationanddatafromtheCourtMonitor,andallowtheCourtMonitoraccesstoClassMembers,ClassMemberrecords,andWilliamsfacilities.TheCourtMonitorfoundtheDefendantsincompliancewiththerequirementtoresponsivelysupplyinformationanddatathatreasonablyrelatedtotheConsentDecree.WhiletheDefendantssubstantiallysuppliedrequestedinformationinFY2018(duringtheCourtMonitor’snine-monthperiodofserviceduringFY2018),itwouldnotbeunreasonabletoassignapartialcompliancedeterminationtothisrequirementduetotheDefendants’refusaltoprovideallrequestedinformationintheirSemi-AnnualReport13.MoreinformationonthisoccurrenceiscontainedunderRequirement40below.Despitethis,theCourtMonitorassignedadeterminationofcompliantunderthisrequirementandhopesthatfuturereportscontainallrequestedinformation.

§ Requirement42:PertheConsentDecree,theDefendantsmustalsoprovideanyinformationanddatatothePlaintiffs,uponrequest,thatisreasonablyrelatedtotheDecree.ThecurrentCourtMonitorqueriedPlaintiff’sCounselregardingtheirexperiencewithDefendants’compliancewiththisrequirementduringFY2018.98TheyrespondedthattheDefendantsultimatelycompliedwithallinformationanddatarequests,althoughattimesnotuponfirstrequestorinatimelymanner.Thatestablished,theDefendantswereassessedasincompliancewiththisrequirementduringFY2018.

§ Requirement44:TheDefendantsareincompliancewiththerequirementthatallcostsfortheConsentDecreemustbebornebytheDefendants.

§ Requirements45and46:TheCourtMonitormustaddresswiththePartiesissuesofnon-complianceandsubmitannualreportstotheCourt.BoththepreviousandcurrentCourtMonitorconvenedandchairedregularLargePartiesMeetingstoidentifyandattempttoresolveissuesofdisagreementornon-compliance.DuringthetransitionbriefingsbetweentheformerandcurrentCourtMonitors,itwasindicatedthattheformerCourtMonitorconvenedmeetingsanddiscussionsregardingareasofnon-compliance.UnderthecurrentCourtMonitor,monthlyLargePartiesMeetingsandadhocmeetingsincludeongoingfocusonthoseareasjudgedashighriskforout-of-compliancedeterminations.Asrequired,theCourtMonitorwillalsorequestameetingwiththePartieswithin30daysofissuanceofthisreporttodiscussareasofnon-complianceandremedies.

98TheCourtMonitorcorrespondedwithBenjaminWolf,JD,leadPlaintiffCounsel,onSeptember5,2018,requestingdataandinformationrelativetothisrequirement.


79

ThePlaintiffsindicatedtotheCourtMonitorthattheyrequestedthattheDefendantscollectandanalyzeinformationaboutissuesthat,intheirview,requireinvestigationsuchasarepeatedrequesttoprojectClassMemberserviceneedsortoanalyzereasonsthatClassMemberswereplacedontheCASTlist.ThePlaintiffselectedtoresolvetheseconcernsaspartofbroaderdiscussionsintheParties’regularmeetingswiththeCourtMonitorratherthanformallyassertthattheyconstituteviolationsofRequirement46oftheDecree.PerRequirement45,thepreviousCourtMonitorsubmittedanannualreportonJune30,2017tosharehisassessmentoftheDefendants’compliancerelativetothesecondhalfofFY2017;thecurrentCourtMonitorsubmitsthisreportassessingtheDefendants’performanceandcomplianceforFY2018.BothCourtMonitorswereincompliancewiththisrequirementduringtheirrespectivetenuresinFY2018.

