Dunn et al v. Thomas et al

Filing 1354

PHASE 2A INVOLUNTARY MEDICATION CONSENT DECREE. Signed by Honorable Judge Myron H. Thompson on 9/6/2017. (Attachments: # 1 Administrative Regulation 621)(kh, )

State of Alabama

KAY IVEY

Alabama Department of Corrections
301 S. Ripley
P. O. Box 301501
Montgomery, AL 36130

GOVERNOR

JEFFERSON DUNN
COMMISSIONER

May 5, 2017
ADMINISTRATIVE REGULATION
NUMBER 621

OPR: Office of Health Services

ADMINISTRATIVE REVIEW FOR
INVOLUNTARY PSYCHOTROPIC MEDICATION(S)
I.

GENERAL
This Alabama Department of Corrections (ADOC) Administrative Regulation (AR)
establishes the responsibilities, policies and procedures for administrative review for
involuntary psychotropic medication.

II.

POLICY
The recommendation to involuntarily treat an inmate with psychotropic medication will
be considered only after less restrictive/intrusive attempts have been exhausted and were
unsuccessful. The Institutional Psychiatrist and other members of the inmate’s treatment
team will evaluate the inmate, and the Involuntary Medication Review Committee will
review their recommendation. In no instance shall an inmate be threatened by any
individual associated with ADOC, including its employees and/or independent
contractors, with the use of force or a threat of disciplinary actions such as segregation,
loss of privileges, or loss of good time, as a means to coerce the inmate to accept
psychotropic medications; however, nothing herein shall restrict the authority of a person
providing current mental health care from notifying an inmate regarding the events which
might transpire in the event that he or she refuses psychotropic medication, including
initiation of the involuntary psychotropic medication process.

III.

DEFINITION(S) AND ACRONYM(S)
Refer to AR 602 for definitions of the following terms used in this AR:
Seriously Mentally Ill (SMI)
Treatment Team
Involuntary Medication Review Committee

Intensive Psychiatric Stabilization Unit (SU)
Residential Treatment Unit (RTU)
IV.

RESPONSIBILITIES
A.

B.

V.

The Institutional Psychiatrist and other members of the inmate’s treatment team
are responsible for evaluation of the inmate and submitting their recommendation
to the Involuntary Medication Review Committee.
The Involuntary Medication Review Committee is responsible for reviewing the
treatment team’s recommendation, notifying the inmate of a hearing date,
evaluating evidence/testimony, and making and documenting their decision.

PROCEDURES
A.

Prior to consideration of involuntary medication, the inmate must be transferred to
an Intensive Psychiatric Stabilization Unit for aggressive and intensive mental
health treatment. The lack of effectiveness of treatment measures that are less
intrusive than involuntary medication must be documented.

B.

Before involuntary psychotropic medication(s) is authorized for an inmate, he/she
must:
1.

Have been diagnosed with a serious mental illness, and

2.

Have been transferred to an Intensive Psychiatric Stabilization Unit (SU)
for less intrusive treatment; and

3.

Have, as a result of the serious mental illness, a current high likelihood of
serious harm to self, others or property, or be unable to successfully
perform basic, life-sustaining activities of daily living such as eating or
drinking, or manifest severe deterioration in routine functioning, such as
repeated and escalating loss of cognitive or volitional control over
personal actions; and

4.

Refuse voluntary treatment.

5.

In assessing the current risk of harm, the Committee may consider
evidence of past serious harm to self, others and property. If the
Committee considers such evidence of past conduct in determining current
likelihood of harm, it must document the evidence considered in ADOC
Form MH-028, and must document the basis for the determination that
these past events support a finding of an ongoing, current serious risk of
harm that could present in the current environment

6.

The Committee must find that the administration of the contemplated
psychotropic medication is in the inmate’s best medical interest.

C.

After deciding to pursue the authorization for involuntary medication, the
inmate’s treatment team will complete an ADOC Form MH-029, Involuntary
Medication Request form. The documentation will include:
1.
2.

Diagnosis in accordance with DSM 5 or the latest subsequent version
thereof.

3.

Indication that the inmate presents a current substantial likelihood of
serious physical harm towards self or others, a substantial likelihood of
significant property damage or who is incapacitated to the extent that
he/she is unable to perform basic, life sustaining functions such as eating
and drinking or manifests severe deterioration in routine functioning by
repeated and escalating loss of cognitive or volitional control over
personal actions as a result of the serious mental illness. In assessing the
current risk of harm, the Committee may consider evidence of past serious
harm to self, others and property. If the Committee considers such
evidence of past conduct in determining current likelihood of harm, it must
document the evidence considered in ADOC Form MH-028, and must
document the basis for the determination that these past events support a
finding of an ongoing, current serious risk of harm that could present in
the current environment.

