American History After 1998 on the Forcible Administration of Psychotropic Drugs - #Michael A. Ayele (a.k.a) W Decision to File Habeas Corpus Complaint After January 10th 2016 - #Health Insurance Portability and Accountability Act (HIPAA)

PAGE NUMBER Internal Regulation Process 8 of 12 DEPARTMENT OPERATING REGULATION NUMBER DOR MARK STRINGER, DEPARTMENT DIRECTOR SUBJECT NUMBER OF PAGES MISSOURI DEPARTMENT OF MENTAL HEALTH 4.140 Use of Seclusion and Restraints in CPS 12 EFFECTIVE DATE 6-5-19 b. Should a restraint and seclusion continue beyond the time limits specified in the initial order, a face-to-face evaluation shall be completed by a physician or APN designee, not an SPN. c. Every four (4) hours thereafter a face-to-face evaluation shall be performed by a physician or APN designee, not an SPN, if the restraint or seclusion continues. 2. The written orders/documentation in the individual’s record shall contain at least the following information: A. Completion of face-to-face evaluations; B. Individual’s condition, symptoms and/or behavior demonstrated necessitating restraint or seclusion; C. Alternative interventions attempted that failed; D. Rationale for the type of restraint or seclusion selected; E. Individual’s response to restraint or seclusion, and the need for continued use; F. Behavioral criteria for the individual’s release; G. Methods for staff to use to assist individuals in regaining control; H. Consideration of any pre-existing medical conditions that might be exacerbated by restraint or seclusion; and I. Assessment for physical injury. (C) Each order for restraint or seclusion shall be time limited and shall not exceed four (4) hours for adults, two (2) hours for youth nine (9) to seventeen (17), and one (1) hour for children under nine (9). (D) Facility policy is to specify mechanisms for notification of the facility medical director or his/her designee when restraint or seclusion is used in any of the following circumstances: 1. Any episode that lasts twelve (12) consecutive hours; 2. Any two (2) or more episodes within a twelve (12) consecutive hour period; and 3. Any episode that continues beyond twenty-four (24) consecutive hours, with provisions for continued notice for every twenty-four (24) hour period thereafter. (E) While individuals are in restraints or seclusion, trained staff shall: 1. Observe and assess the individual continuously to assure appropriate care and treatment including bathing, intake of fluids, regular meals, exercise and use of toilet; 2. During observation, if it is believed that the individual’s dangerous behavior has ceased, the observer shall immediately notify an RN who shall verify observation; 3. Observations under paragraphs 1 and 2 shall be documented per facility approved flow sheet; and an RN shall assess the individual and document at least every hour. (F) When a restraint involves a manual hold, a staff person not assisting with the hold shall be assigned to observe the individual. (G) In situations where a physician or his/her APN designee are not physically available and there exists an imminent danger or reasonable likelihood of serious physical harm to

PAGE NUMBER Internal Regulation Process 9 of 12 DEPARTMENT OPERATING REGULATION NUMBER DOR MARK STRINGER, DEPARTMENT DIRECTOR SUBJECT NUMBER OF PAGES MISSOURI DEPARTMENT OF MENTAL HEALTH 4.140 Use of Seclusion and Restraints in CPS 12 EFFECTIVE DATE 6-5-19 self/others, trained staff may initiate the manual or mechanical restraint of an individual or placement of the individual in seclusion. 1. The RN approved per facility policy to sanction restraint or seclusion procedures shall observe and assess the individual immediately and document the following in the medical record per facility policy: A. The necessity for manual or mechanical restraint or seclusion, and inadequacy of less restrictive intervention and what interventions have already been attempted; B. The type of manual or mechanical restraint or seclusion; C. The expected behavior necessary for release from manual or mechanical restraint or seclusion; and D. The physical condition of the individual prior to the use of restraint or seclusion. 2. Until a physician, or his/her APN designee, is reached for an order, individuals may be restrained or secluded under sanction from an RN. In these emergency application situations, an order must be obtained either during the emergency application of the restraint or seclusion, or immediately (within a few minutes) after the restraint or seclusion has been applied. The failure to immediately obtain an order is viewed as the application of restraint or seclusion without an order. Emergency or critical situations that delay the RN’s ability to obtain an order beyond the expected few minutes should be documented in the client record. The RN who sanctioned the restraint or seclusion on an emergency basis shall document the phone/verbal order. 3. RN documentation shall proceed according to the facility policy, including the following: A. When procedure is initiated; B. Every hour while in restraints or seclusion; C. Upon release from restraint or seclusion; and D. Upon notification the individual’s dangerous condition appears to have ceased. (10) Procedures for restraint used to ensure the physical safety of the non-violent or non-selfdestructive individual shall include the following requirements: (A) If an assessment reveals a medical condition or symptom that indicates the need for an intervention to protect the individual from harm, the least restrictive intervention that will effectively protect the individual from harm must be used. Upon making this determination, the use of a restraint may be considered; however, that consideration must weigh the risks of using a restraint against the risks presented by the individual’s behavior. There must then be a determination of the type of restraint intervention that will meet the individual's needs with the least risk and most benefit to the individual. (B) Use of restraint shall cease when the RN, physician or APN designee determines that the need for restraint is no longer present or that the individual’s needs can be addressed using less restrictive methods. The physician may specify how these criteria may be demonstrated or assessed prior to release, as documented on the physician’s order. This criteria will be considered prior to release.

PAGE NUMBER Internal Regulation Process 10 of 12 DEPARTMENT OPERATING REGULATION NUMBER DOR MARK STRINGER, DEPARTMENT DIRECTOR SUBJECT NUMBER OF PAGES MISSOURI DEPARTMENT OF MENTAL HEALTH 4.140 Use of Seclusion and Restraints in CPS 12 EFFECTIVE DATE 6-5-19 (C) A physician, or his/her APN designee, may authorize an RN to use restraint to ensure an individual’s physical safety with a written order and modification to the individual’s plan of care, or as an emergency measure as described in section (10)(E). (D) Order renewals or new orders shall be issued no less often than once each calendar day and is based on the physician’s or his/her APN designee’s evaluation of the individual. (E) If a physician or his/her APN designee is not available to issue a written order, an RN may initiate restraint use based on an appropriate assessment of the individual and determination that a risk to the individual’s physical safety exists. 1. The RN shall notify a physician or his/her APN designee immediately (within a few minutes) after the restraint or seclusion has been applied, and secure a verbal or written order. The failure to immediately obtain an order is viewed as the application of restraint or seclusion without an order. 2. Emergency or critical situations that delay the RN’s ability to obtain an order beyond the expected few minutes should be documented in the client record. (F) While individuals are in restraints, trained staff shall: 1. Observe and assess the individual at least every two (2) hours or sooner according to individual need, to assure appropriate care and treatment including bathing, intake of fluids, regular meals, exercise and use of toilet; 2. Observations shall be documented in the individual’s medical record per facility approved flow sheet; and, 3. An RN shall assess the individual and document at least every eight (8) hours. (11) Procedures for restraint of individuals that engage in intractable behavior that is severely self injurious, and who have not responded to traditional interventions and are unable to demonstrate the ability to behave safely (including those diagnosed with a chronic medical or psychiatric condition, such as Lesch-Nyhan Syndrome) are as follows: (A) The use of restraints to prevent self-injury may be needed for these types of rare, severe, medical and psychiatric conditions. Use of restraint must be determined as the least restrictive intervention that will effectively protect the individual from harm. Upon making this determination, the use of a restraint may be considered; however, that consideration must weigh the risks of using a restraint against the risks presented by the individual’s behavior. There must then be a determination of the type of restraint intervention that will meet the individual's needs with the least risk and most benefit to the individual. (B) Use of restraint in these situations must be consistent with a behavior management plan used to foster adaptive behaviors that has been approved by facility clinical/ management leadership. Such a plan must be thoroughly documented as to the need, interventions, evaluation, and discontinuation criteria and must be reviewed and renewed at least monthly. (C) All staff implementing the plan must be trained in its implementation. (D) The specific requirements (1-hour face-to-face evaluation, time-limited orders, and evaluation every 24 hours before renewal of the order) for the use of restraint to manage violent or self- destructive behavior do not apply.

