A Critical Examination of State Agency Investigations into ...

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