4.

Description of the methods used to motivate the inmate to accept
medication and the inmate’s responses to these efforts.

5.

Consideration and rejection of less intrusive alternatives.

6.

Any recognized religious objection to the medication.

7.

Proposed type, dosage range, and route of administration of the
psychotropic medication, including injectable and oral alternatives.

8.

Any history of side effects, including severity, from the proposed
involuntary medication.

9.

Statement that the patient-specific goals anticipated from the proposed
medication outweigh potential risks or side effects.

10.

D.

Psychiatric evaluation of inmate’s current mental health condition.

Statement that the administration of the contemplated psychotropic
medication is in the inmate’s best medical interest.

If less intrusive measures are unsuccessful, the Institutional Psychiatrist and the
inmate’s treatment team will document recommendations on ADOC Form MH028, Involuntary Medication Request. After completion, the form is submitted to
the Involuntary Medication Review Committee Chair. The review process will be

conducted in accordance with the Washington v. Harper decision. The use of
involuntary medication as a punitive measure is strictly prohibited.
E.

The Involuntary Medication Review Committee consists of one Psychiatrist
(Chair), one licensed psychologist, and either a master’s level in psychology,
Social Worker, Nurse Practitioner or Registered Nurse. No member of the
committee, no person assigned any appeal from the granting of an Involuntary
Medication Order, can be currently assigned as the primary mental health provider
or primary psychiatric provider for the inmate. “Primary mental health provider”
is defined as a professional who, in the last six (6) months has provided treatment,
group or individual counseling, medication or medication management, or
regularly scheduled care or follow up care. It does not include isolated instances
of medication for emergency purposes or consultation for purpose of suicidality or
mental health or suicide watch status. This committee will:
1.

Meet within one working day of receipt of the Involuntary Medication
Request for a preliminary review.

2.

Provide the inmate with ADOC Form MH-029, Notice of Involuntary
Medication Hearing, at least one working day prior to the hearing, during
which time the inmate may not be medicated. Such Notice shall include:
a.

The tentative diagnosis;

b.

Diagnostic criteria currently met by the patient in support of the
diagnosis listed;

c.

The reasons why the staff believes medication is necessary;

d.

The inmate’s rights at the hearing, including the right to call,
examine and cross-examine witnesses, the right to an advisor who
has not been involved in the inmate’s case and who understands
the psychiatric issues involved, the right to receive a copy of the
minutes of the hearing, the right to appeal the decision
administratively and through judicial review, the name of the
advisor, and a means to contact the advisor

3.

Obtain the inmate’s signature to acknowledge receipt, and maintain the
signed notice with documentation of the hearing process. If the inmate
refuses or is unable to sign or acknowledge receipt, then two mental health
staff members will sign the form and the inmate’s refusal will be
documented in a progress note.

4.

Provide a copy of the signed notice to the inmate and to the Warden of the
institution.

5.

Assign an advisor not currently involved in the inmate’s treatment to
facilitate the inmate’s understanding of the hearing process prior to and
during the hearing. The person assigned as the inmate advisor must be

independent and knowledgeable in the provision of mental health care
based on education and/or training.
F.

During the Involuntary Medication Hearing, the inmate:
1.

2.

May be permitted to be present, provide testimony, or have witnesses
testify on their behalf, but the Chair may limit testimony from a witness or
witnesses who are cumulative or redundant.

3.

May choose of their own free will not to participate in the hearing, or may
be removed from the hearing if, after repeated warnings, the inmate
continues to interrupt the proceedings inappropriately.

4.

Members of the treatment team and other relevant institutional staff will
provide evidence relevant to the request for involuntary medication.

5.

The inmate will be permitted to question witnesses supportive of
involuntary medication.

6.

The inmate may call as a witness any treating professional who is or has
been active in their treatment, who presents an alternate therapy to
involuntary medication.

7.

The mental health professionals who initially sought or are currently
pursuing an involuntary medication request shall be available in person, or
via video, to testify and be questioned by the inmate at the hearing.

8.
G.

Will be advised of his/her hearing process rights through review of ADOC
Form MH-029.

Minutes of the hearing will be documented.

The Chair of the Involuntary Medication Review Committee may limit the
inmate’s right to be present at the hearing or limit the inmate’s right to present
testimony and question witnesses at the hearing if, after repeated warnings, the
inmate continues to interrupt the proceedings inappropriately, or there are
documented concerns related to institutional security and order.
1.

If the inmate chooses not to participate in the hearing or is precluded from
attendance by the Chair, the advisor will exercise the rights of the inmate
on the inmate’s behalf.

