Introduction

Hello. I am 19 years old. I have Autism Spectrum Disorder, Bipolar, and Anxiety. I have been in the mental health system for many years and seen some things change things stay the same. I want to help other people who are in it. So, this is why I'm writing this. This is not a complaint and is not meant to be investigated. It does not reference a specific program or facility, but the system as a whole. This contains things that I have heard about. Some things are second hand information. Things should be improved. Sit back, relax, and enjoy your journey through The Odyssey of the Failing NJ Mental Health and Developmental Disability System. A lot of this goes for any person with mental illness and sometimes is overlooked in New Jersey and everywhere. Although this uses all New Jersey terminology and is mainly concerning New Jersey, a lot of the problems included exist nationwide and solutions can be implemented around the United States.

Change the system. Change the lives affected by it.

Involuntary Commitment
DCF and DHS

1.The commitment laws are stretched with patients when the person isn't truly dangerous. *(e.g. CEPP is overused with minors).
2.Some people can get committed without adequate justification. Judges like to “rubber-stamp” doctor's and social worker's testimony. For example, Judges have asked psychiatrists and other staff, “Are we all in agreement that the patient needs care?” One person says, “yes.” The Judge is already finished writing the renewed order
3.Two minute court hearings are not enough to decide if someone needs to be committed
Psychiatrists do it for power and because they can.  Allow appeals with an independent psychiatric evaluation funded by the Court system. Allow for a jury trial like some states already do.
4.Courts need to weigh in on transfers. The courts need to take on the power to decide about transfers and do notification of transfer.
5. Limit commitment reviews to 1 month at a time. No more 3 and 6 month commitment orders. People lose hope that way. People also do not get discharged when they are ready. This does not help census reduction efforts. Doctors like to commit people for long times, even if the patient does not need it.
6. Stop committing patients that ask to be voluntary. Make sure to offer voluntary admission. This is such a problem. I do not understand why the voluntary units are not accepting certain patients. These certain patients end up getting committed because no voluntary unit wants them. Thus, consensual admission to a STCF clause is rarely used. Doctors like to commit for spite and retribution, thus, denying consensual admission as an option.
7. Allow outpatient psychiatrists to commit their patients from the community and bypass screening.
8. There needs to be a notice of transfer for transfer that is served on the patient by a court official at least 5 days prior to transfer, unless an emergency exists. In an emergency, the 5 days can be reduced to 24 hours.
9.In hospitals, they do not let you read your clinical certificates. They should be served on the patient along with notice of hearing and their rights prior to court, like a few days before, by a court official.

Outpatient Commitment and Conditional Release
DHS

1. There is no real way to implement an outpatient commitment or conditional release if screeners and police do not know about it. Most times, the service recipient will not say anything about it.
2. There are a lot of "built to fail" commitments. For example, they can't get their medications because they don't have transportation to the pharmacy and there is a condition that they need to take their medication.

Screening Children
DHS and DCF

1.We need screeners and screening centers just for children and separate from adults that are licensed by DCF.
2.The screening centers for adults have different incidents and types of people. Children view this and learn from it (e.g. bad language).
3.A screening center does not allow people shut off lights to go to sleep, which would make sleeping difficult for anyone.
4.The screening centers need renovations.
5. Create specialty screeners for children.

Specialty screeners
DHS and DCF

1.There needs to be screeners specialized in children, developmental disabled persons, and elderly. Eliminate SCCAT and SCOPE.
2.Children, DDMI, the elderly should not be in the locked screening units and should be in an ER setting to minimize contact with other populations. This should take effect immediately.
3.Screeners need to stop calling Centralized Admissions to help find STCF beds for difficult to place patients. Centralized Admissions is not magical and can not make a bed appear, if there is no bed or the patient is denied from everywhere. Centralized only has true control over the State Hospitals.

Stigma surrounding Involuntary Commitment
DCF and DHS

1.There is a great deal of stigma surrounding Involuntary Commitment in the hospitals amongst staff and in the community at large.
2.Social Workers like to scare adolescents with the practice of commitment. This happens to adults, too.
3.Sometimes, in both of the intermediate units and at some of the short term places, during team activities, the teams are based on commitment status. Staff discreetly segregate the children with voluntary patients on one team and the committed/CEPP patients on the other. This was not a difficult conclusion to draw after court. The Public Advocate has heard about this ongoing in the children's system. It is not okay to segregate children based on this criterion. This practice needs to stop immediately with children and adults.
4.The public in general stigmatizes people who have gotten committed. Bullying and harassment in schools because of the child's recent discharge does not promote further healing.
5.People’s commitments should not be for public view and should be confidential to only police, screeners, and mental health providers.

Screening Centers and Screeners
DHS

1. Patients need to be able turn the lights off to sleep. In one county, it is not allowed to turn lights off because the "cameras don't work in the dark".
2. Aesthetically, the screening centers are lacking. There should not be dust balls the size of a golf ball in the rooms. Paint jobs are necessary.
3. Cease putting children near adult.
4. Medical clearance is sometimes incomplete. They do not medically evaluate repeat consumers in a specific screening center.
5. I think the back areas used for screening are deplorable. That's why the screening centers should exist within an emergency room, not adjacent to it. In other words, eliminate locked screening units.
6. Screeners need to stop concealing information or lying to patients about where referrals are going.

Involuntary Medications/Consent
DHS and DCF

1. It does not resolve anything.  If the person is experiencing side effects, they need to change the medication and not force the person to take medication that does not help.
2. They give high doses of medication sometimes dangerous doses.  This happens because they have the  power to do this.  The higher the dose, the more power the doctor has.
3. They should not force a consumer or guardian, if applicable, to consent to a mediation that they are opposed to.  They need to give you the full information on side effects.
4. Drugs of choice for involuntary medication are Haldol, Ativan, Navane.
5. Involuntary Medication Administration Review process should be transitioned to the courts. There should be separate medication hearings.
6. The 3 step process is still being used in some places. This has been found to be unconstitutional. Stop using it.

Mobile Response and Stabilization Services
DCF

1.MRSS should be a program to de-escalate the crisis not just an assessment and referral source
2.Adding a therapist or clinical worker to help de-escalate the situation
3.Adding an UCM case manager in the case of UCM involved children.
4.Adding DCPP case manager in case of suspected child abuse/ neglect or DCPP involved families.
5.For youth involved with the justice system, involve courts and probation offices, as necessary.
6.Changing the role will divert more families away from hospital level of care.
7.Make it a 15-30 minute wait time as opposed to the 24 hour response time, so it will be effective to de-escalate. The crisis is happening at the time it is happening, not 24 hours later.
8.The MRSS team needs to reach the family before the family reaches the point of needing to call the police and/ or go to the Screening Center.

Smoking Cessation
DHS

1. Whether to smoke or not should be up to the consumer.
2. It should occur outside in a designated area.

Maximum Lengths of Stay
DHS and DCF

1.Extend lengths of stay for patients. Levels of care should not be based on how long someone is at a program or hospital.
2." We are short term" should not be a reason for transferring someone.
3. Facilities should not have a long term or short term designation. All facilities should care for both long term and short term patients. It should be an option to the patients or guardians to accept a transfer.

