A Critical Examination of State Agency Investigations into ...

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that the additional complaints of abuse, neglect and molestation were contained in the“Miscellaneous Information” section of the report from the State Central Register ratherthan the actual narrative of the allegation. The second explanation provided was thatother investigative bodies were looking into all of the other allegations, relieving CQC ofits r esponsibility of investigating these aspects of the child abuse allegation and report.The claim that CQC must only limit its investigation to complaints documented inone section of the child abuse intake report, while ignoring information and allegationscontained in the miscellaneous or other sections of the report is specious. In fact, MentalHygiene Law requires that CQC commence “an appropriate investigation” of a report ofabuse or neglect of a child in residential care that includes, “A determination of thenature, extent, and cause of any condition enumerated in such report.” 43It is improperfor an investigative agency such as CQC to ignore allegations because they do not appearin the first section of the report.The second explanation, that other investigative bodies were looking into all ofthe other allegations, also falls short. CQC is charged by law with investigatingallegations of abuse or maltreatment at residential institutions like the Anderson School.It must make a recommendation of its findings to the State Central Register. It cannotchose one portion of an abuse allegation and refer other allegations that may constituteabuse to another agency. Even if it were permitted, there is no evidence that CQC madesuch a referral and as mentioned above, CQC took no steps to obtain materials reviewedby other agencies.43 Mental Hygiene Law § 45.07(c)(2)(e).170
No attempt to determine whether Jonathan suffered serious emotional injury or was putat risk of serious emotional injuryCQC’s finding that Jonathan did not suffer abuse at the Anderson School was, inpart, supported by a lack of evidence of physical abuse. Although a finding of abuse canbe based on a finding of serious emotional injury or risk of serious emotional injury to thechild, CQC failed to sufficiently explore this possibility and ignored statements regardingJonathan’s changed demeanor and increasingly violent behavior.Despite CQC progress notes showing that the Careys told the emergency roomnurse that Jonathan’s “demeanor has changed significantly” and that “he has increasinglybecome violent,” General Counsel Boehlert declared when interviewed by the InspectorGeneral, “I don’t think there was any suggestion at the time from the parents thatemotional impact was an issue; it was not a finding that we made. We had no evidence tosuggest that there was emotional impact.” CQC Director of Quality Assurance andInvestigations Mark Keegan expressed the same denial, stating, “There was never, to myknowledge, any complaint, any concern, any evidence of anything given to us thatJonathan was at risk of emotional harm. There’s nothing that we saw from his record thatwould indicate that he was in any way emotionally harmed. There was not even aconcern, a consideration.” CQC Investigator Bowser said, “In looking at the stuff from[the hospital] and in talking with the parents, it was never implied that… Jonathanhas…suffered greatly as a result of all of this.”In contrast to these assertions, Michael and Lisa Carey reported to the InspectorGeneral that Jonathan’s behavior had changed and that he had become more violent.Also, interviews with the Careys revealed that Jonathan displayed unusually obsessive171
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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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Central Office. Although the Anders
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acknowledged there was a “propose
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Taconic Regional Office’s Letter
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it is not his office’s policy to
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SURVEY BY THE OMRDD CENTRAL OFFICEA
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Page 134 and 135: Former Regional Director Articola s
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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
Page 164 and 165: The second paragraph of the case su
Page 166 and 167: CQC Director of Quality Assurance a
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Page 170 and 171: interview notes would have been exp
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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
Page 202 and 203: The oversight deficiencies were eve
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Page 206 and 207: In the following sections the Inspe
Page 208 and 209: On at least one previous occasion,
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Page 212 and 213: facility employee and CQC recommend
Page 214 and 215: Restrictive Statutory LanguageAltho
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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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