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DRAFT CONFIDENTIAL - revised February 20, 1997Charts and illustrations mentioned in this document are not included. To receive the complete illustrated document, email Sally Clay at <zangmo@sallyclay.net>
Plaintiffs for Sanbourne v Chiles have worked for the last several years to improve mental health services in South Florida. This work is done on behalf of residents at South Florida State Hospital (SFSH), and persons who have been discharged from that institution. Sanbourne class members include all persons currently residing at SFSH and persons discharged within a period of eighteen months.
Over the years, as part of the effort to monitor and improve conditions for class members, plaintiffs visited the community residences provided to class members upon their discharge from SFSH. Plaintiffs were particularly concerned at the paucity of residences available to class members, and the undesirable conditions that prevail at the ones that exist. Because of this, it was determined that a more systematic evaluation was warranted. Accordingly, a survey was conducted during the months of October through December 1996 to determine the type and quality of the residences.
Interviews were conducted by two teams of consumer-survivors, led by Sally Clay, Consumer Expert for the plaintiffs. The first team, Dave Roberts and Diane Hoover, surveyed residences and class members in Districts 9 and 15. The second team, Maureen Huggins and John Daley, and later Charles Kraus, conducted interviews in District 10. Activities in District 11 were conducted by members of both teams.
Included in the survey were all class members of Sanbourne v. Chiles discharged between the period of March 17, 1995, and October 31, 1996. Residences surveyed were nearly all group residential facilities in South Florida where class members live. Excluded from the interview process were persons living in their own or their family's residences and others not living in HRS-licensed facilities (see Chart 1 below).
An attempt was made to interview both the staff of the residences and the class members who lived there, although in some cases the residents were not available at the time of the interview. Some of these class members were interviewed at a later time. Interviewers used two survey instruments (see Appendix A). The principal instrument was a four-page questionnaire, used to obtain discrete information about the residence. This document included questions directed to the staff and a visual checklist of information gathered on a tour of the facility.
Since responses to the principal questionnaire relied on much information given by staff, some of the data may not accurately reflect the problems present at a particular residence. In an attempt to compensate for potentially inaccurate or evasive answers, surveyors supplemented this information with the second instrument, an open-ended one-page form used in interviews with class members.
LOCATION OF CLASS MEMBERS
From the first, the survey project presented itself as a logistical nightmare. Although South Florida State Hospital (SFSH) periodically provides the plaintiff team with lists of all discharged class members, these contain only names and dates of discharge. Documentation of class member locations and status after discharge has been haphazard at best, and the information provided by the four districts (9, 15, 10, and 11) is generally incomplete. Often missing are addresses, phone numbers, case managers, and even the primary agency or mental health center and the actual location of the class member. The terminology and format used for reporting types of residences and class member status are not consistent among the districts and agencies. In several instances in Districts 9 and 10, the local ADM offices could not locate a particular class member, or were themselves unaware that a class member had moved from one location to another. Additionally, seven persons who had escaped from SFSH were discharged from elopement status. Their whereabouts remain unknown.
Chart 1: Location for all class members (total=126)As shown in the chart [not pictured here], a total of 126 locations were identified for the persons who were class members during the period of the survey. The total number of discharged class members was 117. Of the locations shown in the chart, only the first four, representing discharges for 65 class members, were included in the survey:
RTF - A residential treatment facility is a group residence licensed by the Florida Department of Children & Families (formerly HRS) to accommodate persons with a psychiatric diagnosis.
APT - A supervised or supported apartment is a program also licensed by HRS to operate individual apartments for mental health clients.
ALF - An adult living facility (formerly known as ACLF) is a congregate living facility for residents of all types, and is also licensed to include psychiatric clients.