PartialComplianceRatings§ Requirement39:Duringeachfiscalyear,theDefendantsarerequiredtosubmita

detailedreporteverysixmonthscontainingdataandinformationsufficienttoevaluatecompliancewiththeDecree.TheDefendantssubmittedbothsemi-annualreportsinFY2018,whichcontaineddataandinformationontheirperformancerelativetotheConsentDecree.TheDefendantsarefoundaspartiallycompliantastheydidnot,asrequired,meetwiththeCourtMonitortodiscussthe“dataandinformationthatmustbeincludedin[semi-annualreports],”specificallySemi-AnnualReport13,whichcoveredthefirsthalfofFY2018.Additionally,aftertheCourtMonitorreceivedtheSemi-AnnualReport13,sheidentifiedandrequestedadditionaldataneededforcomplianceassessment.TheDefendants,viaDHSDeputyGeneralCounselofLitigation,refusedtosupplytherequestedinformation,stating,“thereporthasalreadybeensubmittedtothelegislature…[andthey]cannotmakesubstantiverevisionsatthispoint.”Finally,Semi-AnnualReport13wassubmittedinearlyDecember,priortotheendoftheperiodthatitsdataandinformationwastocover(throughDecember31,2017).InSemi-AnnualReport14,coveringthesecondhalfofFY2018,theDefendantsprovidedasubstantiallyimprovedsemi-annualreportwithmorecompletedata,includingsome,butnotall,instanceswheredatawasneededandprovidedforallofFY2018.Evenso,thatreportstillrequiredthreeiterationstoeithersupplyallofthenecessarydatafortheCourtMonitortofullyassesscomplianceortostatethatsuchdatawasnotcollectedduringFY2018andthereforenotavailable.


80

CourtMonitorRecommendationsforAchievingorEnhancingCompliancewithAdministrativeRequirements

1. Developmethodologyandprocesstotrackandreportoneachcompliance

requirement.TheCourt,Parties,ClassMembers,andthepublicareentitledtocomplete,specific,andaccurateinformationregardingtheperformanceandoutcomesofConsentDecreecomplianceandimplementationbytheDefendants.TheCourtMonitor’sexpresseddutyandcommitmentistotransparentlyandneutrallymonitorandassesscompliancebasedontheexplicitrequirementsoftheWilliamsConsentDecreeandanyotherCourtdocumentsthatimpactthoserequirements.Assuch,theCourtMonitordevelopedandprovidedWilliamsstaffwithaspreadsheetlistingeachpastandcurrentcompliancerequirement,similartothecomplianceelementtablesthatappearineachsectionofthisreport.ThepurposeofsupplyingthistableandtheensuingmeetingswiththeWilliamsprogramdirectorandassignedDHScounseltodiscussit,wastoforthrightlyprovideearly-onandtransparentnoticetotheDefendantsofeachcomplianceelementonwhichtheCourtMonitorwouldmeasure,assess,andreportcompliance.TheCourtMonitorhas,onmultipleoccasions,providedtheDefendantswithwrittenanalysesthatidentifycompliancerelatedprocesses,datacollection,and/orreportingobligationsthatremainunfulfilledorinsufficient,severalofwhichhavealsobeenidentifiedherein.TheDefendantsareencouragedtoutilizeandbuilduponthesetoolsandanalysestodevelopandimplementtheactivitiesandreportingnecessarytoachieveanddemonstratefullcompliancewithalloftherequirementsintheConsentDecree.ItisintheDefendants’bestinteresttoinvestin,ensureclearachievementof,anddemonstratecompliancewiththeDecree’srequirementstoresultinotherbenefits,suchasreducedneedforancillaryinformationanddatarequests,requestsforsupplementaldata,andrepeatedcommunicationsandmeetingsduetomissing,partial,orunclearcomplianceactivityandreporting.

2. EducateallWilliams-relevantstateagencystaffonConsentDecreerequirements.ItisimportantthatallstatestaffaffiliatedwiththeWilliamsprogram,includingnamedDefendants,attorneys,andprogram-levelstaffwithDefendantandotherrelevantstateagencies,areeducatedontheConsentDecreeandunderstandthattheyareboundtocomplywithitsadministrativeandotherrequirementsandarenottocreateadministrativeorotherbarrierstoaccessinginformation,refusetosupplyinformation,orrefusetopermitaccesstostatestaff,includingforprivateinterviews.Thiscouldbeachievedthroughanorientation(orre-orientation)ontheresponsibilitiesofstatestaffassociatedwiththeWilliamsprogramand,then,theprovisionofresultingpoliciesandprocedures.


