A Critical Examination of State Agency Investigations into ...

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this allegation. The letter was transmitted to OMRDD on more than one occasion. OnNovember 2, 2004, the letter was transmitted to the Taconic regional office by theCareys’ attorney. Also on this date, a facsimile was sent from Taconic regional office toOMRDD Central Office.The Inspector General’s Office questioned former OMRDD Commissioner Maulregarding the misleading information provided to the Governor’s Office. He told theInspector General’s Office he did not recall ever reviewing the document. He said that hisspecial assistant likely reviewed the document and briefed him on its contents.Release of RecordsOMRDD Central Office does not notify parents of the result of its surveys, even ifa survey finds systemic deficiencies that impact a particular child. The Statement ofDeficiencies is provided only to the surveyed facility with a request for a responding Planof Corrective Action. The Careys made a written request pursuant to the Freedom ofInformation Law to obtain a copy of the November 24 Statement of Deficiencies and theAnderson School’s Plan of Corrective Action. According to the Careys, they receivedthe documents from an OMRDD attorney in the summer of 2005, approximately sixmonths after the Plan of Corrective Action was accepted. Michael and Lisa Carey claimthat they requested this material multiple times prior to this date, but OMRDD never sentthem the items as promised. While OMRDD could have been more responsive to theCareys’ request, it appears that they complied with their obligations under the Freedom ofInformation Law to release the records. Effective May 5, 2007, “Jonathan’s Law” waspassed, entitling parents and guardians greater access to records of investigations ofabuse and mistreatment at facilities regulated by OMRDD.146
The Careys also alleged that OMRDD interfered with an investigation by theState Education Department by refusing to release records. According to the StateEducation Department, their investigation was closed because they believed the Careyshad declined to cooperate. The State Education Department informed the InspectorGeneral that they initially had difficulty obtaining records from OMRDD, but StateEducation Department records revealed that OMRDD eventually agreed to allow StateEducation investigators to review its entire file. Thus, the Inspector General’s Officefound no evidence that the State Education Department closed its investigation becauseof OMRDD’s failure to produce records. As noted above, the Inspector Generalcommunicated to the State Education Department that the Careys wished theinvestigation to go forward, and the case was reopened.Additional Monitoring of the Anderson SchoolOMRDD Central Office appropriately continued to monitor the Anderson Schoolfollowing its initial survey in November 24, 2004. These activities, as described below,indicate that OMRDD identified the serious problems associated with the AndersonSchool’s treatment of Jonathan, and sought to pursue additional reforms throughsubsequent monitoring.From late 2004 and continuing into early 2007, OMRDD Central Office staffmaintained a regular presence at the Anderson School, providing technical assistance toimprove behavioral intervention, consumer rights, incident management, dietary services,and coordination of services. OMRDD Central Office staff conducted at least 17 separatesite visits to the school between November 2004 and January 2007, a 27-month span.147
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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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the psychiatrist wrote (in part),
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V. State Agency Investigations of A
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On October 25, 2004, the Careys att
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INVESTIGATION BY THE TACONIC REGION
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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
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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
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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
Page 138 and 139: Seclusion / unauthorized time-out /
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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 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
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
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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
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
Page 196 and 197: focuses. “We did it at the same t
Page 198 and 199: 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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