Full opinion text
MEMORANDUM OF DECISION AND ORDER ELLEN BREE BURNS, Senior District Judge. This class action challenging the defendants’ administration of Southbury Training School (“STS”), an institution for the mentally disabled in the State of Connecticut, was brought in 1994 by residents of STS and by three advocacy organizations. The plaintiffs, who seek solely injunctive relief, allege constitutional and statutory violations relating to the conditions, services and programs at STS. On January 25, 1999, a 123-day bench trial was commenced before the court. The case is now ready for decision. BACKGROUND On July 8, 1996, pursuant to Federal Rule of Civil Procedure 23(b), the court certified the plaintiff class to include all current STS residents, persons who might be placed at STS in the future, and persons who were transferred from STS but remain under the control of the STS Director. As of the date of the trial in this case, the plaintiff class included approximately 700 residents of STS. The defendants in this case are STS itself, the Director of STS, and the Commissioner of the Connecticut Department of Mental Retardation (“DMR”)- First, the plaintiffs claim that STS and DMR violated the class members’ substantive due process rights by (1) failing to provide adequate shelter, clothing, nutrition, and medical care; (2) failing to provide adequate habilitation and training services to class members such that class members could retain self-care skills and remain free from the unnecessary use of restraints; (3) failing to provide safe conditions to class members and to protect them from bodily harm; and (4) failing to exercise professional judgment in making decisions about whether or not to place class members in the community rather than at STS. (Third Am. Compl. ¶¶ 48-64, 69-75, 83, 86(a)-(I).) Second, the plaintiffs claim that the defendants violated Title II of the Americans with Disabilities Act of 1990 (“ADA” or “Title II”), 42 U.S.C. § 12132 (1997), and Section 504 of the Rehabilitation Act of 1973 (“Section 504”), 29 U.S.C. § 794 (1997), by failing to place class members in community-based residential . settings. The plaintiffs claim that the defendants violated these statutes in two different ways. The plaintiffs first claim that STS and DMR violated the “integration mandates” of the ADA and Section 504 by failing to make sufficient efforts to place class members into integrated settings in the community. {Id. ¶ 87.) The plaintiffs’ second claim under the ADA and Section 504 is that the defendants discriminated on the basis of the severity of class members’ disabilities by failing to consider community placement for certain profoundly and severely retarded STS residents. {Id. ¶¶ 81, 83, 87.) Third, the plaintiffs seek relief pursuant to 42 U.S.C. § 1983 for violations of Title XIX of the Social Security Act (“Title XIX”), codified at 42 U.S.C. § 1396a et seq., which governs the certification that is required by an intermediate care facility for the mentally retarded (“ICF/MR”) in order to receive certain federal funding. The plaintiffs claim that the defendant Commissioner of DMR violated Title XIX by failing to provide some class members with “active treatment” as required by § 42 U.S.C. § 1396d(d), as well as by failing to provide medical and other services consistent with that statute. (Third Am. Compl. ¶ 88.) Many of the instances of inadequate medical care, security and habilitation programming at STS have been the subject of a related case, United States v. Connecticut, No. 3:86-cv-252 (D.Conn.1986), which was, until recently, pending before this court. The United States v. Connecticut litigation was initiated in 1986, when the United States Department of Justice brought suit against the State of Connecticut seeking to remedy allegedly unconstitutional conditions at STS. Later in 1986, a consent decree was negotiated by the parties and was approved by the court. The court approved additional consent decrees in 1990 and 1991. In 1993, attorneys from the Department of Justice, along with a team of experts, investigated conditions at STS and concluded that the defendants had failed to comply with the consent decrees. See United States v. Connecticut, 931 F.Supp. 974, 975-76 (D.Conn.1996). After conducting a hearing, the court found by clear and convincing evidence that defendants had not complied with the terms of the consent decree and held them in contempt. Id. The contempt hearing revealed numerous deficiencies in the conditions at STS and the services and programs provided to its residents. The court found that “STS’s systemic flaws [had] caused many residents to suffer grave harm, and, in several instances, death.” Id. at 983-84. The court found that STS provided inadequate medical care to its residents. Id. at 980. The court found that STS had failed to implement the habilitation programs needed to train residents to avoid injury. Id. at 977-78. The court found that STS administered behavior modifying medication in cases where the institution should have provided habilitation. Id. at 979-80. The court found that physical therapy services as STS were so inadequate as to have caused “several residents who, only a few years earlier, were ambulatory, to be permanently bed-ridden.” Id. at 983. In United States v. Connecticut, as the plaintiffs here were aware, the court appointed a Special Master to review many aspects of care and treatment at STS and to work with the parties in implementing changes to STS’s operations. Id. at 985. Following his appointment in 1997, Special Master David Ferleger and the parties created a comprehensive Remedial Plan that specified certain objectives upon which the parties had agreed. Remedial Plan, U.S. v. Conn. (April 1, 1998). The Remedial Plan set forth 95 Court Requirements (“CR”), thus establishing standards that the institution would be required to meet in order to purge itself of contempt. These Court Requirements covered most areas of STS’s operations including staffing, quality assessment procedures, medical treatment, administration of medication, habilitation programming, and case management. In a process of evaluation lasting almost a decade, the Special Master, with the assistance of experts commissioned by him and the parties, measured improvements at STS against the standards set forth in the Court Requirements. Periodically, when the Special Master concluded that the defendants had demonstrated compliance with a particular Court Requirement, he recommended that the court release STS from oversight for that Court Requirement. Finally, in 2006, after the Special Master found STS to be in compliance with all remaining requirements of the Remedial Plan, the court released STS from judicial oversight and purged the defendants of contempt. See Order Purging Defendants of Contempt and Ending Active Judicial Oversight, U.S. v. Conn., (Mar. 24, 2006). DISCUSSION AND FINDINGS I. The Due Process Requirements for Programs and Services at State-Run Institutions Residents of state-operated institutions for the mentally retarded “have a constitutional right to adequate food, shelter, clothing and medical care.” Society for Good Will to Retarded Children, Inc. v. Cuomo, 737 F.2d 1239, 1243 (2d Cir.1984) (citing Youngberg v. Romeo, 457 U.S. 307, 316, 102 S.Ct. 2452, 73 L.Ed.2d 28 (1982), and Estelle v. Gamble, 429 U.S. 97, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976)). Residents also have