SPEC - Specialized facilities are residences such as nursing homes, geriatric residences, substance abuse programs, and facilities for persons with developmental disabilities. They are licensed for mental health clients, but may also include persons who are not mental health consumers.The remaining categories on the chart were excluded from the survey. These comprised locations for class members who:
were in jail or a forensic facility (JAIL)
had moved out of the South Florida districts (OOD)
were in whereabouts unknown ("???"),
were living in private residences with family or on their own (PRIV)
had returned to long-term hospitalization (HOSP)
had died after discharge (DEAD).The surveyed locations -- a total of 49 -- represented discharges for class members who, during the interview period, were living in group residences in South Florida. The four general types of eligible facilities are shown in Chart 2 below: The figures represent the percentage of class members living in each of the four locations:
Chart 2: Discharge surveyed in South Florida (Total class members = 57)Of these residences, only eight were not interviewed, usually for reasons of geographical inaccessibility. Thus the actual locations visited in the course of the survey were 41 residences, representing discharges for 57 class members.
As can be seen in Chart 2 above, nearly a quarter (14 of the 57 class members) lived in specialized facilities. Another quarter (24.6%) were discharged to group residences (RTF's) linked to mental health services, with 14.0% discharged to supervised apartments (APT's). Among the class members, 21 out of 57 were discharged to ALF's or boarding homes. These represented over a third (36.8%) of the discharges in South Florida.
TYPES OF RESIDENCES
A residential treatment facility (RTF) or supervised apartment (APT) generally is operated under the aegis of a mental health center, and its residents are closely linked to a continuum of services including medication monitoring, day treatment, and case management. Staff at RTF's and APT's are usually experienced in psychiatric issues and in the needs of mental health consumers. Such a residence, and the services available through it, are desirable for class members who have been institutionalized for a long period of time. Such individuals, when discharged from SFSH, almost always need to learn or relearn basic living skills. Psychosocial rehabilitative services are needed for these class members to become reintegrated into the community. In some cases, it is argued, a more structured living setting (sometimes called "Level 1") is also needed for people newly returned to the community.
Adult Living Facilities (ALF's) are privately-run, for-profit facilities that are little more than boarding homes. Such facilities provide some necessary services such as medication storage and distribution, and occasional visits from medical professionals. For the most part, however, ALF's offer little more than a bed to sleep in and 2 or 3 meals a day. Interestingly, many of the ALF's that we visited called themselves "retirement homes," a euphemism for the kind of housing they offer, since many SFSH residents discharged to retirement homes are considerably younger than retirement age. These retirement homes are "end of the line facilities" where residents are warehoused. When a class member is discharged to one of these, the mental institution is merely replaced by another institution. In some of these, there is the sense that the residents there are waiting for death.
The sample studied included at least two facilities that are not licensed by HRS (Bob Mays in Lantana and the Royal Plaza in Miami Beach). Also included in the ALF category were group foster homes. These licensed foster homes are private residences that have been converted for group living. There were only two group foster homes among the residences surveyed, both in District 11. They were included under the ALF category because they share many qualities with boarding homes. Like ALF's, they are private facilities run for profit by persons who are not mental health professionals, and they are not as closely linked to community services as RTF's. They are more homelike than ALF's, however, since they accommodate only a small group of people, and are generally in a private home.
The fourth category of residences (SPEC) comprises specialized facilities for persons with other disabilities or dual diagnoses (see Chart 3 below). Their large number, especially facilities that accommodate persons who are elderly or physically handicapped, indicates the fragility and degradation of the residents from South Florida State Hospital. Many persons discharged from SFSH are physically disabled, and have been institutionalized much of their adult lives.
Chart 3: Specialized residences surveyed = 9In some cases, class members with health problems or a physical disability enjoy dramatic improvement upon discharge to a homelike environment where they receive personal care and a sense of independence. For example, at The Patrician Arms, a geriatric residence in Pompano Beach, a staff member pointed out that all four of their current class members had arrived from SFSH in wheelchairs, and all of them have improved since discharge to the point where they can get around on their own. This illustrates the importance of discharging class members to residences that have competent staff, and a link to rehabilitative services that can repair the damage of institutionalization.
RESIDENCES BY DISTRICTS
Less than one-third of the residences in District 9, 10, and 11 were operated specifically for mental health consumers, and linked to mental health services. Only three of the 10 residences in District 9 were RTF's or APT's; in Districts 10, the number amounted to 3 out of 10, and in Districts 11, 5 out of 18 (see Chart 4 below).
