A Critical Examination of State Agency Investigations into ...
A Critical Examination of State Agency Investigations into ... A Critical Examination of State Agency Investigations into ...
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
- 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
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- Page 122 and 123: SURVEY BY THE OMRDD CENTRAL OFFICEA
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- 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
- Page 148 and 149: Inaccurate Information Provided to
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- Page 160 and 161: target(s) of the complaint engaged
- Page 162 and 163: arely used by CQC to substantiate a
- 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
- Page 180 and 181: • Anderson School did not have co
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- 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
- Page 200 and 201: Although the statement provided to
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- Page 206 and 207: In the following sections the Inspe
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Sufficiency <strong>of</strong> InvestigationFailure to interview all pertinent witnessesCQC Investigator Bowser interviewed only four individuals during the course <strong>of</strong>her child abuse investigation. She interviewed the three subjects <strong>of</strong> the child abusecomplaint, along with a nurse at the school. She did not interview any otheradministrators or any <strong>of</strong> the numerous members <strong>of</strong> 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 <strong>of</strong>Clinical Services, who was ultimately responsible for behavioral programming at theschool. Jonathan’s behavior plan called for treatment techniques that constituted the crux<strong>of</strong> the allegations <strong>of</strong> abuse. Bowser said she did not interview the Director <strong>of</strong> ClinicalServices because this individual was not available at the time <strong>of</strong> her single visit to theAnderson School. Instead, she relied on a written statement which had been previouslyprepared by the Director <strong>of</strong> Clinical Services for the Taconic regional <strong>of</strong>fice’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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