Centralized Admissions, State Hospitals, and Ann Klein Forensics
DHS

1.Convert Trenton into a less restrictive forensic center. Remove forensic patients from the other hospitals. Mixing forensic patients with the other patients can cause fights and physical altercations.
2. There are a lot of bogus referrals because the Centralized Admissions continues to buy into trumped up referrals. The Centralized Admissions psychiatrist and team needs to interview the potential patients and families to determine if admission to a State Hospital is appropriate.
3.There are riots, fights, and physical altercations. More staffing is necessary. Perhaps, getting at least one or two security guards for each ward.
4. Stop admitting people that do not need to be there other than for the sole reason that there is no other hospitals that are willing to accept them. Then there's no issue with discharging them. State Hospitals should be able to deny a patient that would not be appropriate. The state hospital is used as a dumping ground for unwanted patients. There needs to be a way that Centralized can force another hospital to take a patient.
5. Hospitals discriminate against I/DD patients. It's wrong and needs to end.
6. Stop using transfer as a threat. It sets the stage for referrals being made for retribution and punishment, not for the treatment needs.
7. Patients are having sex and smoking various substances in the treatment mall. Increase supervision in the treatment mall areas.
8. Misuse of medication is an issue. They seem to not know how to recognize side effects and treat them. Stop using one medication to cover up side effects of another over and over.
9. Assaultive patients need to be transferred away more vulnerable patients. After 3 assaults in one month against patients or staff, they need to go to Forensics.
10. Staff has to be trained in Satori Approach to Managing Aggression. If staff knows how to de-escalate and physically intervene appropriately, there will not be as much violence toward self and others. Also, less charges will be pressed on patients if this occurs and then we won't need as many Forensic beds and can allow for specialization there.
11. The State Hospitals have become a "school in bad behavior". Patients learn from others' behaviors, like hurting people or head banging.
12. Start sending people out to the community for medical issues, instead of all the current on grounds treatments, especially with severe injuries. Even "fakers" should be sent out to be cleared. They sometimes even have conditions that need to be dealt with urgently. Medical neglect of a developmentally disabled or elderly person is a crime and the state does not care. There are a lot of elderly and developmentally disabled people located in the facilities. Also, see the section on setting up medical/psychiatric units in general hospitals to reduce the reluctance to send people out.
13. Set up Autism and Asperger wards in addition to the DDD wards. No ABA with Asperger individuals. Mostly CBT and DBT. Lower functioning individuals should have access to ABA therapies. Separate high and low functioning individuals.
14.Allow 18-21 year olds to access group therapies and other programs than education on the treatment mall. Add young adult units with their own treatment malls.
15. Change the model to an acute care model followed by the STCF. Group therapy should exist from wake up until bedtime. No more of this sitting around in day rooms.
16. More individual and family therapy is necessary to help patients leave and do well. End the red tape to therapy.
17. Group homes and residential settings can not continue to dump unwanted former patients at crisis centers just because they do not want them. All that happens is they get readmitted and the census raises.
18. Recidivism is a problem. People return to the hospital because no one tries to help them stay out, including staff at residential setting, ICMS, PACT, DDD, family, friends, etc. They also do not have the survival skills when they leave because there is no treatment.
19. This "even exchange" modality with Forensics is not safe in anyway. When a State Hospital sends a civilly committed (no criminal charges) patient to Forensics because they are highly aggressive and in need of secure stabilization, they get a patient from Forensics that is just as unstable. It's meant to prevent overcrowding there. But, they could send someone who is stabilized in exchange for the violent patient. Also, if someone is going to Forensics, warn them before the referral is made to stop what they are doing. Warn them explicitly of the possibility of a referral to Forensics. Don't just spring it on them when they least expect it.
20. The State Hospitals are not nursing homes for elderly people. This has become a problem.  People are placing their elderly family members in these places because a secure nursing home is expensive. This is not okay. Centralized Admissions needs to start dealing with this immediately as the elderly can get really hurt, physically and emotionally, in these places.
21. Centralized should take on the responsibility of admissions to specialized DDMI units, specialty elderly units, medical psychiatric units and Forensics.
22. Staffing is a huge issue. The current "census person" model is not kosher. There needs to be a 1:4 ratio.
23. There needs to be serious potty training going on with the DDMI patients. Adult diapers or “pull-ups” are not a solution that will work in the community.
24. The daily structure needs to be redone where patients are not sitting around doing nothing.
25. Specialization must happen. It will be easier once the census is reduced. Separate DDMI from autistic individuals. Separate young adults. Create units for less seriously ill and more seriously ill patients.
26. Create OCD and eating disorder programs similar to the model of Rogers Memorial Hospital in Wisconsin.
27. Give more consumer choice, especially as to program selection.
28. Allow more outside time at the facilities.
29. Stop ignoring patients.
30. Eliminate the modality where people are encouraged to stay for long periods of time. This creates discharge resistance. Length of stay is too long. Stop committing people over and over for relatively minor infractions of hospital rules.
31. Direct admissions should be allowed to Forensics from STCF for extremely aggressive patients. However, it needs to be carefully screened for bogus referrals.
32. Install cameras with audio recording.
33. Create 3 more forensics facilities for the north, south and specialty populations located in the center.
34. Make the facilities more aesthetically appealing. Tear down APH and rebuild it. Same with TPH. They are too antiquated to be effective.  Get rid of the prison fences. Change the door locks to a swipe card system. Get rid of the mismatched and chipped paint and cinder block walls. Carpets would be nicer than tile floor. Eliminate the ugly green floors at APH.
35. Get rid of people that don't need to be there as soon as it is realized that the admission was bogus.  Don't just change their status to CEPP.
36. Let people wear their own clothes. It takes away self esteem making people wear state clothes.
37.Make this optional. If people want to stay in short term, allow it. Sometimes, this level of care does not work well.
38. Encourage social workers to recant referrals that are not yet scheduled for admission, on a continuing basis.
39. There should be a record kept at Centralized of who is not appropriate for a State Hospital and reject those referrals. An official DO NOT ADMIT list should be created.
40. Create CEPP wards, to facilitate the timely discharge of those patients. Also, have more social work staff assigned to those areas.
41. There needs to be more private long term beds, like that at Northbrook. Some people prefer to be in a private hospital than a State Hospital.
42. Consumers in a State Hospital are not state property. Stop thinking of people as property. Stop referring to patients as state property. It is very dehumanizing and fosters a culture of abuse and neglect.
43. No one should be going to a State Hospital from screening. There are too many referrals being accepted from Crisis Centers by Centralized.
44. Individual bedrooms would be nice. It would be safer. Then, we can use the bedrooms as seclusion rooms like Ann Klein’s practice..
45. Stop using violence against patients to control them.
46. Involve consumers in their own treatment. Collaborative Problem Solving is a good model to follow for resolving behavior problems.
47. Certain Human Services Assistants and Human Services Technicians need to eliminated. The big statewide superiors in the Office of State Hospital Management should just do a full fire and rehire shake up in all the facilities. Other direct care, administrative, clinical, and social work staff also need to disappear, too.
48. The Human Services Police need more training in the disorders they are dealing with and a lot of departmental policies need to be changed to suit the population. When the Human Service Police pick up an escaped civilly committed (no criminal charges) patient that is not resisting, there is no need for the cuffs and shackles. Also, the police need to be more understanding in situations on the wards during fights. When the police does transports to Forensics, only officers with de-escalation training should be assigned. If the person is not resisting for any transport, there is no need for the cuffs and shackles, unless they are under arrest and going to jail.  The police should be contacted if a patient wants to press charges on another patient or staff at the time it is requested, rather than waiting for the team.

STCF
DHS

1. There are secret DO NOT ADMIT lists being created by psychiatrists. Eliminate rejections from STCF.  These lists contain names of people not to be admitted. The fact that psychiatrists hide the lists indicate that they know it is wrong.
2. The elderly and DDMI patients should be in a specialized unit or medical psychiatric unit, not a traditional STCF.
3. There needs to be more STCF beds. There should not be people in crisis for days.
4. STCF social workers like to threaten patients with Centralized Admissions and long term care. Think of it as a treatment measure, not a consequence.
5. When people are transferred to STCF as an 18 year old experiencing the first adult hospital unit, they are not told or made aware of the differences between an adult unit and a children's unit.

Olmstead Initiatives
DHS

1. Census reduction in New Jersey is a joke. They're just releasing people to improve statistics.  People need to learn coping skills in order for census reduction to be successful.
2. Work toward minimizing the institution  population by downsizing to state run group homes that are equally as equipped to deal with stuff.
3.The residential situation is deplorable that's why people just sit in state hospitals until they die.

Psychiatric Advance Directives, Durable Power of Attorney, and Guardianship
DHS

1. There needs to be a pro bono attorney to create power of attorneys for those with disabilities.
2. Psychiatric advance directive take too long to register with DMHS.
3. It is very difficult to create an advance directive in a hospital that does not agree with your wishes. In a specific facility, social worker “lose” advance directives because she did not like the patients and the wishes detailed in the document.
4. Search for less restrictive alternatives to guardianship.
5. Add a step between durable power of attorney and guardianship, such as joint decision making.
6. Screener's and social workers should make sure they honor Advance Directives, including facility choices. For example, if an advance directive says not to send someone to a State Hospital and they call Centralized to do so, it should be a violation of the law. If an advance directive says the person does not feel comfortable in a locked screening unit, then screen them in an ER setting.This is also an issue that continues to happen to in New Jersey. Make accommodations for advance directives.
7. Staff should help out with the plan and items described in the directive.
8. Make psychiatric advance directives into federal law, like health care advance directives.
9. Some guardians like to withhold basic needs because they can and for spite.
10. Some guardians abandon their consumer and leave their consumer with no means of living.
11. Some guardians are lazy and people are left in State Hospitals and Developmental Centers because the guardian does not feel like working with case management to find community placement.
12. People are left to die, by their guardian, without access to money to buy food or shelter.
13. There needs to be yearly judicial reviews of guardianships to be sure the consumer needs a guardian and is being treated right by the guardian.
14. There needs to be some way the consumer can make decisions, if the guardian is unavailable.
15. Guardians like to dump their consumers in psychiatric facilities to get them out of the way. Make it harder for guardians to sign their consumer in.
16. Centralized should view advance directives and facility choices before accepting a referral or diverting a referral to a specific facility. It is very clear in some advance directives where someone wants to go or does not want to go. Somehow they are sent places that they officially stated that they did not like.

Adult Residential and Day Programs
DHS

1. Certain RHCF and boarding homes are deplorable. Increase sanitation.
2. There needs to be group homes offering the same level of care as a State Hospital, but in the community. They need to be allowed to chemically and mechanically restrain. This will help get people out of the state hospitals into smaller possibly more specialized homes.
3. When giving community choices, there needs to be discussion of whether it's appropriate or it's just available. There needs to be more choices.
4. Group homes should work toward transition to supervised apartments.
5. There should be emergency placements available.
6. Work opportunities should be more available to the consumer.
7. Some consumers want to go to college. They should be allowed to go and learn or participate in online classes
8. People shouldn't be doing nothing at the day programs.
9. Sexual intercourse should not be allowed at homes or program.
10. Individual and group therapy should be available at the day programs.
11. There should be programs specialized in specific therapies like DBT or CBT.
12. We need more A+ group homes and RHCF.
13. We need to allow DMHAS adults to go outside New Jersey to residential centers like Woods Services, Farren Care Center, etc funded by DMHAS.
14. New Jersey should go back to the practice of admitting some mentally ill people to nursing homes, not just senior citizens.

Catchment areas
DHS and DCF

1. The catchment areas need to be eliminated or made much more flexible to allow for specialization.
2. The catchment areas should go to a regional model then to a specialized model. Then gradually get rid of catchment areas by giving more consumer choice in facility admission and more specialization.

Developmental Centers
DHS

1. Stop closing them. They are needed.
2. Change the minimum age to 18 so that 18-21 year olds are not inappropriately sent to state hospitals. Medical needs and behavioral needs can be more readily addressed in a Developmental center for DDD individuals.
3. Continue to advocate for census reduction and community integration.
5. Developmental Centers are not rehabs. They are meant for medical conditions associated with the disability, not an accident cause.
6. State Hospitals should be able to transfer individuals to Developmental Centers.
7. Developmental Centers should accept individuals with Asperger’s and high functioning disorders. They should not be excluded because of their high IQ. Although it is rare, there are individuals with Asperger's, who probably could benefit in a Developmental Center rather than another alternative placement, especially if they have severe ritualistic behaviors and can not function outside in the community.
8. There should be a means for long term care of developmentally disabled individuals at a Developmental Center, if they need it.