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SectionX.ImplementationPlanningWithinitiativesthatrequirecoordinationandcommunicationacrossmultiplesystemssuchastheWilliamsprogram,implementationplanningisanintegralactivityandshouldbeusedtoidentifydesiredperformanceindicatorsandoutcomemeasures,keytasksandactionsteps,stakeholder/responsibleparties,andtimeframes/duedates.TheWilliamsConsentDecreelaysoutarequirementthatDefendants“shallcreateandimplementanImplementationPlan”99thatoutlineshowtheyplantooperationalizeconcretestrategiestosatisfytheirConsentDecreeobligations.PertheConsentDecree,thisplan—tobeupdatedandfiledwiththeCourtatleastannually—mustincludeanumberofspecificcomponentsandprovidearoadmapforthesubsequentyear’sactivities.Requiredelementsinclude“specifictasks,timetables,goals,programs,plans,strategies,andprotocols;”adescriptionof“hiring,trainingandsupervision;”activitiestodevelopcommunity-basedsettingsandhousing;servicesandsupports“anticipatedorrequiredinServicePlans”andinformedby“demographicorotherdata;”neededregulatorychangesorshifts;andmethodstoensurecompliancewithoutreachandevaluationrequirements.100ImplementationPlanning-RelatedComplianceRequirements:ComplianceAssessmentforFY2018TheConsentDecreerequirestheDefendantstosubmitanannualImplementationPlandesignedtodelineate,“specifictasks,timetables,goals,programs,plans,strategies,andprotocolstoassurethatDefendantsfulfilltherequirementsoftheDecree.”101AprojectasimportantandlargeastheWilliamsConsentDecreenecessitatesaclear,cogentplanthatoutlineskeyactivitiesinsequentialorder,linksactivitiestoexpected,measurableoutcomes,andidentifiesresponsibleparties,neededresources,timeframes,andcriticaldependencies.Thesecomponents—acrossthemanydomainsoftheWilliamsprogram—areintegraltoawell-organizedandmultiprongedeffort.WithintheConsentDecree,thereare13distinctrequirementsundertheimplementation-planningdomain,asdisplayedinFigure26.TheDefendantshavebeenfoundincompliancewithonerequirementandout-of-compliancewiththeremaining12requirements.

99WilliamsConsentDecree,SectionVIII.100Ibid.101Ibid.


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Figure26.SynopsisofFY2018ComplianceAssessmentsforImplementationPlanning-RelatedRequirements




Figure27displaystherequirementspertainingtoimplementationplanning,primarilyfoundinSectionVIIIoftheConsentDecree.Requirement61isnotrelevanttothisreportingperiod,asitrelatestotheinitialImplementationPlan.Asindicatedbelowthisisanareaofdeepnon-compliancebytheDefendantsduringFY2018.

Figure27.FY2018ComplianceAssessmentRatingsforImplementationPlanning-RelatedWilliamsConsentDecree

Req.#

Source/Citation


CourtMonitorFY2018


Rating

48Williams


TheImplementationPlanshalldescribemethodsbywhichsuchinformationwillbedisseminated,theprocessbywhichClassMembersmayrequestservices,andthemannerinwhichDefendantswillmaintaincurrentrecordsoftheserequests.

Out-of-Compliance

49Williams


TheImplementationPlanshalldescribemethodsforengagingresidents,includingwhereappropriate,providingreasonableopportunitiesforresidentstovisitandobserveCommunity-BasedSettings.

Out-of-Compliance

50Williams


Defendants,withtheinputoftheMonitorandPlaintiffs,shallcreateandimplementanImplementationPlantoaccomplishtheobligationsandobjectivessetforthintheDecree.

Out-of-Compliance

51Williams


TheImplementationPlanmust,ataminimum:a)Establishspecifictasks,timetables,goals,programs,plans,strategies,andprotocolstoassurethatDefendantsfulfilltherequirementsoftheDecree.

Out-of-Compliance

52Williams


TheImplementationPlanmust,ataminimum:b)Describethehiring,trainingandsupervisionofthepersonnelnecessarytoimplementtheDecree.

Out-of-Compliance

53Williams


TheImplementationPlanmust,ataminimum:c)DescribetheactivitiesrequiredtodevelopCommunity-BasedServicesandCommunity-BasedSettings,includinginter-agencyagreements,requestsforproposalsandotheractionsnecessarytoimplementtheDecree.

Out-of-Compliance

54Williams


TheImplementationPlanmust,ataminimum:d)Identify,basedoninformationknownatthetimetheImplementationPlanisfinalizedandupdatedonaregularbasis,anyservicesorsupportsanticipatedorrequiredinServicePlansformulatedpursuanttotheDecreethatarenotcurrentlyavailableintheappropriatequantity,qualityorgeographiclocation.