PAGE NUMBER Internal Regulation Process 11 of 12 DEPARTMENT OPERATING REGULATION NUMBER DOR MARK STRINGER, DEPARTMENT DIRECTOR SUBJECT NUMBER OF PAGES MISSOURI DEPARTMENT OF MENTAL HEALTH 4.140 Use of Seclusion and Restraints in CPS 12 EFFECTIVE DATE 6-5-19 (12) The facility shall document in the staff personnel records that the training and demonstration of competency related to use of restraint and seclusion were successfully completed at the time of new employee orientation and annually thereafter unless otherwise stipulated in a specific module of study (e.g. cardiopulmonary resuscitation recertification every two (2) years). (13) Persons providing staff training must be qualified as evidenced by education, training, and experience in techniques used to address individual’s behaviors. (14) The following steps shall be taken to reduce the likelihood of re-occurrence of the use of manual or mechanical restraint or seclusion: (A) A debriefing with staff members involved in the application shall take place immediately following the procedure in order to determine: 1. Any improvements that could be made to reduce the likelihood of reapplication; 2. Any improvements in the procedure that could have made the event less traumatic; and 3. Assess any trauma reactions on the part of the staff. (B) Facility Leadership shall review debriefing reports of restraint or seclusion incidents at regular intervals to ensure that every effort was made to avoid the application. Furthermore, in its review leadership shall assess the extent to which the individual’s physical and psychological well being was cared for and the potential for traumatization was minimized. Areas for improvement identified through such reviews shall be conveyed to the individual’s treatment team. (C) Upon application, there shall be a written modification to the treatment plan to reflect the use of restraint or seclusion and to identify methods of reducing the likelihood of reoccurrence. (D) As soon as possible, but no later than twenty-four (24) hours after each incident, a debriefing shall take place (including the family as appropriate) in order to: 1. Identify what led to the incident and what could be done differently; 2. Ascertain that the individual’s physical well-being, psychological comfort and right to privacy were addressed; and 3. Counsel the individual for any trauma. (E) The individual’s treatment team shall review modification to the treatment plan made during the incident and develop a permanent plan for dealing with the issues that led to the restraint or seclusion. (15) The medical staff through the Quality Management Office for that facility is responsible for the risk management issues regarding restraint or seclusion. These shall include, but not be limited to, the following: (A) Identify and report when restraint or seclusion is used longer than twelve (12) hours or when two (2) or more incidents happen in any twelve (12) hour period; (B) Identify and report all unusual or possible unwarranted patterns of utilization including but not limited to trends in shift, initiating staff, episode length, date and time,

PAGE NUMBER Internal Regulation Process 12 of 12 DEPARTMENT OPERATING REGULATION NUMBER DOR MARK STRINGER, DEPARTMENT DIRECTOR SUBJECT NUMBER OF PAGES MISSOURI DEPARTMENT OF MENTAL HEALTH 4.140 Use of Seclusion and Restraints in CPS 12 EFFECTIVE DATE 6-5-19 day of the week, type, injuries to individuals or staff, the individual’s age, and individual’s gender; (C) Identify and report facility utilization of restraint or seclusion at periodic intervals, but not less than quarterly; (D) Annually review facility policies, procedures and training programs and recommend necessary changes to the facility head; and (E) Identify and approve restraint procedures for use in the facility. (16) Facility Leadership shall maintain continuous efforts to reduce the use of restraint and seclusion and traumatic effects associated with their application by prominently reflecting such efforts in strategic initiatives and performance improvement processes. (17) Each facility will develop procedures for reporting deaths associated with the use of restraint or seclusion to the Centers for Medicare and Medicaid (CMS) Region 7, Kansas City, MO, 816-426-5233. (A) The facility shall report the following information: 1. Each death that occurs while an individual is in restraint or seclusion. 2. Each death that occurs within twenty-four (24) hours after the individual has been removed from restraints or seclusion. 3. Each death known to the facility that occurs within one (1) week after a restraint or seclusion where it is reasonable to assume that the use of restraint or seclusion contributed directly or indirectly to an individual’s death. “Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation. (B) Reports to CMS shall be made by telephone no later than the close of business the next business day following knowledge of the individual’s death. (C) Staff shall document in the individual’s medical record the date and time the death was reported to CMS. History: Original DOR Effective December 1, 1983. Amendment effective February 8, 1984. Amendment effective February 1, 1994. Amendment effective July 1, 2002. On July 1, 2003 the sunset date was extended to July 1, 2004. On July 1, 2004 the sunset date was extended to July 1, 2005. Amendment effective July 1, 2005. Amendment effective September 10, 2007. Amendment effective February 11, 2009. Amendment effective April 12, 2010. On June 15, 2013 the sunset date was extended to July 1, 2016. Amendment effective June 23, 2016. On June 5, 2019 the sunset date was extended to July 1, 2022.

DEPARTMENT OPERATING REGULATION NUMBER DOR MARK STRINGER, DEPARTMENT DIRECTOR CHAPTER SUBJECT PERSON RESPONSIBLE AUTHORITY SUBCHAPTER Clinical NUMBER OF PAGES Standards and Procedures HISTORY See Below SUNSET DATE 7/1/24 EFFECTIVE DATE Administration of Psychotropic Medications Involuntarily PAGE NUMBER 6/8/21 5 1 of 5 Program Implementation and Records MISSOURI DEPARTMENT OF MENTAL HEALTH 4.152 Section 630.050, RSMo Director, Division of Behavioral Health PURPOSE: Prescribes procedures for involuntary administration of psychotropic medications. APPLICATION: Applies to Division of Behavioral Health inpatient adult facilities. In addition to adults, this DOR does apply to any individual under 18 years of age who has been certified to stand trial as an adult and placed with the Department pursuant to Chapter 552 or 557, RSMo, or Chapter 632, RSMo. This does not apply to other minors. This DOR does not apply to individuals civilly detained pursuant to 632.305 RSMo. All patients must be given the opportunity to consent to the administration of psychotropic medications before involuntary medication procedures are considered. (1) EMERGENCY PROCEDURES – ALL PATIENTS REGARDLESS OF LEGAL STATUS All patients in the Department of Mental Health (DMH) facilities may be administered psychotropic medication on an involuntary basis when a determination of emergency is made by appropriate clinical personnel at the facility. An emergency exists where there is reasonable likelihood of imminent physical harm and/or life threatening behavior to the patient or others. The treating provider who prescribes the psychotropic medication shall document the circumstances of the emergency, the facts surrounding the medication need, and why involuntary psychotropic medication is considered the least restrictive treatment. A new order shall be written for each emergency dose. Only short- acting medications may be prescribed. The administration of emergency involuntary medication as set forth in the preceding paragraph shall not exceed 96 hours (from the time of the initial involuntary medication order), as defined in Section 632.005(14) (computed to exclude Saturdays, Sundays, and legal holidays). If needed, a subsequent emergency period of 96 hours may be authorized within an 8 day evaluation period (from the time of the initial involuntary medication order) only after the treating psychiatrist has received a written concurrence from a psychiatrist not currently involved in the patient’s treatment. If the patient continues to refuse medication and the treating psychiatrist determines that psychiatric medication is still necessary, procedures for administering medication in a non-emergency situation as set forth below should be initiated as soon as the treating psychiatrist makes the determination. (2) NON-EMERGENCY PROCEDURES - INVOLUNTARY PATIENTS OVER 18 It is permissible to recognize a court order which specifically authorizes the involuntary administration of psychotropic medication.

PAGE NUMBER 2 of 5 MARK STRINGER, DEPARTMENT DIRECTOR EFFECTIVE DATE 6-8-21 DEPARTMENT OPERATING REGULATION NUMBER DOR MISSOURI DEPARTMENT OF MENTAL HEALTH SUBJECT NUMBER OF PAGES 4.152 Administration of Psychotropic Medications Involuntarily 5 Patients admitted for Inpatient Pre-Trial Evaluations pursuant to Section 552.020, RSMo, and detainees pursuant to Section 632.480 et seq., RSMo., may not be medicated, absent an emergency, without either the consent of the patient, or expressed written consent from the committing court. The psychiatrist must communicate the desire to medicate such a patient to a designated assistant general counsel, who will communicate with the committing court and obtain a written order from the judge. For all other involuntary patients over 18 who refuse psychotropic medication in a nonemergency situation, when the patient is gravely disabled and/or a danger to herself/himself or others, the treating psychiatrist shall make a referral for hearing before the Clinical Due Process Review Committee. (A) Clinical Due Process Review Committee: The Clinical Due Process Review Committee shall be appointed by the Chief Operating Officer (COO) and shall consist of the following three voting members: (1) A non-treating psychiatrist, who shall act as chairperson (2) A non-treating Qualified Mental Health Professional (3) A designee of the COO of the patient’s facility (B) Pre-Hearing: (1) The hearing provided for in (2)(C) should be set within 5 business days of the determination for the need for involuntary medication. (2) The COO or designee will determine the availability of the Clinical Due Process Review Committee members and schedule a date for the hearing. (3) The COO/designee of the facility will assign a certified mental health peer specialist or patient advocate who will meet with the patient to determine why the patient is unwilling to take psychotropic medications. (4) Within 24 hours of the determination of the need for hearing and the setting of such hearing, the COO or designee will serve notice on the patient that a clinical determination has been made that involuntary medication is needed and that a clinical due process hearing has been scheduled. The notice will contain the time, date, place, and purpose of the hearing. The notice will inform the patient of the right to hear evidence providing the basis for the involuntary medication, and the right to ask questions, testify and present relevant evidence in her/his behalf. (C) Hearing: (1) The patient will be present at the hearing unless it is clinically contraindicated or the patient refuses to attend. The peer specialist or patient advocate will be present at the hearing. If the patient’s clinical condition is such that the patient’s attendance at the hearing is not feasible, the Committee will state the reasons for determining that the presence of the patient is not feasible, and will allow the peer specialist or patient advocate an opportunity to present facts relevant to whether an involuntary medication order should be issued.

