A Critical Examination of State Agency Investigations into ...

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