A Critical Examination of State Agency Investigations into ...

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Investigation of complaint by an involved partyOMRDD regulations specifically prohibit an individual involved in a complaint ofabuse from participating in the investigation of that complaint. 38During OMRDD’sNovember 3, 2004, site visit to the Anderson School, an OMRDD surveyor found thatthis regulation had been violated. OMRDD did not mention this violation in itsNovember 24 Statement of Deficiencies. OMRDD noted in a subsequent letter to theAnderson School, dated December 10, 2004, that the school had improved its proceduresregarding investigations. However, like the November 24, 2004, Statement ofDeficiencies, the December 10, 2004, letter did not mention Jonathan Carey or theAnderson School’s violation of protocols in this instance.Unreported allegation of abuseA violation identified in the Taconic regional office’s letter of findings to theAnderson School, but not in OMRDD’s Statement of Deficiencies, was a finding of“Inadequate follow-up on staff comment about alleged abuse (633.9 violation) –Behavior Management Report 10/4/04.” An Anderson School staff member wrote in aBehavioral Report Form on October 4, 2004, that he considered it to be abusive to denyJonathan food because he would not put on his shirt. Regulations require that allegationsof abuse be “recorded, reviewed, investigated, and reported to designated parties.” 39Anderson School supervisory staff did not generate a required report and make the propernotifications regarding the incident. This finding was not included in OMRDD’sNovember 2004 Statement of Deficiencies, although internal e-mails following the38 14 NYCRR § 624.5(c)(1).39 14 NYCRR § 624.4(a).138
surveyors’ first site visit on November 3, 2004, noted problems with reporting abuseallegations.Inaccurate example regarding meal modificationThe Statement of Deficiencies criticized the Anderson School for deprivingJonathan of his regular meals on October 16, 2004, noting that “he was denied access tomeals at the table contingent upon appropriate behavior and dress” and “there were noprovisions for [him] to receive any meal or supplements if he did not get dressed.” Thelanguage in the one example given implies that Jonathan received no food on this date,which is inaccurate. Although Jonathan did miss meals on October 16, the InspectorGeneral’s Office found that Jonathan was provided with substitute foods in the morningand ate a large meal with his parents in the afternoon. As noted above, OMRDD officialsexplained to the Inspector General that it is typical for a Statement of Deficiencies to giveonly one example of a violation. However, the statement should be accurate in theexamples that it does reference.Acceptance of a Plan of Corrective Action Containing Factual ErrorsOMRDD required the Anderson School to prepare a Plan of Corrective Actionthat would remedy all violations identified in the Statement of Deficiencies. AlthoughOMRDD required the Anderson School to revise its Plan of Corrective Action, it lateraccepted the document even though the school made statements contradicting OMRDD’sfindings and provided dubious explanations for Jonathan’s treatment.On December 21, 2004, the Anderson School submitted its Plan of CorrectiveAction, which responded to each of the violations cited in the Statement of Deficiencies139
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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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OMRDD regulations, OMRDD called the
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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
Page 106 and 107: an entry on an October 4, 2004, Beh
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
Page 122 and 123: SURVEY BY THE OMRDD CENTRAL OFFICEA
Page 124 and 125: additional information was availabl
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Page 130 and 131: clinical director role, psychiatris
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
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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 170 and 171: interview notes would have been exp
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Page 178 and 179: systemic significance.” In a hear
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Page 186 and 187: Documentation of investigatory acti
Page 188 and 189: As noted above, Bowser also failed
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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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