A Critical Examination of State Agency Investigations into ...

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treatment review to the Careys, the Inspector General, the New York State Senate, andGovernor Pataki’s office.Sufficiency of InvestigationThe Inspector General found that CQC’s care and treatment review was not onlyinsufficient, it was nonexistent. Despite assertions under oath by CQC senior officials tothe contrary, Investigator Bowser admitted that she did not conduct a care and treatmentreview, but rather communicated certain findings of her child abuse investigation underthe guise of a care and treatment review. CQC policies indicate that a care and treatmentreview should include a thorough examination of the child’s care, including interviewswith relevant witnesses and a review of documents related to the child’ s care going backsix months. Because she merely repackaged findings of a care and treatmentinvestigation that focused solely on Jonathan’s meals and related behavior plans, thefindings of the purported care and treatment review were necessarily limited to thesetopics as well.As noted above, Bowser’s care and treatment investigation did not involve anyinvestigative activities other than those she had already completed for the child abuseinvestigation. Despite her admission under oath that she did not conduct a care andtreatment investigation, CQC officials nonetheless insisted that she did. They contendedthat the reviews were performed simultaneously, with the investigator looking at theevidence with two different purposes in mind.Bowser maintained that there was just one investigation, and that she opened thecare and treatment review merely to issue a letter to the Anderson School, pointing out180
some of its deficiencies. In her interview with the Inspector General’s Office shetestified that the care and treatment investigation “was the exact same thing” as the childabuse investigation.Bowser acknowledged that she could have written her findings into the childabuse letter of findings, but she said she wanted to make her findings accessible to thepublic. According to CQC staff, child abuse files are not subject to Freedom ofInformation Law (FOIL) and are sealed once they are completed. Bowser reported, “Icould have written in to the closing child abuse letter our concerns, but you can’t FOILthose [requests] and I thought it was important enough that somebody -- that this is aserious matter. It needs to be FOIL’ed.”According to her own testimony, Bowser issued findings of a care and treatmentreview that she never actually conducted. She simply transposed findings from her childabuse investigation under the umbrella of a care and treatment review. Had Bowserconducted a comprehensive examination of Jonathan Carey’s care while investigating theallegation of child abuse, it may have been legitimate to rely on the evidence shecollected during the child abuse investigation to make care and treatment findings.However, as discussed above, Bowser limited her review of the child abuse allegation tothe single accusation regarding Jonathan’s meals and related behavior plans, and didn’tfully explore other aspects of his care and treatment that were detailed by the Careys. Asnoted above, CQC’s care and treatment policies and testimony from several CQCexecutives suggest that the care and treatment review should have been a comprehensiveexamination of Jonathan’s care.181
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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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the table contingent on appropriate
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Page 138 and 139: Seclusion / unauthorized time-out /
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Page 150 and 151: this allegation. The letter was tra
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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 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 178 and 179: systemic significance.” In a hear
Page 180 and 181: • Anderson School did not have co
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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
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,
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Page 212 and 213: facility employee and CQC recommend
Page 214 and 215: Restrictive Statutory LanguageAltho
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Page 228 and 229: the meeting, “We left it with the
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Page 232 and 233: 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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