A Critical Examination of State Agency Investigations into ...
A Critical Examination of State Agency Investigations into ... A Critical Examination of State Agency Investigations into ...
compared to consumers in state-operated programs. Draft OMRDD regulations datingback to at least 1994 provide additional clarification and guidance on the practice ofbehavior modification, including the issues of restraint, seclusion, restrictive behaviormodification techniques, and time-out. All of these policies would have guided theAnderson School’s treatment of Jonathan. Although the draft regulations were neverpromulgated, OMRDD issued them as policies applicable to state-operated facilities.However, private providers like the Anderson School are not required to abide by them.This results in consumers receiving different protections and guidance solely due towhether they are placed in state-operated or voluntary programs.CQC’s InvestigationsThe Inspector General found that CQC conducted a cursory investigation of thechild abuse complaint that did not address all of the allegations presented to it. Inaddition, the agency issued findings under the umbrella of a separate care and treatmentreview, even though no such review was conducted. When criticized for theshortcomings of its investigation of the Careys’ allegations, CQC repeatedly overstatedthe extent of its investigative activities to several parties, including the Careys, the NewYork State Senate, the office of Governor Pataki, and the Inspector General. Also,deficiencies in documentation of investigative activities revealed a lack of supervisionwithin the agency.As required by Social Services Law, CQC investigated the allegations regardingJonathan Carey’s abuse which was referred to it by the State Central Register of ChildAbuse and Maltreatment. In contrast to the comprehensive review of the Taconicregional office of OMRDD, CQC made only one site visit to the Anderson School and12
conducted only four interviews. Three of these interviews were with the targets of thechild abuse investigation. Only one non-target witness was interviewed, and the notesfrom this interview were difficult for the CQC investigator to interpret and explain to theInspector General. In violation of CQC policy, the investigator failed to document heractivities of her one site visit to the school or her initial telephone discussion withMichael Carey. The investigator also failed to review all relevant documents, including alogbook in the possession of Michael and Lisa Carey that they claimed containedevidence of abuse against Jonathan. CQC was made aware of the logbook on multipleoccasions.The investigation focused solely on whether Jonathan’s meals were withheldinappropriately, on the related behavior plans, and on whether, as a result, Jonathan wasphysically injured or placed at risk of physical injury. None of the Careys’ otherallegations regarding bruising, missed school, isolation, limited communication with theirson, the stark conditions in his bedroom, or unsanitary practices were investigated byCQC. CQC did not obtain investigative results from the Taconic regional office, nor didit obtain the results of the OMRDD Central Office’s survey, documents that CQC islegally entitled to and routinely requests in its investigations. These documents couldhave assisted CQC in determining whether all of the Careys’ complaints had beenidentified, addressed, and corrected.Likewise, CQC did not adequately attempt to determine whether Jonathanexperienced serious emotional injury, or was at risk of serious emotional injury, as setforth in the Social Services Law definitions of “abuse” and “neglect.” Although CQCidentified some concerns that it planned on addressing “under separate cover,” it13
- Page 2 and 3: Pursuant to Executive Law § 53, th
- Page 4 and 5: INVESTIGATION BY THE TACONIC REGION
- Page 6 and 7: The alleged abuse began in Septembe
- Page 8 and 9: Michael and Lisa Carey. Along with
- Page 10 and 11: The Careys filed a complaint with t
- Page 12 and 13: The Taconic Regional Office’s Inv
- Page 14 and 15: egulatory violations identified in
- Page 18 and 19: determined that Jonathan’s treatm
- Page 20 and 21: Statements from CQC executives and
- Page 22 and 23: investigating agencies or the Gover
- Page 24 and 25: 7. There is no justification for a
- Page 26 and 27: Legislative RecommendationThe Inspe
- Page 28 and 29: and give positive reinforcement for
- Page 30 and 31: separate reports. Taconic’s was i
- Page 32 and 33: 4. Did the investigating agencies e
- Page 34 and 35: in the Department of Special Educat
- Page 36 and 37: III. BackgroundNEW YORK STATE SERVI
- Page 38 and 39: abuse or maltreatment within New Yo
- Page 40 and 41: certain OMRDD-certified facilities,
- Page 42 and 43: instances in which the Anderson Sch
- Page 44 and 45: appropriateness of the Dutchess Cou
- Page 46 and 47: Diagram of the Anderson School camp
- Page 48 and 49: Additionally, the Mental Hygiene La
- Page 50 and 51: Among the protections offered in th
- Page 52 and 53: To ensure the safety of the residen
- Page 54 and 55: The reports are shared with the fam
- Page 56 and 57: esident’s physical condition, inc
- Page 58 and 59: He could also become physically agg
- Page 60 and 61: RESIDENCY AT THE ANDERSON SCHOOLIn
- Page 62 and 63: Shortly after his admission, Jonath
- Page 64 and 65: a snack such as cereal or verbal pr
compared to consumers in state-operated programs. Draft OMRDD regulations datingback to at least 1994 provide additional clarification and guidance on the practice <strong>of</strong>behavior modification, including the issues <strong>of</strong> restraint, seclusion, restrictive behaviormodification techniques, and time-out. All <strong>of</strong> these policies would have guided theAnderson School’s treatment <strong>of</strong> Jonathan. Although the draft regulations were neverpromulgated, OMRDD issued them as policies applicable to state-operated facilities.However, private providers like the Anderson School are not required to abide by them.This results in consumers receiving different protections and guidance solely due towhether they are placed in state-operated or voluntary programs.CQC’s <strong>Investigations</strong>The Inspector General found that CQC conducted a cursory investigation <strong>of</strong> thechild abuse complaint that did not address all <strong>of</strong> the allegations presented to it. Inaddition, the agency issued findings under the umbrella <strong>of</strong> a separate care and treatmentreview, even though no such review was conducted. When criticized for theshortcomings <strong>of</strong> its investigation <strong>of</strong> the Careys’ allegations, CQC repeatedly overstatedthe extent <strong>of</strong> its investigative activities to several parties, including the Careys, the NewYork <strong>State</strong> Senate, the <strong>of</strong>fice <strong>of</strong> Governor Pataki, and the Inspector General. Also,deficiencies in documentation <strong>of</strong> investigative activities revealed a lack <strong>of</strong> supervisionwithin the agency.As required by Social Services Law, CQC investigated the allegations regardingJonathan Carey’s abuse which was referred to it by the <strong>State</strong> Central Register <strong>of</strong> ChildAbuse and Maltreatment. In contrast to the comprehensive review <strong>of</strong> the Taconicregional <strong>of</strong>fice <strong>of</strong> OMRDD, CQC made only one site visit to the Anderson School and12
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