A Critical Examination of State Agency Investigations into ...

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additional information was available regarding Jonathan Carey that could have aided thesurveyors in identifying additional regulatory violations.OMRDD’s survey consisted of site visits on three separate dates in whichinvestigators reviewed case files and interviewed employees and supervisors at theAnderson School. During the first visit, on November 3, 2004, surveyors primarilyreviewed the care of Jonathan Carey. OMRDD surveyors interviewed several AndersonSchool administrators and staff and reviewed numerous records. OMRDD Central Officesent a second survey team to the Anderson School on November 9 and 10, 2004. Thefocus of this visit, according to OMRDD Central Office officials, was to assess systemicweaknesses and deficiencies in behavior plans and residents’ treatment, rather thanfocusing only on Jonathan Carey. Thus, surveyors reviewed other Anderson Schoolresidents’ behavior plans and records to determine if the problems identified inJonathan’s case reflected broader issues and problems at the Anderson School.Inspector General’s Findings Regarding Survey ActivitiesAlthough surveyors did spend one full day at the Anderson School dedicated toreviewing Jonathan’s care, and included him in the sample of residents whose behaviorplans were reviewed, the Inspector General notes additional steps that could have beentaken to identify regulatory violations related to his treatment. Most significantly,coordinating with the Taconic regional office’s investigation would have taken littleeffort but would have provided the surveyors with a wealth of information regardingJonathan’s care and regulatory violations that had been identified during the Taconicregional office’s investigation of the abuse allegations.120
Failure to coordinate with Taconic regional officeAlthough the Taconic regional office conducted a thorough investigation of theallegations and noted a number of regulatory violations, the OMRDD Central Officefailed to obtain Taconic regional office’s findings or speak to investigators prior toissuing its Statement of Deficiencies. As a result, the Statement of Deficiencies issued bythe OMRDD Central Office was incomplete, and at times was inconsistent with findingsof the Taconic regional office’s investigation. In addition, the OMRDD Central Officewas able to interview one witness, the Director of Clinical Services, who would not makeherself available to the Taconic regional office. The Taconic regional office’sinvestigation could have benefitted from OMRDD Central Office’s sharing ofinformation obtained from this witness.On November 16, 2004, OMRDD Regional Director Tom Articola wrote an e-mail indicating that the Statement of Deficiencies would include findings from theOMRDD Central Office’s two site survey visits, as well as information obtained duringTaconic regional office’s investigation. However, the Statement of Deficiencies wasmailed to the Anderson School on November 24, a week before the Taconic regionaloffice completed its final report. On November 16, 2004, Investigator Searle, who ledthe Taconic regional office investigation, sent an e-mail to Articola, identifying himselfas the investigator assigned to the Carey case and requesting that they discuss the matter.Searle told the Inspector General’s Office that no one at OMRDD Central Officeresponded to his November 16, 2004, e-mail. According to Articola, who drafted theStatement of Deficiencies, he never saw the report from the Taconic regional office andhe could not recall speaking with anyone there regarding its investigation. Furthermore,121
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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
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To ensure the safety of the residen
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The reports are shared with the fam
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esident’s physical condition, inc
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He could also become physically agg
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RESIDENCY AT THE ANDERSON SCHOOLIn
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Shortly after his admission, Jonath
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a snack such as cereal or verbal pr
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weekend, his behavior was so bad, s
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Experts retained by the Inspector G
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The October 9, 2004, Anderson Schoo
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eally losing it, going bananas basi
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Page 84 and 85: continues. Does he take a multivita
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Page 90 and 91: CQC investigator’s notes reflecte
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Page 94 and 95: V. State Agency Investigations of A
Page 96 and 97: On October 25, 2004, the Careys att
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Page 104 and 105: Taconic Regional Office’s Finding
Page 106 and 107: an entry on an October 4, 2004, Beh
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Page 112 and 113: What were the employees doing that
Page 114 and 115: Central Office. Although the Anders
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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
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Page 134 and 135: Former Regional Director Articola s
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Page 138 and 139: Seclusion / unauthorized time-out /
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Page 148 and 149: Inaccurate Information Provided to
Page 150 and 151: this allegation. The letter was tra
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Page 156 and 157: egistry, and then it seems there wa
Page 158 and 159: INVESTIGATION BY THE NEW YORK STATE
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Page 164 and 165: The second paragraph of the case su
Page 166 and 167: CQC Director of Quality Assurance a
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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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