2.

If the inmate chooses not to be present at the hearing or is precluded from
attending by the Chair, if testimony presented by the inmate or his/her
witnesses is substantially limited or disallowed, the Chair will document
reasons for the absence of the inmate or restrictions in testimony and
questioning as part of the final decision.

H.

The decision to medicate the inmate requires a majority of the committee, with the
Psychiatrist among the majority, and remains in effect for ninety days.

I.

Documentation of the decision made by the Involuntary Medication Review
Committee will include:
1.

Each member explaining his/her decision on ADOC Form MH-040,
Progress Notes, and signing ADOC Form MH-030, the Record of
Involuntary Medication Review in the inmate’s medical file.

2.

The Chair explaining the rationale for the Committee’s decision on ADOC
Form MH-028, Involuntary Medication Request.

3.

Copies of ADOC Form MH-030 will be sent to the Warden and the inmate
within one working day of the committee’s decision.

4.

Notification to the inmate, concerning his/her option to appeal the decision
within one working day after receipt.

5.

Maintenance of the original documentation in the inmate’s medical record,
with copies forwarded to the Office of Health Services.

J.

The advisor will assist the inmate in submitting an appeal if the inmate desires to
do so. An inmate’s appeal will be reviewed and the decision rendered in writing
by a designated psychiatrist within one working day of its receipt. The designated
psychiatrist may not be a member of the inmate’s Involuntary Medication
Committee. The inmate shall be informed of the right to appeal any decision to a
court of appropriate jurisdiction.

K.

An inmate may voluntarily accept medication without invalidating an existing
involuntary medication order.

L.

If the treating psychiatrist recommends continuation of the involuntary medication
for longer than ninety days, he/she will complete a new ADOC Form MH-028 and
submit it to the Chair of the Involuntary Medication Review Committee at least
two working days before the previous authorization expires.

M.

The same Involuntary Medication Review Committee, which considered the initial
involuntary medication request, will consider the treating Psychiatrist’s
recommendation on or before the day the prior authorization expires, utilizing the
procedures outlined in V.E. through J.

N.

If the second Involuntary Medication Hearing decides that involuntary medication
should be continued, the authorization will be in effect for 180 days.

O.

Continuation of the authorization for involuntary medication will be re-evaluated
after the initial 180-day order to continue to involuntarily medicate the inmate
expires. An inmate will be given a thirty (30) day respite at the completion of the
initial 180 day order to involuntarily medicate. The inmate’s ability to be self-

directed with medication compliance will be evaluated within this time period.
Should an inmate choose to miss three consecutive doses at any time within the
thirty (30) day respite or show signs of deterioration in his/her mental health, the
treating psychiatrist may order a continuation of the authorization for involuntary
medication for a second 180 day interval.
P.

Q.

The psychiatrist’s order for involuntary psychotropic medication will include a
note of “Involuntary medication.”

R.

The nurse transcribing the Psychiatrist’s involuntary medication order for an
inmate will note “Involuntary medication” within the medication administration
record/system.

S.

If an inmate refuses involuntary medication or does not appear for a psychotropic
medication noted on the medication administration record as “involuntary
medication,” the nurse administering the medication will immediately notify the
facility supervising health authority.

T.

VI.

The procedures outlined within Section V: subsections C through J are to be
followed prior to any reauthorization of involuntary medication for an inmate who
has had orders to involuntary medicate for a total of 365 cumulative days within a
consecutive sixteen (16) month period of time.

The Supervising Psychologist of the Intensive Psychiatric Stabilization Units (SU)
and Residential Treatment Units (RTU) will complete and submit ADOC Form
MH-031, Mental Health Unit (RTU/SU): Inmates Receiving Involuntary
Medication, with monthly Mental Health Services reports.

DISPOSITION
See AR 601, Mental Health Forms and Disposition.

VII.

FORMS
Refer to AR 601, Mental Health Forms and Disposition for:
A.

ADOC Form MH-028, Involuntary Medication Request

B.

ADOC Form MH-029, Notice of Involuntary Medication Hearing

C.

ADOC Form MH-030, Record of Involuntary Medication Review

D.

ADOC Form MH-031, Mental Health Unit (RTU/SU): Inmates Receiving
Involuntary Medication

E.

ADOC Form MH-040, Progress Notes

VIII. SUPERSEDES
This AR supersedes all prior versions of AR 621 and 621-1 dated September 20, 2004
and March 14, 2005, respectively.
IX.

PERFORMANCE
This administrative regulation is published under the authority of:
A.

National Commission on Correctional Health Care: Standards for Health Services
in Prisons, 2014

B.

The Code of Alabama 1975, Section 22-50-11.