a constitutionally protected interest in safe conditions and in freedom from bodily restraint except to the extent that restraint must be used to assure safety. Youngberg, 457 U.S. at 315-16, 323, 102 S.Ct. 2452; see also Society for Good Will, 737 F.2d at 1245. Due process also requires that an institution provide its residents with a minimal level of training, or “habilitation.” Youngberg, 457 U.S. at 324, 102 S.Ct. 2452. These constitutional requirements are satisfied when state actors have exercised “professional judgment” in determining what services and care should be provided to residents of state-run institutions. Youngberg, 457 U.S. at 321-22, 102 S.Ct. 2452. This standard, which is highly deferential to the decisions of the state’s professionals, is intended to strike a balance between the “liberty interest of the individual” and the “legitimate interests of the State, including the fiscal and administrative burdens additional procedures would entail.” Id. at 321, 102 S.Ct. 2452 (citing Parham v. J.R., 442 U.S. 584, 599-600, 99 S.Ct. 2493, 61 L.Ed.2d 101 (1979)). Under this standard, a “decision, if made by a professional, is presumptively valid.” Id. at 323, 102 S.Ct. 2452. Plaintiffs may demonstrate a violation of the requirement that the state exercise professional judgment in at least two ways. Plaintiffs will prevail, for example, when state actors “simply failed to exercise any professional judgment.” See, e.g., Valentine v. Strange, 597 F.Supp. 1316, 1318 (D.C.Va.1984) (declining to dismiss complaint by patient who set fire to herself after hospital officials took no action to confiscate her cigarettes and lighter despite the fact that she had unsuccessfully attempted to burn herself earlier in the day). Deference under Youngberg is not owed to decisions made by individuals who are not qualified professionals. See, e.g., Cameron v. Tomes, 783 F.Supp. 1511, 1520-21 (D.Mass.1992) (finding due process violation where facility’s administrator ignored recommendation of professionals and ordered a patient to be transported in shackles). For the purposes of determining whether such judgment has been exercised, a professional is defined as “a person competent, whether by education, training or experience, to make the particular decision at issue.” Youngberg, 457 U.S. at 323 n. 30, 102 S.Ct. 2452. Plaintiffs may also prevail where a decision made by a qualified professional was “such a substantial departure from accepted professional judgment, practice, or standards as to demonstrate that the person responsible actually did not base the decision on such a judgment.” Id. at 323, 102 S.Ct. 2452; see also Terrance v. Northville Regional Psychiatric Hosp., 286 F.3d 834, 850 (6th Cir.2002). Plaintiffs cannot establish a violation of constitutional norms merely by showing that the state did not “follow[ ] ... the optimal course of treatment.” Society for Good Will, 737 F.2d at 1248. A court cannot find a constitutional violation simply because experts testify that they would have made a different treatment choice. P.C. v. McLaughlin, 913 F.2d 1033, 1043 (2d Cir.1990) (“The requirement that professional judgment be exercised is not an invitation to a court reviewing it to ascertain whether in fact the best course of action was taken.”); Griffith v. Ledbetter, 711 F.Supp. 1108, 1110 (N.D.Ga.1989). Generally, testimony of the plaintiffs’ experts will be relevant to show that the decisions made substantially departed from professional standards. Society for Good Will, 737 F.2d at 1248 (“Expert testimony is ... relevant not because of the expert’s own opinions-which are likely to diverge widely-but because that testimony may shed light on what constitutes minimally acceptable standards across the profession.”); see also Youngberg, 457 at 323 n. 31, 102 S.Ct. 2452. II. Collateral Estoppel In their Post-Trial Brief, the plaintiffs argue that the defendants are collaterally estopped from claiming that the conditions and services at STS satisfy the constitutional requirements established in Youngberg. (Pl.’s Post-Trial Br. at 148.) The plaintiffs argue that the defendants “resolved such issues by entering into a consent decree in United States v. Connecticut” and are therefore barred from relitigating the issues covered in the consent decree. (Id.) “Under the doctrine of offensive collateral estoppel, a plaintiff may preclude a defendant from relitigating an issue the defendant has previously litigated and lost to another plaintiff.” Faulkner v. Nat’l Geographic Enters. Inc., 409 F.3d 26, 37 (2d Cir.2005) (citing Parklane Hosiery Co. v. Shore, 439 U.S. 322, 329, 99 S.Ct. 645, 58 L.Ed.2d 552 (1979)). The defendants will be estopped from rearguing the constitutionality of conditions and services at STS only if all four conditions of the following test are satisfied: (1) the identical issue was raised in a previous proceeding; (2) the issue was actually litigated and decided in the previous proceeding; (3) the party had a full and fair opportunity to litigate the issue; and (4) the resolution of the issue was necessary to support a valid and final judgment on the merits. Boguslavsky v. Kaplan, 159 F.3d 715, 720 (2d Cir.1998) (quotations omitted); see also Faulkner, 409 F.3d at 37 (quoting Gelb v. Royal Globe Ins. Co., 798 F.2d 38, 44 (2d Cir.1986)). The flaw in the plaintiffs’ collateral estoppel argument is that the constitutional claims they raise in this case were not “actually litigated and decided” in United States v. Connecticut. The consent decree was a settlement, not a judgment on the merits. Even insofar as some of the constitutional issues raised by the plaintiffs in this case are identical to some of the claims raised by the Department of Justice in the earlier case, the court did not, in approving the consent decree, decide those issues. “[Settlements ordinarily occasion no issue preclusion (sometimes called collateral estoppel), unless it is clear ... Case 3:94-cv-01706-EBB Document 881 Filed 06/05/2008 Page 11 of 113 that the parties intend their agreement to have such an effect.” Arizona v. California, 530 U.S. 392, 414, 120 S.Ct. 2304, 147 L.Ed.2d 374 (2000). In some instances, a consent judgment “may involve a determination of questions of fact and law by the court.” United States v. Int’l Bldg. Co., 345 U.S. 502, 505-6, 73 S.Ct. 807, 97 L.Ed. 1182 (1953). However, “unless a showing is made that that was the case, the judgment has no greater dignity, so far as collateral estoppel is concerned, than any judgment entered only as a compromise of the parties.” Id.; see also Klingman v. Levinson 831 F.2d 1292, 1296 (7th Cir.1987) (“If the parties to a consent decree ‘indicated clearly the intention that the decree to be entered shall not only terminate the litigation of claims but, also, determine finally certain issues, then their intention should be effectuated.’ ”) (quoting Kaspar Wire Works, Inc. v. Leco Eng’g & Mach., Inc., 575 F.2d 530, 539 (5th Cir.1978)). As the defendants point out, the consent decree in United States v. Connecticut explicitly disclaimed any admission of liability on the part of state officials and stated that the decree was “enforceable only by the parties.” (See Defs.’ Posh-Trial Br. at 27) (quoting Consent Decree, U.S. v. Conn (Dec. 12, 1986).) In entering into the decree, the parties agreed that state officials did “not admit any violation of law” and that the Consent Decree “may not be used as evidence of liability in any other civil proceeding.” Consent Decree at 3, U.S. v. Conn (Dec. 12, 1986). It is therefore obvious that the parties in United States v. Connecticut did not intend the consent decree to act as a determination of questions of law or fact that would preclude future litigation of those issues in other cases involving other parties. In their Reply to the Defendants’ Posh-Trial Brief, the plaintiffs offer an additional collateral estoppel argument. The plaintiffs now argue that the court’s contempt findings in United States v. Connecticut bar the defendants from asserting the constitutionality of the conditions and services at STS. (See Pis.’ Reply at 75-79.) However, in finding contempt in that case, the court was required only to consider whether the defendants had violated the terms of the Consent Decree. The court did not consider whether the defendants had also violated the constitution. The plaintiffs are correct in pointing out that United States v. Connecticut arose out of claims of constitutional violations that are similar to the claims in this case. However, “[u]se of collateral estoppel ‘must be confined to situations where the matter raised in the second suit is identical in all respects with that decided in the first proceeding and where the controlling facts and applicable legal rules remain unchanged.’ ” Faulkner, 409 F.3d at 37 (quoting Comm’r v. Sunnen, 333 U.S. 591, 599-600, 68 S.Ct. 715, 92 L.Ed. 898 (1948)). The United States v. Connecticut Consent Decree set out in considerable detail the obligations of the defendants. The consent decree included, for example, an obligation to ensure specific staff-to-resident ratios. See Consent Decree at 8-9, U.S. v. Conn (Dec. 12, 1986). The terms of the consent decree, therefore, do more than simply restate the defendants’ constitutional obligations. A court could find that the defendants in United States v. Connecticut had violated the terms of the Consent Decree even though they had not violated the constitution. The legal and factual issues determined by the court in its contempt finding are simply not identical to the issues in this case. Therefore, neither the Consent Decree in United States v. Connecticut nor the court’s finding of contempt based on violations of the Consent Decree preclude the defendants from arguing in this case that they have fulfilled their obligations under the Constitution. III. Conditions and Services at STS In their Post-Trial Brief, the plaintiffs organize their claims into four subject areas. They claim that they have demonstrated at trial 1) that the defendants provided inadequate medical care to class members; 2) that the defendants failed to protect class members from physical harm; 3) that the defendants failed to provide the plaintiffs with adequate habilitation and “active treatment”; and 4) that the defendants failed adequately to consider community placement for class members. The relief sought by the plaintiffs as a remedy for the defendants’ alleged violations relating to the first three of these areas is somewhat limited. The plaintiffs ask that deficiencies in the provision of medical care, protection from harm and habilitation programming be referred to the Special Master’s remedial process in United States v. Connecticut. (See Pls.’ PostTrial Br. at 163-65, 167-68, 170-71.) As described above, the Special Master in United States v. Connecticut has already conducted a thorough inquiry into conditions and services at STS and, along with the Department of Justice, has overseen STS’s efforts to remedy deficiencies in these three areas. Much of what the plaintiffs in this case seek from the Special Master’s remedial process has already been achieved. In many instances, there will be no need for the court to determine whether or not the defendants are liable. Insofar as the plaintiffs here have committed themselves to deferring to the Special Master and his remedial process for the resolution of any particular constitutional violation, and the Special Master has directly addressed that issue, the court need not revisit that particular violation. As indicated in the following discussion, the court declines to consider whether the defendants are, in fact, liable for almost all of the alleged violations relating to the provision of medical care, protection of STS residents from harm and provision of adequate habilitation. The court declines to consider whether the defendants are liable under these claims not because the plaintiffs have failed to present sufficient evidence to prove constitutional or statutory violations in these areas but, rather, because these claims are moot since the plaintiffs have achieved everything for which they ask. See Powell v. McCormack, 395 U.S. 486, 495-96, 89 S.Ct. 1944, 23 L.Ed.2d 491 (1969) (noting that a court should find as moot claims in which the relief sought had already been obtained); Martin-Trigona v. Skiff, 702 F.2d 380, 386 (2d Cir.1983) (“The hallmark of a moot case or controversy is that the relief sought can no longer be given or is no longer needed.”); County Motors, Inc. v. General Motors Corp., 278 F.3d 40, 43 (1st Cir.2002); Blanciak v. Allegheny Ludlum Corp., 77 F.3d 690, 698-99 (3d Cir.1996) (“If developments occur during the course of adjudication that eliminate a plaintiffs personal stake in the outcome of a suit or prevent a court from being able to grant the requested relief, the case must be dismissed as moot.”) (citations omitted). A. Medical Care The plaintiffs point to evidence of numerous problems with the medical care that was provided at STS prior to the trial. (Pis.’ Posh-Trial Br. at 3-48; Pis.’ Proposed Findings at 69-194.) The plaintiffs claim to have established at trial that in many cases, the medical conditions of STS residents went completely untreated by STS staff, and that- some residents’ medical conditions worsened as a result of the actions of STS doctors, nurses and physicians assistants. They claim that physicians assistants were not properly supervised and that there was insufficient oversight and review regarding the administration of psychotropic medication. They claim that medical professionals failed to properly take note of abnormal laboratory findings and failed to keep legible medical records. They also claim that STS failed to adhere to proper standards regarding the writing and implementation of “do not resuscitate” orders. To remedy these alleged instances of deficient medical care, the plaintiffs ask the court to order the defendants to provide “adequate medical and nursing care to all class members.” (Pis.’ Post-Trial Br. at 164.) More specifically, the plaintiffs “request that inadequacies in medical care be referred to the remedial mechanism in” United States v. Connecticut for “resolution provided plaintiffs can participate fully in the remedial process.” (Id. at 164-65.) The plaintiffs ask the court to refer the following specific issues to the Special Master: a. The adequacy of nursing services provided to class members. b. The development of a process to remedy cases of inadequate nursing or medical care. c. The development of a system of oversight over physicians assistants such that the use of physicians assistants at STS complies “at the very least” with Conn. Gen.Stat. § 20-12d. d. The development of a system “to ensure that the ultimate oversight of all aspects of medical care rest with the treating physician” and to ensure that “laboratory testing and overall medical condition of the class member will be taken into account when psychotropic medications are administered.” e. The need for a requirement that physicians should participate in the interdisciplinary team (“IDT”) process so that the use of psychotropic medications can be adequately coordinated with other aspects of each class members’ overall plan of service. f. The need for a requirement that class members’ records should contain an explanation of why psychotropic medication was prescribed as well as a “medication reduction plan.” g. The need for systematic review of the use of medications at STS, as well as a plan to reduce the use of medications. h. A requirement that physicians comment on abnormal laboratory findings in a class member’s medical record. i. The establishment of a plan to improve the legibility of class members’ medical records. j. The creation of “memoranda of understanding” with area hospitals addressing, among other issues, the use of DNRs. k. A requirement that STS adhere to DMR 87-2, which is the regulation relating to the writing and implementation of DNRs. l. The implementation of nursing care that is “consistent with the ICF/MR regulations.” m. The need to ensure that nurses and other direct care staff receive adequate training so that they are able to understand the health care needs of class members and are able to implement the class members’ “care plans[s].” Id. at 165-67. I. Medical Care Issues Addressed in United States v. Connecticut The Remedial Plan implemented by the Special Master in United States v. Connecticut addressed medical care at STS at great length. More than 30 of the 95 Court Requirements in the Remedial Plan directly addressed issues of medical care and the administration of medication. In 2006, after a final expert report commissioned by the Special Master showed sufficient improvements in medical care, he reported that STS was in compliance with all of these Court Requirements, and the court released STS from judicial oversight of all outstanding aspects of the Remedial Plan relating to medical services. Order on Medical Services Compliance, U.S. v. Conn. (March 22, 2006); see also Report to the Court No. 63: Medical Services, U.S. v. Conn. (Feb. 22, 2006). During this process, the Special Master addressed most of the plaintiffs’ specific concerns listed above. The Special Master addressed oversight over medical staff, which is the issue raised in the plaintiffs’ specific concerns b. and d. from the above list. The Remedial Plan set standards for medical care, nursing care, and specialist medical care (see CR 60, 61, 63-65), set minimum acceptable staffing levels and ratios of supervisory staff to direct care staff (see CR 13-32), and set standards for communication between care-givers and other staff (see CR 34-40). The Special Master oversaw the implementation of a “Quality Assurance” system designed to monitor the care received by STS residents and to ensure that residents received an adequate level of care from all medical staff. See Consultation and Review of Medical Services: Report to the Special Master, U.S. v. Conn. (Feb. 17, 2006). Because these aspects of the relief sought by the plaintiffs have been realized, the court sees no need to determine liability related to this issue. The court will not address the issue of whether the defendants failed to provide for adequate oversight over medical staff. Similarly, oversight over the administration of behavior modifying medication by physicians assistants, the issue raised in specific concern c. from the above list, was addressed in the Remedial Plan by CR 66, which required “that only personnel authorized by state law shall administer medication.” See Quarterly Report No. 5, U.S. v. Conn. (Dec. 2, 1998) (finding STS in compliance with CR 66). The plaintiffs’ concern about the quality of nursing services at STS, expressed in specific concerns a. and l. in the above list, was addressed by the Remedial Plan in CR 61, which set standards for nursing care. In order to give effect to these Court Requirements, the Special Master and the parties in United States v. Connecticut developed and implemented plans to correct deficiencies in the nursing services. See Report to the Court No. 42: Nursing, U.S. v. Conn. (Aug. 23, 2002). The Remedial Plan also addressed deficiencies in the training of staff at STS, an issue raised by the plaintiffs’ specific concern m. from the list above. See CR 33 (requiring the implementation of a training plan); see also Report to the Court No. 19: Staff Training, U.S. v. Conn. (Mar. 27, 2001) (noting the new kinds of staff training added at STS and recommending release from judicial oversight for CR 33). The administration of behavior-modifying medication at STS, an issue raised by the plaintiffs’ specific concerns d., e., f. and g. from the list above, received considerable attention in United States v. Connecticut. See, e.g., 931 F.Supp. at 979-80 (noting the “[problematic] implications of unqualified (e.g., unlicensed) personnel, in effect, making major decisions regarding pharmacological interventions”) (quoting the report of Dr. Volkmar). The Remedial Plan set forth several Court Requirements intended to remedy deficiencies in the manner in which medication was administered. The Remedial Plan established procedures for approving the use of medication (see CR 53) and procedures requiring physicians to systematically review the need for behavior-modifying medication in individual cases (see CR 54). The Remedial Plan subjected “polypharmacy” to additional scrutiny. See CR 55. The Remedial Plan set standards for evaluation of STS residents who received narcoleptic drugs and required that these individuals be screened for tardive dyskinesia. See CR 56-57. The Remedial Plan required that each resident’s primary care physician, as well as all appropriate medical records, be made available to the Program Review Committee, which is responsible for approving IDT decisions about each resident’s care and medication. See CR 58-59. In accordance with the Remedial Plan, the Special Master devoted considerable effort to correcting deficiencies in the manner in which behavior-modifying medications were administered at STS. See, e.g., Report to the Court No. 28: Compliance Review: Court Requirement 57, EC 3, U.S. v. Conn. (Sept. 11, 2001); Report to the Court No. 33: Court Requirement 54 and 56, U.S. v. Conn. (Jan. 15, 2002). The Special Master thus addressed all of the plaintiffs’ concerns related to the administration of behavior-modifying medication, and the court will not consider liability on this issue. The United States v. Connecticut litigation also addressed STS’ record-keeping procedures. See 931 F.Supp. at 981 (finding that, as of the Contempt hearing, “STS’s recordkeeping procedures [were] ... below professional standards, causing important medical information to be obscured, and jeopardizing its residents’ health”). Several of the Court Requirements in the Remedial Plan specifically addressed record-keeping procedures (see CR 79-85), thus addressing the plaintiffs’ specific concerns h. and i. Prior to STS’s release from judicial oversight for these requirements, the Special Master’s consultant reported that records at STS are now mostly typed, rather than handwritten and that STS has implemented “problem lists” to track individuals’ ongoing medical issues. See Consultation and Review of Medical Services: Report to