A Critical Examination of State Agency Investigations into ...
A Critical Examination of State Agency Investigations into ... A Critical Examination of State Agency Investigations into ...
clinical director role, psychiatrist - over medication dangers.” The minutes cited JonathanCarey as an example, noting an “11 year old child with autism withheld food as abehavior management; leaving him in his room for 36 hours (unsubstantiated); lack ofclothing; no food.”OMRDD’s former Deputy Commissioner for Quality Assurance, Dr. JanAbelseth, reported that the initial survey team substantiated the majority of the Careys’allegations. She recalled that the planned ignoring was one of the problems withJonathan’s behavior plan and further told the Inspector General’s Office that Jonathan’splan was “not planned ignore, that’s neglect.” She added, “You use planned ignoring allthe time….Think about as a parent, you ignore behaviors because you don’t want toreinforce it by giving it attention. But the planned ignoring, when you are actuallyrefusing to give people basic services, is when it becomes abuse.” Trent stated to theInspector General’s Office, “I think the techniques that Anderson School [used] clearlymet the definition of abuse. What they were doing was abusive; whether they intended itto be, or not, is beside the point…you can’t do that stuff.” She referred to the behaviormanagement procedures used with Jonathan Carey as “appalling.” When informed bythe Inspector General that a proposed behavior plan did not get approval from the familyand that the techniques did not seem to be properly vetted, former OMRDDCommissioner Maul indicated that, “Some [behavioral] programs should not be offeredup for approval anyhow….You seem to be talking about a situation that totally removesall dignity and all rights from an individual.”E-mail correspondence from the November 9-10, 2004, survey team indicates thatthe team identified, among other problems, systemic flaws in behavior plans, inadequate126
staff training, and a lack of coordination at the Anderson School. It was noted in the e-mail that the surveyor “did not find any gross negligence or failure at the school,however, there does appear to be some significant flaws that if left unchecked could leadto serious problems for individual students.”Description of Statement of DeficienciesThe Statement of Deficiencies identified a number of violations of rights set forthin 14 NYCRR § 633.4. All individuals in facilities certified by OMRDD are entitled tothese rights, as outlined earlier in this report, with any limitations being “on an individualbasis, for a specific period of time, and for clinical purposes only.” According to theregulation, “The rights… are intended to establish the living and/or program environmentthat protects individuals and contributes to providing an environment in keeping with thecommunity at large, to the extent possible, given the degree of the disabilities of thoseindividuals.” The following violations were identified by OMRDD:• The Anderson School presented completed treatment plans toparents/guardians for review, not providing them with the opportunity toparticipate in the development of the plans and with little or noopportunity to object to plans (§ 633.4(a)(4)(viii)(a)).• The Anderson School violated the right to “services, including assistanceand guidance, from staff who are trained to administer servicesadequately, skillfully, safely, and humanely, with full respect for theindividual’s dignity and integrity” (§ 633.4(a)(4)(ix)). The lack of clarityand guidance in treatment plans, and specifically the failure to specify atime limit for forcing Jonathan to remain in his room were criticized inthis finding.• The Anderson School violated the right to “a balanced and nutritious diet,served at appropriate times and in as normal a manner as possible, andwhich is not altered or totally denied for behavior management ordisciplinary purposes” (§ 633.4(a)(4)(xvii)). According to the Statementof Deficiencies, the behavior plan for Jonathan made his access to meals at127
- Page 80 and 81: naked to prevent him from leaving t
- 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 102 and 103: School policies and procedures. Inv
- 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 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
- Page 152 and 153: While reports indicated that the An
- Page 154 and 155: facilities like the Anderson School
- Page 156 and 157: egistry, and then it seems there wa
- Page 158 and 159: INVESTIGATION BY THE NEW YORK STATE
- Page 160 and 161: target(s) of the complaint engaged
- Page 162 and 163: arely used by CQC to substantiate a
- Page 164 and 165: The second paragraph of the case su
- Page 166 and 167: CQC Director of Quality Assurance a
- Page 168 and 169: primarily to the provision of meals
- Page 170 and 171: interview notes would have been exp
- Page 172 and 173: Jonathan’s “demeanor has change
- Page 174 and 175: that the additional complaints of a
- Page 176 and 177: and aggressive behavior related to
- Page 178 and 179: systemic significance.” In a hear
staff training, and a lack <strong>of</strong> coordination at the Anderson School. It was noted in the e-mail that the surveyor “did not find any gross negligence or failure at the school,however, there does appear to be some significant flaws that if left unchecked could leadto serious problems for individual students.”Description <strong>of</strong> <strong>State</strong>ment <strong>of</strong> DeficienciesThe <strong>State</strong>ment <strong>of</strong> Deficiencies identified a number <strong>of</strong> violations <strong>of</strong> rights set forthin 14 NYCRR § 633.4. All individuals in facilities certified by OMRDD are entitled tothese rights, as outlined earlier in this report, with any limitations being “on an individualbasis, for a specific period <strong>of</strong> time, and for clinical purposes only.” According to theregulation, “The rights… are intended to establish the living and/or program environmentthat protects individuals and contributes to providing an environment in keeping with thecommunity at large, to the extent possible, given the degree <strong>of</strong> the disabilities <strong>of</strong> thoseindividuals.” The following violations were identified by OMRDD:• The Anderson School presented completed treatment plans toparents/guardians for review, not providing them with the opportunity toparticipate in the development <strong>of</strong> the plans and with little or noopportunity to object to plans (§ 633.4(a)(4)(viii)(a)).• The Anderson School violated the right to “services, including assistanceand guidance, from staff who are trained to administer servicesadequately, skillfully, safely, and humanely, with full respect for theindividual’s dignity and integrity” (§ 633.4(a)(4)(ix)). The lack <strong>of</strong> clarityand guidance in treatment plans, and specifically the failure to specify atime limit for forcing Jonathan to remain in his room were criticized inthis finding.• The Anderson School violated the right to “a balanced and nutritious diet,served at appropriate times and in as normal a manner as possible, andwhich is not altered or totally denied for behavior management ordisciplinary purposes” (§ 633.4(a)(4)(xvii)). According to the <strong>State</strong>ment<strong>of</strong> Deficiencies, the behavior plan for Jonathan made his access to meals at127
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