A Critical Examination of State Agency Investigations into ...
A Critical Examination of State Agency Investigations into ... A Critical Examination of State Agency Investigations into ...
his supervisor at the time, then-Area Director Judy Trent, also acknowledged that she didnot recall reading the Taconic regional office’s investigation report.The Inspector General’s Office asked senior officials at OMRDD about the lackof coordination and apparent breakdown in communication between OMRDD and theTaconic regional office. Former Executive Deputy Commissioner Helene DeSantoagreed that, ideally, OMRDD Central Office and the Taconic regional office should havebetter coordinated their efforts, but she could not explain why they did not. When askedif she thought the surveyors should have had the results of the Taconic regional officeinvestigation prior to issuing the Statement of Deficiencies, DeSanto replied, “Yes, that’sthe best practice.”Trent acknowledged that the Statement of Deficiencies might have been a moredramatic document if OMRDD had obtained information from the incident investigation.“Maybe, on our part, we could have done more, too,” she said, with regards tocoordinating responses. Trent added, “In this instance…we might have profitably joinedforces.” She conceded that, “It is a fair comment that maybe there should have beenbetter coordination.”Former OMRDD Commissioner Maul also confirmed that coordinating the twoprocesses could have strengthened OMRDD Central Office’s November 2004 Statementof Deficiencies. He expressed surprise that OMRDD Central Office did not obtain theTaconic regional office’s findings. Maul stated, “That shouldn’t be. My response is,obviously, that dialogue [between OMRDD and Taconic] should have existed.” Hecontinued, “If you don’t know the specifics of Jonathan, or at least as known at the time,it is very difficult to make an overall judgment. The purposes are very, very related.”122
Failure to interview the family or obtain all pertinent informationAccording to OMRDD documents, a survey generally entails a review ofpertinent documents and interviews of consumers/residents or their parents.Documentation suggested that OMRDD did not communicate with Michael and LisaCarey at any point during their survey, nor did they obtain a logbook from the Careys thatthey claimed proved the abuse of their son. The logbook would have given the surveyorsa more complete picture of Jonathan’s daily treatment, and might have led to additionalregulatory findings, some of which are discussed below.According to an October 30, 2006, e-mail from former OMRDD General CounselPaul Kietzman, it appeared OMRDD first reviewed the logbook in the fall of 2006, nearlytwo years after the Statement of Deficiencies was issued. Given that Jonathan’s allegedabuse was the impetus for the survey, and that interviews with parents are typically a partof the survey process, it would have been appropriate for surveyors to speak toJonathan’s parents and obtain any evidence they could provide.Findings of OMRDD Central Office’s SurveyThe Inspector General reviewed internal memos and correspondence of theOMRDD survey team, which recorded their observations and preliminary conclusions.Several e-mails and the minutes of one meeting reflect a wide range of concernsregarding Jonathan’s care. Most of these findings were later included in the resultingStatement of Deficiencies.Several violations that were omitted from the Statement of Deficiencies had beennoted by surveyors in internal communications. One finding included in internal memos123
- Page 76 and 77: notified and she consented to the m
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- Page 118 and 119: Taconic Regional Office’s Letter
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his supervisor at the time, then-Area Director Judy Trent, also acknowledged that she didnot recall reading the Taconic regional <strong>of</strong>fice’s investigation report.The Inspector General’s Office asked senior <strong>of</strong>ficials at OMRDD about the lack<strong>of</strong> coordination and apparent breakdown in communication between OMRDD and theTaconic regional <strong>of</strong>fice. Former Executive Deputy Commissioner Helene DeSantoagreed that, ideally, OMRDD Central Office and the Taconic regional <strong>of</strong>fice should havebetter coordinated their efforts, but she could not explain why they did not. When askedif she thought the surveyors should have had the results <strong>of</strong> the Taconic regional <strong>of</strong>ficeinvestigation prior to issuing the <strong>State</strong>ment <strong>of</strong> Deficiencies, DeSanto replied, “Yes, that’sthe best practice.”Trent acknowledged that the <strong>State</strong>ment <strong>of</strong> Deficiencies might have been a moredramatic document if OMRDD had obtained information from the incident investigation.“Maybe, on our part, we could have done more, too,” she said, with regards tocoordinating responses. Trent added, “In this instance…we might have pr<strong>of</strong>itably joinedforces.” She conceded that, “It is a fair comment that maybe there should have beenbetter coordination.”Former OMRDD Commissioner Maul also confirmed that coordinating the twoprocesses could have strengthened OMRDD Central Office’s November 2004 <strong>State</strong>ment<strong>of</strong> Deficiencies. He expressed surprise that OMRDD Central Office did not obtain theTaconic regional <strong>of</strong>fice’s findings. Maul stated, “That shouldn’t be. My response is,obviously, that dialogue [between OMRDD and Taconic] should have existed.” Hecontinued, “If you don’t know the specifics <strong>of</strong> Jonathan, or at least as known at the time,it is very difficult to make an overall judgment. The purposes are very, very related.”122
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