Jail, Prison, Incompetent to Stand Trial, Not Guilty by Reason of Insanity, and Detainers
DHS

1. Stop putting mentally ill people in general population. Create mental health units in jail or send them out on detainer.
2. Create 2 more "Ann Klein"s for prisoners, inmates, forensic patients, and assaultive individuals. Rehabilitation is key.
3. Divert people from jail and prison into treatment services.
4. Create a plea called "Guilty But Mentally Ill" where they serve time in the hospital but are guilty. This would be for those whom could not serve time in a penal environment because of their condition.
5. Gradually transition all mentally ill people from jail and prison into a forensics center. No more mentally ill people in regular prison or jail. There should be prisons and jails for those with mental illness with specially trained corrections officers.
6. Create an Ann Klein Unit for developmentally disabled and autistic inmates and assaultive patients run by DMHS. No more forensic clients at Developmental Centers. Get rid of Class 1 commitments for DDD. Just use the mental health proceedings for DDD clients and admit them to a mental health facility with a developmental component.
7. Do not put mentally ill inmates in solitary confinement without mental health consultation daily. Avoid the placement of mentally ill clients in segregation units. Have correctional officers use other means of discipline, such as taking commissary time away.
8. DMHS should open an Ann Klein Unit for the elderly and medically needy.
9. Detainers are excellent to manage suicidal, manic, or psychotic inmates. Committing them to a hospital would be a better solution than close observation in understaffed jails or prison. They can receive treatment services in a hospital.
10. Detainers should be allowed from prison to Ann Klein.
11. People with serious charges should get a public defender with some understanding of mental illness and Incompetent to Stand Trial and Not Guilty Reason Insanity proceedings and when they are appropriate to use the procedures.
12. People on NGRI should not be committed indefinitely unless they absolutely need it.
13. Ann Klein should take all forensic clientele, not just the “7 Deadly Sins” (Murder, Manslaughter, Criminal Sexual Contact, Sexual Assault, First Degree Robbery, Aggravated Assault, Aggravated Arson). 200 beds will not be enough.

Community Corrections
DHS

1. A parole or probation plan should include a provision of treatment.
2. The officer should not try to have the person go to jail unless such a violation exists that is very criminal in nature. The officer should work with the offender to live without crime and develop coping skills that are not illegal.
3. Specialty parole and probation officers should exist for mentally ill offenders.
4. Jail diversion needs to be offered in more counties.

Comments and De-escalation by Police
DHS

1.Police need better training in verbal de-escalation, such as by an agency such as Crisis Prevention Institute (CPI).
2.They need to stop being deceptive when they take people to screening centers. They need to start being honest about where the officer is taking them. I have been told, “you're just going to talk to someone”, “you're coming right back”, We're just going for a ride”. Especially adults and adolescents who have been through the hospital, know what screening is, and will resist more if people lie to them. People know when people are lying to them, even during a mental health crisis. This usually escalates the crisis where the person resists going to the hospital and needs to be restrained.
3. Guns and tasers are never necessary.
4. Handcuffs, shackles, and other restraints should be avoided in situations where the person is cooperative.
5. I don't know if the police just don't know better or they are trained to be this way, but they are very deceptive when they take people to the screening center. Sometimes, they don't tell you that they are taking you to crisis to be committed and say you are going to talk to someone at the hospital. Most experienced consumers know that the police will say anything they can to make the job easier. I don't know if they know what really happens in crisis centers after they leave or they are just trained to act like this or they are just being lazy. But either way, retraining needs to happen and police need to be prohibited from using this stupidity to get people to cooperate and go to crisis.

Juvenile Detention/ Probation for Children
DCF

1.I have met Children in treatment programs who have been in Juvenile Secure Care, Juvenile Detention, etc. because behavior that manifested as a result of BiPolar Disorder,  PTSD, Schizophrenia, etc. The courts have to implement treatment for mentally ill youth that may also have pending legal charges instead of traditional probation/ detention.
2.Youthful offenders have been taken out of hospitals in handcuffs and escorted to detention. The courts should allow the child to receive the treatment in the hospital and when the child is ready for discharge, law enforcement may then take possession of the child and bring him to detention.
3.There should be separate detention facilities for mentally ill juvenile offenders in the North, Central, South regions of the state that are similar to a hospital, but more secure, like Ann Klein for adults.
4. Youth need transportation from hospitals and programs to court, if they are scheduled to have a hearing.

Partial Care/ Intensive Outpatient Programs (PHP/PC/IOP)
DCF and DHS

1.Partial care and IOP, if used better could prevent residential and psychiatric hospital admissions of younger patients or patients who are recently diagnosed with a mental health concern.
2. A lot of people in the hospitals are admitted because of behaviors that got worse over time. When those behaviors start occurring and the person is referred for services, partial care should be a first option, not the hospital or residential programs.
3.There  needs to be a partial care and IOP program for those with developmental disabilities and mental illness (DD/MI) in the North, Central, Southern regions.
4.There should be a PC  and IOP program for those with legal charges located in the North, Central, and South regions of the state.
4. A medically ill/ mentally ill program should exist in each of the 3 regions.
5. There should be more partial care programs for Substance Abuse and Mental illness similar to that of High Focus.
6. People should not be just sitting around doing nothing.
7. There should be intensive CBT and DBT therapy.

Visiting/Phone
DCF and DHS

1.Visiting/phone should not be a reward.  It should not be a privilege.  It should be a right, as it is for adults. Eliminate any “blackout” periods of any form where parents/guardians are not encouraged to visit.
2.Hospitals in New Jersey have a pervasive issue, with timeliness of visiting.  They reduce the one visiting hour to less amounts of time.  Visiting needs to be on time and be for a minimum of two hours. Eliminate the grace-periods for staff to get visitors onto units. This decreases family time. Early departures are also caused by this. These visiting discrepancies are caused by understaffing and activities of staff. Staff need to learn time management and stop charting during or around visiting. Stop using visiting staff for 1:1’s during or around visiting. Stop scheduling visiting during shift change. This occurs in both the private and state facilities.
3. Staffing needs to be increased during visiting shifts to include one or two people assigned to only opening the door to let people on and off the unit and helping with visitors, such as a family advocate.There should be extra security/front desk personnel at the facility during visiting shifts.
4. Staff are lazy in certain facilities and can not get consumers to the visiting area on time. Staff who have a pattern of this should be eliminated.
5. Visiting needs to be on time. Eliminate "grace periods" for staff convenience. If there is an emergency leading to lateness, staff should have to document it for the State inspection. The State should have the authority to check cameras to see when visitors arrived or show up unannounced during visiting acting as a visitor.

Education
DCF

1. Stop using safety as a reason not to send youth to school.
2. DCF schools have no educational value.  Right now, they are just a hang out.
3. Make sure children go to appropriate schools, even if they are in a program.
4. When children get sent to DCF schools, they are at risk. But now they are sending DDMI children to these schools.  The population mixture is not good.
5. DCF should contract with therapeutic boarding schools, like Grove School, FL Chamberlain School,  Chaddock.
6. The DCF schools at the State Hospitals are deplorable. There is no education going on. Possibly, send the young adults out to appropriate community schools and return to the state hospitals at night.
7. On the CCIS units and intermediate units, there is no education going on.  Bring in more specialized teachers or send the children out to community schools.
8. At the STCF units, there is no education for young adults, so school districts need to address this.

Short Term Hospital for Children
DCF

1.There is no manual of requirements made by DCF for the CCIS's or private hospitals. There should be standards similar to that of group homes and residential child care facilities. This manual should apply to the Intermediate units as well.  RFP contracts are not enough.
2.This is necessary because these places are doing stuff that other places in NJ wouldn't be allowed to do, such as taking away communication with outside persons such as parents,UCM, lawyers, etc for violation of “house rules”.
3.There are only formal inspections by DOH. DOH regulates all hospitals for medical, psychiatric, and physical rehabilitation, so it is not specialized to child mental health. DCF should do inspections on the child mental health programming and address concerns related to clinical decisions. DCF State Reviews are not inspections that break through the smoke and mirrors about patient care.
4. Aesthetically, the CCIS are lacking greatly. They should have a recovery oriented atmosphere, not a 1970's mental health type of atmosphere.
5. Rules of silence should be prohibited.
6. CCIS should be regulated like STCF for adults.
7. CCIS and intermediate patients should not be combined, during the holidays or summer when the census gets too low.
8. Make sure restraint laws are followed.
9. Create specialty units for DDMI youth and drug dependent youth. CCIS should not reject non specialty patients.

Therapy
DCF and DHS

1.CCIS and STCF should be required to provide individual and family therapy, so the patient can resolve the problems that they are embarrassed to talk about in group therapies.
2.Providing individual and family therapy will help reduce long term care and residential admissions.
3.This should also uncover the reason for admission and coping skills.
4. Art therapy should be more often and provided on an individual basis.
Same for music therapy.
5. Poetry therapy should be mixed into the creative arts therapy category. Poetry is a big coping skill for people.
6. Recreational therapy should be more fair and more therapeutic.
7. Therapists should not make excuses to not do therapy, when they should.
8. Residential should get ropes courses.
9. Therapists should do a mixture of open discussion and curriculum based groups.
10. Therapists should not be doing therapies that they do not know how to do. If a client needs a specific therapy that they do not have experience or training in, they should transition them to a different therapist.
11. Therapy should not skirt around issues. They should address what is really bothering the client, not necessarily what's written in a treatment plan.
12. Therapy should not be confrontational. Ban all confrontation therapies.
13. Therapists should use active listening approaches more often.
14. Eliminate "reverse psychology" approaches when people are disclosing thoughts of self harm or aggression.
15. Therapists need to avoid calling 911 unnecessarily.  It undermines a therapeutic and trusting relationship. Find and exhaust other means of safety before using crisis services, such as “no harm contracts”, having a family member stay with them, increasing staff support services, etc.
16. Therapists should receive Psychiatric Advance Directives and Power of Attorneys, so they know the client and his wishes in a crisis.
17. Therapy is not the same as social work. Discharge planning should not be the only focus of therapy.

Restraint, Seclusion, “Holding”, and  “Escorting”
DHS and DCF

Dangerous Restraint Holds.
DHS and DCF

1.Eliminate the use of face down/ prone holds and basket holds. Prone holds and Basket holds are known to restrict breathing when done incorrectly. Unfortunately, a lot of staff who work in facilities and group homes overdo restraint holds and do not do the restraint as trained in their course. Staff tend to modify the holds to suit how they're feeling.
2.Eliminate the use of holds when they get out of hand or last longer than one hour in residential settings and utilize a screening center. If a person needs to be held longer than one hour, they need hospital care.
3.Staff do holds and escorts that they are not trained to do. For example, there are choke holds being used.
4. The whole state and contracted programs should be trained in Satori Approach Managing Aggression(SAMA). No more Handle With Care, CPI, SCM, Mandt, etc. This includes physical and verbal interventions.
5. Kneeling and standing on people is dangerous and illegal. It is happening in more than one place.