the Special Master at 24-27, U.S. v. Conn. (Feb. 17, 2006). ii. DNR and DNI Orders The plaintiffs’ specific concerns j. and k. relate to the use of Do Not Resuscitate (“DNR”) orders at STS. Unlike the other items in the above list, Special Master Ferleger did not address this issue in United States v. Connecticut. In asserting their claims that DNR orders were written improperly, the plaintiffs rely on the district court’s opinion in Connecticut Ass’n for Retarded Citizens v. Thorne, Civ. A. No. H78-653, 1993 WL 765698 (D.Conn. Feb.12, 1993), rev’d on other grounds, 30 F.3d 367 (2d. Cir.1994), which held that when a decision to withhold potentially lifesaving treatment from an incompetent patient is made by a guardian appointed by the state, due process requires adherence to procedural safeguards to ensure that “the decision would reflect the wishes of the patient.” The court in Thorne found that implementation of the procedures set forth in DMR directive 87-2 would satisfy due process. Id. at *11. The plaintiffs argue that the defendants in this case have violated due process by failing to implement DMR 87-2. (Pis.’ Post-Trial Br. at 21-29.) A DNR order allows medical professionals to withhold cardiopulmonary resuscitation (“CPR”) from a patient who is undergoing cardiac or respiratory arrest. DMR 87-2 allows a DNR order to be written only with the consent of a patient or, if the patient is not competent, with the consent of a “surrogate,” who may be a guardian, conservator, next of kin, or close relative. (Pis.’ Ex. 509.) DMR and its personnel cannot consent to a DNR order on behalf of STS residents. Rather, DMR’s role is to ensure that any DNR order is “medically acceptable.” (Id.) Under DMR 87-2, after an attending physician has obtained consent, he or she may write a DNR order for a patient who is in a “terminal condition,” a state defined as “the final stage of an incurable or irreversible medical condition which, without the administration of a life support system, will result in death within a relatively short time period, in the opinion of the attending physician.” (Id.) (quoting Conn. Gen.Stat. § 19a-570(ll).) If the patient is expected to die “during the next several days or weeks,” the signature of the attending physician is sufficient to create a valid DNR order. (Id.) When the attending physician cannot make a prediction that the patient will die within this time frame, a DNR may be written for a patient who is nonetheless in the final stage of a terminal condition, but such a DNR order is subject to certain additional procedural safeguards, which include notifying the DMR Commissioner and the Attorney General. (Id.) DMR policy does not impose any additional procedural safeguards for the writing of a “do not intubate” (“DNI”) order, which allows medical professionals to withhold additional forms of treatment designed to assist patients undergoing respiratory arrest. (Tr. 6/30/99 at 206 (McDonald).) A DNI order may be written only for residents who have valid DNR orders. (Id.) 1. Allegations that DNR Orders Were Written for Non-Terminally Ill Class Members The plaintiffs first claim to have established that STS personnel violated the DMR’s procedures by writing DNR orders for class members for whom death was not imminent. In support of this claim, the plaintiffs cite cases in which a DNR order was written for a patient a substantial amount of time before the patient actually died. For example, class member Gloria DeBartholomew had a DNR order in her file for six years before she died (Pis.’ Ex. 801), and Agnes Vernik had a DNR order in her file for two years before she died (Pis.’ Ex. 282). The plaintiffs cannot meet their burden with this kind of evidence. The mere passage of time between the writing of a DNR and the patient’s subsequent death does not establish that the attending physicians signed a DNR at a time when he or she could not have said that the patient was expected to die within days or weeks. Insofar as the plaintiffs have presented expert testimony stating that DNR orders were written for patients who were not in the final stages of a terminal condition, this testimony is no more persuasive. The opinion of expert witness Dr. Robert Ku-gel that class member Eleanor Fuchs had a DNR in her file even though she was not terminally ill is also based merely on the passage of time between the writing of the DNR and her death two years later; this opinion does not seem to be based on an analysis of Ms. Fuchs’ medical condition. (See Tr. 3/22/99 at 132.) Similarly, Dr. Kugel’s testimony that class member Oscar Hansen’s DNR order was written at a time when “it would have seemed to me .that he was not in imminent danger of dying” (Tr. 3/22/99 at 117) is vague and unsupported by reasoning or reference to facts. Furthermore, Mr.‘Hansen’s DNR order was signed in 1992, before the DMR had implemented changes in the protocol for DNR orders following the decision in Thorne. (See Pis.’ Ex. 509.) Furthermore, the plaintiffs have not established that it would be a violation of due process for a state doctor to sign a DNR order for a patient who is in a terminal condition but who is predicted to die within months or years rather than days or weeks. On the contrary, DMR 87-2, a directive of which the plaintiffs seem to approve, explicitly provides for DNRs to be written under such circumstances, as long as certain officials are notified. Nowhere have the plaintiffs argued that failure to take these additional steps transforms an otherwise valid DNR into a due process violation. The court is unwilling to draw this legal conclusion. The court is therefore not persuaded by the plaintiffs’ claim that the defendants violated due process when an STS doctor recommended a DNR order for class member Robert Fus-co, who was in the “end-stage of a progressive and irreversible condition” and was expected to live for “months to years” with a feeding gastronomy tube. (See Pis.’ Ex. 615.) The other cases cited by the plaintiffs as evidence that the defendants wrote DNR orders for non-terminally ill patients are also unhelpful. The plaintiffs’ reference to the case of Sandra Zukowski is odd in this context given that no DNR order was written prior to her death, apparently because her family did not consent. (Pis.’ Ex. 300.) Dr. Kugel’s testimony that an STS attending physician’s decision to recommend a DNR order for Elsie Backus was unjustified (see Tr. 3/22/99 at 134-35) is flatly contradicted by the consultation report of a speciality clinic that recommended a DNR “in view of advanced cancer” (Pis.’ Ex. 291). Dr. Kugel testified that his opinion was based on the facts that Ms. Backus was “in good spirits” and “ambulating” when the DNR order was signed. (Tr. 3/22/99 at 135.) This explanation calls into question Dr. Kugel’s helpfulness to the court as an expert witness. Similarly, Kugel’s testimony that Thomas Jasinski remained under a DNR order even though he ceased be in a terminal state seems to have no basis in fact. (See Tr. 3/22/99 at 125.) There is no evidence that Mr. Jasin-ski ceased to be in a terminal state at any point after the DNR order was signed. The plaintiffs themselves moved into evidence a chart showing that STS staff reviewed the DNR order multiple times in 1996. (Pis.’Ex. 619.) 