Chart 4: Type of Residence by District (Total facilities=41)With the exception of District 15, where all three of the residences were RTF's, many discharged class members were obliged to live in for-profit boarding homes (ALF's or foster homes). In District 9, these amounted to 40% of the total. In both Districts 10 and 11, a full half (50%) of the residences visited were ALF's. In Broward County, ALF's accounted for 5 out of 10 sites, and in Dade County, 9 out of 18. In District 9, ALF's accounted for 5 out of 10 sites, and the ones in that District were among the worst (see "Worst Cases" below).
IDENTIFYING RED FLAGS
With a few exceptions, the residences where discharged Sanbourne class members live are less than ideal for persons needing special support and rehabilitation to adjust to life outside the institution. Of the class members surveyed, at least nine returned to long-term hospitalization before 18 months had passed. Many class members succumbed to the pressures of living in inadequate facilities, and suffered at least one short-term hospitalization.
Even for those getting along day to day with no incident, it is clear to the plaintiffs that the environment and the staff at many of the residences licensed by HRS are often substandard and otherwise unpleasant or stressful. In order to identify markers that would serve as "red flags" to serious problems in facilities, ten categories were created that were then associated with particular answers on the questionnaire.
The red flags were grouped into three types:
Institutional Problems - these included lack of wheelchair accessibility (Access), an excessive number of people living at a residence (Capacity), bedrooms, bathrooms, or living areas that were too small for the number of people using them (Crowding), and common areas that were unattractive or uncomfortable (Common).
Safety and Well-Being - these included dangerous or impoverished neighborhoods (Location), health hazards such as lack of cleanliness, foul odors or evidence of pests (Health), physical structures that endanger clients, such as damaged floors or walls, or inadequate emergency exits (Safety), and problems with staff or program, especially complaints of abuse or disrespect made by class members (Staff).
Income - these included cases in which a facility received all of a client's checks but failed to provide him or her with adequate spending money or were unable to produce accurate records of client accounts (Allowance), and failure to provide necessities such as toiletries and other personal care items (Pers Care).
Chart 5: Red Flags Identified at InterviewsA table listing all of the residences and their "red flags" may be found in Appendix B**.
Institutional Problems
Persons discharged from a state institution need a place to live that provides them a homelike environment and a living situation conducive to recovery and rehabilitation. They often need to recover from the institution itself. Class members need a place to live that is on a par with the homes or apartments that everyday people enjoy. Only then can they have a chance to take their place as full members of society without being stigmatized as "mental patients."
For a residence to be a home, it should be able to provide a comfortable and attractive living space to a limited number of people. Many of the residences visited by the plaintiffs had a cold and institutional feel to them, and are not conducive to creating a homelike environment. They are not homes.
ACCESSIBILITY
The survey looked for halls and doorways that would accommodate wheelchairs, as well as handrails and handicapped seating in bathrooms. Nearly two-thirds of the residences (at least 27 of the 41) were not wheelchair accessible. One conclusion from this situation is that disabled persons otherwise ready for discharge from SFSH might be prevented from leaving due to a lack of an accessible residence. Another conclusion might be that a disabled person would find themselves trapped in a large institutional setting, such as a nursing home, simply because it is wheelchair accessible.
As noted above, many persons discharged from SFSH are fragile due to age or other physical disability. Thus the proportion of persons requiring wheelchair-accessible living space is much greater than in the general population. Yet, with the exception of the four large nursing homes in the survey - in every case, large institutional facilities - few of the residences are fully accessible.