Escorting
DCF and DHS

1.A lot of training programs do not teach staff to carry people. Staff carries people to locations like the Quiet Room, across the hall to another unit, the car,etc. This is dangerous.
2.Staff in hospitals have strapped a child into a wheelchair with restraints and moved them. A wheelchair is not a restraint chair and it can be dangerous to do that.
3. Trying to push someone in a wheelchair and hold them in the chair is dangerous. People are pushed from a Crisis Center to a STCF while being physically restrained in the chair and it hurt. It happens in the State Hospitals a lot because staff does not feel like pushing the heavy restraint chair that is not on wheels.
4. Teach staff to escort correctly and consequence staff that uses dangerous practices to move uncooperative patients. Also, perhaps, buying devices like transport coats, restraint chairs on wheels, restraint boards, etc. would be a good idea to replace incorrect physical escorts.

Spit Guards and Helmets
DCF and DHS

1. Stop putting things like towels over people's faces to stop spit. Use an actual spit guard.
2. Stop using helmets. Use restraints. People can still get hurt with helmets. People can still get brain damage with a helmet from head banging, because their brain is still making impact with their skull.

5 Point Restraint
DCF and DHS

1. Five points is never appropriate. It is dangerous for breathing to restrain someone in more than four points. 5 point restraint refers to restraining all of the limbs and putting a strap across their chest to prevent them from sitting up.
2. I heard it happens for transport, which is so dangerous in a crash situation.

Restraint Reduction
DCF and DHS

1.Staff like to restrain when they get angry with a patient/ resident. This use of restraint is inappropriate and needs to be banned.
2.Restraint is not used only when there is an imminent danger. Restraint is used as regular behavior management such as a behavior modification technique known as a planned restraint.
3.Eliminate holds when they last longer than 1 hour and either use a screening center (residential) or mechanical restraints (hospital). Some staff think restraint is the only intervention that works. Staff does not use verbal de-escalation well although they are trained in in it.
4.Use more verbal de-escalation. Verbal intervention should be according to SAMA's assisting process only.

Mechanical Restraint
DCF and DHS

1. They should be allowed in higher levels of residential care.
2. People have suffered trauma and pain in restraints.
3. People are not always monitored.
4. Eliminate the leather restraints from the New Jersey continuum of care.  They are very old fashioned and reminiscent of older times in mental health history. Replace them with newer Velcro restraints.
5. Restraint needs to be monitored more by the state.
6. Some people have gotten hurt by fighting restraints. Make sure they are medically cleared by an outside emergency physician after each restraint.
7. Limit restraint to 24 hours. After that, switch to a hold, chemical restraint, or seclusion.

Seclusion
DCF and DHS

1.Don't use seclusion for self injury
2.Staff does not monitor people  in seclusion at some facilities.
3.In certain facilities, seclusion is not documented and used as punishment.
4. Create seclusion rooms in the State Hospitals or put locks on the bedroom doors, like at Ann Klein supposedly has.
5. Allow it in IRTS and out of state placements for children.
6. Seclusion rooms are not solitary confinement cells. Stop using seclusion as punishment.
7. There are several mutations of seclusion that do not seem to be recognized in New Jersey as it is elsewhere. Locking someone in their room where they can not leave is seclusion, even though it is not in a seclusion room. Also, threatening a patient where they believe they can not leave an isolated area is seclusion by definition.

Chemical Restraint
DCF and DHS

1.A lot of times, people are feeling normal emotions are given excessive PRN's. A lot of times they are hyper, but not aggressive and nurses medicate them to create staff convenience. A lot of times the drugs of choice are powerful like Haldol, Thorazine, Ativan, Zyprexa,Geodon, and other high potency medications.
2.  This is done for power and control.
3. Allow voluntary use of PRN in all residential placements for children and adults.
4. For IRTS and out of state placements allow emergency injections when a hold or seclusion is out of hand to help the child calm down or for adults in certain closely regulated RHCF and group homes with an emergency intervention license.
5. Stop over medication to shut patients up.

“Strip Seclusion and Restraint”
DCF and DHS

1.This describes the practice of seclusion and restraint without clothes. This needs to be eliminated as it is re-traumatizing to those with sexual abuse histories. This also puts people at risk for abuse when staff of the opposite gender are on the unit.
2.If there is a suicide risk, utilize a paper gown or suicide smock.

Time and Restraint
DCF and DHS

1.People are restrained for way longer than permitted and way longer than they need restraint.
2.Nurses have too much control over this.
3. If a nurse does not like the patient, they will be restrained excessively.
4. Patients have been restrained for days, which is much longer than permitted by law and needed.

Excuses
DHS and DCF

1. There is a serious problem with professionals making excuses for inappropriate behavior or other situations on the milieu that are negative. Excuses such as "it happens everywhere" or lack of staffing or "it's a State Hospital" or "its like this, so you don't want to come back" or "we are not a Hilton" shifts the focus from the problem to other issues that are not the topic of discussion.
2. Staff, administration, and clinicians need to take responsibility for the problems in our system in order for it to change.
3. Therapists should not be making excuses not to do therapy with consumers, especially in long term hospitals and residential placements.

The Out of Home Treatment Waiting List
DCF

1.Because there is more awareness of mental illness, more People are referred to services. Our system needs to meet this growing need for services, including out of home services.
2.Stop removing People from out of home settings. Stop closing and consolidating services.
3.Have more beds instead of housing these People in hospitals and IRTS programs. Most of the People on the intermediate units  are waiting for placement.
4.The waiting list is growing exponentially each month.
5. Eliminate the red- tape to referral making, maintaining services, etc. Make the Strengths and Needs assessments less often for the clients on UCM services.Providing better treatment services will help reduce the youth in the “revolving door”.

Deception and Honesty
DHS and DCF

1. There are a lot of lies being told to consumers, especially new consumers.
2. For example, when the police go to people's houses, they say, " we're just going for a ride to talk to someone and you're coming right back." They seem to exclude the idea that they are potentially going to get committed. Stop allowing police to do this.
3. When people are taken to Forensics from the State Hospitals, the Human Services Police tell them that "they are going for a ride" and should just say they're going to Forensics.
4. Hospitals tell adolescents and adults that they will be there for only 7 days. People been in places for over two months and then transferred to long term care.
5. There are bold face lies being told about different facilities. The children's intermediate care facilities have a terrible reputation. One deserves it. The other has a reputation of horror because of rumor.
6. Stop trumping up referrals. Referrals are being made to weed out hard to treat consumers. Interviewing people may help resolve this phenomena.
7. In a patient handbook for a State Hospital; the contents were only what the state wanted people to know. It should be edited for lies.
8. Stop springing discharge or transfer on patients when they least expect it. Warn them of the changes ahead of time. Give them at least 24 hours to process it, regardless of their expected reaction.

Specialization
DCF and DHS

Addiction services.
DHS and DCF

1.Drug addiction is an issue that is treated much differently than most mental health issues.
2.Set up child / adolescent drug medical detoxification and rehabilitation facilities around the state. Also, substance abuse group homes should be available for children.
3.Rehabilitation should be a separate specialty for residential and intermediate care.
4. Also, have additional programs for video gaming, gambling, food, etc.
5. Adults should have commitment procedures for substance abuse treatment.

Medically Ill/ Mentally Ill and Medically Fragile
DHS and DCF

1.Medical condition such as diabetes can have psychiatric symptoms. The programs for these disorders should help the client learn to manage the medical and mental effects of his/ her condition.
2.There should be medical and psychiatric nurses and doctors on staff 24 hours a day.
3.There should be a CCIS and STCF with a lower medical clearance standard for patients recovering from serious suicide attempts or if they have unstable chronic conditions such as seizures, diabetes, etc. so they can be monitored appropriately.
4.Medical long term psychiatric  hospital Units should be available as well.
5.There are only 3 good medical fragility programs for children 2 of which are outside NJ. Bancroft Neurohealth, Pediatric Specialty Care at Point Pleasant, and Woods Service-Mollie Woods.
6. DDD should provide medical services in place for medically fragile adults with mental health needs in community settings
7. Create medical psychiatric units as described in their own section.
8. Create medical rehabilitation and nursing care facilities for medically fragile children.
9. Medically needy adults should be served in the community in group homes and apartments with 24 hour nursing.
10. DCF should provide a regional nurse like DDD.

Eating Disorders
DCF and DHS

1.Eating disorders are treated differently than most mental illnesses.
2.Behavior modification is not appropriate for this population.
3.Treatment should focus on increasing body image/awareness and self-esteem.
4.Treatment should be separate from other populations.
5.Usually, eating disorders require long term residential care with medical supervision.
6.Sometimes a person with an eating disorder should be in a medical/surgical setting as they are so underweight.
7. Eliminate bathroom restrictions. Change it to supervision while using the bathroom for 1 hour after meals or whatever the order states.
8. Create specialized eating disorder programs, such as that run by Rogers Memorial Hospital in Wisconsin.

