A Critical Examination of State Agency Investigations into ...

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Former Regional Director Articola stated that surveyors do not have to cite eachand every instance of the violation; only one must be cited as an example of a violation.He said citing every example of a violation could lead to multiple pages ofdocumentation of the same violation. Former Executive Deputy Commissioner DeSantoalso explained to the Inspector General that the surveyor is not expected to cite all thedates, rather citing one example as an illustration. Former Area Director Trent similarlymaintained that the purpose of the survey is not to identify every instance ofnoncompliance, but to identify one example, illustrating there could be more, and toensure the agency takes systemic corrective action.As set forth below, OMRDD Central Office’s Statement of Deficienciessufficiently criticized the Anderson School for several violations that were outlined bythe Careys in their allegation of abuse.Lack of parental consent for behavior plansThe first item of the Statement of Deficiencies criticizes the Anderson School forfailing to include parents or guardians in developing treatment plans, instead presentingcompleted treatment plans to them for approval. OMRDD noted the appropriateregulatory violation, and required the Anderson School to correct this deficiency. TheInspector General notes, however, that the Statement of Deficiencies could have gonefarther in describing this violation. It fails to mention that during the period of crisisprior to Jonathan’s removal from the school, his behavior plan was modified withouteven informing the Careys of the modifications after the fact.130
Dietary restrictionsStaff at the Anderson School admitted that Jonathan was fed dairy products onsome occasions, even though his parents had requested a casein-free diet. Evidenceindicates that this was due to a lack of understanding at the school regarding Jonathan’sdietary requirements. Although Jonathan is not mentioned, the Statement of Deficienciessufficiently notes violations of training requirements regarding dietary needs, andcriticizes the staff dietician for not taking a more active part in supervising meals at theschool.Withholding of regular meals for behavior management purposesThe Statement of Deficiencies was accurate in criticizing the Anderson School forviolating Jonathan’s right to a balanced and nutritious diet served at appropriate timesand in as normal a manner as possible, and which is not altered or totally denied forbehavior management purposes, except under the conditions stated in the regulations.Although the Statement of Deficiencies provided only a single example of thewithholding of Jonathan’s regular meal, this, as explained earlier, is not inconsistent withthe surveyors’ purposes.Careys denied communication with JonathanThe Statement of Deficiencies appropriately criticizes the Anderson School fordeveloping and implementing a behavior plan that limited Jonathan’s contact with hisfamily in violation of Jonathan’s rights and without approval from his parents.131
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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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document indicated that Jonathan at
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notified and she consented to the m
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The Anderson School Executive Direc
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naked to prevent him from leaving t
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Anderson School Weekly Body Check F
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Page 86 and 87: Executive Director stated that arou
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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
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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
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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
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 136 and 137: BruisingAlthough the Careys noted t
Page 138 and 139: Seclusion / unauthorized time-out /
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Page 142 and 143: Investigation of complaint by an in
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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
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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
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
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Page 172 and 173: Jonathan’s “demeanor has change
Page 174 and 175: that the additional complaints of a
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Page 178 and 179: systemic significance.” In a hear
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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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