PAGE NUMBER 3 of 5 MARK STRINGER, DEPARTMENT DIRECTOR EFFECTIVE DATE 6-8-21 DEPARTMENT OPERATING REGULATION NUMBER DOR MISSOURI DEPARTMENT OF MENTAL HEALTH SUBJECT NUMBER OF PAGES 4.152 Administration of Psychotropic Medications Involuntarily 5 (2) The treating psychiatrist will present evidence regarding the basis for the diagnosis, the need for involuntary medication, the class or classes of medication indicated, and the maximum dosage recommended for candidate agents within each recommended class, the benefits and risks of the medication, the measures that will be taken to address the risks, and why involuntary psychotropic medication is considered the least restrictive treatment. (3) The patient, if present, will be asked to testify and will be advised of her/his right to question the treating psychiatrist regarding the need to be placed on involuntary medication. (4) The entire hearing will be digitally audiotaped by the chairperson. The COO will store all Committee hearing audiotapes for a period of at least 12 months from the date of the hearing. (D) Decision: (1) The written majority decision of the Committee shall be reflected in the Clinical Due Process Hearing Summary (form attached) and shall be provided to the patient within 24 hours of the hearing. If the majority vote is to administer medication involuntarily, but the non-treating psychiatrist member does not agree, the non-treating psychiatrist’s decision shall prevail. A copy of the Clinical Due Process Hearing Summary shall be sent to the DMH Chief Medical Director and a copy shall be placed in the patient’s chart. (2) The patient will have 24 hours after receipt of the written decision to appeal the decision to the DMH Chief Medical Director, or designee. The peer specialist or patient advocate shall assist in the appeal process if so requested by the patient. If the decision is appealed, while the appeal is pending, only emergency medication may be administered to the patient absent consent. The DMH Chief Medical Director shall issue a written decision within 2 business days of receipt of the appeal. The written decision of the DMH Chief Medical Director shall be delivered to the patient, the treating psychiatrist, and the Medical Director of the facility. (E) After Decision: (1) The Clinical Due Process hearing will be repeated every 6 months if the patient still needs to be involuntarily medicated or until the patient is discharged from the facility. (2) Should the patient transfer to another DMH facility, the order for involuntary medication will continue. Any necessary lab tests and examinations needed for safe administration or monitoring of the medication will be covered by the decision to involuntarily medicate.

PAGE NUMBER 4 of 5 MARK STRINGER, DEPARTMENT DIRECTOR EFFECTIVE DATE 6-8-21 DEPARTMENT OPERATING REGULATION NUMBER DOR MISSOURI DEPARTMENT OF MENTAL HEALTH SUBJECT NUMBER OF PAGES 4.152 Administration of Psychotropic Medications Involuntarily 5 (3) NON-EMERGENCY PROCEDURES - UNDER 18 AND CERTIFIED TO STAND TRIAL AS ADULT (A) Committed for a pretrial evaluation – absent an emergency, shall not be involuntarily medicated without expressed written consent from a committing court. (B) Committed as incompetent to proceed or not guilty by reason of mental disease or defect – absent an emergency, the following consents must be obtained to involuntarily medicate: 1. Parents – if the patient has a parent(s) whose rights have not been previously formally terminated by the juvenile court, the parent(s) shall be informed of the need for medication and written consent obtained from the parent(s). 2. Legal guardian other than parents – if the patient has a legal guardian other than the parent(s), that guardian shall be informed of the need for medication and written consent obtained from the guardian. 3. Agency with legal custody – if there is no parent and no other legal guardian, ascertain whether there is another agency with legal custody (i.e. Department of Social Services, Children’s Division). If so, that agency shall be informed of the need for medication and written consent obtained from the agency representative. 4. None – if there is no parent, no legal guardian, and no agency with legal custody available to consent, the guidelines of section (2) of this DOR should be followed. (4) NON-EMERGENCY PROCEDURES - VOLUNTARY PATIENTS (A) With Guardians 1. If the patient is adjudicated fully incompetent or granted a limited guardianship where medical needs are the basis of the guardianship and psychotropic medication is identified as part of the treatment plan, the guardian shall be informed of the need and written consent, or telephone consent with a second staff member participating as a witness, obtained from the guardian. If the consent is obtained by telephone, one of the two persons receiving the consent shall be a registered nurse. 2. Every effort shall be made to address the reasons for objections by the guardian. 3. If the guardian refuses to authorize that the patient is to receive psychotropic medication, the patient may be discharged from the program only if medication is the primary treatment available for the patient’s condition. 4. The guardian’s permission overrides any patient objection or refusal. (B) Without Guardians 1. Voluntary patients have the absolute right to refuse psychotropic medications, except in an emergency. 2. Patient’s verbal refusal or written refusal shall be made a permanent part of the patient’s medical record. 3. Once refused, the patient shall be provided with written notice stating specific reasons why psychotropic medication is indicated, the specific psychotropic

PAGE NUMBER 5 of 5 MARK STRINGER, DEPARTMENT DIRECTOR EFFECTIVE DATE 6-8-21 DEPARTMENT OPERATING REGULATION NUMBER DOR MISSOURI DEPARTMENT OF MENTAL HEALTH SUBJECT NUMBER OF PAGES 4.152 Administration of Psychotropic Medications Involuntarily 5 medication and the possible side effects, and why involuntary psychotropic medication is the least restrictive treatment 4. If the patient refuses to receive psychotropic medication, the patient may be discharged from the program if medication is the primary treatment for the patient’s condition, no other treatment is suitable for the patient’s condition, and the patient has adequate mental capacity and does not present a reasonable likelihood of serious harm to self or others. 5. If the patient is determined to lack adequate mental capacity but is not imminently dangerous, clinicians shall proceed by filing for guardianship. Until the guardianship process is completed, the patient’s refusal to take medication should be honored, absent an emergency. 6. If the patient presents a likelihood of serious physical harm to himself or others, the patient’s voluntary status should be changed to involuntary status, and the guidelines of section (2) of this DOR should be followed. (5) REFUSAL OF MEDICATION DUE TO RELIGIOUS BELIEF (A) Any patient not under guardianship who is currently an active, practicing member of a generally recognized, organized church or religion which teaches reliance upon treatment by prayer or other spiritual means of healing may refuse the administration of medication unless an emergency exists as defined in section (1) of this DOR. (B) Whenever a patient seeks to refuse medication due to religious belief, the COO shall convene and chair a review panel consisting of a facility chaplain, a licensed social worker, a psychologist and the medical director. The panel shall seek advice from an outside member of the patient’s religion or church whenever possible. The panel shall interview the patient, review records, and seek outside advice and confirmation that: 1. the patient’s religion is a generally recognized, organized faith which teaches reliance on spiritual means; 2. the patient has been and is currently an active participating member. (C) If the review panel confirms sections 5(B) 1 and 2, the patient’s refusal of medication shall be honored. If either section 5(B) 1 or 2 are not confirmed, the refusal will be handled as set forth in section (2) of this DOR. HISTORY: Original DOR effective January 1, 1995. Amendment effective July 1, 1997. amendment effective May 1, 1997. Amendment effective October 1, 2002. On July 1, 2006 the sunset date was extended to July 1, 2009. On July 1, 2009, the sunset date was extended to July 1, 2012. Amendment effective May 3, 2011. On June 17, 2014, the sunset date was extended to July 1, 2017. Amendment effective May 5, 2017. Amendment effective October 2, 2017. On June 8, 2021, the sunset date was extended to July 1, 2024.