Developmental Disabilities/ Mental Illness
DCF and DHS

1.This population is truly unique. These People have functional, social, or other limitations that are not behaviorally based. They are neurologically or functionally based because the child needs to communicate something or can't control the behavior or lacks coping skills.
2.The limited number of beds at Trinitas is not enough for hospital level of care. Most DD/MI individuals are hospitalized for aggression, self injury (e.g. head banging, hand biting, etc.), elopement behaviors, medication issues/ noncompliance, pica behaviors, etc. and not as often do you see a DD/MI individual for cutting, suicidal thoughts, etc. Although higher functioning individuals go to the hospital for such reasons, it is usually developmentally based, not behaviorally based. It should not be seen as defiance or a behavior issue, it should be viewed as an opportunity to teach the coping skills necessary to prevent it from happening again.
3.Appropriate treatments for DD/MI individuals are usually Positive Behavior Supports such as an individual behavior plan, a point sheet, psychotherapy, and medications.
4.Making sure programs are appropriate to an individual's needs is a family's priority when looking for placement. DCF SRTU needs to interview the individual, his/her family and provider, before making placement suggestions.
5.Specialized hospital units and residential  care should be available for these individuals.
6.Some facilities outside the state that provide an ideal care model for these individuals are Sheppard and Enoch Pratt Hospital-1H Neuropsychiatry Unit in Towson, MD; Kennedy Krieger Institute-Neurobehavioral Unit in Baltimore, MD; Woods Services in Langhorne, PA; Meridell Achievement Center in Texas; FL Chamberlain School in Massachusetts;The Cumberland Children's Center in Virginia; Genesee Lake School in Wisconsin; etc. The reasons these programs are models is because most of them treat high functioning individuals, offer Positive Behavioral Supports (not just punishes negative behavior), offer sound medication advice, keeps the DD/MI individuals separate from other populations, and ultimately maintains or improves the level of functioning at admission. The programs should accommodate both high and low functioning individuals.
7.Pull contracts from programs that abuse this vulnerable population.
8.Danielle’s Law should be followed in all hospitals, not just the community. Danielle's Law is not followed when it should be. Nurses think they do not need to call 911. Examples include seizures, heart attack symptoms, etc. Some psychiatric hospitals do not even know about Danielle's Law. This is a big problem at the State Hospitals for adults and intermediate units for children.
9.These individuals need a separate environment, not just “beds” in another program meant for general use.
10. DD/MI people can get injured by other clients who do not understand them. Increase staff supervision for protection around them.
11.Staff doesn’t recognize these individuals’ limitations and triggers. This causes behavioral episodes when they are supposed to be supporting their needs. This is a rampant issue across settings.
12.Quality DD/MI services are non-existent in NJ. NJ has the highest Autism rate and this can not go on like this. Also, this system can not be allowed to be so limited in these services.
13. DDMI consumers with Aspergers can not be in low functioning programs that will not expand their horizons.
15. Closing Developmental Centers is not going to help these people. Make them better, don't eliminate them. All that is happening because of the closures is DDMI people are getting diverted into State Hospitals, which is not acceptable. Stop closing places now.
16. People with disabilities are being abused daily in the mental health system because they were wrongly placed in mental health services when it's really developmental in nature.
17. Create its own system for DDMI persons with their own facilities. Or combine adult services DMHS and DDD like DCF did for children.
18. There needs to be DDMI units at places other than Trinitas and State Hospitals. Create one in the north, central, and south regions for both children and adults.
19. Potentially, admitting the DDMI person into a medical psychiatric unit as I discuss in its own section, should be an option if the DDMI units are unavailable or DDMI person requires some more supervision from nursing or requires self care assistance or is vulnerable to other patients as a protective measure.
20. DDD eligibility needs to be more open to Aspergers individuals.
21. Have direct care staff support services similar to CPEP to help care for DDMI individuals in facilities without relying on untrained staff. This should mean than DDMI individuals have a 1:1/2:1 aide or aides to help with daily needs and protection around the clock. This should be done by private developmental disability agencies, like Bancroft or AdvoServ. There should also be the option of behavioral specialists to provide support to DDMI individuals in facilities.
23. Make sure DDMI individuals are protected from staff, other patients, and themselves.
24. Have community alternatives like locked group homes who are authorized to use mechanical restraint and emergency injections for those with extreme behaviors.
25. Allow DDMI individuals to access PACT and ICMS services if they are high functioning and can benefit from mental health services in addition to DDD
26. Medication misuse is a big issue with DDMI people. Have more therapy.
27. Offer therapy other than ABA like trauma and psychotherapy.
28. The hospital including DDMI units are not always the solution. Screening should have access to more varied services for DDMI individuals. There should never be no where to send a person.
29. There needs to be Aspergers programs.
30. Open up some independent living settings.
31. Bancroft Neurohealth Lindens Neurobehavioral Stabilization Program is excellent. Bancroft should open a Unit for adults with similar programming.
32. Trinitas SCCAT should work with Bancroft to bring Positive Behavior Supports to families in crisis.

Trauma Informed Care
DCF and DHS

1.Trauma Informed Care should be more readily available, especially after Hurricane Sandy.
2.These programs for children should have liaison to DCPP in case of unreported or open child abuse/ neglect cases.
3.They should be aware of non-abuse trauma such as from accidents, the hurricane, etc.
4. Trauma affects a lot of people. The issues contained are best treated using trauma focused cognitive behavioral therapy. A lot of other therapies are good, but have not been proven to the success of it.

Elderly
DHS

1. The elderly are dumped in psychiatric facilities instead of nursing homes because families do not feel like paying for a nursing home.
2. The elderly have disorders like dementia and that can lead to behaviors. They need to have behavioral supports training for nursing home staff and for families caring for them at home.
3. In home supports for these people are crucial to avoiding higher levels of care.
4. There needs to be more secure nursing home units in New Jersey for those with a lot of elopement behaviors. This should prevent a lot of psychiatric admissions for elopement behavior and wandering that family or staff can't handle.
5. The elderly need a safe environment away from chronically mentally ill people when they are hospitalized in a psychiatric unit run by the county or state.
6. The elderly should have a specialized units similar to that of the Trinitas DDMI unit, but for the elderly. This should marginalize the number of elderly in units with younger, more chronic patients. Elderly should not be in STCF. There should be a unit in the north, central, and south regions of New Jersey.
7. The elderly need special medical assistance and should be in a medical psychiatric unit.
8. Sometimes, the elderly will require psychiatric care, at that point, it needs to be dealt with in a courteous and cautious manner, where there is a form of dealing with the various issues that come with age. Coping mechanisms and medications that work with younger patients do not work for older adults. For example, individual therapy may be a little difficult or if it not frustrating for someone with dementia-related symptoms. Talking groups often pose difficulty.
9. Elderly should be admitted to the elderly specialized unit or a medical psychiatric unit as they likely need assistance with ambulation and other self care tasks or require significant nursing attention.
10. Create elderly at units at Forensics with officers trained in dementia related symptoms.  Alzheimer's disease and dementia carries combative behaviors that might get someone sent to Forensics. They should open “Difficult to Manage” elderly psychiatric units in the nursing homes and State Hospitals, such as Trenton and Ancora.
11. Recognize age related behavior. Distinguish it from mentally ill behavior.
12. Nursing homes should be trained in verbal and physical intervention.
13. Psychiatric facilities, especially the State Hospitals, are not always appropriate for someone with Alzheimer's or dementia related behaviors.
14. Allow the elderly to be committed to a nursing home secure unit instead of a psychiatric facility. This will hopefully be possible, if they open up “Difficult to Manage” units in nursing homes for long term medical and psychiatric care that would not be available elsewhere.

Intermediate Care
DCF

1.Expand the current the intermediate care system to contain about (3) 40 bed facilities for each region. 12 beds at Bridgeton and 22 beds at Trinitas is not enough capacity
2. Make sure there is not a negative climate at the facilities. Make sure allegations of abuse are attended to by Institutional Abuse Investigation Unit (IAIU) right away.  There is a serious negative climate currently.
3.There should be 6 hours of school/Treatment per day unlike our current system which provides 2 hours a day. Treatment should be given on a pull-out basis similar to a school model. Treatment should be mandatory for the clinicians.
4.The DCF SRTU office or similar office should manage these admissions because there are youth getting admitted without justification. There should be a system similar to youth link for hospital, intermediate, IRTS, and other acute care services to manage admissions.
5.Social workers threaten children with the current intermediate care system. This needs to stop. It increases anxiety in children.  Rumors need to stop about these places.
6.There should be specialized programs/ units for developmentally disabled, forensic, medically ill, drug rehabilitation, general psychiatric. Specialty patients should have access to these facilities from screening centers
7.The medical psychiatric units should be available to those in care.
8.There should be a behavioral analyst, psychiatrist, psychologists, social workers available by phone 24/7 each day. Nurses and direct care workers should attend to the children 24 hours a day including during school.
9.These facilities would be funded by Medicaid like our current system.
10. Make this optional.  Allow patients to stay in short term, if a short term program has been working.
11.There are a lot of patient on patient assaults at these facilities.  There are riots.  There needs to be more staffing.
12.There should be less restrictive units on grounds to supplement our limited number of IRTS and PCH beds.
13. Children should not be forced to wear hospital clothes.
14. There shouldn't be children sitting in front of a television all day.
15. Eliminate room time as it resembles solitary confinement and causes claustrophobia and makes depression worse.
16. Children tell other children war stories about both facilities. Staff participate in this story time activity. Stop this story time.
17. Social workers tell children and families horror stories about all the bad things that will happen after transfer. Stop the horror stories. The reputation of this level of care is very poor. It needs to be recognized and dealt with in order to stop using Bridgeton and Trinitas inappropriately.
18. Stop admitting children who do not need to be admitted.

Misuse of Medication
DHS and DCF

1. Stop using medications to counteract other medication.
2. Stop medicating people as a consequence for unruly behavior.
3. Medication is not to be included in a behavior plan, especially emergency injections. Behavior plans are meant to prevent behavioral crises where that would be necessary.
4. Stop doing increases of medication to shut patients up. If staff are not equipped to deal with a patient, they need to become equipped. Medication is not meant to make people quiet, it is meant to manage symptoms that cannot be managed using therapy.
5. Medication needs to be reasonable, where the patient will take it after they leave the supervised environment.
6. Involuntary medication should be a last resort and again should not be used abusively or because staff is not equipped.
7. Medication is not meant for the purpose of stopping patients from complaining. It should definitely not be given just because there is an inspection and people have the tendency to tell the truth to inspectors. The nature of some medications will make people forget abuse and neglect situations. This is a problem.
8. Medications have side effects and for patients with more complex disorders, to  treat them adequately, some patients may need to be placed in a medical hospital's  medical surgical floor rather than a traditional psychiatric unit or hospital.
9. When high doses are used to treat maladaptive behaviors, mania, or psychosis, the client needs to be medically supervised. When the techniques known as "rapid neuroleptization" or "cross titration" or using Clozaril and other potentially dangerous procedures are done with medications, the service recipient should remain in a medical surgical unit, not a psychiatric facility, regardless of commitment status.
10. Inform consumers or their guardians of the ability to withdraw consent for the medication.

Passes and Brief Visits
DCF and DHS

1. Do not send someone on a pass if they have bad impulses or psychiatric symptoms. You might as well discharge them.  It is just as dangerous.
2. Make sure the consumer has a crisis safety plan.
3. Make sure to ask if they will come back. Don't send them out if they're not coming back so the police don't have to go get them.
4. Make sure they have enough medication.

