A Critical Examination of State Agency Investigations into ...

did not do a full care and treatment review in this case. She explained that if the Careyshad contacted CQC, as opposed to the Taconic regional office, and CQC was conductinga typical care and treatment investigation, then she would likely have interviewed morepeople and explored more issues. She contended that she told Mr. Carey on October 29,2004 that she was going to focus on the child abuse allegation and that Taconic regionaloffice was addressing the other issues. She reportedly told him that if he was unhappywith Taconic regional office’s investigation, he could then complain to CQC. Bowsersaid that she told Mr. Carey that “since the [Taconic regional office] is going in...andlooking at his concerns and doing an investigation, that we wouldn’t be duplicating that.You know, I have to do this piece...for the SCR [State Central Register], which is whatI’d be concentrating on and that if he wasn’t satisfied with the outcome of the [Taconicregional office] investigation, he could always give us a call.”The Inspector General recognizes that CQC has discretion to choose the focus ofits care and treatment investigations. In its responsibility as an oversight agency, it maylogically and appropriately choose not to devote resources where OMRDD hassufficiently done so. However, evidence in this case does not indicate that a thoughtfulapplication of CQC’s discretion was the cause of its abbreviated care and treatmentrev iew. Rather, the findings of the care and treatment review were based on anabbreviated child abuse investigation, which necessarily limited the scope of the care andtreatment review.In interviews with the Inspector General’s Office, CQC officials overstated theagency’s role in coordinating with OMRDD and the Taconic regional office and ensuringthat aspects of the investigation were addressed by both. CQC claimed it communicated186