Missouri Department of Mental Health Fulton State Hospital Hospital Policy _________________________________________________________________________________________________________________________ ET APPROVAL: July 15, 2021 Chapter PROVISION OF CARE, TREATMENT AND SERVICES Title RESTRAINT AND SECLUSION Subchapter Special Conditions Responsible Party Medical Director Effective Date August 8, 2005 Review Date May 2022 HOSPITAL POLICY: PC.03.01 PURPOSE: Prescribes the policy on the use of seclusion and restraint. PHILOSOPHY: The leadership of Fulton State Hospital recognizes that the use of restraint and seclusion poses an inherent risk to the physical safety and the psychological well-being of individuals and staff. In particular, there is recognition that the individuals we serve have high rates of violence towards themselves and others; they also have a high incidence of exposure to sexual, emotional and physical abuse. Consequently, any application of emergency interventions which have the inherent potential for trauma is likely to be re-traumatizing and is to be avoided wherever possible. Furthermore, we recognize that despite best intentions, decisions concerning the use of seclusion and restraint are necessarily made under less than ideal circumstances (i.e., emergencies) and involve the urgent weighing of significant risks versus the benefits of physical safety. As part of this commitment, leadership explicitly espouses the following principles and values in regard to seclusion and restraints: 1. Use of Seclusion and/or Restraint is seen as an intervention of a last resort rather than a treatment intervention and its use should be an uncommon event; 2. An organizational philosophy of non-violence is to be articulated in all policies, procedures and practices; 3. Individuals are to have a voice in determining treatment options; 4. Practices that are sensitive to those with a history of trauma are to be in place; 5. Key models are to be identified that support a culture of individual empowerment and recovery that is supportive, compassionate and non-punitive; and 6. An environment of care is to be created that is welcoming and attractive and adaptable as possible. APPLICATION: Therefore, restraint and seclusion shall be used only in emergency situations in which the individual presents an imminent danger to self or others. When possible, alternatives listed on the Personal Safety Plan and other less restrictive therapeutic measures should be attempted first. Non-physical interventions are the first choice as an intervention unless safety issues demand immediate physical intervention. The facility’s approved early intervention crisis prevention techniques will be used to de-escalate conflict when possible. Restraint/seclusion shall not be used for the convenience of staff, as a substitute for a program, or as punishment. The individual's rights, dignity, and well being shall always be protected. 1. The following specific situations are recognized as exceptions to this policy: A. Forensic restrictions and restrictions imposed for security purposes by law enforcement or by facility security staff (e.g., use of security devices for transportation outside a locked center and/or outside the facility for individuals who are EITHER on police/sheriff hold status OR who are involuntarily committed and at risk of eloping during transport out of the facility for court hearings or medical appointments). B. Procedures specific only to NFC (High Security) regarding the maintenance of a security environment equivalent to that of a jail or correctional setting for an individual transferred to these settings whose legal status is that of jail detainee, correctional inmate, pre-trial evaluation. All other applications of this policy apply.

Hospital Policy PC.03.01 Restraint and Seclusion Page 2 of 8 C. Proper use of security escort devices or extraordinary measures employed by the head of the facility to ensure the safety and security of individuals during times of natural or manmade disasters. DEFINITIONS: 1. The following terms mean: A. Emergency situation is an event in which the individual presents an imminent danger to self or others. B. "Seclusion" is the involuntary confinement of an individual alone in a room or area from which the individual is physically prevented from leaving and is a restriction of a person's freedom with no therapeutic value. C. “Restraint” is any involuntary method of physically restricting a person’s freedom of movement, physical activity, or normal access to his or her body. 1) For the purpose of this definition, restraint includes: a) A restraint - Any physical method or manual hold or mechanical device, material, or equipment that immobilizes or reduces the ability of an individual to move his or her arms, legs, body or head freely. This includes usage of mechanical restraints in which the person is either ambulatory or non-ambulatory. Manual holds instituted to administer involuntary medications are considered restraint. b) Only the application of approved restraint principles will be used when restraining an individual. c) Only facility approved mechanical restraint devices will be applied should mechanical restraint be required. 2) A chemical restraint – A drug or medication used as a restriction of the individual’s freedom of movement or to manage the individual’s behavior and is not a recognized treatment for the individual’s medical or psychiatric condition (i.e. chemical restraint). Use of a medication is considered inappropriate if: (a) it is not a recognized treatment for the individual’s mental disorder; or (b) the medication is administered excessively, such that it can be expected to produce sedation or limit the individual’s ability to participate in the treatment process rather than treat symptoms of the mental disorder. However, medication may be used appropriately to treat behavioral symptoms of mental disorder, including aggressive behavior, and in that case, the specific medication use shall be included in the treatment plan and shall not be considered chemical restraint. 3) For the purposes of this definition, restraint does NOT include: a) A physical intervention from which an individual can easily break away; this includes: b) Physical redirection that continues to provide the individual the opportunity for independent movement in more than one direction (e.g., use of approved techniques for the management of physical aggression to block a blow OR a momentary grasp of a hand or arm that prevents a individual from striking another individual, provided that the individual is still able to move independently in other directions).

Hospital Policy PC.03.01 Restraint and Seclusion Page 3 of 8 c) Devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of an individual for the purpose of conducting routine physical examinations or tests, or to permit the individual to participate in activities without the risk of physical harm. • Hand mitts are not considered restraints unless the mitted hands are tied down and cannot be removed intentionally by the individual in the same manner as it was applied by staff. • Bed side rails used to protect a person from falling out of bed are not considered restraints. Conversely, bed side rails used to restrict the person’s freedom to exit the bed are considered a restraint. Clinical judgment must be used in determining this distinction. Prohibited – as restraint techniques are those that interfere with breathing such as choking, covering the mouth or holding the head in a manner in which it cannot move freely, etc. At any time during the restraint process the individual appears to be in respiratory distress, starts agonal breathing or stops breathing, Code Blue is to be called by dialing 911. Remember, just because an individual can talk does not mean they can breathe. Talking occurs on an exhale. Individuals can continue to talk while they are still unable to get sufficient oxygen. Do not assume. Always assess the individual’s capacity to breathe. D. "Trained staff", such persons designated by facility policy who have been approved, tested, and recognized as competent to provide one of the following services: 1) All direct care staff and other staff involved in the use of restraint and seclusion shall receive education and training and shall demonstrate a working knowledge of the underlying causes of threatening behavior, related medical conditions that may cause aggression, events and environmental factors that may trigger the need for restraint or seclusion, impact of staff behavior, how to choose the least restrictive intervention based on individual assessment information, de-escalation techniques and other non-physical intervention skills, recognizing and responding to symptoms of physical distress, an individual’s viewpoints regarding use of restraint or seclusion, first aid procedures, and be certified in cardiopulmonary resuscitation. 2) Physicians shall demonstrate a working knowledge of the policies and procedures associated with the use of restraint and seclusion. 3) Those who apply the restraint receive the above and demonstrate the safe use of restraint including; physical hold applications, floor assisted restraint, and the application and removal of mechanical restraints. 4) Those authorized to provide monitoring or assessment are competent as above and demonstrate competence in: taking and interpreting vitals, checking circulation and range of motion, skin integrity, signs of incorrect application of restraints, addressing hygiene and elimination needs, recognizing nutritional/hydration needs, addressing physical and psychological status, recognizing signs of potential readiness for discontinuation, assisting the individual to meet the behavioral criteria for discontinuation, and recognizing the need to contact medical personnel for further evaluation. 5) The assigned RN shall be competent in the above and demonstrate competence in assessing physical, and psychological status, and assessing for discontinuation.

Hospital Policy PC.03.01 Restraint and Seclusion Page 4 of 8 6) Persons authorizing restraint or seclusion in emergency situations and/or determining the need to secure a new order, are competent as above, are a licensed registered nurse, and have demonstrated competence in; recognizing how age, developmental considerations, gender issues, ethnicity, and history of sexual or physical abuse or other trauma may affect the individual’s reactions, and using behavioral criteria for discontinuing restraint/seclusion and assisting individuals in meeting these criteria. E. "Physician," responsible psychiatrist, on call physician, officer of the day, treatment team physician and other designated licensed physicians clinically privileged to perform the functions as physicians as privileged by the Medical Staff. PROCEDURE: 1. Staff will be trained in the proper use and maintenance of restraint and seclusion equipment. 2. Staff will collect from individuals and relevant others, at the time of admission, key information that will assist in preventing the use of restraint or seclusion or in minimizing the extent of their use. This process will include: A. Information about the individual’s history of exposure to traumatic events, including physical, emotional and sexual traumatic events, including trauma from previous use of seclusion or restraints or other prior mental health interventions; B. History of violent acts committed by the individual. C. Systematic collection of information about stimuli or situations that typically increase the individual’s degree of agitation, activities or interventions that are typically calming when the individual is agitated, and the individual’s history of restraint or seclusion in psychiatric settings; D. Designation of a family member or other individual the individual wishes to be informed if restraint or seclusion is used. This information will be used in the development of the individual’s treatment plan; and E. This information will be reviewed with the individual and updated by the treatment team after each incident of restraint/seclusion and during the treatment plan reviews. 3. While it may be necessary to initiate restraint or seclusion when the treating physician is not physically present, it is desirable that any application of restraint or seclusion be supervised by a responsible physician to the greatest degree possible. The responsible physician, which may be the primary physician, on call physician, officer of the day, or designated licensed physician should be notified at the earliest time possible when a situation has a significant likelihood of leading to restraint or seclusion. The responsible physician must be notified as soon as possible after the initiation of seclusion or restraint if notification has not yet been made. When notified of such a situation, the responsible physician who gives an order for any form of restraint or seclusion should come personally to evaluate the situation as soon as is reasonably possible, but no later than 1 hour. Once the responsible physician is physically present, he or she will assume leadership responsibility and direct the other clinical staff in managing the individual’s behavior. An attending is notified as soon as possible when applicable. 4. Procedures for restraint or seclusion shall be discontinued at the earliest possible time based on determination that the individual’s behavior is no longer a threat to self or others and includes the following: A. Use of seclusion or restraint shall cease when the RN or physician determines the need for restraint or seclusion is no longer present or that the individual’s needs can be addressed using less restrictive methods.