Creating Medical Psychiatric units
DCF and DHS

1.Creating medical psychiatric units in general hospitals in addition to STCF, voluntary unit, State Hospitals, county hospitals for adults and CCIS and intermediate care units for children will create more beds, provide this type of service separate from other medically Ill patients, and provide a medically safe environment for the stabilization of medical conditions  to take place.
2.The medical psychiatric units would serve patients who need medical care for reasons like medications, diabetes, seizures, developmental disorders, and other injuries and illnesses. This would reduce the reluctance of hospitals to send people out and the ERs reluctance to admit psychiatric patients, eliminate dual admissions to both medical and psychiatric facilities and ultimately reduce the systemic medical neglect of patients who have been admitted to a psychiatric facility. This would eliminate psychiatric hospital staff having to stay with the patient as it would be treated as a transfer. After the stay at the medical psychiatric unit, they would return to the original facility they were admitted to or to a different facility if requested through the patient, the guardian, the court, or the original facility, etc. It would have to be known that the medical units are not a dumping ground for unwanted patients. They need to not have "physically healthy" patients, unless it is a specific arrangement for a vulnerable elderly or DDMI patient who may become unhealthy or injured if placed elsewhere.
3. This would require pediatric, med/surg nurses, psych nurses and doctors collaborate to create something like this, in hospitals with STCF or even within the STCF and separated by locked doors. It is the complete intention that med/psych patients are never mixed with the STCF patients whatsoever.
4. Each county would need a med/psych unit associated with it. Start with 2 in each region.
5. The units would be similar to a medical surgical floor, but has locked doors, restraints, PRN injections, the power to commit, the power to continue involuntary medication regimens, 1:1 precautions, suicide proof infrastructure, etc.
6. There would be a stricter medical clearance protocol for regular units and thus there should never be a situation where medical neglect is occurring in the system.
7. "Fakers" would be sent here to be cleared and returned to where they came from. "Fakers" will no longer be blown off as sometimes they may really have a medical emergency. If someone says they are having a life threatening emergency, then they need to go out, even if the person is obviously faking, because there could be underlying conditions.
8.The treatment of individuals on a long term basis should be allowed in these units, provided there is benefit arising from the individual remaining in the unit after they are stabilized medically. For example, it is a quieter environment, and their self injurious behaviors that got them injured arise from noise, they should be allowed to stay. Or a chronic "faker" stops feigning illness while on the medical unit, it may be more beneficial to keep them at the unit than expending all the time transferring the individual back and forth daily. Or for long term conditions like Parkinson's disease.
9. State Hospital patients should access these units in lieu of providing service in a medical ward or “clinics” there. This also could serve as a diversion point for those patients not appropriate for the State Hospital level.
10. The treatment provided in these units should be geared to be short term, however,  there should be maybe a few beds for each county that are for long term patients for an indefinite time period.
11. There should some means of Medicaid funding for the long term patients. There should also be an option for private insurance or private pay. It is not meant as a state funded unit.
12. It would be located in a medical hospital,  such a Lourdes or Trinitas, which also has a STCF attached to it.
13. There needs to be regulations separate from the STCF regulations and medical surgical floor regulations. It needs to be a cross between the two sets of rules.
14. There should never be a patient on fall risk in a psychiatric unit once these units have opened.
15. There should be an equal amount of group therapy to a STCF, for those who are able to participate.
16. The units would also be an alternative to protect a DDMI or elderly patient from other patients when they are considered vulnerable. This would be an option, if they are placed at an STCF, State Hospital, county hospital, or other mainstream facility or at risk of such a placement.  Then they could stay however long they need to be in a facility and not be transferred anywhere, unless it is determined that either they are able to be treated in a specialized unit and can be discharged from there without returning to a mainstream facility or they become violent and must go to the Forensic Medical Psychiatric Unit.
17. The units would be used when a DDMI or elderly patients can not get into the specialized unit for them, as well.
18. The units exist primarily for those with conditions that impede their ability to exercise their self care skills, ambulate, or require significant attention from nursing staff.
19. Staffing would be a 1:2 staff to consumer ratio. Nursing would be 1:2 nurse to consumer ratio. There would options for 1:1 and 2:1 staff/nurse to consumer ratio. Plus, a charge nurse and a med nurse. There would always be at least one employee assigned to each patient either nurse or staff. Usually they would generally stay with the patient, except for certain things. The patients with more medical needs would receive a nurse and others would receive a tech. The charge nurse and med nurse is not included in the ratio.
20. Therapists, psychiatrists, social workers, attending physician and house physician, and  specialty consults should be available at the beck and call of the psychiatrist, house physician, or attending physician. PT, OT, speech, and respiratory therapies should be available at reasonable times.
21. Set up medically supervised forensics beds, at Ann Klein Forensic Center, as they do a lot of medication changes that require strict medical supervision and sometimes receive patients with significant medical problems.
22. The point of entry to the units should be Centralized to avoid inappropriate admissions and dumping of unwanted patients. These units are not meant for a mixture of patients that do not fit under any other category.
23. It should be a quiet environment like a medical surgical unit to provide rest for the medically fragile patients.
24. Use medical psychiatric units for medication changes that may have medical or neurological effects, such as Dystonia or Neuroleptic Malignant Syndrome.
25. The medical units for children should resemble the ones for adults.
26. Medical psychiatric units are not "beds" on a general unit. It is a separate environment.

Discipline in the Hospitals for Children
DCF

1.Limit what is known as “room time” or “room program” to not exclude the child from clinical treatment or education.
2.Limit room time to 24 hours, including extensions. Room time is when children are confined to their bedroom for a minimum of 24 hours for minor disciplinary offenses.
3.Ensure that Youth are not claustrophobic or have other clinical contraindications when this type of discipline is implemented.
4.Eliminate the use seclusion and restraint as discipline.
5.Stop using security to scare children into positive behavior.
6. Use positive rewards and point systems. Don't take things away. Let them earn things. Form positive behavior supports that will be continued after discharge.

Institutional Abuse Investigation Unit, Inspections,  DDD Special Response Unit, and Secrecy
DCF and DHS

1.Staff tend to prepare for investigations and inspections by removing/destroying evidence, cleaning, moving dangerous items to safe locations, etc. “Pop-by” inspections are a good way to keep places following regulations. If they do not know when the State is coming, they can not prepare for their arrival.  Do not give any indication as how often inspections are. When it comes to end of review period, they know to expect an inspection.
2.A lot of abuse is construed as behavior management, treatment plans, etc. Abuse is abuse under any disguise.
3.IAIU should have the power to compel a removal or transfer of a person within 3 days, if they are at risk of further abuse. Sometimes, to another program, youth shelter, home, hospital, psychiatric facility, etc.  This needs to happen at the commencement of the investigation.
4.Verbal/Emotional abuse is considered child abuse and is not investigated.
5.IAIU should have the same standard for child abuse as DCPP.
6.Office of Licensing is very unresponsive to obvious violations.
7.A lot of obvious abuse is occurring and is being unfounded by the IAIU. Or SRU. This may result from staff backing each other up, destruction of evidence, etc. A lot of the abuse is emotional abuse and does not have physical evidence other than psychiatric evaluations. The idea that there is minimal evidence does not excuse abuse.
8.There is physical, sexual and verbal abuse that is not taken care of by IAIU or SRU.
9.There needs to be a zero tolerance rule on abuse.
10.Medication is given to have the child forget abuse by staff.
11. There needs to be an agency similar to IAIU for adults with mental health issues not just DDD.
12. SRU needs to respond to family homes, not just group homes in the community.
13. There has been obvious abuse that is swept under the rug at multiple facilities and homes.
14. SRU needs to respond to homes and facilities for people ages 18-21 because IAIU doesn't respond.
15. When the State documents "life and safety" violations, they should visit everyday to maintain some level of safety and order until things are resolved or the place is eliminated from the continuum of care.
16. Patient statements of abuse at the State Hospitals are not dealt with or investigated thoroughly. The State Hospitals are so abusive.
17. IAIU needs to start responding to all DCF homes and programs even for 18-21 year old. And SRU needs to respond to all DHS homes and facilities, even for an 18-21 year old. 18-21 year olds are left in the dark during abuse situations because neither agency will respond to the allegations
18. The state does not know a lot of the ongoings in the programs and facilities.  There is a lot of  “smoke and mirrors” that places put  up during inspection.  They lie, destroy evidence, edit documentation, change behavioral plans, etc before an inspection. Undercover inspectors may work where an inspectors dressing as normal people goes into the program for a week and reveals themselves at the end and the findings. It would have to remain completely unannounced.
19. The public does not know about mental health enough.  The state should post all approved programs and units and investigation findings online.
20. A lot of places will not tell families that they had a bad inspection, substantiated investigation or other actions against the facility or their staff.
21.There should be an office handling complaints about programs/hospitals that are not abuse or licensing allegations, but a need of for review of a clinical decision especially involving treatment, fairness, medications, discharges/transfers, ejections, behavior management, use of restraints, etc.
22. There should be an online database for the public to see program licensing, investigations, inspection reports, etc.

Closing Bad Places
DCF and DHS

1.There are some places in New Jersey that should be closed due to the chronicity of abuse allegations and ineffective treatment.
2.These programs generally are overly strict or lack structure all together.
3. The facilities should be given reasonable chance to change, with daily state monitoring. If after some time, it does not change, eliminate them from the continuum of care.
4. There needs to be stricter regulations about shutting bad places down and the current regulations need to be enforced.
5. Work toward census reduction and the eventual closure of most of the State Hospitals and Developmental Centers.
6. The high ups in DCF and DHS should sweep through the state with inspections and determine which places should be closed and which should stay open. After that, they should compel changes. If changes are not satisfactorily made, close the place down.

Aesthetics
DCF and DHS

1.The poor aesthetics in facilities needs to stop. They look very reminiscent of older times in mental health treatment.
2.There is a screening center that makes people to keep the lights on while sleeping because their surveillance cameras don't work in the dark. This is does not help people sleep. This is overstimulating. When people have autism, bipolar, or other mental health issues, they can not sleep or function in this environment. This cause crises to escalate.
3.Facilities need to be redone and made more comfortable to be in. They need to stop using the excuse, "it looks terrible, so you don't want to come back".
4. The beds are uncomfortable.
5. They need better food.
6. The group homes are so small and old. Too small for 5 people and staff.
7.The institutional decor is unacceptable in modern treatment. It needs to change.
8. Aesthetics go a long way with changing attitudes toward the program by staff and consumers.
9. Clean up the facilities. They should not be so dirty.  There are dust balls the size of a golf ball in a screening center.

