A Critical Examination of State Agency Investigations into ...

CQC Director of Quality Assurance and Investigation Bureau Mark Keegan,Bowser’s supervisor, explained that the investigator did not meet Jonathan because hehad already left the school. “There wasn’t a whole lot that we could do to try and makesure that his services and programming and life in general at Anderson School werebetter, because he was already gone….He was gone. We can’t make his life any better,”stated Keegan. He added, “In the ordinary course of events in a typical child abuse case,we, of course, will meet the child. We, of course, will try and interview the child, butagain this is a different situation because the child was gone.” Bowser acknowledgedthat CQC has interviewed children at their homes, but she “didn’t feel that it waswarranted [in this case].”In contrast to CQC’s four total interviews, the Taconic investigator conducted atleast 25 interviews with all levels of management and staff at the Anderson School in itsinvestigation of the Careys’ complaints.Failure to obtain all pertinent documentsOn March 5, 2007, the New York Senate Committee on Mental Health andDevelopmental Disabilities held a public hearing to discuss “the use of restraints on ourmost vulnerable population in the care of OMRDD run or licensed facilities.” Thetestimony noted the recent tragic death of Jonathan Carey had raised concerns about thequality of care children with disabilities were receiving. In a hearing before the StateSenate regarding CQC’s investigative process, CQC Chairman Gary O’Brien stated thatCQC will “go about doing a thorough investigation, looking at record reviews andinterviewing folks, looking at medical records or any record we can find.” However,O’Brien’s description of CQC’s investigative standards is not reflected in the agency’s162