Hospital Policy PC.03.01 Restraint and Seclusion Page 5 of 8 B. A responsible physician may authorize a registered nurse to use seclusion or restraint to control an emergency situation with a physician’s written order. 1) A responsible physician shall conduct a face to face clinical assessment of the individual within 1 hour of initiation of restraint/seclusion and at 6 hours if renewed a second time, then every 8 hours thereafter to evaluate the individual’s situation, their reaction to the intervention, their medical/behavioral condition and the need to continue or terminate the restraint/seclusion before writing an order authorizing the use of physical or mechanical restraints. 2) The responsible physician’s written orders/documentation in the individual’s record shall contain at least the following information: a) Behavior demonstrated necessitating restraint/seclusion; b) Alternative interventions attempted that failed; c) Rationale for the type of restraint/seclusion selected; d) Behavioral criteria for the individual’s release; e) Consideration of any pre-existing medical conditions that might be exacerbated by restraint or seclusion; and f) Physical examination for injury. C. Each initial order for seclusion or restraint shall be time limited and shall not exceed 2-hours for adults, and 2 hours for youth 17 or under. Continuation orders shall be time limited not to exceed 4 hours for adults and 2 hours for youth. D. Clinical executive/management leadership is notified as soon as is practically possible in the event that seclusion or restraint is used. The clinical executive will review the situation with the clinical staff members involved, and there will be a discussion that explores alternative strategies that might have been used. A report by the clinical executive will form part of the documentation of the episode of restraint or seclusion. Notification of clinical leaders is required when seclusion or restraint is used in any of the following circumstances: 1) any episode that lasts 12 consecutive hours; 2) any two or more episodes within a 12 consecutive hour period; and 3) any episode which continues beyond 24 consecutive hours, with provisions for continued notice for every 24 hour period thereafter. E. Facility policy is to specify the mechanisms for notification and any authorization required from clinical leadership. A physician shall observe the individual, assess the necessity for continued physical or mechanical restraints and provide documentation on the Seclusion/Restraint Doctor's Order form within 1 hour of initiation of restraint or seclusion and at 6 hours if renewed a second time, then every 8 hours thereafter. He/she shall provide written documentation to clinical leadership for each additional 24 hours of physical or mechanical restraints. All of the conditions set out in this section also apply to new physical or mechanical restraint orders. F. While individuals are in restraint or seclusion, trained staff shall assess the individual at the initiation of restraint or seclusion and every 15 minutes thereafter. This assessment includes, as appropriate to the type of restraint or seclusion, the following: 1) Observe and assess the individual continuously, to assure appropriate care and treatment including bathing, intake of fluids, regular meals, exercise and use of toilet; a. Signs of any injury associated with applying restraint or seclusion b. Nutrition or hydration c. Circulation and range of motion in the extremities d. Vital Signs e. Hygiene and elimination f. Physical and psychological status and comfort g. Readiness for discontinuation of restraint or seclusion

Hospital Policy PC.03.01 Restraint and Seclusion Page 6 of 8 2) Offer comfort measures and therapeutic support; i.e. dim lights, pillows for support, speak in a calm, therapeutic manner, offer reassurance; 3) During observation, if it is believed that the individual’s dangerous behavior has ceased, the observer will immediately notify a registered nurse who will verify observation; 4) Observations under # 1 and 2 shall be documented per facility approved flow sheet, and an R.N. shall assess the individual and document at least every hour. G. When a restraint involves a physical hold, another staff person is assigned to observe the individual. H. When restraint or seclusion is ordered for an individual, the physician ordering the restraint or seclusion will consult as soon as possible with the physician providing ongoing care to the individual. The consultation is to be documented in the progress notes. 5. In an emergency trained staff may initiate physical or mechanical restraint with an individual or place the individual in seclusion. The trained registered nurse approved per facility policy to sanction the use of restraint or seclusion procedures shall observe and assess the individual immediately and document the following in the progress notes: 1) The necessity for physical or mechanical restraint or seclusion, and inadequacy of less restrictive intervention and what interventions have already been attempted; 2) The type of physical or mechanical restraint or seclusion; 3) The expected behavior necessary for release from physical or mechanical restraint or seclusion; and 4) The physical condition of individual prior to the use of mechanical restraint or seclusion. 5) Methods for staff to use to assist the individual in regaining control. A. Until a physician is reached for an order, individuals may be mechanically restrained or secluded under sanction from a registered nurse. In these emergency application situations, an order must be obtained either during the emergency application of the restraint or seclusion, or immediately (within a few minutes) after the restraint or seclusion has been applied. The failure to immediately obtain an order is viewed as the application of restraint or seclusion without an order. Emergency or critical situations that delay the registered nurses ability to obtain an order beyond the expected few minutes should be documented in the individual record. The registered nurse who sanctioned the restraint or seclusion shall document the physician phone/verbal order on an emergency basis. B. The physician giving the verbal order shall conduct a clinical assessment of the individual within one hour of the initiation of the seclusion or restraints and enter a written order authorizing the restraints or seclusion in the individual’s record at time the assessment is completed. C. Registered nurse documentation shall proceed according to the facility policy, including the following: 1) When procedure is initiated; 2) Every hour while in restraints or seclusion; 3) Upon release from seclusion or restraint; and 4) Upon notification that individual’s dangerous condition appears to have ceased. 6. All staff who implement written orders for restraint or seclusion shall have documented annual training and be certified in the proper use of the procedure for which the order was written.

Hospital Policy PC.03.01 Restraint and Seclusion Page 7 of 8 7. The following shall apply to any use of physical or mechanical restraints or seclusion; A. Only approved principles and techniques consistent with SMART Training for physical or mechanical restraints are used; B. Instances in which physical, mechanical restraint or seclusion is used is documented on appropriate facility forms; and C. Standing or PRN order shall not be used. D. Mechanical restraint of individuals in a prone position is prohibited 1. In the event that a technique/procedure used to initiate a manual restraint results in the individual being in a prone (“face down”) position, staff will as soon as possible proceed to move the individual into a side or supine (“face up”) position. 2. Staff will monitor for any signs of seizure, choking or aspiration in individuals in supine positions, and reposition such individuals on their sides as indicated. 3. In the event that the individual cannot be immediately moved into a side or supine position, a staff member solely responsible for monitoring the status and well being of the individual in restraint will be assigned so as to alert staff engaged in the restraint of any immediate need to release or to alter the restraint technique. 8. As any application of restraint or seclusion is seen as an indicator of a suboptimal response to treatment, the following steps shall be taken to reduce the likelihood of reoccurrence of the need for restraints or seclusion: A. Facility Leadership will review debriefing reports of seclusion or restraint incidents at regular intervals to ensure that every effort was made to avoid the application. Furthermore, in its review, leadership will assess the extent to which the individual’s physical and psychological well being was cared for and the potential for traumatization was minimized. Areas for improvement identified through such reviews will be conveyed to the individual’s treatment team. B. Upon application, there will be a written modification to the treatment plan to reflect the use of restraint or seclusion and in an attempt to identify methods of reducing the likelihood of reoccurrence. C. As soon as possible, but no later than 24 hours after the incident, an individual debriefing will take place (including the family as appropriate) in order to: 1) Identify what led to the incident and what could be done differently; 2) Ascertain that the individual’s physical well-being, psychological comfort and right to privacy were addressed; and 3) Counsel the individual for any trauma. D. Modifications to the ITRP will be made as necessary based on the debriefings and treatment team review. E. Restraints shall not be used as a means of coercion, as discipline or punishment, for the convenience of staff, as retaliation by staff, as a substitute for treatment or rehabilitation programming as a sole purpose of transfer from an individual psychiatric facility to a more secure psychiatric setting or a replacement for adequate levels of staff, or used in a manner that causes undue physical discomfort or pain to the individual. F. Improper use of a restraint technique or any excess application of force shall be considered abuse and is cause for disciplinary action against the employee. Staff members are encouraged to consider utilizing ASAP as a result of the seclusion/restraint event. 9. The medical staff through the Quality Management Department is responsible for the risk management issues regarding seclusion or restraint. These shall include, but not be limited to, the following: A. Identify and report when seclusion or restraint is used longer than 12 hours or when 2 or more incidents happen in any 12 hour period;

Hospital Policy PC.03.01 Restraint and Seclusion Page 8 of 8 B. Identify and report all unusual or possible unwarranted patterns of utilization including but not limited to trends in shift, initiating staff, episode length, date and time, day of the week, type, injuries to individuals or staff, individual age, individual gender; C. Identify and report facility utilization of seclusion or restraint at periodic intervals, but not less than quarterly; D. Annually review facility policies, procedures and training programs and recommend necessary changes to the facility head; and E. Identify and approve physical restraint procedures for use in the facility. 10. The executive team will maintain continuous efforts to reduce the use of seclusion and restraint and traumatic effects associated with their application by prominently reflecting such efforts in strategic initiatives and performance improvement processes. 11. Failure to follow this policy could result in disciplinary action up to and including dismissal as a result of but not limited to client abuse, incompetence, insubordination, or for good of the service. Reference: Individualized Treatment Planning Manual Nursing Policy PC.03.01.06 SMART Training Manual & Curriculum DOR 4.140 – Use of Restraints, Seclusion and Time Out DOR 4.152 – Administration of Psychotropic Medications Involuntarily

APPEND

DIX B.