Inappropriate Admissions
DHS and DCF

1.First off, there are a lot of bogus referrals that get accepted. Facilities need to stop accepting referrals that do not meet their criteria. Social Workers need to be educated on criterias for each level of care. Receiving social Workers need to stop buying into referrals that are not justified.
2.Social Workers and other staff tend to tell horror stories about the place they are sending the consumer.  This scares the consumer and happens in more than one location.
3.Sometimes, they don't give information to service recipients as soon as it happens or is known. They pretend that they don't know or shift the focus of the situation by saying things like "I know how to do my job."  They do in fact know a lot of information and this has been tested as true. This happens in residential and hospitals and is very rampant.
4.No Reject/No Eject protocols creates inappropriate admissions because facilities/programs can not reject a client. This protocol needs to be eliminated. Facilities can not care for highly aggressive People, DDMI People, etc. However,they are forced to by the State.
5.There is rumor that certain programs/facilities provide kickbacks for admissions.  If this is true, it needs to be banned.  If it is false, the rumors have to stop.
6. Referrals need to stop being made for retribution.
7. Avoid transferring someone who does not want to be transferred. The courts need to weigh in on this.

Out of State Placements
DCF

1.Allow out of State placements funded by New Jersey for specialty populations.
2. New Jersey CCIS have a profound issue with out of state transfers to another CCIS – equivalent that is specialized to someone’s needs.  They have strong objections and will do anything in their power to impede it.  That can include sabotaging insurance funding for anywhere else and involuntary commitment.
3.Some families want their child in a specialized residential out of state facility.  The State, the hospitals, Perform Care, group homes, UCMs tend to balk at this idea.  It needs to be condoned until New Jersey has more specialized care.
4. Adding out of state placements for high functioning individuals, like therapeutic boarding schools.
5. Eliminate Billy's Law list.  Send children to reasonable placements around the country.

Harmful and Ineffective Treatment Approaches
DCF and DHS

1.There are programs that utilize “tough love” approaches involving restricting family contact, threatening children, getting physical with children in non-dangerous situations, prohibit talking with peers, and ignoring children.
2.These techniques do not effectively modify behavior for most people.
3.Sometimes, it leads to staff burnout and high staff turnover rates.
4.Eliminate the practice of recommending that family do not visit/call, threatening people with consequences, rules of silence where people are not allowed to talk with other people, etc.
5. Ignoring is a big problem. Serious bans need to occur in our State for this.
6. Stop threatening people with transfers or ejections.

Applied Behavioral Analysis
DHS and DCF

1. There should never be situations where children and adults are treated poorly under the guise of ABA. B.F. Skinner never intended ABA become an excuse for abuse and neglect.
2. "Aversives" need to be eliminated from the NJ continuum of care.
3. Facilities and homes should be prohibited from using behavior interventions to coerce a client to say or not say certain things during inspections. The state inspection is not a reward or consequence contingency.
4. The state should view all behavior plans not just the current plan because they get changed prior to the inspection.
5. Limit edible reinforcements to healthy food choices.
6. Forensics is not a behavior intervention. It was not built for that. It was built to protect other patients from highly aggressive patients. It is not a “consequence” of people’s behavior.
7. Commitment is not a good "consequence". Commitment is a safety measure, not a mode of behavior therapy.
8. There are unwritten behavior plans. Inspectors need to be aware of this and watch for patterns that indicate this.
9. Ban planned ignoring.
10. Point sheets and level systems need to be used more often.
11. There should be hospital wide positive behavior supports at the state hospitals and long term facilities for adults, like a reward store or some sort of token economy, in addition to the Levels of Supervision system.
12. There should be more individualized supports for children.
13. Behavior Support Technicians are not behaviorists. The state needs to hire real behavior specialists. These technicians are quasi- behaviorists. They do not know how to create a functional analysis to guide appropriate intervention.
14. All DDMI individuals do not benefit from ABA. Offer other therapies.
15. DCF should contract with the Kennedy Krieger Institute Neurobehavioral Unit in Maryland for intensive evaluation and behavioral modification.

Support Services
DCF or DHS.

1. Bring back CPEP for children and adults. However staff should only do CPEP, not multiple jobs within an agency.
2. Model it after Woods Services START program where there is intensive behavior support, not just activities and babysitting.
3. A lot of staff came in said "what do you want to do?"  That is respite, not behavior support.

Respite and Summer Camp
DCF

1. There needs to be at least 2 summer camps that take youth with behavior problems of a serious nature. They should be allowed to give voluntary PRNs and physically restrain up to 30 minutes with parental consent. Their families need a break, too.
2. There needs to be more regulations for camps and respite under contract with the department because of the special children they serve.
3. They need to have a wide variety of functional activities, not just lower functioning activities, like beading.
4. Inclusive camps should offer a peer buddy, not always a 1:1 counselor, or both. This will enhance the experience because the individual has a friend, not just an adult.
5. DCF needs to fund camps outside of New Jersey.
6. DCF should have more camps similar to the nature of Elks Camp Moore in Haskell,NJ. DCF should go visit it over the summer to get an idea of what it's like to have fun there and the structure of the program.
7. Summer camps need a minimum of a 1:2 ratio up to 2:1 for extreme situations.
8. Eliminate respite admissions to Developmental Centers. We are trying to reduce the census and reliance on institutions.
8. Create respite for DMHS to attempt to divert hospital admissions.  Some families bring their consumer to crisis and make them get committed, so they can go on vacation for the week.
9. Camps need to separate adult and child cabins and activity groups. If possible, eliminate combinations of adults and children in the same program areas.

Creating One Big Statewide Camp
DHS and DCF

1. DCF and DHS should create one big year round camp run by a private agency that has experience in recreational and residential services to supplement our limited respite beds and emergency capacity beds.
2. The camp should replace developmental center respite admissions. It should have an equal level of services as a developmental center.
3. They should accept those with significant medical and behavioral issues. Staff should be trained in the use of medical equipment and appropriate crisis intervention techniques.
4. The camp is not meant as another institution.
5. CEPP patients can go to the camp after a placement has been found and they are waiting for a bed.
6. Emergency capacity campers and respite campers should be separated as emergency capacity campers will likely be there much longer.
7. The counselor to camper ratio should be 1:2;1:1;2:1.  There should be a 1:4 nursing ratio.
8. Possibly, converting New Lisbon Developmental Center into the camp would be a fine idea.
9. Activities should be arts and crafts, swimming, leisure and recreation, music, drama, etc and other day program type activities.
10. There should be a day camp associated for caregivers unable to provide care during the day for respite purposes.
11. Easter Seals or Eden Family of Services is a good provider agency for the camp.
12. The state should not run the camp as it is a camp, not a facility.
13. Cabins should be based on age and level of functioning
14. Cabins should have no more than 8 campers.
15. Fairness is a must at the camp.
16. The camp must be closely regulated by the state to ensure the safety of the campers.
17. There should be 200 beds for children, 200 beds for adults, 50 day camp spots for adults, 50 day camp spots for children.
18. Campers should be allowed to call home, email, and letter write.
19. This should help keep people in the community by providing a break for caregivers.
20. The camp should take the campers on outings to the community.
21. The program should be set up similar to Elks Camp Moore.

Aging Out Youth
DCF and DHS

1.When an adolescent reaches the age of 18, they go to adult mental health units, but still receive community and residential services from the the children's system of care. There is a gap in aftercare service planning because of the inter-agency coordination. This is especially true with discharges out of the State Hospitals to residential.
2.When youth reaches age 17.5, they can not get into many programs. They mostly get an independent living level of care. A lot of youth with more severe impairments or those with developmental disabilities need more supervision than those settings provide.
3.Add an IRTS for ages 17.5 – 21.
4.Either allow developmentally disabled youth to access other more supervised environments or create a DD/MI independent living setting with more support in living skills.
5.Reduce the overlap between DMHS services and CSOC services.
6. Set up young adult community services like ICMS and PACT.
7. Open up some young adult RTCs.
8. We need aging in programs run by agencies other than YCS.
9. Young adults should be able to get into supervised apartments.
10. When an 18 year old goes to STCF, they are not told that it will be different at screening. Please have screeners tell new adults that were consumers as youth what's happening. For example, adult units do not do "points and levels".
11. Add young adult programs, homes, and units for 18-30 year olds.

Precautions, Close Observation, 1:1, Line of Sight, and Escape Precautions
DCF and DHS

1.People are not supervised according to their needs. For example, a patient on 1:1 arms length-- sometimes, the staff is 10 feet away or not even in the room. When People require safety precautions, they need to be adhered to according to their needs.
2.Elopement precautions are sometimes inappropriately used. If a patient is being a little unruly, they will be put the on elopement precautions, even if they are not a run risk. This is used to discipline patients because they enjoy going outside and this is the way they get around policies surrounding outdoor access.
3. Make sure 1:1 staff are of the same gender as the person as a lot of times they are watched in bathroom/sleeping/showering.
4.Sometimes, precautions are used unnecessarily or not used when they should be.
5. Checks are not completed when they should be which is generally every 15 minutes. They document on the sheet that they check, but they do not physically get up and check. This could be easily caught by viewing cameras.
6. Line of sight precautions are not adhered to at all. It's too vague for staff to know how close to the patient they need to be. Eliminating line of sight may be an option if no one can deal with it safely. It definitely should be defined clearly that the staff need to be in visual range of the patient, preferably within a distance that allows for immediate interventions like 10 feet.
7. 2:1 precautions are excellent for highly aggressive or self abusive patients and those with medical fragility like lifting out of wheelchairs.
8. Create medical precautions where a patient can receive 1:1 or 2:1 supervision with a tech and/ or nurse. This would increase medical capabilities and reduce medical transfers. Make sure they are medically cleared first in the emergency room or by an outside physician.
9. Add protective custody precautions.
10. Elopement precautions need to be dealt with differently. Restricting outdoor access is not okay.

Outdoor Access and Fresh Air Breaks
DCF and DHS

1.Ensure that all people in hospitals and IRTS programs get access to the outdoors daily.
2.If there is an elopement risk, use a fenced area or assign a 1:1 staff to stay within arms length of the person at risk for elopement.
3. There needs to a minimum of 2 fresh air breaks for 30 minutes for adults and two 1 hour breaks for children.
4. State Hospitals for adults and intermediate units for youth need much more outdoor access for all patients.
5. There must be more outdoor time than there currently is at all facilities.
6. Fresh air breaks must occur at the long term facilities for all consumers.
7. Outdoor time should not be based on temperature. However, if a consumer can not medically handle the heat or cold, it should be for shorter durations.
8. There is a staff at a children's facility saying there is a Professional Thermometer Temperature Taker employed only to take temperatures. This extra employee is a waste of resources and the position should be reconfigured to a tech doing it.
9. The regulations should allow children to build snowmen and stomp in puddles and do other kid activities that are currently prohibited by the state.
10. Eliminate hospital wide Cold and Hot Weather Precautions at the State Hospitals. It should be individualized. If a patient is going to go out and stand in the cold for two hours, they should not be allowed out without an escort. It should not be an all for one and one for all type of thing.
11. There are not enough staff to take people out.