Out-of-Compliance


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55Williams

ConsentDecreeVII(11).e.

TheImplementationPlanmust,ataminimum:e)Identify,basedoninformationknownatthetimetheImplementationPlanisfinalizedandupdatedonaregularbasis,anyservicesandsupportswhich,basedondemographicandotherdata,areexpectedtoberequiredwithinoneyeartomeettheobligationsoftheDecree.

Out-of-Compliance

56Williams


TheImplementationPlanmust,ataminimum:f)IdentifyanynecessarychangestoregulationsthatgovernIMDsinordertostrengthenandclarifyrequirementsforservicestopersonswithMentalIllnessandtoprovideforeffectiveoversightandenforcementofallregulationsandlaws.

Out-of-Compliance

57Williams


TheImplementationPlanmust,ataminimum:g)DescribethemethodsbywhichDefendantsshallensurecompliancewiththeirobligationsunderParagraph6(Evaluations)ofthisDecree.

Out-of-Compliance

58Williams


TheImplementationPlanmust,ataminimum:h)DescribethemechanismsbywhichDefendantsshallensurecompliancewiththeirobligationsunderParagraph10(Outreach)ofthisDecree.

Out-of-Compliance

59Williams

ConsentDecreeVIII.13.

TheImplementationPlanshallbeupdatedandamendedannually,oratsuchearlierintervalsasDefendantsdeemnecessaryorappropriate.TheMonitorandPlaintiffsmayreviewandcommentuponanysuchupdatesoramendments.IntheeventtheMonitororPlaintiffsdisagreewiththeDefendants'proposedupdatesoramendments,themattermaybesubmittedtotheCourtforresolution.

Out-of-Compliance

60Williams

ConsentDecreeVIII(14)

TheImplementationPlan,andallamendmentsorupdatesthereto,shallbeincorporatedinto,andbecomeenforceableaspartoftheDecree.

InCompliance

61Williams

ConsentDecreeVIII(14)

Within135daysofApprovaloftheDecree,DefendantsshallprovidetheMonitorandPlaintiffswithadraftImplementationPlan.TheMonitorandPlaintiffswillparticipateindevelopingandfinalizingtheImplementationPlan,whichshallbefinalizedwithinnine(9)monthsfollowingApprovaloftheDecree.IntheeventtheMonitororPlaintiffsdisagreewiththeDefendants'proposedImplementationPlan,themattermaybesubmittedtotheCourtforresolution.


Toguideathoughtfulanddeliberatesetofactionsandactivitiesdesignedtoreachcompliance,annualImplementationPlanupdatesmustbesubmittedpriortothefiscalyearthattheyintendtoimpact.However,therehasbeenaconcerningpatternofsubmittingImplementationPlansneartheveryendorevenaftertheconclusionofthefiscalyearoffocus.Whileoutsidethetimeframeforthisreport,discussionoftheverylatefilinginFY2017isgermaneforatleasttworeasons:(1)timelyfilingoftheFY2017planshouldhavehadadirectimpactonimplementationactivitiesthatoccurredduringthetimeframecoveredbythiscomplianceassessmentreport;and(2)itrepresentsapatternoflateimplementationplandevelopmentandfiling.TheFY2017ImplementationPlanshouldhavebeenfinalizedbyJune30,2016butwasnotfileduntilJune15,2017,twoweeksbeforetheendofthefiscalyear.Thus,thisplanhadnoreal,practicalvalueforprogramplanningorimplementation.


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TheDefendantsdidnotsubmittheFY2018ImplementationPlanuntilafterthefiscalyearended,onJuly26,2018,whenitshouldhavebeensubmittedatleast13monthsearlier,byJune30,2017.Additionally,theFY2018ImplementationPlanwas“abbreviated,”withtheDefendantsrestrictingthecontentbecauseitwasfiledsolate.ThePlaintiffsdidagreetothelateandabbreviatedfilingcitingtheirmutualdesiretonotwastetimeondiscussingaplanthathadvirtuallyexpiredbeforeitwassubmitted;theydidnotfullyendorsetheplan’scontent.TheCourtMonitorabstainedfromthedecisionstatingthatshewouldbecompelledtofindtheDefendantsout-of-complianceiftheplanwasnotsubmittedinatimelymanner.SimilartotheFY2017plan,becauseofsuchlatefiling,theFY2018planalsohadnopracticalvalueforprogramplanningorimplementation.TheDefendantscitetheformerCourtMonitor’s(Mr.DennisJones)retirementandaninabilitytoreachconsensusamongthePartiesasthereasonsforthelatesubmissionandabbreviatedcontentoftheFY2018ImplementationPlan.TheDefendantsindicatedthatthisdecisionwasnotmemorializedinwriting.102Thisjustificationisproblematicforseveralreasons:• TheConsentDecreesetsforthaprocesstoaddresstheParties’inabilitytoreach