U.S. EQUAL EMPLOYMENT OPPORTUNITY COMMISSION Office of Legal Counsel 131 M St, N. E., Fifth Floor Washington, D. C. 20507 Free: (833) 827-2920 ASL: (844) 234-5122 FAX: (202) 827-7545 Website: www.eeoc.gov February 7, 2022 VIA: [email protected] Michael Ayele (aka) W ASSOCIATION FOR THE ADVANCEMENT OF CIVIL LIBERTIES P.O. Box 20438 Addis Ababa, ETHIOPIA 10013 Re: FOIA No.: 820-2022-003264 Communications about the NCD making recommendations on disability issues Dear Mr. Ayele (aka) W: Your Freedom of Information Act (FOIA) request, received on 01/03/2022, is processed. Our search began on 01/19/2022. The initial due date was extended by 10-business days per our correspondence dated 01/31/2022. The paragraph(s) checked below apply. [X] Portions of your request are as follows: [X] Granted; [X] Denied pursuant to the subsections of the FOIA indicated at the end of this letter. An attachment to this letter explains the use of these exemptions in more detail; and [X] Procedurally denied as no records fitting the description of the records you seek disclosed exist or could be located after a thorough search. See the Comments page for further explanation. [X] I trust that the furnished information fully satisfies your request. If you need any further assistance or would like to discuss any aspect of your request, please do not hesitate to contact the FOIA Professional who processed your request or our FOIA Public Liaison (see contact information in above letterhead or under signature line). [X] You may contact the Acting EEOC FOIA Public Liaison Michael L. Heise for further assistance or to discuss any aspect of your request. In addition, you may contact the Office of Government Information Services (OGIS) to inquire about the FOIA mediation services they offer. The contact information for OGIS is as follows: Office of Government Information Services, National Archives and Records Administration, 8601 Adelphi Road-OGIS, College Park, Maryland 20740- 6001, email at [email protected]; telephone at (202) 741-5770; toll free 1-877-684-6448; or facsimile at (202) 741-5769. The contact information for the FOIA Public Liaison is as follows: Michael L. Heise, EEOC FOIA Public Liaison, Office of Legal Counsel, FOIA Division, Equal Employment Opportunity Commission, 131 M. Street, N.E., Fifth Floor, Washington, D.C. 20507, email to [email protected], telephone at (202) 921-2542; or fax at (202) 827-7545. [X] If you are not satisfied with the response to this request, you may administratively appeal in

820-2022-003264 2 | Page writing. Your appeal must be postmarked or electronically transmitted in 90 days from receipt of this letter to the Office of Legal Counsel, FOIA Division, Equal Employment Opportunity Commission, 131 M Street, NE, 5NW02E, Washington, D.C. 20507, email to [email protected]; online at https://eeoc.arkcase.com/foia/portal/login, or fax at (202) 827-7545. Your appeal will be governed by 29 C.F.R. § 1610.11. [X] See the attached Comments page for further information. Sincerely, Michael L. Heise Assistant Legal Counsel (Acting) [email protected] Applicable Sections of the Freedom of Information Act, 5 U.S.C. § 552(b): Exemption(s) Used: [X] (3)(A)(i) [X] Section 706(b) of Title VII [X] Section 709(e) of Title VII [X] Section 107 of the ADA [X] Section 207 of the GINA Exemption 3 to the Freedom of Information Act (FOIA), 5 U.S.C. § 552(b)(3)(A)(i) (2016), as amended by the FOIA Improvement Act of 2016, Pub. L. No. 114-185, 130 Stat. 538, states that disclosure is not required for a matter specifically exempted from disclosure by statute if that statute: (A)(i) requires that the matters be withheld from the public in such a manner as to leave no discretion on the issue[.] Sections 706(b) and 709(e) of Title VII of the Civil Rights Act of 1964, 42 U.S.C. §§ 2000e-5(b), 2000e8(e)(2006), are part of such a statute. Section 706(b) provides that: Charges shall not be made public by the Commission . . . . Nothing said or done during and as a part of [the Commission's informal endeavors at resolving charges of discrimination] may be made public . . . . Section 709(e) of Title VII provides: It shall be unlawful for any officer of the Commission to make public in any manner whatever any information obtained by the Commission pursuant to its authority under this section [to investigate charges of discrimination and to require employers to maintain and submit records] prior to the institution of any proceeding under this title involving such information. Section 107 of the Americans with Disabilities Act (ADA) and § 207 of the Genetic Information Nondiscrimination Act (GINA) adopt the procedures of Sections 706 and 709 of Title VII. See EEOC v. Associated Dry Goods Co., 449 U.S. 590 (1981); Frito-Lay v. EEOC, 964 F. Supp. 236, 239-43 (W.D. Ky.

820-2022-003264 3 | Page 1997); American Centennial Insurance Co. v. EEOC, 722 F. Supp. 180 (D.N.J. 1989); and EEOC v. City of Milwaukee, 54 F. Supp. 2d 885, 893 (E.D. Wis. 1999). INFORMATION WITHHELD PURSUANT TO THE THIRD EXEMPTION TO THE FOIA: Entire Charge file, to include communications, for Charge No. 28E–2014–00485C. COMMENTS This office’s response to your request is as follows: (1) Your request for “formal and informal ties existing between the Equal Employment Opportunity Commission (EEOC), the National Council on Disability (NCD), the Department of Justice (DOJ), and the Department of Health and Human Services (HHS),” is granted. The EEOC provides leadership and guidance to federal agencies on all aspects of the federal government's equal employment opportunity program. The requested information is already available online, via EEOC’s public website. See the following link: https://www.eeoc.gov/federalsector. (2) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as an independent federal agency mandated to make recommendations to the President and Congress on disability issues” is procedurally denied procedurally denied. No records exist within the EEOC. (3) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency emphasizing that people with disabilities should be the ones who make the major decisions about their lives” is procedurally denied. No records exist within the EEOC. (4) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency that endorses and supports the principles of independent living” is procedurally denied. No records exist within the EEOC. (5) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which recognizes that people with psychiatric disabilities are routinely deprived of their rights in a way no other disability group has been” is procedurally denied. No records exist within the EEOC. (6) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which has previously heard testimony graphically describing how people with a psychiatric disability have been beaten, shocked, isolated, incarcerated, restricted, raped, deprived of food and bathroom privileges, and physically and psychologically abused, in institutions and in their communities” is procedurally denied. No records exist within the EEOC. (7) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which has previously been informed about the routine use and overuse of psychiatric drugs, often against people’s will,” is procedurally denied. No records exist within the EEOC. (8) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the overuse of psychiatric drugs against people’s will being inconsistent with Title IX of the Education Amendments Act of 1972” is procedurally denied. No records exist within the EEOC.