CAPACITY
The greatest indication that a facility is an institution, and not a home, is that a large number of people live there. Plaintiffs have observed that that when 10 or more people live in one location, it begins to seem like an institution. Independent research has shown that the optimal number of persons who should be congregated in one residence is ______. For purposes of this survey, however, plaintiffs allowed up to 19 people per residence before it was flagged as having the quality of an institution. Adult Living Facilities (ALF's) are often characterized by the large number of people warehoused there. For example, 20 of the 41 residences in the survey housed 20 or more people, and most of these were ALF's. They included: Lazaro's ALF, with 48 people; F. Lauderdale Retirement Annex, with 70; W. Palm Beach Retirement, with 88; and Henry's Retirement Center, with 118. Nursing homes also generally house large numbers of people. For example, there are 176 people living at Treasure Isle Care Center.
CROWDING
Other indications of institutional living are crowded bedrooms and bathrooms, and unattractive common areas. Three or more beds in a room impart an institutional feeling, as do bathrooms used by four or more people. Needless to say, many of the ALF's also contained crowded bedrooms and bathrooms. At Henry's retirement Center, for example, some residents live in wards and use large group bathrooms. In all, 26 of the 41 residences exhibited bedrooms or bathrooms that were used by too many people.
Others provided residents with adequate bedrooms and living space, but had areas for eating, recreation, or outdoor activity that were cold and impersonal, or unattractive. These included New Vistas Parkside and New Beginnings (UMI II).
Some of the residences met most other standards of care and even homelike environment, but contained living areas that were crowded. These included Butler Group Home, Patrician Arms, and Lovett's Foster Care. At one group foster home, Lovett's, an additional bedroom was being built onto to an already small house on a small lot, adding more residents to an already crowded living situation.
Safety and Well-Being
LOCATION
Many class members complained about the presence of drugs, prostitutes, or violent crime in their neighborhoods. In addition, undesirable or impoverished neighborhoods were easily identified by the interviewers on their visits.
The housing survey was conducted, by necessity, in teams of two persons. One reason for this was that many residences for class members are located in remote locations of all of the counties. It was necessary to use one person who had a car and could act as navigator in locating the residences. Another reason was that many of the locations visited were in the very worst neighborhoods of each district. Interviewers were warned by an official at HRS not to visit these locations alone; they were advised carry a cell phone at all times, in order to be able to call for help in case of danger.
Of the 41 residences visited, at least 20 of them were in neighborhoods that could be described as severely impoverished or extremely dangerous -- or both. The District 15 residences in Fort Pierce, particularly "Safe Harbor" (another ironic name), were located in an area around Avenue D notorious for drug dealing and prostitution. This area was even featured for that reason in a recent edition of 60 Minutes. In District 10, four of the residences (New Vistas Parkside, Briarwood Manor, Nova GRTS, and Brandon House) were all located in the same block of buildings in Lauderhill. This block forms a kind of mental health ghetto. According to members of the PEER Center in Oakland Park, residents living on this street are isolated from the rest of the neighborhoods, and are often targets for theft and harassment on the part of local teenagers. In 1995, a resident of New Vistas Parkside was murdered in her Lauderhill neighborhood. The young woman, was, at the time, a Sanbourne class member.
In District 11 several residences are located in the worst areas of North Miami, particularly Hialeah. The CASP residence, located in Little Havana, was in such a dangerous neighborhood that staff said they were afraid to drive to work, for fear that their cars would be stolen if they parked them outside the door. At several of the residences, staff required that residents be accompanied at all times if they left the residence -- not because of their own mental state, but because of the dangerousness of the neighborhood.
All of the supervised apartments were located in rundown or dangerous areas, as were over half of the ALF's. Even many of the RTF's, that were otherwise well-run and beneficial for class members, were situated in undesirable neighborhoods. It is hard to imagine how a person discharged from a mental hospital can make a successful transition to the community when they are obliged to live in areas infested with drugs, violence, and crime.
HEALTH AND SAFETY
Problems affecting the health or safety of residents existed in 25 residences . At some of these facilities, such as Avante, Bob Mays, Lazaro's, and West Palm Beach Retirement Home, standards of cleanliness were compromised by the odor of urine or dirty food storage areas.