consensusregardingImplementationPlancontent.Assuch,thiscannotbeusedanexcusefornotsubmittingaplan.Inthisinstance,theDefendantscansubmitanImplementationPlanandthePlaintiffsandtheCourtMonitorarepermittedtosubmitadditionalinformationtotheCourttoraiseanyissuestheyhavewiththePlanortoproposelanguageorcontentthattheplanshouldinclude.

§ ThepreviousCourtMonitorannouncedhisretirementnearthebeginningofFY2018,atwhichtimetheFY2018ImplementationPlanshouldhavealreadybeencompletedandfiled.ThenewCourtMonitorwasappointedinSeptember2017andrepeatedlyrequestedthePlanaftershecommencedhermeetingswithDefendantsinDecember2017.

§ ConsentDecreerequirementssuchasthisonedonotbecomevoidiftheCourtMonitordoesnotdirectlyrequestactionrelativetoaspecificrequirement.TheonusforcomplianceisontheDefendantstocomplywitheachConsentDecree-requiredactivityoractiontosatisfyConsentDecreerequirements,regardlessofwhethertheCourtMonitorspecificallyanddirectlyrequestedthatactivityoraction.

ItisimportanttoacknowledgeandforecastthattheDefendants’complianceinthisareaofimplementationplanninghasimprovedsignificantlyinFY2019.TheFY2019ImplementationPlan—developedduringthesecondhalfofFY2018—wasmorecomprehensive,compliant,andtimelythanpriorplansandincludedmanyoftherequiredcomponentsofimplementationplansoutlinedintheConsentDecree—andwasfiledattheverybeginningoftheFY2019fiscalyear,onJuly2,2018.

102WilliamsvRaunerConsentDecree.WilliamsSemi-AnnualReport13.SubmittedDecemberof2017.


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InComplianceRating

§ Requirement60:TheDefendantshaveacknowledgedduringLargePartiesMeetingsthattheFY2019ImplementationPlanispartoftheConsentDecreeandthereforeenforceable.TheCourtMonitorassignedanincomplianceratingforthisrequirement.

Out-of-ComplianceRatingsThereareseveralrequirementsintheWilliamsConsentDecreethatobligatetheDefendantstoprovidededicatedcontentgermanetoeffectiveplanningandeffectuationofimplementationactivitiesundertheWilliamsprogram.Theseinclude,butarenotlimitedto,outreachmethods,staffing,developmentofservicesandhousinginformedbyClassMemberServicePlandata,andregulatorychangesnecessarytoimplementtheprogram.Thecompliancedeterminationofout-of-compliancewereassignedtoallninerequirementsduetothefollowingperformancedataandinformation:§ Requirements48and57:TheDefendantsdidnotoutlinetheirapproachesto

evaluatingClassMembersortheirprocessesandrecord-keepingproceduresassociatedwithClassMembers’requestsforservices.

§ Requirements49and58:IntheFY2018ImplementationPlan,theDefendantsdidnotdelineatestrategiesforClassMembersoutreachandengagementsuchasprovidingopportunitiesforthemtovisitandobservecommunity-basedsettings.

§ Requirements50and51:TheDefendantsdidnotofferadetailedplanfocusedoncomplyingwithalltheDecree’srequirementsandmeetingitsobjectives,includinggoals,timelines,responsibleparties,strategies,andapproaches.Ofspecialnote,theImplementationPlanlackedsufficientcontentandcommitmentsrelativetothedevelopmentofadditionalcommunity-basedservicesandsettings,acriticalaspecttoConsentDecreecompliance.

§ Requirement52:TheDefendantsdidnotidentifythetraining,staffing,andsupervisionnecessarytosupportactivitiesandactionsnecessarytocomplywiththeConsentDecree.