820-2022-003264 4 | Page The U.S. DoEd Office of Civil Rights (OCR) ensures equal access to education under Title IX. You may wish to submit a request to that Agency. See the following link: https://www2.ed.gov/policy/gen/leg/foia/foiatoc.html. (9) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the overuse of psychiatric drugs against people’s will being inconsistent with the concept of affirmative and effective consent” is procedurally denied. No records exist within the EEOC. (10) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the overuse of psychiatric drugs against people’s will being comparable to what the HHS refers to as a “drug facilitated sexual assault” is procedurally denied. No records exist within the EEOC. (11) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the HHS identifying Rohypnol (flunitrazepam), GHB (gamma hydroxybutyric acid), and Ketamine, as the three most common date rape drugs” is procedurally denied. No records exist within the EEOC. (12) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the statement provided by Marcie Kelley to the NCD attesting that “eight men jumped on top of [her] (…) wrestled her to the floor (…) and shot [her] up with Thorazine”” is procedurally denied. No records exist within the EEOC. (13) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which has concluded that the manner in which American society treats people with psychiatric disabilities constitutes a national emergency and a national disgrace” is procedurally denied. No records exist within the EEOC. (14) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which has concluded that one of the reasons public policy concerning psychiatric disability is so different from that concerning other disabilities is the systemic exclusion of people with psychiatric disabilities from policymaking” is procedurally denied. No records exist within the EEOC. (15) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which recommends for the use of involuntary treatments, such as forced drugging and inpatient and outpatient commitment laws, to be viewed as inherently suspect and as incompatible with the principles of self-determination,” is procedurally denied. No records exist within the EEOC. (16) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which recommends for aversive treatments that involve the infliction of pain or the restriction of movement for purposes of changing behavior to be banned” is procedurally denied. No records exist within the EEOC. (17) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which recommends for people labeled with psychiatric disabilities to have a major role in the direction and control of programs and services designed for their benefits” is procedurally denied. No records exist within the EEOC. (18) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which recommends for public policy to move toward the elimination of electro-convulsive therapy and psycho surgery” is procedurally denied. No records exist within the EEOC. (19) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which recommends for research and demonstration resource to place

820-2022-003264 5 | Page a higher priority on the development of culturally appropriate alternative” is procedurally denied. No records exist within the EEOC. (20) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which recommends for services in the community to not be contingent on participation in treatment programs” is procedurally denied. No records exist within the EEOC. (21) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which recommends for employment and vocational rehabilitation program to account for the wide range of abilities, skills, knowledge, and experience of people labeled with psychiatric disabilities” is procedurally denied. No records exist within the EEOC. The U.S. DOL Office of Federal Contract Compliance Programs (OFCCP) is responsible for the administration and enforcement of nondiscrimination in employment by government contractors and subcontractors. You may wish to submit a request to that Agency. See the following link: https://www.dol.gov/general/foia. (22) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which recommends for federal income support programs like Supplemental Security Income and Social Security Disability Insurance to provide flexible and workfriendly support options so that people with episodic or unpredictable disabilities are not required to participate in the current ‘all or nothing’ federal disability benefit system, often at the expense of pursuing their employment goals,” is procedurally denied. No records exist within the EEOC. (23) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which recommends for parity to be defined in terms of voluntary treatments and services” is procedurally denied. No records exist within the EEOC. (24) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which recommends for government civil rights enforcement agencies and publicly-funded advocacy organization to work more closely together and with adequate funding to implement effectively critical existing laws like the Americans with Disabilities Act, Fair Housing Act, Civil Rights of Institutionalized Persons Act, Protection and Advocacy for Individuals with Mental Illness Act, and Individuals With Disabilities Education Act,” is procedurally denied. No records exist within the EEOC. (25) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the NCD as a federal agency, which recommends for children and young adults with disabilities, particularly those labeled seriously emotionally disturbed, to not be placed in correctional facilities and other segregated settings” is procedurally denied. No records exist within the EEOC. (26) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the articles published in the Hartford Courant on October 11, 1998, entitled A Nationwide Pattern of Death” is procedurally denied. No records exist within the EEOC. (27) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the article published in the Hartford Courant entitled Why They Die: Little Training, Few Standards, Poor Staffing” is procedurally denied. No records exist within the EEOC. (28) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the decision of the Hartford Courant to quote a psychologist who stated that staff of mental health institutions were really behaving like cowboys” is procedurally denied. No records exist within the EEOC.

820-2022-003264 6 | Page (29) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the article published in the Hartford Courant on October 13, 1998, entitled Patients Suffer In A System Without Oversight” is procedurally denied. No records exist within the EEOC. (30) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the decision of the Hartford Courant to quote a doctor who said that staff members of mental health institutions should follow their conscience” is procedurally denied. No records exist within the EEOC. (31) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the Health Insurance Portability and Accountability Act (HIPAA) providing the opportunity for covered entities of mental hospitals to object to the treatment of a patient/prisoner” is procedurally denied. No records exist within the EEOC. (32) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the Government Accountability Office (GAO) September 1996 report entitled Medicaid: Oversight of Institutions for the Mentally Retarded Should Be Strengthened” is procedurally denied. No records exist within the EEOC. (33) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the Hartford Courant October 14, 1998, article entitled People Die and Nothing Is Done” is procedurally denied. No records exist within the EEOC. (34) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the May 1997 report into the Napa State Hospital’s Failure to Protect Residents from Abusive Seclusion and Restraint Practices and to Properly Investigate Related Potential Criminal Acts by Staff” is procedurally denied. No records exist within the EEOC. (35) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the May 1997 report highlighting within Napa State Hospital (NSH) a failure to speak out when wrongdoing is committed by co-workers” is procedurally denied. No records exist within the EEOC. (36) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the decision of several news outlets to report on the “blue wall of silence” that was crumbling in the Derek Chauvin trial” is procedurally denied. No records exist within the EEOC. (37) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the October 15, 1998, article published in the Hartford Courant entitled From Enforcer to Counselor” is procedurally denied. No records exist within the EEOC. (38) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about Michael A. Ayele, a.k.a. W, as a Black man who applied for a Social Security card with the assistance of Westminster College, located in Fulton, Missouri, between January 2010 and March 2010” is procedurally denied. No records exist within the EEOC. (39) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about Michael A. Ayele, a.k.a. W, as a Black man whose application for a social security number (SSN) was granted by the Social Security Administration (SSA) in 2010” is procedurally denied. No records exist within the EEOC. (40) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about Michael A. Ayele, a.k.a. W, as a Black man who worked for the Fulton State Hospital (FSH) between June and December 2013” is denied pursuant to the third exemption to the FOIA. 5 U.S.C. § 552(b)(3)(A)(i).

820-2022-003264 7 | Page The confidentiality provisions of Title VII of the Civil Rights Act, the ADA, and GINA, prohibit the EEOC from granting access to, or copies of, a charge brought by an individual to a third party of the charge. The third exemption to the FOIA exempts this information from disclosure. (41) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about Michael A. Ayele, a.k.a. W, as a Black man who has expressed concerns about the language used by the Director of the Division of Behavioral Health (DBH) pertaining to the involuntary administration of psychotropic drugs” is denied pursuant to the third exemption to the FOIA. 5 U.S.C. § 552(b)(3)(A)(i). See #40 above. (42) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about Michael A. Ayele, a.k.a. W, as a Black man who has cautioned the DBH to refrain from forcibly administering psychotropic drugs unto patients/prisoners not posing harm to themselves and others” is denied pursuant to the third exemption to the FOIA. 5 U.S.C. § 552(b)(3)(A)(i). See #40 above. (43) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about Michael A. Ayele, a.k.a. W, as a Black man who has advised the DBH to submit video and audio evidence of patients/prisoners posing harm to themselves and others before any hearing where employees and legal representatives of the DBH are considering the drastic measure of forcibly administering psychotropic drugs” is denied pursuant to the third exemption to the FOIA. 5 U.S.C. § 552(b)(3)(A)(i). See #40 above. (44) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about Michael A. Ayele, a.k.a. W, as a Black man who has opposed preferential treatment in the service of healthcare as a former employee of the FSH” is denied pursuant to the third exemption to the FOIA. 5 U.S.C. § 552(b)(3)(A)(i). See #40 above. (45) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about Michael A. Ayele, a.k.a. W, as a Black man who had expressed these objections pursuant to the Health Insurance Portability and Accountability Act (HIPAA) when he was a covered entity of the FSH” is denied pursuant to the third exemption to the FOIA. 5 U.S.C. § 552(b)(3)(A)(i). See #40 above. (46) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about Michael A. Ayele, a.k.a. W, as a Black man who has lived several horrible experiences between January 07, 2016, and July 2016 similar to the testimonies provided to the NCD” is procedurally denied. No records exist within the EEOC. (47) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about Michael A. Ayele, a.k.a. W, as a Black man who has had similar experiences to Marcie Kelley between January 07, 2016, and January 13, 2016,” is procedurally denied. No records exist within the EEOC. (48) Your request for “documents outlining the policy adopted by your mental health service provider on limiting the use of restraint and seclusion for people with disabilities” is procedurally denied. No records exist within the EEOC. (47) Your request for “documents outlining the policy adopted by your mental health service provider on the forcible administration of psychotropic drugs” is procedurally denied. No records exist within the EEOC. (48) Your request for “documents outlining the exception(s) granted by your mental health service provider to religious practitioners of Rastafarianism” is procedurally denied. No records exist within the EEOC.

