A Critical Examination of State Agency Investigations into ...

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The second paragraph of the case summary finds that there was no breach of duty,one of the criteria needed for indication, according to CQC, for finding abuse. The finalparagraph finds that Jonathan was not injured; injury is the second criterion for findingabuse.On the basis of these findings, on December 20, 2004, CQC recommended to theState Central Register that the allegation of child abuse be unfounded. CQC’srecommendation was accepted by the register, which sent a letter to the Anderson Schoolon December 21, 2004, officially notifying the school that the case was unfounded.CQC also directly notified the Anderson School of its recommendation that thecase be unfounded by letter dated December 20, 2004. In this, CQC noted that during thechild abuse investigation, CQC “found several concerns which we plan on addressingwith the [school] under separate cover.”The Inspector General’s Analysis of CQC’s Child Abuse InvestigationIn comparison with the investigation by the Taconic regional office and thesurvey by the OMRDD Central Office, the investigation by CQC of Jonathan’s treatmentat the Anderson School was the most cursory. CQC Investigator Bowser conducted onlyone site visit, during which she interviewed only four witnesses, three of whom were thesubjects of the complaint. In addition, she failed to investigate or issue findings related tothe majority of the abuse allegations regarding Jonathan, focusing solely on the provisionof meals. Finally, Bowser did not fully document her investigative activities andmanagerial oversight of the entire investigation was lacking.160
Sufficiency of InvestigationFailure to interview all pertinent witnessesCQC Investigator Bowser interviewed only four individuals during the course ofher child abuse investigation. She interviewed the three subjects of the child abusecomplaint, along with a nurse at the school. She did not interview any otheradministrators or any of the numerous members of the direct care staff who personallyimplemented Jonathan’s Behavior Support Plan, provided Jonathan with meals andsubstitute foods throughout this period, and witnessed the conditions in his bedroom.One important witness who was not interviewed by Bowser was the Director ofClinical Services, who was ultimately responsible for behavioral programming at theschool. Jonathan’s behavior plan called for treatment techniques that constituted the cruxof the allegations of abuse. Bowser said she did not interview the Director of ClinicalServices because this individual was not available at the time of her single visit to theAnderson School. Instead, she relied on a written statement which had been previouslyprepared by the Director of Clinical Services for the Taconic regional office’sinvestigation.Investigator Bowser also never met or observed Jonathan Carey, even thoughCQC’s policies state, “As determined necessary by the work plan, we [CQC] will attemptto obtain written statements from the victim, witnesses and subject.” Although Jonathanwas largely non-verbal, personally observing him and assessing his weight, as well as hisoverall physical and mental condition, might have proved valuable in this investigation.161
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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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School policies and procedures. Inv
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Taconic Regional Office’s Finding
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an entry on an October 4, 2004, Beh
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When questioned about the Taconic r
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involved “fully in the program pl
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What were the employees doing that
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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 134 and 135: Former Regional Director Articola s
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Page 138 and 139: Seclusion / unauthorized time-out /
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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
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Page 168 and 169: primarily to the provision of meals
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Page 172 and 173: Jonathan’s “demeanor has change
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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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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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Page 204 and 205: that OCFS’s rate of indication is
Page 206 and 207: In the following sections the Inspe
Page 208 and 209: On at least one previous occasion,
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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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