§ Requirement53:TheDefendantsdescribedafewprocess-relatedactivitiesassociatedwiththedevelopmentofcommunity-basedservicesandhousing(e.g.,reviewoftheMultiyearProviderGrowthPlanandplanningforexpansionofthediversionpilotintoaprogram)butdidnotsufficientlydescribeeffortsorcommitmentstoidentifyorexpandneededcommunity-basedservicesandhousingtomeetClassMembers’needs.

§ Requirement56:TheDefendantsdidnotofferanyregulatorychangesthatcouldstrengthen,clarify,orbuttresstheWilliamsprogram—oranyprocesstoengagestakeholdersorotherwiseidentifypotentialneededregulatorychanges.


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§ Requirement59:TheDefendantsdidnotfiletheImplementationPlanontime,andthusarefoundout-of-compliancewiththeannualupdateandamendmentrequirementforImplementationPlans.

§ Requirements54and55:Broadlyspeaking,theFY2018ImplementationPlan—beyondmissingrequiredelements—makesnoclearlinkbetweenClassMemberdemographicsandserviceneedsdataandeffortsandactivitiesoutlinedintheplan.PerRequirement54,theDefendantsmust,“Identify,basedoninformationknownatthetimetheImplementationPlanisfinalizedandupdatedonaregularbasis,anyservicesorsupportsanticipatedorrequiredinServicePlansdevelopedpursuanttotheDecreethatarenotcurrentlyavailableintheappropriatequantity,quality,orgeographiclocation.”103Inaddition,theDefendantsmustusedemographicdatatoinformthedevelopmentofcommunity-basedservicesandhousing(Requirement55).Thisdatacanandshouldbeusedtounderstandresourcegapsandsubsequentlysupportrapidexpansionofcommunityserviceandhousingprovidercapacity.Insteadofofferingtheneededprovidercapacityexpansionstrategywithfirmcommitments,theDefendants’ImplementationPlancenteredonabstractandprocess-orientedactivitiessuchashavingdiscussionsandexploringrecommendations.

CourtMonitorRecommendationsforAchievingorEnhancingCompliancewithImplementationPlanningRequirements1. Includeinfutureimplementationplanshowserviceplananddemographicdata

willbeusedtoinformdevelopmentofcommunity-basedhousingandservices.TheDefendantscanimproveWilliams’compliancebydevelopingandapplyingamethodologyforregularlyreviewingindividualandaggregatedatafromClassMemberserviceplans,aswellasdemographicdata.Theregularreviewofserviceplansanddemographicdatacreatesaninfrastructuretoassess,identify,andunderstandanygapsorshortagesinservices,supports,andhousingonanongoingbasisandcanbeusedtoidentifyimmediateactionsandresourcesneededtoaddressknownandunderstoodsystemgaps(e.g.,AssertiveCommunityTreatmentteams,occupationaltherapy,medicationmanagementservices)andtoexpandneededservicesbasedonthisdata.Usingthisapproach,itisenvisionedthatatthetimeoftheImplementationPlan’sdevelopment,theDefendantswouldhavealreadyfullyanalyzedthisdataanddevelopedaplantoensurethattheappropriatetype,quantity,andlocationsofservicesareavailabletomeetClassMemberneeds.

103WilliamsConsentDecree,SectionVIII.


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2. Usedatatodriveimplementationplanning.

TheDefendantshaveseveralrelevantdatasetsthatcanbeusedtoanalyzeWilliamsimplementationoperations,gaps,barriers,andfacilitatorstopastcomplianceoutcomes,programweaknessesorshortcomings,andotherareasthatcanstrengthenprogramimplementation.Instead,WilliamsImplementationPlansreadascurrently-utilized/plannedactivitieswithlittledetailabouthowprogramdatasuggeststhatcertainactivitiesandinvestmentswillsupportprocessimprovements,increasedtransitions,diversion,andotherDecreeobligations.GiventheDefendant’spatternofconsistentunderperformanceandnon-complianceduringFY2018,pastyears,andto-dateinFY2019,futureImplementationPlansofferanimportantopportunitytoprovideinformationanddatathatcanbeusedtoidentifyissuesandforecasthowproposedsolutionsmayremedythoseissues,thusimprovingcompliance.3. Increaseimplementationplanningprocessefficiency.