820-2022-003264 8 | Page (49) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the decision of the Joseph R. Biden White House Administration to issue a statement on the Celebration of Enkutatash on September 10, 2021,” is procedurally denied. No records exist within the EEOC. (50) Your request for “[EEOC] communications in the form of e-mails and postal correspondence about the article published by the British Broadcasting Corporation (BBC) pertaining to the Ethiopian calendar on September 11, 2021,” is procedurally denied. No records exist within the EEOC. (51) Your request for “the academic background, the professional responsibilities, and annual salaries, of Yerker Andersson, Dave N. Brown, John D. Kemp, Audrey McCrimon, Gina McDonald, Nonnie O’Day, Lilliam Rangel-Diaz, Debra Robinson, Shirley W. Ryan, Michael B. Unhejm, Rae E. Unzicker, Ella Yazzie-King, Ethel D. Briggs, Mark S. Quigley, Kathleen A. Blank, Geraldine Drake Hawkins, Susan Madison, Allan W. Holland, Brenda Bratton, Stacey S. Brown, Rae E. Unzicker, Kate P. Wolters, Leye Chrzanowski, Mike Ervin, and Judi Chamberlin,” is procedurally denied. No records exist within the EEOC. This response was prepared by Joanne Murray, Government Information Specialist, who may be reached by telephone at (202) 921-2541.

U.S. EQUAL EMPLOYMENT OPPORTUNITY COMMISSION Office of Legal Counsel 131 M St, N. E., Fifth Floor Washington, D. C. 20507 Free: (833) 827-2920 FAX: (202) 827-7545 Website: www.eeoc.gov January 31, 2022 VIA: [email protected] Michael Ayele (aka) W Association for the Advancement of Civil Liberties P.O. Box 20438 Addis Ababa, ETHIOPIA 10013 Re: FOIA No.: 820-2022-003264 Communications about the NCD making recommendations on disability issues Dear Mr. Ayele (aka) W: This letter is in response to your request or appeal under the Freedom of Information Act (FOIA), received by our office on 01/03/2022. As provided in U.S.C. § 552(a)(6)(B) (2007), we hereby provide you with the required written notice that we are extending by ten (10) working days the time in which we shall respond. Such extension is necessary because of the following “unusual circumstances”: [X] (i) the need to search for and collect the requested records, if any exist, from field offices or other establishments that are separate from this office; [X] If you have any questions or wish to discuss reformulation or an alternative time frame for the processing of your request, you may contact Joanne Murray, the FOIA Professional handling your request, at (202) 921-2541. Additionally, you may contact the Office of Government Information Services (OGIS) at the National Archives and Records Administration to inquire about the FOIA mediation services they offer. The contact information for OGIS is as follows: Office of Government Information Services, National Archives and Records Administration, 8601 Adelphi Road-OGIS, College Park, Maryland 20740-6001; email at [email protected]; telephone at (202) 741-5770; toll free (877) 684- 6448; or facsimile at (202) 741-5769. We will make every attempt to respond to your request by 02/15/2022. Sincerely, / Joanne Murray / for _____________________________ Michael L. Heise Acting Assistant Legal Counsel [email protected]

U.S. EQUAL EMPLOYMENT OPPORTUNITY COMMISSION Office of Legal Counsel 131 M St, N. E., Fifth Floor Washington, D. C. 20507 Free: (833) 827-2920 TTY: (202) 663-6056 FAX: (202) 663-7026 Website: www.eeoc.gov 01/03/2022 VIA: [email protected] Michael Ayele (aka) W Association for the Advancement of Civil Liberties P.O.Box 20438 Addis Ababa, ETHIOPIA Addis Ababa, ETHIOPIA, ETHIOPIA 10013 Re: FOIA No.: 820-2022-003264 Dear Mr. Ayele (aka) W: Your request under the Freedom of Information Act (FOIA), 5 U.S.C. § 552, received by the Office of Legal Counsel on 01/03/2022, is assigned to the [ X ] Simple [ ] Complex [ ] Expedited track with the above FOIA number. Your request will be processed by Government Information Specialist Joanne Murray who can be reached at (202) 921-2541. [ X ] EEOC will make every effort to issue a determination on your request on or before 02/01/2022. FOIA and EEOC regulations provide 20 working days to issue a determination on a request, not including Saturdays, Sundays and federal holidays. In unusual circumstances, EEOC may extend the 20 working days by 10 additional working days or stop processing your request until you respond to our request for fee or clarifying information. Should EEOC take an extension or stop processing your request, notice will be issued prior to the expiration of the 20 working days. You may contact the FOIA Requester Service Center for status updates on your FOIA request or for FOIA information via toll free at (833) 827-2920, to our non-toll free number at (202) 921-2542, by e-mail to [email protected], by facsimile to (202) 653-6034, or by mail to our office address in the letterhead above. Additionally, if your request was filed online through the EEOC FOIA Web Portal, you may monitor its status at https://eeoc.arkcase.com/foia/portal/login. You may also contact the EEOC FOIA Public Liaison, Stephanie D. Garner, for assistance. Sincerely, Joy Shealey/for _____________________________ Stephanie D. Garner Assistant Legal Counsel [email protected] Endnotes

APPEND

DIX C.

Page 1 of 2 GOVERNMENT OF THE DISTRICT OF COLUMBIA BOARD OF ETHICS AND GOVERNMENT ACCOUNTABILITY January 25, 2022 Via Electronic Mail W(AACL) Michael A. Ayele P.O. Box 20438 Addis Ababa, Ethiopia [email protected] RE: FOIA Request 2022-FOIA-02352 Dear Mr. Ayele: This letter responds to Freedom of Information Act (FOIA) request, 2022-FOIA-02352, received on January 4, 2022. You requested the following: “The bases for this request for records are (1) the National Council on Disability (NCD) January 20th 2000 report entitled From Privileges to Rights: People Labeled with Psychiatric Disabilities Speak for Themselves and (2) the Hartford Courant series of article published between October 11 and October 15, 1998. (...) What I am requesting for prompt disclosure are all records within your possession detailing (1) formal and informal ties that exist between your offices, the National Council on Disability (NCD), the Department of Justice (DOJ), the Equal Employment Opportunity Commission (EEOC) and the Department of Health and Human Services (HHS); (2) your communications about the NCD as an independent federal agency mandated to make recommendations to the President and Congress on disability issues; (3) your communications about the NCD as a federal agency emphasizing that people with disabilities should be the ones who make the major decisions about their lives; (4) your communications about the NCD as a federal agency that endorses and supports the principles of independent living; (5) your communications about the NCD as a federal agency, which recognizes that people with psychiatric disabilities are routinely deprived of their rights in a way no other disability group has been; (6) your communications about the NCD as a federal agency, which has previously heard testimony graphically describing how people with psychiatric disability have been beaten, shocked, isolated, incarcerated, restricted, raped, deprived of food and bathroom privileges, and physically and psychologically abused in institutions and in their communities; (7) your communications about the NCD as a federal agency, which has previously been informed about the routine use and overuse of psychiatric drugs, often against people’s will; (8)

Page 2 of 2 your communications about the overuse of psychiatric drugs against people’s will being inconsistent with Title IX of the Education Amendments Act of 1972; (9) your communications about the overuse of psychiatric drugs against people’s will being inconsistent with the concept of affirmative and effective consent; (10) your communications about the overuse of psychiatric drugs against people’s will being comparable to what the HHS refers to as a “drug facilitated sexual assault;” (11) your communications about the HHS identifying Rohypnol (flunitrazepam), GHB (gamma hydroxybutyric acid) and Ketamine as the three most common date rape drugs; (12) your communications about the statement provided by Marcie Kelley to the NCD attesting that “eight men jumped on top of [her] (…) wrestled her to the floor (…) and shot [her] up with Thorazine;” (13) your communications about the NCD as a federal agency, which has concluded that the manner in which American society treats people with psychiatric disabilities constitutes a national emergency and a national disgrace.” Upon review of your request, the undersigned, Sheree DeBerry, Attorney Advisor for the Office of Open Government, Board of Ethics and Government Accountability (BEGA), has determined that your requested records are not maintained by BEGA. If for any reason, you disagree with this finding, you may submit an administrative appeal to the Mayor via the District of Columbia Government Freedom of Information Act Public Access Website (PAL) by logging in with your username and password. You may also submit an appeal via email to [email protected] or by U.S. Postal Service to: Mayor’s Correspondence Unit FOIA Appeal 1350 Pennsylvania Ave, NW Suite 407 Washington, D.C. 20004 The appeal letter must include “Freedom of Information Act Appeal” or “FOIA Appeal” in the subject line of the email and marked on the outside of the envelope. If sending an appeal by email or hard copy, it must include a copy of the original request as well as a copy of the denial letter issued to you. The appeal must include a written statement of the arguments, circumstances, or reasons in support of the information sought by your request. /s/ Sheree DeBerry Attorney Advisor Board of Ethics and Government Accountability