A Critical Examination of State Agency Investigations into ...

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Seclusion / unauthorized time-out / abuse / neglectThe school’s use of planned ignore is cited in two places in the Statement ofDeficiencies, in relation to a lack of guidance and clarity to staff in plan implementationas well as a lack of review by a special committee to examine high-risk therapies.However, to the extent that the planned ignore treatment involved extended periods inwhich Jonathan was confined to his room, and the conditions therein, the treatmentconstituted additional violations, including seclusion, unauthorized time-out, or neglect,all of which are forms of abuse.OMRDD regulations defining abuse specifically prohibit seclusion, “Theplacement of a person in a secured room or area from which he or she cannot leave atwill.” 33Although regulations permit a temporary time-out, its use must be implementedby “appropriately trained staff” according to a “written plan” and with “appropriatepermissions.” Use of time-out for disciplinary purposes is prohibited. Neglect is aform of abuse defined as, “A condition of deprivation in which persons receiving servicesreceive insufficient, inconsistent or inappropriate services, treatment, or care to meet theirneeds; or failure to provide an appropriate and/or safe environment for persons receivingservices. Failure to provide appropriate services, treatment, or care by gross error injudgment, inattention, or ignoring may also be considered a form of neglect” 35 (emphasisadded).3433 14 NYCRR § 624.4(c)(4).34 14 NYCRR § 624.20(ap); 14 NCRR § 624.4(c)(7).35 14 NYCRR § 624.4(c)(10).134
Although staff interviewed by the Inspector General’s Office differed as towhether Jonathan’s treatment constituted seclusion, time-out, or neglect, many agreedthat it was at least one of the above. Former OMRDD Executive Deputy CommissionerDeSanto said that the Anderson School violated regulations regarding time-out becausethere was no approved time-out room and written time-out plan utilized by staff. FormerDeputy Commissioner Abelseth told Inspector General’s Office investigators that theterm, time-out or seclusion “is pretty irrelevant…if you want to call it bad time-out [or]bad seclusion, it was neglect….It was planned ignoring gone wrong….This was his ownbedroom, they weren’t letting him out of his bedroom.” Former Area Director Trent said:“I would call that seclusion if they’re not letting him out….[Planned ignoring] is notabout sticking someone in a room….It’s prohibited and considered abuse in our system.”Trent added, “I would have classified it as seclusion and therefore abuse.”An OMRDDsurveyor who had visited the Anderson School on November 3, 2004, reported that “thispractice, taken in the extreme in which it was used with [Jonathan], constitutes seclusion,unauthorized time out or even neglect”(emphasis original).When asked why the Statement of Deficiencies did not cite the Anderson Schoolfor using seclusion, unauthorized time-out, neglect, or mistreatment, Abelseth explainedto the Inspector General that the behavior plan was not written as such. According toAbelseth, this means that Jonathan’s behavior plan, which was focused on implementinga planned ignore, did not appear to intend to implement seclusion or time-out, per se.Abelseth added, “Through a lot of incompetence at all levels, staff was doing what theythought was right.” She continued, “It was a poor behavior plan to begin with, JonathanCarey was very difficult, very difficult…staff were at their wits’ end, there was no135
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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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continues. Does he take a multivita
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Executive Director stated that arou
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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 100 and 101: are responsible for conducting thei
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Page 104 and 105: Taconic Regional Office’s Finding
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Page 108 and 109: When questioned about the Taconic r
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Page 112 and 113: What were the employees doing that
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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
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Page 124 and 125: additional information was availabl
Page 126 and 127: his supervisor at the time, then-Ar
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Page 134 and 135: Former Regional Director Articola s
Page 136 and 137: BruisingAlthough the Careys noted t
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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
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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
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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
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Page 172 and 173: Jonathan’s “demeanor has change
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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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A Critical Examination of State Agency Investigations into ...

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