A Critical Examination of State Agency Investigations into ...

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While reports indicated that the Anderson School made improvements in many of theseareas, ongoing issues continued to be found and documented.Only two weeks after it issued its Statement of Deficiencies regarding JonathanCarey, OMRDD made another visit to the Anderson School. On December 6-7, 2004,OMRDD Deputy Commissioner for Quality Assurance Abelseth, Chief Psychologist JillPettinger, and other OMRDD staff members conducted this monitoring site visit at theAnderson School. After the visit, Abelseth notified the Anderson School, in a letter datedDecember 10, 2004, of various deficiencies relating to behavior plans, use of plannedignore, and incident management. Although the letter noted incident management andinvestigation procedures had improved since OMRDD’s last visit, other areas of concernremained. With regard to one of the school’s residential programs, OMRDD noted thatone behavior plan sampled was “poorly written,” while another behavior plan lacked“adequate data collection methodologies as only target behavior data was collected.”Similar deficiencies were found by OMRDD with the agency’s educationalprogram. Problems with data collection were noted in the sample of behavior plans,which included Jonathan Carey’s plan:The data collection methods at the…School were deficient as they onlyinvolved collecting data on the target behaviors and did not provide a datacollection or tracking system to monitor progress with use of the identifiedreplacement behaviors.The December 10, 2004, letter also stated that there were “no monthly psychologynotes related to monitoring the progress of the consumers related to the goals/objectivesidentified in their Behavior Support Plans” and “no indication as to when the plans get148
eviewed by the team to determine their effectiveness and when and if changes are inorder.”The December 10 letter further addressed the Anderson School’s use of plannedignore, citing Jonathan Carey as an example. “As written in the behavior plan for[Jonathan], planned ignoring could occur for a very lengthy period of time if theconsumer did not meet the criteria for reentering the residence environment. Also, therewere no time limits identified as to how long this time-out could occur and/or how manyrepeat interventions were appropriate.”OMRDD issued another Statement of Deficiencies in July 2005 related to qualityof behavior plans and incident management systems. In July 2006, yet another Statementof Deficiencies was issued for continued problems with program monitoring andimplementation, dietary processes, and Individualized Education Program coordinationbetween the residential and educational programs at the Anderson School. In eachinstance, Anderson School responded with a plan of correction action. As recently asJanuary 2007, OMRDD issued a Statement of Deficiencies to the Anderson School forcontinued problems in the area of behavior plan implementation and monitoring, and lackof an appropriate number of occupational and/or physical therapies for residents.Differing Regulatory Standards for Consumers in State-Operated andPrivate SettingsUnder New York State law, OMRDD has broad discretion in managing stateoperatedprograms, but must satisfy more stringent procedural requirements when issuingregulations applicable to private facilities. While OMRDD need only issue a policy tobind state facilities under its jurisdiction, in order to impose standards upon private149
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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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are responsible for conducting thei
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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
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Page 132 and 133: the table contingent on appropriate
Page 134 and 135: Former Regional Director Articola s
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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
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Page 156 and 157: egistry, and then it seems there wa
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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 186 and 187: Documentation of investigatory acti
Page 188 and 189: As noted above, Bowser also failed
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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
Page 200 and 201: 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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