A Critical Examination of State Agency Investigations into ...

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systemic significance.” In a hearing before the New York State Senate on March 5,2007, CQC Chairman O’Brien provided the following information about CQC’s care andtreatment reviews:Pursuant to Mental Hygiene Law, any one can contact the Commission toregister a concern about their care and treatment, or that of a loved one.As a first step, we try to resolve the issue by offering the requestor advice,or by contacting the facility on the requestor’s behalf. When necessary,we initiate a review of the individual’s care and treatment, which usuallyentails site visits, record reviews, interviews, etc. During the course of ourreview we keep the requestor, usually a family member, regularlyinformed of the status of our investigation and, at its conclusion, weinform them of our findings both by telephone and letter. Last year [2006]we conducted nearly 250 such reviews.The primary purpose of both death investigations and care and treatmentreviews is to offer facilities recommendations on actions they should taketo improve the quality of the care they offer individuals. In both of thesetypes of investigations, we issue a written report of findings to the facility.When recommendations are offered, we request that the facility respond inwriting within 30 days.Chairman O’Brien added, “In the process of investigating a child abuse allegationwe may see broader problematic issues that do not fit into the Social Services Law’sdefinitions of abuse or maltreatment. In such cases, we initiate separate care andtreatment reviews which result in reports of findings, recommendations and requirementsfor submission and implementation of corrective action plans that are subject to furthermonitoring by the Commission.”Investigative Activities Related to the Care and Treatment ReviewAccording to CQC Investigator Bowser, although she could not substantiate thechild abuse allegations of Jonathan Carey, her investigation revealed problems at theAnderson School that merited correction. Approximately two months after theconclusion of the child abuse investigation, on February 14, 2005, CQC Investigator174
Bowser opened a “care and treatment” review regarding Jonathan Carey. On this samedate, she sent the Anderson School a letter describing her findings. Although reportedlythe result of a separate investigation, the findings of the care and treatment investigationwere based solely on the information she collected for the initial child abuseinvestigation. Bowser testified to the Inspector General’s Office that she took noadditional investigatory steps for the care and treatment review.Findings of the Care and Treatment ReviewCQC’s care and treatment letter to the Anderson School noted some of the sameviolations that were found by OMRDD Central Office in its survey of behavior plans atthe school. Like OMRDD, CQC criticized the Anderson School for failure to include theparents in treatment plan development, and for providing insufficient detail in Jonathan’sbehavior plan. The primary concerns listed in Bowser’s letter to the Anderson Schoolwere as follows:• The Anderson School did not include Jonathan’s family in the “treatmentteam meetings or in the development of his behavior plans. It is alsounclear what information from these meetings was shared with the familyand when.”• The Anderson School’s behavior plans and memos “did not provide staffwith direction on how to respond if Jonathan refused to get dressed tocome to meals.”• There was no way to determine if the Anderson School’s September 27,2004 memo (directing staff to document Jonathan’s food intake) wascommunicated to staff, as it was not part of Jonathan’s clinical record norwere staff signatures on it.• Anderson School staff failed to track Jonathan’s food intake as required bynursing staff in the September 27, 2004 treatment team meeting untilOctober 9, 2004.175
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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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additional information was availabl
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his supervisor at the time, then-Ar
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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 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
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Page 212 and 213: facility employee and CQC recommend
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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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A Critical Examination of State Agency Investigations into ...

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