A Critical Examination of State Agency Investigations into ...
A Critical Examination of State Agency Investigations into ... A Critical Examination of State Agency Investigations into ...
Documentation of investigatory activitiesBelow are forms from the file of Jonathan Carey’s care and treatment review thatare intended to document investigative activities. (The date February 18, 2005, appearsto be an error. It should read February 14, 2005.) While a separate investigation shouldhave resulted in a complete and distinct case file, the care and treatment file progressnotes and docket sheet were blank, as shown below.Actual CQC case file documents for Jonathan’s care and treatment review.Even if Bowser relied on documents and interviews related to the child abuseinvestigation, the documents she relied on to make her care and treatment findings shouldhave been recorded in the care and treatment file. Bowser told the Inspector General’s182
Office that progress notes and a document inventory related to the care and treatmentinvestigation were not completed because she did not do a care and treatmentinvestigation.Interview of witnessesCQC’s General Counsel Boehlert told investigators from the Inspector General’sOffice, “Our investigators would interview anyone who they thought may haveinformation relevant to care and treatment.” However, since CQC’s investigator onlyinterviewed four individuals at the Anderson School for her child abuse investigation, sherelied only on those interviews in making her care and treatment findings. In doing so,she missed issues related to Jonathan’s care and treatment that were identified by Taconicregional office Investigator Searle. Many witnesses interviewed by Searle voicedconcerns about the way Jonathan was treated at the Anderson School. Someacknowledged that they were uncomfortable about the way Jonathan was kept in hisroom and the practice of holding the door, that his regular meals were withheld if hewould not get dressed, and that he was observed lying in his own urine, among otherconcerns.Obtaining documentsCQC policies on care and treatment investigations require, “If possible, allinformation recorded for at least the past six months should be reviewed to ensure that anaccurate and thorough review is completed” (emphasis original). Bowser did not obtainall information recorded for the last six months regarding Jonathan for her child abuseinvestigation, and therefore did not have it for her care and treatment review.183
- Page 136 and 137: BruisingAlthough the Careys noted t
- Page 138 and 139: Seclusion / unauthorized time-out /
- Page 140 and 141: monitoring or supervision by clinic
- Page 142 and 143: Investigation of complaint by an in
- Page 144 and 145: and included supporting documentati
- Page 146 and 147: think they wanted him to have the r
- 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
- 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
- Page 168 and 169: primarily to the provision of meals
- Page 170 and 171: interview notes would have been exp
- Page 172 and 173: Jonathan’s “demeanor has change
- Page 174 and 175: that the additional complaints of a
- Page 176 and 177: and aggressive behavior related to
- Page 178 and 179: systemic significance.” In a hear
- Page 180 and 181: • Anderson School did not have co
- Page 182 and 183: Jonathan’s casein-free diet, that
- Page 184 and 185: treatment review to the Careys, the
- 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,
- Page 210 and 211: emotional injury was impossible in
- Page 212 and 213: facility employee and CQC recommend
- Page 214 and 215: Restrictive Statutory LanguageAltho
- Page 216 and 217: ecognizes that the determination of
- Page 218 and 219: CQC policy does not require further
- Page 220 and 221: CQC wrote in its unfounded notifica
- Page 222 and 223: INVESTIGATION BY THE NEW YORK STATE
- Page 224 and 225: develop sufficient evidence to supp
- Page 226 and 227: There is not proper and safe oversi
- Page 228 and 229: the meeting, “We left it with the
- Page 230 and 231: this important matter. Your corresp
- Page 232 and 233: VI. RECOMMENDATIONSThe Inspector Ge
- Page 234 and 235: ehavior management (14 NYCRR § 633
Documentation <strong>of</strong> investigatory activitiesBelow are forms from the file <strong>of</strong> Jonathan Carey’s care and treatment review thatare intended to document investigative activities. (The date February 18, 2005, appearsto be an error. It should read February 14, 2005.) While a separate investigation shouldhave resulted in a complete and distinct case file, the care and treatment file progressnotes and docket sheet were blank, as shown below.Actual CQC case file documents for Jonathan’s care and treatment review.Even if Bowser relied on documents and interviews related to the child abuseinvestigation, the documents she relied on to make her care and treatment findings shouldhave been recorded in the care and treatment file. Bowser told the Inspector General’s182
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