A Critical Examination of State Agency Investigations into ...

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School policies and procedures. Investigators analyzed available records to determine thenumber of meals Jonathan missed during the time he was in crisis.Investigators interviewed and obtained statements from 25 Anderson Schoolemployees, including 15 staff members who had direct interaction with Jonathan on analmost daily basis, either in the residence or the classroom. Investigators alsointerviewed the school’s Executive Director, the Director of Children’s ResidentialServices, Jonathan’s Behavioral Specialist, the Birch Residence Manager, the Committeeon Special Education Coordinator, the Staff Development Specialist, Jonathan’s casemanager, the residential coordinator and Jonathan’s OMRDD Medicaid ServiceCoordinator. Additionally, Taconic regional office investigators conducted a telephoneinterview with the Careys.Inspector General’s Findings Regarding Investigative ActivitiesInitial deferment of investigation to Anderson SchoolWhile the Taconic regional office’s initial decision to have the Anderson Schoolconduct the investigation probably had no substantive impact on the final outcome, itwould have been best practice for the Taconic regional office to accept primaryresponsibility for investigating the Careys’ allegation from the outset. Although theInspector General acknowledges that OMRDD regional offices may not have theresources to investigate every allegation at a private facility, the agency should closelyexamine potential conflicts of interest at the facility that is the subject of the complaint,rather than deferring automatically to its policy requiring voluntary agencies to conducttheir own investigations. Where the facility’s administrator has openly acknowledged a98
conflict of interest, whatever the source, OMRDD has a responsibility to preserve thecredibility of the investigatory process and avoid the appearance of bias.Failure to interview two pertinent witnessesThe Inspector General’s Office determined that the Taconic regional officeinvestigators failed to interview two Anderson School employees who could haveprovided valuable information.The Director of Clinical Services, who is responsible for supervision ofimplementation of behavior programs at the school, declined to be interviewed and onlyprovided a written statement. When asked to be interviewed, she reportedly said that“she had other things of greater importance to do and very limited time rather than tospeak with the investigators concerning Jonathan Carey.” Although OMRDDinvestigators are authorized by regulation to interview any staff or other person in thecourse of investigating incidents and allegations of abuse, they did not do so in thisinstance.Likewise, in what appears to be an oversight, investigators did not interview orattempt to interview the registered nurse who had observed and treated Jonathan. Thisnurse had direct evidence regarding Jonathan’s physical condition, noted he was going“longer periods of time…without nourishment,” and identified the substitute food itemsto be offered to Jonathan.99
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Pursuant to Executive Law § 53, th
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INVESTIGATION BY THE TACONIC REGION
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The alleged abuse began in Septembe
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Michael and Lisa Carey. Along with
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The Careys filed a complaint with t
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The Taconic Regional Office’s Inv
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egulatory violations identified in
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compared to consumers in state-oper
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determined that Jonathan’s treatm
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Statements from CQC executives and
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investigating agencies or the Gover
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7. There is no justification for a
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Legislative RecommendationThe Inspe
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and give positive reinforcement for
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separate reports. Taconic’s was i
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4. Did the investigating agencies e
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in the Department of Special Educat
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III. BackgroundNEW YORK STATE SERVI
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abuse or maltreatment within New Yo
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certain OMRDD-certified facilities,
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instances in which the Anderson Sch
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appropriateness of the Dutchess Cou
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Diagram of the Anderson School camp
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Additionally, the Mental Hygiene La
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Among the protections offered in th
Page 52 and 53: To ensure the safety of the residen
Page 54 and 55: The reports are shared with the fam
Page 56 and 57: esident’s physical condition, inc
Page 58 and 59: He could also become physically agg
Page 60 and 61: RESIDENCY AT THE ANDERSON SCHOOLIn
Page 62 and 63: Shortly after his admission, Jonath
Page 64 and 65: a snack such as cereal or verbal pr
Page 66 and 67: weekend, his behavior was so bad, s
Page 68 and 69: Experts retained by the Inspector G
Page 70 and 71: The October 9, 2004, Anderson Schoo
Page 72 and 73: eally losing it, going bananas basi
Page 74 and 75: document indicated that Jonathan at
Page 76 and 77: notified and she consented to the m
Page 78 and 79: The Anderson School Executive Direc
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Page 82 and 83: Anderson School Weekly Body Check F
Page 84 and 85: continues. Does he take a multivita
Page 86 and 87: Executive Director stated that arou