At others, structural problems threatened the safety of class members. At the Royal Plaza ALF and CASP, floorboards were severely warped and protruding, a very hazardous situation. At Briarwood Manor, a large hole in the wall exposed bathroom plumbing. At Madrone Manor, bars on bedroom windows blocked emergency exit in the event of fire. Other structural problems included unmarked or locked exits, broken windows, and absent or broken smoke detectors. Ten of the residences exhibited problems with emergency exits that were locked, inaccessible, or absent
COMPLAINTS ABOUT STAFF
The focus of the housing survey was to obtain information about the residences, and not the degree of satisfaction of the class members living there. Nevertheless, in conducting the survey, plaintiffs spoke with many of the class members. Their complaints were noted and are added here to the report. Under other circumstances, a consumer evaluation survey would no doubt unearth more information of this type.
Some class members complained about abusive language from staff. These complaints were made about Briarwood Manor, CASP, and Bob Mays. At Bob Mays, physical abuse was reported. At other residences, staff treated class members more like prisoners than residents. The cook at Briarwood Manor stated that a meal would not be held for a late resident if they were "just fooling around." At Paradise Palms, residents are not allowed to watch TV if they fail to abide by the orders of the staff. At some of the residences, staff does not post house rules or information about rights of residents. At Royal Plaza ALF, for example, no information of any sort is posted, including licenses and fire inspection certificates.
Chart 6: Red Flags of Safety and Well-Being (Total facilities=41)In all, 35 of the 41 residences exhibited at least one red flag for a serious problem in the area of Health and Safety. More than half of these were licensed Adult Living Facilities (ALF's). In Chart 6 above, it can be clearly seen that the ALF's exhibited a disproportionate number of serious problems that threatened the health and comfort of the class members.
Income
ALLOWANCE
In preparing for the interviewing process, plaintiffs incorporated advice from consumers at the PEER Center and elsewhere, since many of the members there had themselves lived in group residences upon discharge from SFSH and other mental hospitals. According to them, many of the residences, particularly the ALF's and boarding homes, withhold funds that belonged to their residents. The interview instrument thus included several questions about how much was charged to live there, how this money was received and distributed, what personal care items were provided to residents, and how much residents received in monthly allowances.
At the time of the survey, most persons discharged to a licensed residence from SFSH received Supplemental Security Income (SSI) amounting to $476 a month. Most of the facilities interviewed were payees for the class members, and they kept the entire amount of the SSI check. In addition, the residence is given a state supplement (OSS) of $160. The OSS supplement amounts to $160/month, and $43 of this is required to be distributed to residents as a personal allowance. This allowance may be distributed to the class member as a lump sum monthly or in a budgeted amount daily or weekly. Ironically, the facilities that charge the most rent and keep the most money are the ALF's (see Table _____). Several of the Residential Treatment Facilities actually charged a little less than the full amount of the entitlement, and thus made more money available to their clients. These included Lakeside and UMI II (New Beginnings). In general, the supervised apartments also withheld less of the residents' SSI payment, since in the apartments a resident is expected to handle more daily expenses such as food and utilities.
Although interviewers were unable to document any actual withholding of funds, often the questions about money were answered vaguely or evasively, and there were several places where the records of a clients' account was questionable. At the Butler Group Home, for example, thorough records were keep of money spent by or for the residents, but in the case that was examined, there was no record of total funds in the client's account, and the amount spent was considerably less than the allowance due. At the CASP residence in Miami, one class member was distraught that a large amount of her money had been stolen. The staff member disparaged her claims, alleging that they were merely a reflection of her mental illness.
PERSONAL CARE ITEMS
The usual allowance of $43/month is scarcely sufficient to cover even minimal living expenses. It must be used to purchase necessities such as bus fare and clothing, and leaves little or nothing for an occasional treat or afternoon at the movies. Fortunately, most of the residences surveyed did provide their residents personal care items such as soap, shampoo, and razors. However, there were several that provided no personal care items at all, or that were vague about what they would provide. These were the Summit, Oasis Motel, Briarwood Manor, Phoenix II, CASP, Henry's Retirement Home, and Nova GRTS. At Briarwood Manor in District 10, not only are no toiletries provided, but also bathrooms are bare even of toilet paper. Class members are expected to buy toilet paper out of their meager monthly allowance.