2. Alleged Improper Use of DNR Orders to Withhold Treatment From Class Members Suffering From Cardiac or Respiratory Arrest Resulting from Accidents The plaintiffs’ second claim relating to DNR orders is that the defendants relied on these orders to justify withholding treatment in situations not covered by the DNR protocol. Under DMR 87-2 medical professionals may withhold CPR pursuant to a DNR order only “after respiration and cardiac function have ceased spontaneously, as a natural progression of the dying process.” (Pis.’ Ex. 509.) However, a DNR order does not allow medical professionals to withhold CPR from an STS resident who “aspirates food or fluid, or has any other accident that may result in death if left unattended.” (Id.) The plaintiffs claim that the defendants have, in violation of DMR 87-2, implemented policies under which CPR is withheld from class members with DNR orders who experience respiratory and cardiac arrest as a result of accidents or other causes that are not the “natural progression of the dying process.” The plaintiffs contend that direct care staff and nurses, who must often make decisions about whether to perform CPR on class members discovered in respiratory distress, are directed by STS policy to withheld CPR from every resident with a DNR bracelet without considering the cause of the resident’s distress. (Pis.’ Post-Trial Br. 23-24.) If proved, the existence of this policy would be problematic since it would mean that there is confusion about what class members and their guardians had actually consented to when they requested DNR orders. It would be improper for STS to obtain consent from a resident to withhold CPR should the resident undergo respiratory distress as a result of the natural progress of his or her terminal condition and then to use this consent to justify withholding lifesaving treatment in other situations. The plaintiffs claim that STS has implemented a rule that requires staff to withhold CPR from any class member wearing a DNR bracelet, regardless of the cause of the cardiac or respiratory distress. However, this claim was contradicted by STS Medical Director Dr. Robert McDonald, who unequivocally denied that there was any such rule and explained that staff are required to perform CPR on every resident who is discovered to have choked on something, even if the resident has a DNR bracelet. (Tr. 6/30/99 at 161-62.) The plaintiffs have not persuaded the court that Dr. McDonald’s statement of STS policy is inaccurate. Kugel, the plaintiffs’ expert, testified somewhat uncertainly that he did not “think” that direct care staff can distinguish between respiratory arrest caused by accidents and respiratory arrest resulting from the patient’s terminal condition. (Tr. 4/5/99 at 46.) He also testified that he did not know whether nurses at STS have the necessary training to make this distinction. {Id. at 47.) Without claiming any direct knowledge, he testified that the policy at STS “seems to say” that direct care staff and nurses at STS are directed not to perform CPR on any resident with a DNR bracelet who is undergoing respiratory or cardiac arrest, regardless of whether the direct care staff involved are able to discern the cause of the emergency. {Id.) Kugel’s inability to be more definite in describing the training of STS staff and the policy they are directed to follow makes it impossible for the court to attach much weight to his opinion. The plaintiffs also cite the testimony of Nicholas Gabriel, the fire chief at STS, who testified at his deposition that staff are instructed to withhold CPR from residents wearing DNR bracelets who are discovered in either cardiopulmonary or respiratory arrest “no matter what the cause.” (Tr. 3/31/99 at 196.) While this testimony supports the plaintiffs’ claims, it is somewhat inconclusive since it was quoted from Gabriel’s deposition and lacks context. It is completely unclear whether Gabriel was considering the possibility that staff would have to make decisions about whether to perform CPR on class members who are undergoing respiratory arrest as a result of, for example, a choking accident. The court therefore finds that Dr. McDonald’s unequivocal statement of STS policy is more convincing. 3. Alleged Practice of Withholding Treatment Other Than CPR On the Basis ofDNR Orders The plaintiffs also claim that the defendants have relied on DNR orders to withhold treatment other than CPR. Because an individual’s consent to a DNR order encompasses only the withholding of CPR, and not the withholding of other kinds of medical treatment (see Pis.’ Ex. 509), the court agrees with the plaintiffs that a policy of withholding treatment other than CPR would indeed violate class members’ due process rights. However, this claim is not supported by the evidence. The plaintiffs rely, in large part, on misconstruing the testimony of Dr. McDonald. For example, McDonald did not, as the plaintiffs claim, testify that a DNR order may be used to justify denying intubation to class members. (See Pis.’ Proposed Findings at 89.) Dr. McDonald denied this claim. (See Tr. 6/30/99 at 198 (“A DNR order and intubation are two different things.”)) The plaintiffs also interpret one portion of McDonald’s testimony to mean that measures other than CPR, including transfer to a hospital, may be withheld on the basis of a DNR order. (See Pis.’ Proposed Findings at 90-91.) As the court understands his testimony, Dr. McDonald simply stated that treating professionals may exercise their professional judgment to withhold treatment that would not benefit a patient who has a DNR order. (Tr. 6/30/99 at 208-9.) Dr. McDonald explained that this is exactly the kind of “weighting of] risks and benefits” that a medical professional must conduct before making any treatment decision about any patient, regardless of the presence of a DNR order. (See Tr. 7/8/99 at 57-58.) There is no evidence to support the plaintiffs’ claims that particular class members died after treatment other than CPR was withheld. The plaintiffs claim that class member Karen Peterson died after nutrition and fluids were withheld on the basis of a DNR order. (Pis.’ Proposed Findings at 95.) However, Ms. Peterson’s mortality review indicates that the decision to withhold fluid and nutrition was made by her guardian and that this decision, not the DNR order, was the basis for the action. (Pis.’ Ex. 273.) The plaintiffs’ evidence regarding the 1993 death of class member Mark Roy is inconclusive. Dr. Kugel stated that the decision to withhold a bronchoscopy was based on a DNR order in Roy’s file. (Pis. Ex. 432G at 15; Tr. 3/22/99 at 114-15.) Kugel did not explain how he knows that the DNR order was the basis for the decision, and the court is unaware of any evidence supporting this claim. Furthermore, it appears that the decision not to perform the bronchoscopy was made by Waterbury Hospital personnel rather than the defendants. (Id.) Similarly, the decision to remove an intubation tube from Janice Doyle prior to her death in 1993 was made by Waterbury Hospital, not STS. (Pis.’ Ex. 267.) The plaintiffs also claim that DNR orders were used to justify “weaning class members from a ventilator.” (See Pis.’ Proposed Findings at 89.) However, the mortality review cited by the plaintiffs in support of this claim does not demonstrate that any such decision was made. (See Pis.’ Ex. 272.) 4. Alleged Failures to Ensure that Community Hospitals Follow DNR Protocol The plaintiffs also claim that the defendants have violated class members’ due process rights by failing to address situations in which area community hospitals have written DNR orders for STS residents without following DMR protocol. (Pis.’ Post-Trial Br. at 26.) Most of the incidents to which the plaintiffs have drawn the Court’s attention occurred in 1994 or shortly before. During this period, DNR and DNI orders were apparently written for class members at community hospitals without notifying STS or involving STS in the process. (Pis.’ Exs. 260, 262, 621, 631.) The findings of the Mortality Review Committee indicate that some of these orders were written for patients whose medical conditions were not irreversible and thus the DNR orders do not comply with DMR 87-2. (Pis.’ Exs.267, 324, 629.) Dr. McDonald conceded that there had been problems with DNR orders written for class members at community hospitals in the past, but he testified that STS had worked to resolve these problems following his appointment as Medical Director in 1996. (Tr. 6/30/99 at 156-58; Tr. 7/8/99 at 25-27.) He testified that community hospitals are required to comply with STS policies when writing DNR orders for STS residents, and he described how STS takes action whenever it learns that a community hospital has failed to follow these policies. (Tr. 6/30/99 at 157-58, 163-68.) Dr. McDonald also conceded that there have been some problems with community hospitals in this regard since 1996. (Tr. 6/30/99 at 164.) The plaintiffs claim, however, that the defendants have not done enough to resolve these problems and point to instances after 1996 in which community hospitals apparently wrote DNR orders without following DMR protocol. The evidence supports Dr. McDonald’s testimony that STS has taken adequate precautions to ensure that community hospitals comply with DNR protocols. The Mortality Review for STS resident Jose Masso (Pis.’ Ex. 281) indicates that the DNR order written by Danbury Hospital in 1996 was poorly documented and was not processed through DMR. Dr. McDonald agreed that the hospital had failed to follow STS and DMR policy in this instance, and explained that he had addressed the issue with Danbury Hospital personnel. (Tr. 7/8/99 at 30; Pis.’ Ex. 281.) Similarly, in 1997, after Waterbury Hospital wrote a DNR for STS resident Dorothy Goldson without STS involvement, STS responded by reminding the hospital of the need to involve STS personnel when writing DNR orders for STS residents. (Pis.’ Ex. 295.) McDonald addressed this issue again with Waterbury Hospital following the 1998 death of John Cherubino, whose DNR and DNI orders were written without STS involvement. (Pis.’ Ex. 302; Tr. 7/8/99 at 60-61.) The plaintiffs have not established that the defendants’ efforts to force community hospitals to follow DMR protocol have been constitutionally deficient. The defendants are not liable for the actions of community hospitals. Of course, insofar as the defendants are aware that community hospitals frequently fail to follow proper DNR procedures, they should work to resolve the problem. Dr. McDonald described how he informed community hospitals that they must conform to DMR policies, how he consulted with the Attorney General about the situation, and how the community hospitals are “subject to a citation” should they fail to cooperate with STS. (Tr. 6/30/99 at 166.) Furthermore, as an additional safeguard, all non-STS DNR orders are reviewed upon a class member’s discharge from a community hospital back to STS. (Tr. 7/8/99 at 61 (McDonald).) The court declines to find that the defendants’ efforts in this regard deviate from professional standards. The plaintiffs argue that the defendants must establish written “memoranda of understanding” with community hospitals that guarantee that the hospitals follow DMR procedure. (Pis.’ PostTrial Br. at 28-29.) However, the plaintiffs have not drawn to the Court’s attention any evidence — expert or otherwise — -establishing that such memoranda are required by professional standards. 5. Other Claims Regarding DNR Orders The plaintiffs also claim that “there is no process” for writing DNI orders at STS. (Pis.’ Proposed Findings at 89.) However, the plaintiffs support their claim by mis-characterizing Dr. McDonald’s testimony. (See Pis.’ Proposed Findings at 89.) The testimony cited by the plaintiffs related to the fact that DMR protocol allows DNI orders to be written without any procedural safeguards beyond those required under DMR 87-2 for DNR orders. (See Tr. 6/30/99 at 201.) Because a DNI order may only be written for a patient who has a valid DNR order, it is simply not true that a DNI order may be written without following any procedure. The plaintiffs have not argued that the constitution requires additional procedural safeguards in order for a DNI order to be written. The plaintiffs also claim that the defendants improperly allow physicians assistants and nurses to sign reviews of DNR orders. (Pis.’ Proposed Findings at 103.) The plaintiffs only evidence for this claim is a passage of Dr. McDonald’s cross-examination in which plaintiffs’ counsel aggressively but unsuccessfully tried to force the witness to admit that there was a deficiency in this regard. (Tr. 7/9/99 at 81-85.) Dr. McDonald explained clearly that there was “no problem” because the staff who sign DNR reviews do so under the supervision of doctors. (Id.) He testified that any previous problems in this area had been corrected. (Id.) The court therefore finds that the plaintiffs have failed to establish that the defendants’ policies and practices for writing DNR and DNI orders for class members violate due process. B. Protection From Harm and Freedom From Unnecessary Restraint The plaintiffs claim that the defendants have violated their constitutional duty to protect residents at STS from abuse, neglect and injury. (Pis.’ Post-Trial Br. at 48-67.) As with the plaintiffs’ claims relating to the provision of medical care, the plaintiffs set out a list in their Post-Trial Brief of specific matters for which they request a remedy. The plaintiffs state that they do not know if the Special Master has addressed all of these matters and suggest that “that the appropriate course is to request orders to remedy the violations plaintiffs established at trial, and to ask that they be referred to the process established in [United States v. Connecticut] provided plaintiffs can participate fully in the process.” (Id. at 168). The plaintiffs would have the following specific orders implemented by the Special Master: a. An order requiring the defendants to provide physical safety, freedom from restraint and programming that is sufficient to satisfy the requirements of Youngberg. b. An order requiring the defendants to investigate abuse, neglect and injuries to class members and that STS unit staff members should be prohibited from investigating injuries of unknown origin. c. An order requiring adequate reporting, investigation and corrective action in response to all abuse, neglect and injuries. d. An order requiring the defendants to “take all reasonable steps” to prevent resident-to-resident sexual assaults. e. An order requiring the defendants “to take all reasonable and necessary steps” to prevent resident-to-resident assaults. f. An order requiring the defendants to provide prompt medical care to class members who have been injured or abused. g. An order requiring the defendants to maintain data regarding injuries, abuse, neglect, and the use of restraints at STS. h. An order requiring the defendants to use this data in taking corrective