Page 88 and 89: OMRDD regulations, OMRDD called the
Page 90 and 91: CQC investigator’s notes reflecte
Page 92 and 93: the psychiatrist wrote (in part),
Page 94 and 95: V. State Agency Investigations of A
Page 96 and 97: On October 25, 2004, the Careys att
Page 98 and 99: INVESTIGATION BY THE TACONIC REGION
Page 100 and 101: are responsible for conducting thei
Page 104 and 105: Taconic Regional Office’s Finding
Page 106 and 107: an entry on an October 4, 2004, Beh
Page 108 and 109: When questioned about the Taconic r
Page 110 and 111: involved “fully in the program pl
Page 112 and 113: What were the employees doing that
Page 114 and 115: Central Office. Although the Anders
Page 116 and 117: acknowledged there was a “propose
Page 118 and 119: Taconic Regional Office’s Letter
Page 120 and 121: it is not his office’s policy to
Page 122 and 123: SURVEY BY THE OMRDD CENTRAL OFFICEA
Page 124 and 125: additional information was availabl
Page 126 and 127: his supervisor at the time, then-Ar
Page 128 and 129: that is absent from the Statement o
Page 130 and 131: clinical director role, psychiatris
Page 132 and 133: the table contingent on appropriate
Page 134 and 135: Former Regional Director Articola s
Page 136 and 137: BruisingAlthough the Careys noted t
Page 138 and 139: Seclusion / unauthorized time-out /
Page 140 and 141: monitoring or supervision by clinic
Page 142 and 143: Investigation of complaint by an in
Page 144 and 145: and included supporting documentati
Page 146 and 147: think they wanted him to have the r
Page 148 and 149: Inaccurate Information Provided to
Page 150 and 151: this allegation. The letter was tra
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While reports indicated that the An
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facilities like the Anderson School
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egistry, and then it seems there wa
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INVESTIGATION BY THE NEW YORK STATE
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target(s) of the complaint engaged
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arely used by CQC to substantiate a
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The second paragraph of the case su
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CQC Director of Quality Assurance a
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primarily to the provision of meals
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interview notes would have been exp
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Jonathan’s “demeanor has change
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that the additional complaints of a
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and aggressive behavior related to
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systemic significance.” In a hear
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• Anderson School did not have co
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Jonathan’s casein-free diet, that
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treatment review to the Careys, the
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Documentation of investigatory acti
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As noted above, Bowser also failed
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did not do a full care and treatmen
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CQC’s progress notes indicate tha
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epeatedly attempted to exaggerate t
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focuses. “We did it at the same t
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ead, “If he wets again - take she
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Although the statement provided to
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The oversight deficiencies were eve
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that OCFS’s rate of indication is
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In the following sections the Inspe
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On at least one previous occasion,
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emotional injury was impossible in
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facility employee and CQC recommend
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Restrictive Statutory LanguageAltho
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ecognizes that the determination of
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CQC policy does not require further
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CQC wrote in its unfounded notifica
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INVESTIGATION BY THE NEW YORK STATE
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develop sufficient evidence to supp
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There is not proper and safe oversi
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the meeting, “We left it with the
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this important matter. Your corresp
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VI. RECOMMENDATIONSThe Inspector Ge
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ehavior management (14 NYCRR § 633
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child in an institutional setting,
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(a) Records and documents pertainin
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(ii) violent behavior exhibited by
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8. Such commissioners shall provide
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plan of prevention and remediation
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the commission as to the implementa
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Agency Responses to the Inspector G
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incident is reported to have occurr
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Page 2Joseph FischJune 5, 2008conta
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Recommendations: The Inspector Gene
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