A Critical Examination of State Agency Investigations into ...

Jonathan’s care, not just the single allegation of withholding meals. CQC receivedanother copy of the letter by fax from OMRDD Central Office around the same time.Other allegations included failure to provide a casein-free diet, extensive bruising thatwent unreported, missing one-to-two weeks of school, the conditions Jonathan wasplaced in while in his bedroom, planning to suspend parental contact, and filtering theircommunication with Jonathan and staff who cared for him through a “point of contact.”When asked why CQC focused solely on the issues of withholding of meals andthe related behavior plan development and implementation, Keegan replied,“Because...that’s what we chose to do. We get to pick and choose what we’re going tolook at in terms of internal investigations, and that’s what we chose -- that was identifiedto us. That was something that we identified as a problem.” Keegan also offered anotherjustification; “The Careys never made a complaint to us....They made a complaint toOMRDD. OMRDD was already investigating it. They chose to make their complaints toOMRDD, not to CQC.” As noted earlier, the Careys also sent their complaint to CQC,placing CQC on notice of their concerns.Claim of coordination with OMRDDAs an alternative explanation for not conducting an extensive care and treatmentreview, CQC officials indicated that they were aware that other entities were conductingthe investigation, so any duplication of efforts would have been wasteful. “And we’realso aware that OMRDD had received those concerns and was doing an investigation intothose concerns, and it would be -- it would be duplication and a waste of our very, verylimited resources to go in and do exactly what OMRDD was already doing,” saidDirector Keegan. This sentiment was also expressed by Bowser, who admitted that she185