A Critical Examination of State Agency Investigations into ...

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• Anderson School did not have consistent forms for documenting the foodintake, so staff had to write this information freehand. “It is unclear whatstaff were required to document….It was unclear whether Jonathan wasrefusing to eat or refusing get dressed and come to the table to eat.”Correspondence with the Anderson SchoolThe Anderson School responded to CQC’s care and treatment investigationfindings on March 1, 2005, stating that “our responses in no way should be construed asan admission of fact or agreement on the details of this matter.” Despite notacknowledging wrongdoing, the Anderson School outlined an extensive corrective actionplan. Specifically, the Anderson School revised its standard operating proceduresregarding developing and implementing Behavior Support Plans to include parentalinvolvement in the treatment process, consent from the family and an internal reviewcommittee for plans that restrict resident rights or privileges, improved training for staffon behavior plans, development of a Behavior Support Plan tracking document, randomsampling of residents’ Behavior Support Plans by the school’s Risk ManagementCommittee to ensure compliance and oversight; and upgraded dietary services.CQC replied to the Anderson School’s response on March 28, 2005. CQC’s letterstated, “While your response did not comment on our findings specific to this child, it didindicate that you have subsequently updated your Standard Operating Procedure (SOP)for the development and implementation of Behavior Support Plans.” CQC indicatedthat the Anderson School’s response addressed its concerns, so CQC concluded itsreview. CQC promised continued monitoring of the Anderson School’s effectiveness inthe development and implementation of behavior plans.176
CQC sent a letter signed by Bowser to Michael Carey on April 28, 2005,explaining its findings and the Anderson School’s corrective actions. The letter citedmany of the findings related to the development and implementation of Behavior SupportPlans contained in the aforesaid February 14, 2005 letter to the Anderson School.Specifically, the letter said that Jonathan’s Behavior Support Plan was not “updated toprovide staff with specific direction on how to address Jonathan’s refusals and what staffwere required to document. As a result, it is not clear why Jonathan did not always eathis regular meal (refused meal or refused to get dressed for meal), what staff did toaddress these refusals, and what Jonathan actually ate.” CQC concluded that the“Commission [CQC] found no clear evidence that staff were withholding food fromJonathan as punishment. In an attempt to manage Jonathan’s periodic refusal to put onclothes to come to the table and eat, staff did withhold his regular meal and offer a basicnutritional substitute as part of his behavior plan.” Additionally, the letter mentioned thatthe Anderson School had failed to include the family in the development andimplementation of Jonathan’s plans.Complaint by the CareysMichael Carey responded to CQC on May 12, 2005, protesting that many of hiscomplaints were not addressed by CQC and those that were investigated, were not donethoroughly. “We as Jonathan’s parents appreciate the work that was done by Doreen[Bowser], but we feel very strongly that all of our complaints were not followed up with,nor was the most important one, of Jonathan’s food being withheld from him for morethan a month’s time for behavioral management, investigated thoroughly,” wrote MichaelCarey. He reiterated his complaints that the Anderson School did not comply with177
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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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that is absent from the Statement o
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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
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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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