A Critical Examination of State Agency Investigations into ...
A Critical Examination of State Agency Investigations into ... A Critical Examination of State Agency Investigations into ...
think they wanted him to have the regular meal in his room because it was basicallywhere Jonathan would not come out of his room, everybody really wanted him to comeback, and come out of his room…it got to the point where he seemed content to stay inthe room.” An Anderson School nurse commented, “It would not have been in his bestinterest to bring his regular meal into his room because...the behavior wouldn’t haveended. I think [the Behavior Specialist’s] goal was just to get him back to the norm ofgetting dressed and coming to the table.” The Director of Children’s Residential Servicesadded, “Well, we didn’t want to really encourage him to eat his regular meal in his roombecause it would be reinforcing for him.And then he would never want to reintegrateinto it.” The Anderson School’s “safety and rights of others” justification for Jonathan’smeal deprivation went unchallenged by OMRDD.In addition, the Anderson School’s response directly contradicted OMRDD’sfinding that the school had implemented a behavior plan that prevented Jonathan fromspeaking to his parents. The Anderson School claimed that it was only a draft plan andhad not yet been implemented. However, statements from Anderson School staffmembers clearly indicated that communication was being limited to one specific staffperson and that other staff members were instructed not to have any communication withthe parents. Additionally, the Careys reported that staff at the Anderson School “hadalready politely hung up on us before this week, they had already terminated our call.”Lisa Carey reported that the staff person she normally called to speak with Jonathan toldher that she had been instructed not to speak with the Careys.The Inspector General’s Office asked former Regional Director Articola about theAnderson School’s responses and evidence that suggested that some of the responses142
were inaccurate. Regarding the evidence contradicting the Anderson School’s responsethat Jonathan was “consistently offered nutritionally equivalent meal substitutes in hisroom,” Articola stated, “I think you are right and I don’t know what we did about it….This contradicts the findings, so it raises the question of acceptability.” He thought itmight have been accepted because they looked at what the agency planned to doregarding the violation, going forward. He reiterated that there were differences betweenthe focus of the survey and the investigation and that OMRDD Central Office is moreconcerned with preventing similar issues from occurring again.The Inspector General’s Office questioned former Deputy CommissionerAbelseth about the accuracy of the Anderson School’s response with regard to Jonathan’smeal plan. After reviewing the response, Abelseth stated that although the first part ofthe response was not accurate, and more akin to a denial, the Anderson School thenprovided corrective actions to address the problem, including the development of a taskforce and new standard operating procedure. She emphasized that OMRDD’s acceptanceof the Plan of Corrective Action does not signify that OMRDD agrees with AndersonSchool’s denial. “I can definitely see your point,” Abelseth said, responding to theInspector General’s questions about the Anderson School’s response containingmisinformation. She claimed that OMRDD did not get into the rhetoric as long as thecorrective actions were acceptable. “We were pursuing getting correction at that time.”Therefore, while OMRDD appeared to respond aggressively and appropriately toensure systemic corrective actions were taking place, it also accepted a response from theAnderson School that was, in a number of cases, contradicted and unsupported by theevidence in the Jonathan Carey incident.143
- 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 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
- 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 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
- Page 180 and 181: • Anderson School did not have co
- Page 182 and 183: Jonathan’s casein-free diet, that
- Page 184 and 185: treatment review to the Careys, the
- Page 186 and 187: Documentation of investigatory acti
- Page 188 and 189: As noted above, Bowser also failed
- Page 190 and 191: did not do a full care and treatmen
- Page 192 and 193: CQC’s progress notes indicate tha
- Page 194 and 195: epeatedly attempted to exaggerate t
were inaccurate. Regarding the evidence contradicting the Anderson School’s responsethat Jonathan was “consistently <strong>of</strong>fered nutritionally equivalent meal substitutes in hisroom,” Articola stated, “I think you are right and I don’t know what we did about it….This contradicts the findings, so it raises the question <strong>of</strong> acceptability.” He thought itmight have been accepted because they looked at what the agency planned to doregarding the violation, going forward. He reiterated that there were differences betweenthe focus <strong>of</strong> the survey and the investigation and that OMRDD Central Office is moreconcerned with preventing similar issues from occurring again.The Inspector General’s Office questioned former Deputy CommissionerAbelseth about the accuracy <strong>of</strong> the Anderson School’s response with regard to Jonathan’smeal plan. After reviewing the response, Abelseth stated that although the first part <strong>of</strong>the response was not accurate, and more akin to a denial, the Anderson School thenprovided corrective actions to address the problem, including the development <strong>of</strong> a taskforce and new standard operating procedure. She emphasized that OMRDD’s acceptance<strong>of</strong> the Plan <strong>of</strong> Corrective Action does not signify that OMRDD agrees with AndersonSchool’s denial. “I can definitely see your point,” Abelseth said, responding to theInspector General’s questions about the Anderson School’s response containingmisinformation. She claimed that OMRDD did not get <strong>into</strong> the rhetoric as long as thecorrective actions were acceptable. “We were pursuing getting correction at that time.”Therefore, while OMRDD appeared to respond aggressively and appropriately toensure systemic corrective actions were taking place, it also accepted a response from theAnderson School that was, in a number <strong>of</strong> cases, contradicted and unsupported by theevidence in the Jonathan Carey incident.143
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