A report released Tuesday morning by a disability rights advocacy group found “widespread systemic deficiencies” at Whiting Forensic Hospital and called on state lawmakers to “enact immediate reforms” to protect the safety and rights of patients at Whiting and Connecticut Valley Hospital.

It isn’t the first investigation of the state-run maximum security psychiatric hospital to conclude there’s a need for systemic improvements.

“In some ways, there’s nothing new here,” said Kathy Flaherty, the executive director of the Connecticut Legal Rights Project, Inc. The new assessment had “interesting tidbits,” Flaherty said, but there’s a long line of reports dating back to the 1950’s that have looked at Connecticut’s inpatient psychiatric institutions.

“I think this adds to the record of demonstrating that things need to change,” she said. “I just don’t want this to be yet another report that people read and put on a shelf.”

In the wake of the abuse of Whiting patient William Shehadi in 2017, investigators with Disability Rights Connecticut spent two years visiting the hospital, talking with patients and reviewing their records. Over the course of their inquiry, state officials separated the Whiting Forensic Division from CVH, formed a task force to study and make recommendations about conditions at the two hospitals, hired a new CEO for the newly created Whiting Forensic Hospital, and took disciplinary action against 37 staffers involved in the abuse against Shehadi.

“Even after all of the things that have happened related to William Shehadi and the abuses and the staff firings, there remains an organizational culture that needs drastic change,” said Gretchen Knauff, executive director of Disability Rights Connecticut, a statewide nonprofit that is the successor to Connecticut’s Office of Protection and Advocacy for Persons with Disabilities. “What they’ve done so far is scratch the surface. It needs to be a more wholesale, organizational change.”

Among the 11 problems found by Knauff’s organization were, among others, the use of restraints for discipline or for the convenience of staff; inadequate individualized assessment and treatment plans; the denial of a patient’s rights to have visitors and meet with their attorney; a dependence on psychotropic drugs to the extent “that they could be considered as part of the patient’s routine regime of medication;” and inadequate death investigations, and abuse and neglect reporting protocols, among others.

The group made a dozen recommendations in the report to the Department of Mental Health and Addiction Services and state legislators. The proposals include independently investigating all unanticipated deaths; getting rid of punitive patient treatment that undermines therapy; training police on patients’ rights; and removing CVH’s statutory exemption from psychiatric hospital licensing requirements.

The goal, Knauff said, is to change the facilities’ culture so that it’s more conducive to addressing patients’ needs and protecting their safety and rights.

In a statement, Diana Shaw, spokeswoman for the Department of Mental Health and Addiction Services, said the agency was still reviewing the report.

“As a system of care, we continually strive to evolve and identify ways in which we can improve our services. The role of independent agencies, such as DRCT, is an important one as they provide an external review of government, industry and organizations in the public realm,” Shaw said. “We are eager to work with DRCT on ways in which we can continue to improve the quality care and services we provide to the over 100,000 individuals we serve every year.”

Of particular concern to Flaherty was the finding that some of the workers dismissed after the patient abuse scandal had won their jobs back through arbitration. Knauff said it was unclear whether those staffers were providing direct patient care.

“If you are put in a position where you are providing patient care there’s a certain level of a sacred trust you take on when you do that job,” Flaherty said. “When you violate that I have a hard time believing you are entitled to the opportunity to do it again.”

The work of Disability Rights Connecticut is separate from the task force lawmakers approved following the patient abuse scandal. The advocacy group started its investigation before the task force was formed and, unlike the task force, is federally funded.

“Our real mission is to look at the human and civil rights of people with disabilities,” said Knauff. Part of that charge is keeping people free from abuse and neglect.

Knauff said there are two task force members — Paul Acker and Nancy Alisberg — affiliated with her organization, but they did not read the report until it was issued.

“It made it cleaner so there was no perception there was a conflict of interest,” Knauff explained.

Michael P. Lawlor, associate professor of criminal justice at the University of New Haven and task force co-chair, said he was not aware the report would be coming out until it was already published. He said he hopes the task force will invite Disability Rights Connecticut to a future meeting so they can share their findings and proposals. That, Lawlor said, could help the task force come up with a long-term plan to pitch to lawmakers.

Lawlor and his peers are tasked with submitting a report to lawmakers by 2021, meaning their findings won’t be considered in the next legislative session, which begins in February.

“I wouldn’t be at all surprised if there were significant legislative proposals made next year to address some of these things,” said Lawlor.

That’s all the better for Flaherty. She said lawmakers should not wait another year for yet another report, this time from the task force, to act.

“I hope they will consider doing something to protect some of the most marginalized people in our state,” Flaherty said. “There are hundreds of people depending on them to do the right thing.”