action. i. An order requiring adequate staffing of the STS Human Rights Office. j. An order requiring the defendants to take reasonable steps to reduce the use of restraints at STS. k.An order requiring that buildings at STS be inspected and brought into compliance with the state Fire Code. (Id. at 168-70.) The issue of abuse and neglect at STS was an important aspect of the litigation in United States v. Connecticut. See, e.g., 931 F.Supp. at 978 (finding that “STS [had] not only failed to protect its residents from injury to themselves, but [had] also failed to protect its residents from unreasonable risk of injury by other residents”). The Special Master accordingly devoted considerable attention to abuse and neglect at STS. Eleven of the Court Requirements in the Remedial Plan dealt with this issue. See CR 2-12. The Remedial Plan focused on establishing procedures to investigate and respond to instances of abuse and neglect. Court Requirement 4 required that STS implement procedures for systematically recording and tracking instances of abuse, neglect and injuries and required STS to take corrective action based on the data generated from these reports. See Special Master’s Report to the Court No. 49: Investigation of Abuse/Neglect Allegations (“Report No. 49”) at 9-10, U.S. v. Conn. (May 27, 2003) (describing use of the Connecticut Automated Mental Retardation Information System (“CAMRIS”) to track reports of abuse). The Remedial Plan required that STS set standards and establish procedures for reporting and investigating abuse committed both by staff and residents at STS. See CR 6-11; see also Report No. 49 at 2-8 (describing the emergence of a “professional,” “effective” and adequately resourced Human Rights Office tasked with investigating abuse at STS). Therefore, the Special Master has addressed the plaintiffs’ specific concerns a., b., c., f., g., h. and i. In addition to requiring STS to investigate and respond to abuse and neglect, the Remedial Plan required STS to take steps to prevent abuse and neglect. Court Requirement 3 required STS to identify potential victims and abusers, implement programs to prevent victimization, and train staff and clients to recognize and report abuse and neglect. See, e.g., Report to the Court No. 54: Abuse/Neglect Client Training, U.S. v. Conn. (Jan. 20, 2004). Therefore, the Special Master has addressed the plaintiffs’ specific concerns d. and e. The specific order k. from the above list of the plaintiffs’ requests relates to an issue — fire code compliance — that has already been addressed in the United States v. Connecticut remedial process. See CR 86, 87; see also Special Master’s Report to the Court No. 59: Deletion of Several Requirements at 6-7, U.S. v. Conn. (Oct. 24, 2005) (noting that fire marshal inspections and ICF/MR inspections had been satisfactory). Lastly, the Special Master has already addressed the issue of reducing unnecessary use of restraints on class members. See, e.g., CR 48, EC 1-6 (prohibiting use of restraints in lieu of training and requiring systematic review of use of restraints). Also, as discussed below, the Special Master oversaw the improvement of habilitation programming, thus reducing the need to use physical restraint. It is therefore apparent that the Special Master has already addressed the issue raised by the plaintiffs’ specific concerns a. and j. The Special Master has already addressed all of the security and freedom from restraint issues that the plaintiffs would have the court refer to him. The court therefore will not consider whether the defendants are liable for having failed to protect class members from harm and unnecessary restraint. C. Habilitation and Active Treatment The plaintiffs claim that the defendants have violated class members’ due process rights to minimally adequate habilitation and training and they claim that the defendant Commissioner of DMR violated class members’ right to receive active treatment as required by Title XIX of the Social Security Act. (Pis.’ PostTrial Br. at 67-69.) Class members have a due process right to training or habilitation that is adequate to “ensure [their] safety and to facilitate [their] ability to function free from bodily restraints.” Youngberg, 457 U.S. at 324, 102 S.Ct. 2452. Such training must be “sufficient to prevent basic self-care skills from deteriorating.” Society for Good Will, 737 F.2d at 1250. State officials violate due process when they “fail to exercise professional judgment in devising programs that allow patients to live as humanely and decently as when they entered the school.” Id. Class members do not, however, have a due process right to training that will “improve [their] ... skills beyond those with which they entered” STS. See Society for Good Will, 737 F.2d at 1250 (adopting Justice Blackmun’s concurring opinion in Youngberg). “Active treatment,” as the term is used in Title XIX, refers to a level of training and treatment that is more intensive than that required by due process. The regulations promulgated to implement Title XIX explain that [e]aeh client must receive a continuous active treatment program, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services described in this subpart, that is directed toward ... [t]he acquisition of the behaviors necessary for the client to function with as much self determination and independence as possible [as well as] [t]he prevention or deceleration of regression or loss of current optimal functional status. 42 C.F.R. § 483.440(a) (emphasis added). Under Title XIX, unlike the Due Process Clause, the class members enjoy a right to training and other treatment designed to do more than simply preserve basic skills. When they submitted their Post-Trial Brief, the plaintiffs were aware that the Special Master in United States v. Connecticut had addressed or would be addressing many of the alleged deficiencies in STS’s habilitation programming. (Id. at 170.) However, because they were “uncertain as to the extent” that these alleged violations would be addressed in the remedial process in that case, they have also requested a number of specific remedial orders in this case. (Id. at 170-71.) The court construes this request for relief as a request that the court remedy any specific issues related to habilitation which the Special Master failed to address. The plaintiffs request the following specific remedial orders to fill any gaps that may have been left in the Special Master’s oversight over reform of the habilitation services at STS: a. An order requiring the defendants to provide each class member with “minimally adequate habilitation” that is to be monitored by a mental health professional. b. An order requiring the defendants to provide class members with the level of habilitation that a professional would consider adequate to ensure safety and to allow freedom from restraint. c. An order prohibiting STS from administering unnecessary medication and restraint and requiring the defendants to provide habilitation to reduce the need for medication and restraint. d. An order requiring the defendants to “ensure full participation in social, religious, and community group activities.” e. An order requiring the defendants to “promote the participation of legal guardians ... in the process of providing active treatment.” f. An order requiring the defendants to promote informal leave, vacations, and trips away from STS. g. An order requiring the defend