RED FLAGS BY DISTRICT
As can be seen in the chart below, District 9 contained the greatest proportion of residences located in a bad neighborhood. The district also earned the most marks for dangers to health. District 11 earned bad marks for structural problems (safety) and financial problems, such as failure to provide a personal allowance. District 10 had a smaller proportion of red flags with the exception that, in that district, class members were less likely to receive personal care items.
Chart 7: Health and income red flags by District (41 residences)
SOME WORST CASES
Using the ten Red Flag categories, plaintiffs identified seven worst cases among the residences visited. These were determined by the number of red flags listed in each case, as well as by observations of the interviewers and comments from class members. All of the following residences had problems in most of the ten categories (see Table 1).
DISTRICT 9
Paradise Palms is an ALF in West Palm Beach that houses 32 people. Interviewers rated this residence as "awful" in the categories of homelike environment and neighborhood. It is located in a high-crime area with much crack use, and it is not wheelchair accessible. Other red flags found here were crowded bedrooms and unpleasant common areas. Staff claimed that an allowance was given to residents, but the class member there said that he did not receive any money. This facility attempts to micro-manage the behavior of people who make a home there -- it restricts the use of the TV, allowing it to be enjoyed only by residents who "behave" themselves by actively participating in groups.
The West Palm Beach Retirement Home houses 88 people. It is an ALF located in a bad neighborhood of West Palm Beach and is not wheelchair accessible. Red flags found here were crowded bedrooms, unhomelike environment, and unsanitary food storage areas. Interviewers reported that the food storage area was not clean, and that staff attempted to throw out old or spoiled items when they were inspecting the refrigerator. No medical or psychological services are provided here. The smoking area consisted of a second floor balcony overlooking an unpleasant street. This facility, now under new management, has in the past been heavily infested with street drugs, and at the time of the interview was still dealing with this issue.
The Bob Mays boarding home in District 9 has been notorious for years for its substandard physical plant and abusive staff. It is located in one of the worst neighborhoods of Lantana. It provides no activities for its residents, and gives them no allowance. Although 22 people live there, there is no pay telephone for them to use. There is no program for medication storage and distributions, and class members are expected to manage their own prescription drugs. The entire physical plant is in rundown condition, and many of its rooms, both bedrooms and common areas, are crowded. One class member who moved from Bob Mays to another location, told interviewers that he had been hit in the head by Bob Mays. Although this facility is not licensed by HRS, clients of the South County Mental Health Center sometimes live here.
Madrone Manor is a developmental services facility located in a bad neighborhood on the grounds of A.G. Holley in Lantana. Red flags found here were the lack of proper exits and the failure to produce an account record for the class member. At the time of the visit, metal grates covered windows in the bedrooms, not allowing for emergency exit when residents were sleeping there. No fire inspection certificate was found. Residents are expected to distribute their own medications, which are stored in color-coded containers. Staff there were evasive with interviewers, and provided inaccurate information. This facility was licensed for three people, but four were living there. Madrone provides no activities for its residents, and interviewers were not allowed to talk with the class member except under supervision. It is associated with South County Mental Health Center, and residents attend Seagull Day Treatment. It is not wheelchair accessible. Some of the problems the plaintiffs reported here have since been corrected.
DISTRICT 10
Briarwood Manor is an ALF with 34 residents. It is located in an area of Lauderhill that has become a mental health ghetto. The entire block of NW 28th Street is composed of group residences that include New Vistas and NOVA GRTS, with Brandon House around the corner. Briarwood is constructed so that all bedrooms have separate exits -- a nice touch, in some ways, but one that apparently encourages local teenagers to rob residents who neglect to lock their doors. Red flags found here included a non-functioning smoke detector, lack of cleanliness in bathrooms and missing tiles from a wall in one bathroom, exposing the interior fixtures. No personal care items are given out here, and interviewers discovered that there is not even any toilet paper in the bathrooms. The class member interviewed reported that staff "plays favorites" with residents, and insults those not in favor. He said that he was called names such as "asshole" and "faggot." This class member was formerly a client of Henderson Mental Health Clinic. Briarwood is not wheelchair accessible.