TheDefendantswouldbenefitbyconsideringstrategiestouseexpertandexperiencedhealthsystemsplanningprofessionalsinalargeroletosignificantlycontributetothedevelopmentoffutureImplementationPlans.Additionally,theImplementationPlanshouldspeakwithoneclearvoiceonbehalfofalltheDefendants,collectively,includingincreasingthenowlimitedcontributionsfromallagenciesnamedasDefendants.TheDefendantswouldbenefitfromrepresentingthemselvesandtheircommitmentsasanorganizedconsortiuminwhichImplementationPlansincludethenoticeableinvolvement,commitments,resources,andcoordinatedstrategiesrelativetoallinvolvedagencies.


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Conclusion ThisreportissubmittedtotheCourtinfulfillmentoftheCourtMonitor’sdutytoassesscompliancewiththeWilliamsConsentDecreerequirementsatleastannually;itrepresentstheefforttoconductafairandimpartialassessment.Thecomplianceassessmentperiodcoveredisfiscalyear2018.Ofthe61totalConsentDecreerequirements,theDefendantsareresponsibleforcompliancewith50requirementsfortheFY2018assessmentperiod.BasedonFY2018performancedataandoutcomes,theDefendantshavebeenfoundtobeincompliancewith22%ofrequirements,inpartialcompliancewith20%,andout-of-compliancewith58%.NowmorethaneightyearssincetheWilliamsConsentDecree’sfiling,theDefendants,mustbreakthroughtheinertiaofnon-complianceandseizetheopportunitypresentedbytheConsentDecreetodemonstratecommitted,focusedleadershipthatcanbringaboutneededsystemschanges.ThiswillpreventtheinappropriateadmissionofadultswithseriousmentalillnessintoWilliamsfacilitiesandotherinstitutionsandtransitionthosewhoarecurrentlyinstitutionalized,asappropriate,intothecommunitiesoftheirchoice.DynamicandsustainablechangesuchasthisrequirestheacknowledgmentandthoroughconsiderationofnecessarynewapproachesandsolutionsofferedtothembytheformerandcurrentCourtMonitorsandothernationalexpertsincludingthosewhosucceedatthisworkbothinsideandoutsideofIllinois.IftheDefendantsespousetheaboveleadershiproleandsomeoftheprovidedexpertguidance,theycanensurethattheirfutureplans,dedicatedresources,andimplementedactionsnotonlyachievecompliance,butdemonstrablyrespectindividuals’rightstoliveintheleastrestrictivesettingappropriatefortheirneeds.Withoutsignificantimprovements,theDefendantsriskacontinuationofpooroutcomesandunderperformanceand,thus,negativecomplianceassessments,expectedcallsfromthePlaintiffsandtheCourtforincreasedperformanceandaccountability,andprolongedyearsofremainingundertheConsentDecreeversussuccessfullyexitingit.ThispathalsocarriesahumantollonindividualswithpsychiatricdisabilitieswhoareneedlesslyinstitutionalizedinWilliamsfacilitiesordeprivedofappropriateandtimelytransitiontocommunitylivingwheretheycanchoosetoparticipateinsociety.Further,itnegatestheopportunitytoachievesignificantcostsavingsthathavebeendemonstratedtoaccompanycommunity-basedversusinstitutional-basedcare.ItisimportanttoconveythatcomplianceundertheWilliamsConsentDecreeisattainable.TheDefendantshavedemonstratedinthepastthattheyhavetheabilityandtheresourcestotransitionsignificantlyhighernumbersofWilliamsClassMembersthanoccurredduringFY2018orthusfarinFY2019.Today,theDefendantsmustre-dedicatetheirabilitiesandresourcestoaddresscriticaldefectswithintheWilliamsprogram.Usingtherobustdatasettodeviseandimplementacogentcommunityserviceandhousingcapacitydevelopmentstrategy,lessonslearnedregardingeffectivediversionapproaches,andpastcommitmentsandresourcesthatsupportednearcompliancewith


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transitionrequirementsinearlyyearsoftheDecree,theDefendantscandeterminetheirsuccessinfutureyears.Theseexistingresources—coupledwiththeneededhigh-levelleadershipcommitmentandaction-canforgeanewpathfortheStateofIllinoisandtheWilliamsClass.TheCourtMonitoriseagertosupportthispathforward.


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