A Critical Examination of State Agency Investigations into ...
A Critical Examination of State Agency Investigations into ... 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
investigation of Jonathan Carey’s alleged abuse. In fact, CQC was aware of documentaryevidence that was available, but CQC Investigator Bowser never sought or reviewed thisevidence during her investigations.CQC administrators did not obtain the investigative and survey documentsalthough they acknowledged that it has the authority to request and obtain investigativeinformation and findings from other entities as part of its routine activities. For example,CQC never requested a copy of the Taconic regional office’s investigative file, Taconicregional office had statements from approximately two dozen witnesses that were neverseen by CQC. Although, like CQC, the Taconic regional office was conducting aninvestigation to determine whether it could substantiate allegations of abuse againstJonathan, in Keegan’s words, obtaining Taconic’s documents was “not necessary…weknow what they found. It didn’t pertain at all to the child abuse case.” Bowserhypothesized that the statements would not have changed the outcome of the child abusecase because she already had obtained medical evidence that Jonathan was not physicallyharmed. Likewise, CQC never obtained investigative documents from OMRDD CentralOffice’s review.In another example, CQC failed to review a logbook that the Careys’ claim tohave found in Jonathan’s clothes bag. CQC was made aware of the logbook and theCareys’ claim that the logbook contained evidence of Jonathan’s abuse, but CQC nevertook steps to obtain the logbook during its investigation. Bowser’s handwritten progressnotes indicate that she discussed the logbook in detail with the Taconic investigator onNovember 17, 2004. Her notes state, “[the log]book has good handle on the # of mealsmissed [by Jonathan].” As CQC’s findings in the child abuse investigation related163
- Page 116 and 117: acknowledged there was a “propose
- Page 118 and 119: Taconic Regional Office’s Letter
- Page 120 and 121: it is not his office’s policy to
- Page 122 and 123: SURVEY BY THE OMRDD CENTRAL OFFICEA
- Page 124 and 125: additional information was availabl
- Page 126 and 127: his supervisor at the time, then-Ar
- Page 128 and 129: that is absent from the Statement o
- Page 130 and 131: clinical director role, psychiatris
- Page 132 and 133: the table contingent on appropriate
- Page 134 and 135: Former Regional Director Articola s
- Page 136 and 137: BruisingAlthough the Careys noted t
- Page 138 and 139: Seclusion / unauthorized time-out /
- Page 140 and 141: monitoring or supervision by clinic
- Page 142 and 143: Investigation of complaint by an in
- Page 144 and 145: and included supporting documentati
- Page 146 and 147: think they wanted him to have the r
- Page 148 and 149: Inaccurate Information Provided to
- Page 150 and 151: this allegation. The letter was tra
- Page 152 and 153: While reports indicated that the An
- Page 154 and 155: facilities like the Anderson School
- Page 156 and 157: egistry, and then it seems there wa
- Page 158 and 159: INVESTIGATION BY THE NEW YORK STATE
- Page 160 and 161: target(s) of the complaint engaged
- Page 162 and 163: arely used by CQC to substantiate a
- Page 164 and 165: The second paragraph of the case su
- 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
- Page 176 and 177: and aggressive behavior related to
- Page 178 and 179: systemic significance.” In a hear
- Page 180 and 181: • Anderson School did not have co
- Page 182 and 183: Jonathan’s casein-free diet, that
- Page 184 and 185: treatment review to the Careys, the
- Page 186 and 187: Documentation of investigatory acti
- 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
- Page 202 and 203: The oversight deficiencies were eve
- 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,
- Page 210 and 211: emotional injury was impossible in
- Page 212 and 213: facility employee and CQC recommend
- Page 214 and 215: Restrictive Statutory LanguageAltho
investigation <strong>of</strong> Jonathan Carey’s alleged abuse. In fact, CQC was aware <strong>of</strong> documentaryevidence that was available, but CQC Investigator Bowser never sought or reviewed thisevidence during her investigations.CQC administrators did not obtain the investigative and survey documentsalthough they acknowledged that it has the authority to request and obtain investigativeinformation and findings from other entities as part <strong>of</strong> its routine activities. For example,CQC never requested a copy <strong>of</strong> the Taconic regional <strong>of</strong>fice’s investigative file, Taconicregional <strong>of</strong>fice had statements from approximately two dozen witnesses that were neverseen by CQC. Although, like CQC, the Taconic regional <strong>of</strong>fice was conducting aninvestigation to determine whether it could substantiate allegations <strong>of</strong> abuse againstJonathan, in Keegan’s words, obtaining Taconic’s documents was “not necessary…weknow what they found. It didn’t pertain at all to the child abuse case.” Bowserhypothesized that the statements would not have changed the outcome <strong>of</strong> the child abusecase because she already had obtained medical evidence that Jonathan was not physicallyharmed. Likewise, CQC never obtained investigative documents from OMRDD CentralOffice’s review.In another example, CQC failed to review a logbook that the Careys’ claim tohave found in Jonathan’s clothes bag. CQC was made aware <strong>of</strong> the logbook and theCareys’ claim that the logbook contained evidence <strong>of</strong> Jonathan’s abuse, but CQC nevertook steps to obtain the logbook during its investigation. Bowser’s handwritten progressnotes indicate that she discussed the logbook in detail with the Taconic investigator onNovember 17, 2004. Her notes state, “[the log]book has good handle on the # <strong>of</strong> mealsmissed [by Jonathan].” As CQC’s findings in the child abuse investigation related163
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