Exercise
DCF

1.Exercise should be geared toward the group's overall physical fitness, not perfection of an exercise regimen.
2.Staff need to recognize those with varying physical abilities because of medication reactions, developmental disabilities causing motor skills deficits, psychomotor agitation or retardation, etc.

Fairness
DCF and DHS

1.Ban the “everyone's a winner” attitude. This leads to unfairness during games. This also doesn't teach the coping skills to deal with losing a game.
2.The refereeing in games is unfair because the referees are likely to be playing in the game or have “favorites”. Sometimes, there is just not enough staff to monitor the games appropriately.
3.This happens in almost every facility caring for more than 8 children or adults. This is pervasive and it indicates the inability for staff to be sportsmanlike referees. This also happens during seated games like BINGO.
4. The lack of staffing needs to be recognized for there to be fair games.
5. Unfairness needs to be dealt with and recognized both by the agency or facility and by the state.
6. I totally recognize fairness is an issue everywhere in schools, workplaces, etc. It's just like bullying is everywhere. But, unfairness should not be existing as a result of staff in a treatment setting. A person who is recovering should not be subject to this. Recovery can not happen, even in the nicest of places, if unfairness is occurring.
7. Provide handbooks of DCF and DHS approved games and rules for those games and provide training in implementing those fairly.  Have assigned referees for homes and facilities with children and adults. A recreation therapist could be the referee or a lead staff.
8. Games are not behavior modification. You can't win if you did not do group, is not okay. Separate the ideas of games and behavior modification.
9. Homes and facilities should train staff in the proper implementation of games in a fair manner. DCF and DHS needs to come in and do the trainings. All recreation therapists must be trained in refereeing. If need be for large facilities, hiring a DCF or DHS approved agency to implement the games for big events like Olympiads, “Juneteenth”, parties, or Spirit Weeks, where the referees are trained in the DCF and DHS approved games. The referees should never be playing in the game.
10. There should be a way to obtain review on allegations of unfairness by administration and the state.

Group Games Team Division
DCF and DHS

1.There are extreme biases when staff choose teams such as having the higher ability against the lower ability. This demeans those with lower abilities which are a lot of times out of the person’s control.
2.Other biases include diagnosis, gender, commitment status, severity of illness, or other irrelevant criterion for the purpose of the game.
3. There is uneven teams by number of players. Teams need to be even. Therapists should never pull a client out of a game once it has started. Never allow an uneven amount of clients to be participating in group games, until discharge or admission to the program.
4. When there is staff playing, it imbalances the ability level, is biased, and is unfair.
5. Staff vs. Service Recipient tournaments are dangerous and absolutely inappropriate. They must be eliminated immediately. Service recipients can get hurt by staff who are larger and most times stronger than them. Too many times, there has been bad kicks or throws from a staff. It's also unfair to the Service Recipients, if staff members “gang up” on them.
6. To encourage equality, eliminate male vs. female teams.
7. Teams should NEVER be based on treatment issues, especially diagnosis and commitment status. I have seen this ongoing in too many facilities and it should end at once.
8. The nature of team activities has gotten out of control in our system that it may need to be closely monitored at all facilities and homes. The activities may need to be phased out gradually by region. Starting with north Jersey and working south, inspections should occur by the high ups in DCF and DHS, then elimination of team activities in those facilities and homes that can't seem to manage it or have a lot of complaints regarding activities. A lot of times, there may not be complaints, but unfairness is still harmful.
9. Cease exchanging players between teams once the game has started. After commencement, all players should remain on their respective teams.

Staff Actions
DHS and DCF

1. Eliminate staff that is not appropriate for the field they are working in. If staff do not like their jobs, they should not be working at their jobs. It is the responsibility of the superiors to take control of this, if they know about it.
2. Training is very important for all staff.
3. There needs to be enough  staff for there to be good staff.
4. There needs to a warm atmosphere created by staff. It needs to be therapeutic and recovery oriented.
5. Staff should not be saying things like people are "lifers" or discouraging language like that.
6. Staff needs to be allowed to be creative in helping patients. Staff has allowed people to listen to music on their phone and it helped them feel better. Creativity helps patients.
7. Staff should not be distracted during work. Eliminate personal texting or phone calls. Catch it on the cameras.
8. Staff should not be sleeping outside the camera view.
9. Cameras should record audio. Staff should not use profanity.  Teach them respectful ways to manage anger.
10. Staff are involved in drama with other staff.
11. Staff bring in home issues and take it out on consumers.
12.  A lot of bad things happen outside the camera view.

Transportation
DCF and DHS

1.Ambulance attendants need training on mental illness. They need to understand different behaviors and thoughts/phobias.
2.A lot of times, parents and children want to ride in the back of the ambulance together. Unless, there is a child welfare issue, that should be allowed. This is especially important for DD/MI youth or young children.
3.  Ambulance attendants with attitude problems should not be doing psychiatric transports.  These attendants cause additional stress with a person already in an acute crisis.
4.Doctors like to transport people in chemical/mechanical restraints.  This is not always necessary when it happens. This should be eliminated as transporting people who are needing to be restrained should be eliminated.
5. There are medical transportation companies that need serious training in mental health consumers and elimination of certain attendants.
6. Allow one or two family members or friends to travel with adults in the back of the ambulance. It may reduce attitude issues because there are witnesses that understand the consumer.
7. Ambulances should refuse to transfer patients who are in the middle of a crisis. If they are exhibiting self injurious or aggressive behavior at the time of transfer, they should refuse to transfer them until they calm down.
10. Ambulances and other transport vehicles need cameras, like they have on school buses to watch and listen to what the attendants are doing or saying to the patient.
11. Allow families to transport consumers to residential settings.
12. Eliminate the Flying Nurses International from the State's repertoire of transport agencies. Go back to having a Human Services Technician doing transports, if there is no family.
13. Human Services Police should not be doing transfers of patients from Screening Center to Facility, unless the patient is currently on a Legal Status. It is not appropriate to have Human Services Police doing transports of Civilly Committed (no criminal charges) patients.

Discharge-Resistant Consumers
DCF and DHS

1.There are people who tend to act out before discharge in order to stay longer.
2.Not telling them when they are leaving is not an effective means of preventing discharge sabotage.
3.Treatment should focus on why they do not do well where they are living.
4.Not telling them when they are leaving, raises anxiety after discharge. They subsequently demonstrate behaviors that will get them back to the hospital. And that is the revolving-door cycle.
5.Sometimes, there are legitimate reasons why a child does not want to go home, such as a lack of structure, abuse, neglect, etc.
6.There are some people who are discharge resistant, but do not care if they leave. However, they continue to return to hospitals over and over. These people need more support at home or appropriate residential placements.
7. Stop keeping people in facilities all their life unnecessarily. This creates the discharge resistance cycle. Stop expecting patients who have lived in a facility for over 1 year to leave successfully.
8. Create cottages at all the State Hospitals like at TPH Transitional Living Unit to help prepare patients for discharge and provide a separate more comfortable environment for CEPP patients.

Personal property mishaps
DHS and DCF

1. In certain facilities and homes, personal items disappear, usually stolen by staff or patients.
2. When consumers leave thing after discharge they should be notified of that occurrence and given the opportunity to pick up the item or have it mailed to them.

Creating One Nice Neurobehavioral Facility
DCF and DHS

1. It would be for high functioning clients ONLY with developmental disabilities or neurological dysfunction and mental illness.
2. It would address medical and neurological issues that contribute to psychiatric concerns.
3. It should be run by Universal Health Services corporation like Meridell Achievement Center.
4. It should mimic the Meridell Neurobehavioral RTC program all together. It should have only a positive atmosphere with positive staff with education in psychology or related backgrounds.
5. There would need to be a structured schedule with a lot of outdoor access.
6. There would a point system going by collaborative problem solving. Other than that there would be no use of ABA.
7. There would be a lot CBT and DBT.
8. DCF and DHS should go Meridell and get their ideas and maybe invite staff to come set one up in New Jersey.
9. It will need to do a lot of neurological medication management, so 24 hour nursing is a must because of seizure side effects.
10. Also, it needs a lot of safety measures such as holds, seclusions, 1:1 staffing, PRN injections, etc.
11. It should serve adults and children who are hard to treat otherwise.
12. It should not be run by the state. That will ruin the nature of the facility and the atmosphere we are trying to obtain by creating it.
13. There should be a variety of levels of care within the facility including locked units, unlocked units, campus based group homes, and community group homes.
14. The length of stay should be 6 months up to long term care.
14. The children should not be mixed with the adults ever.
15. It should be located in natural area, not in a city, such as Mommouth county or the Wharton State Forest.
16. The schedule should be plentiful and varied treatment.  There should not be people sitting around doing nothing all day.
17. It should not have an overly institutional atmosphere. It should not be made in any way similar to a State Hospital.  It should not be put on the grounds of a State Hospital in empty buildings as it will ruin the therapeutic vibe that it should have.
18. Collaborative Problem Solving model developed by Dr. Ross Greene should be used.
19. Direct Care staff should have a Bachelor Degree in a Human Service or Education related area.

Conclusion

Every person is different. Every family is different. This needs to be accommodated better when in out of home treatments and community treatment. This will reduce recidivism. We need more clinical competence with staff, social workers, etc. We need to reduce the mixing of populations to help improve safer environments. Ending inappropriate admissions is one way to do that. We need to ban harmful and ineffective treatment approaches. The stigma needs to stop in the community and within the system. Inspections need to be unannounced. These are among the suggestions of how to help consumers in care.

Mental illness is not scary when you have the right services. The stigma has to stop. Even in the system, there is stigma going on. Ensuring they get the right help early on can help reduce the revolving-door effect that happens when children do not get quality of services they deserve. Trauma endured during childhood carries on into adulthood. The system itself can traumatize people, especially specific facilities in the State.

Change the System. Change the lives affected by it.