DISTRICT 11
Lazaro's Home is licensed for 48 people. It is another ALF notorious for its poor conditions, and is located in a degraded neighborhood of Hialeah. Red flags found here were crowded, unclean, and abusive conditions. The allowance given residents was stated to be $38, less than the mandatory amount. All of the bedrooms here contained 3 or 4 beds, and looked crowded. Seating was uncomfortable in the living area, and the smoking area was extremely unattractive. There was no pay phone for the use of residents. No fire inspection certificate was found. There are defects in the floor, including faded and chipped paint and cracked terrazzo. The grill of a window AC unit was broken. Interviewers reported a chaotic atmosphere here, with constant conflict among both residents and staff: "Residents were yelling and arguing, staff didn't seem too professional, they were yelling at people. A lady in bed got yelled at for having some clothes on the floor, and she looked scared. Only one person on staff knew some English." It is not linked with any mental health program, although it is associated with NW Dade Mental Health Center. It is not wheelchair accessible.
CASP is an apartment complex in District 11. It is located in an extremely dangerous neighborhood of Miami known as "Little Havana." Residents cannot leave the building without an escort because of the ever-present danger on the streets. Other red flags found here were warped floorboards and the lack of personal care items or snacks. Interviewers reported a stigmatizing attitude on the part of staff, who accused a resident of "hallucinating" when she reported theft of money. CASP is licensed for 16 people, although 18 people were living there. It is associated with Miami Mental Health Center. It is not wheelchair accessible.
SOME POSITIVE FINDINGS
Although all of the residences visited earned at least one red flag for serious problems, a few earned positive comments from the interviewers.
In District 15, it was encouraging to see that at least some residences are not dead-end "placements," where class members are discharged from SFSH only to be warehoused again. At two residences, the class members listed as living there had moved on to higher-level programs within the same mental health agency, New Horizons of the Treasure Coast. In Stuart, Horizon House was rated excellent in all categories, and is considered a "model" program. It received only one red flag for partial accessibility. It is located in an attractive neighborhood and for the most part is wheelchair accessible. Safe Harbor, in Fort Pierce, was located in an undesirable neighborhood, and it operated like a Level 1 program, exacting much control over its residents and providing structured activities within the facility. Nevertheless, Safe Harbor rated the approval of the interviewers for its caring staff and for its work program whereby residents earn spending money in addition to their OSS allowances by doing basic housekeeping chores.
In District 9, UMI II (New Beginnings) received good marks from the interview team. Licensed as a "Level III" residence, this ALF is attractive and homelike, with only eight residents. It is closely linked to case management and other services at South County Mental Health Center. Each resident receives a larger than required personal allowance ($90). There are only two people in each bedroom, which the interviewer described as "beautiful, clean, new-looking."
In District 11, Lakeside is an RTF in a middle-class neighborhood of South Miami. It was also called "excellent" by the interviewers, who commented that the facility had "caring staff, very therapeutic, emphasis placed on helping residents become independent and self-sufficient." Like the District 15 facilities mentioned above, Lakeside offers therapeutic activities to rehabilitate its residents and re-integrate them into the community. The facilities sponsored by Fellowship House, like those run by New Horizons of the Treasure Coast in District 15, seemed well integrated into other services offered by the mental health agency, allowing flexible treatment and living situations according to the needs of the consumer.
For the time period studied, District 10 received only 27 class members discharged from SFSH, and group living facilities were found for nearly 60 per cent of them. Unfortunately, many of these discharges were to large-capacity ALF's or other institutional settings. Because of this, and also because several of the residences were in the "mental health ghetto" area of Lauderhill, the interviewers were unable to find a facility that would meet their criteria for a place desirable to live.
