A Critical Examination of State Agency Investigations into ...

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Jonathan’s casein-free diet, that Jonathan missed “8 full days of school,” that meals wereused as behavior management, that Jonathan had “extensive bruises all over his body,”that he was allowed to lie naked in his room, that he was prevented from leaving hisbedroom, and that the Anderson School attempted to suspend the Careys’ visitation rightsand restrict their communication with Jonathan through a “point-of-contact” person at theSchool. He requested that CQC explain what was done on the investigation and provideclarification on the scope of its review so “we [the Careys] could possibly understand itbetter…. If these questions are outside of the investigation, please let us know. If not,we would like to know that this has been fully reviewed.” Mr. Carey also asked thatCQC further investigate his concerns.CQC acknowledged this complaint in a June 2, 2005 letter to Michael Careysigned by Director Keegan. Keegan informed Michael Carey that he would be reviewingthe investigation conducted by Bowser. CQC General Counsel Boehlert explained to theInspector General’s Office that CQC decided to re-examine the case because MichaelCarey “was unhappy and he wrote to us and he asked us to review it again.” In the daysfollowing this letter, Keegan and Michael Carey spoke on the telephone andcommunicated via facsimile in an effort to clarify CQC’s role in the investigation.On June 9, 2005, Keegan wrote a letter attempting to explain CQC’ s role, theinvestigation, and the findings. Director Keegan reiterated in this letter that CQCconducted “two separate investigations” into the Careys’ complaints. The first, a childabuse investigation on behalf of the State Central Register, was unfounded “based in parton the results of Jonathan’s October 23 medical examination at [a local hospital], whichrevealed that [Jonathan] had no medical problems.” CQC reiterated that the criteria used178
to indicate a child abuse case under Social Services Law are “quite severe.” However, asa result of concerns raised during the child abuse investigation, Keegan continued, CQC“opened a second investigation [the care and treatment investigation] which was designedto look at clinical issues regarding Jonathan’s care.” Keegan restated many of thefindings that were identified in CQC’s April 2005 care and treatment investigation letterto Michael Carey.The letter also informed Michael and Lisa Carey that the Anderson Schoolrevamped its procedures and policies regarding Behavior Support Plans and that CQChad recommended that the school take “systemic action” to ensure that future problems,like those encountered by Jonathan, were prevented. CQC further advised the Careysthat it had met with OMRDD and Taconic regional office staff in December 2004 todiscuss the problems at the facility, including incident management procedures (i.e.,Jonathan’s bruising), and that OMRDD would “take the lead” to monitor the AndersonSchool as it implements change.Inspector General’s Analysis of CQC’s Care & Treatment ReviewAlthough CQC’s care and treatment letter notified the Anderson School of certaindeficiencies related to Jonathan’s care, the Inspector General found that CQC neveractually conducted a discrete care and treatment review as purported. Rather, it based itsfindings solely on the evidence collected during its cursory child abuse investigation.Investigator Bowser did not document any investigative activities in relation to the careand treatment review, and did not follow CQC policies regarding the breadth and scopeof such a review. CQC officials later overstated the extent of the agency’s care and179
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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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clinical director role, psychiatris
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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
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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 178 and 179: systemic significance.” In a hear
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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
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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
Page 208 and 209: On at least one previous occasion,
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Page 212 and 213: facility employee and CQC recommend
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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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