RECOMMENDATIONS
In the plaintiffs' list of "worst cases," most were ALF's (5 out of 7). All but one of them was determined to be in a bad neighborhood, and all but one were not wheelchair accessible. All of the worst cases exhibited problems with staff behavior, from outright abusiveness to disrespect and stigma. They generally were marked as having crowded or unpleasant common areas. Most of them either failed to provide an allowance to their class members, or were dubious in that regard. Ironically, the flagged ALF's also charged some of the highest rents of the residences surveyed. For example, Briarwood Manor told us that it charges $950/month, and Lazaro's charges $598.
REQUIRE ADM'S TO KEEP AND PROVIDE BETTER RECORDS OF CLASS MEMBER STATUS
The Sanbourne team, other advocates, and family members of ADM clients, need timely and accurate records of the location and status of class members.
PHASE OUT THE USE OF BOARDING AND "RETIREMENT" HOMES IN DISCHARGE PLANNING
The ALF's of South Florida are, to put it simply, some of the worst places to live for anyone, anywhere. It in unconscionable to use such residences as homes for persons discharged from a mental institution. The degraded atmosphere of the ALF's is no improvement over the state hospital, and may in fact be just as damaging and impersonal to people as was SFSH.
PHASE OUT OR RELOCATE RESIDENCES SITUATED IN BAD NEIGHBORHOODS
Many residences from all categories were found to be located in neighborhoods not suitable for people recovering from mental illness. It makes no sense to discharge people to locations where they live in extreme danger, or are constantly exposed to street drugs and alcohol that many of them are trying to free themselves from. HRS should phase out all residences in such locations, and establish new ones in acceptable locations.
MENTAL HEALTH RESIDENCES SHOULD BE PHYSICALLY ACCESSIBLE
Under the Americans with Disabilities Act (ADA), accessibility is required by federal law for group residences for disabled people. These regulations should be observed. HRS licensed facilities should meet standards of accessibility.
RESIDENCES SHOULD NOT BE FOR MORE THAN EIGHT PEOPLE
Except for nursing homes and other specialized services, the capacity of any residence provided to discharged class members should not exceed eight in capacity.
HRS SHOULD STRENGTHEN LICENSING STANDARDS FOR RESIDENCES
Most of the residences visited were inspected and licensed by HRS. Apparently the licensing standards allow many of the problems that we observed, such as inaccessibility, crowded bedrooms, etc. Licensing requirements should be tightened up, so that they do not allow these problems to slip by. In particular, plaintiffs recommend that no more than two beds be allowed to a room, and problems of crowding should be prevented. IN THE OLC DISTRICT FILES . . .
ESTABLISH NEW RESIDENCES TO EASE CROWDING AND TO ALLOW MORE DISCHARGES FROM SFSH
As noted in the recent report from FMHI, one of the biggest problems with SFSH is that it is unable to discharge people. One reason that conditions at SFSH have stagnated and festered is that there is no movement of residents back into the community. This situation creates enormous despair and anger among class members. It is estimated that ___________ people who currently reside at SFSH are ready for discharge and would be better served in the community. There simply is no place for them to go!
ALLOCATE MORE RESOURCES TO COMMUNITY RESIDENCES AND OTHER MENTAL HEALTH SERVICES
All of the remedies listed above cost money to implement. Many, if not most, of the red flags and other problems identified in the residences could be ameliorated by an influx of funding. A rent of ________ is not enough to maintain quality in a residence, and an allowance of $43 a month is not enough to live on in anything more than abject poverty. Poverty and inadequate material supports create stress and harm for class members, and they are detrimental to recovery. These stresses often lead to frequent crises and even long-term rehospitalization. The greatest obstacle to improving existing residences and creating new ones is lack of funding.
Florida's funding for mental health services is one of the lowest in the country. In New York State, for example, the state supplement given to consumers discharged to community residences is equal to the amount of their monthly SSI payment. In comparison, Florida's contribution to decent housing for mental health recipients is less than one-third of the SSI entitlement. With an increased contribution by the state of Florida to the OSS program, more funds could be provided to improve current residences and to make new ones available.
- Sally Clay
February 1997