A Critical Examination of State Agency Investigations into ...

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epeatedly attempted to exaggerate the extent of their efforts in investigating JonathanCarey’s treatment at the Anderson School.Claim of Two InvestigationsAs noted above, Bowser, who was assigned to investigate the allegationsregarding Jonathan Carey, testified clearly and repeatedly to the Inspector General thatshe did not conduct a full care and treatment review, but rather she issued findings relatedto her child abuse investigation under the guise of a care and treatment review so that thedocument could be made public. The investigative file related to the care and treatmentreview supported her assertion that she took no additional investigative steps.Nonetheless, CQC executives insisted in interviews under oath with the InspectorGeneral that a care and treatment investigation was conducted, and they overstated theextent of the agency’s activities in a letter to the Careys, in a hearing before the NewYork State Senate, and in a communication to the Governor’s Office.In a hearing before the State Senate Committee on Mental Health on March 5,2007, CQC Chairman O’Brien said that, in addition to the child abuse investigation, CQC“wo rked with the Careys. We [CQC] opened up a care and treatment review….Weinvestigated his care and treatment because we saw significant problems with the waythat Jonathan was being treated at the Anderson School.”Similarly, Director Keegan and General Counsel Boehlert also made after-the-factclaims that CQC conducted two separate investigations. Keegan wrote, in a June 9, 2005letter to the Careys, that “the Commission [CQC] conducted two separateinvestigations….As a result of concerns which surfaced during our initial investigation,190
we opened a second investigation which was designed to look at clinical issues regardingJonathan’s care.” After an inquiry from the Governor’s Office, in August 2006 Boehlertcoordinated a response to the Governor’s Office stating, “CQCAPD conducted twoseparate investigations; a child abuse investigation pursuant to a complaint filed with theState Central Register (SCR) based on the parent’s report that the school had deniedmeals to the child, and a care and treatment review which followed up on issuesidentified by CQCAPD in the course of the SCR investigation.”CQC executives claimed to the Inspector General that its care and treatmentreview was “thorough.” However, the Inspector General finds this claim, that itconducted a separate “thorough” care and treatment investigation, incredible. Asdocumented above, CQC conducted no additional interviews or site visits as part of thecare and treatment investigation. Furthermore, no additional records were obtained byCQC during this so-called second investigation.In fact, CQC conducted only one superficial investigation, the child abuseinvestigation, during which it identified some systemic weaknesses that were latertransmitted in a separate letter. Investigator Bowser admitted that CQC’s claim that twoseparate and independent investigations were done was not accurate, stating, “No, Ididn’t go down and do a separate…site visit and a separate care and treatment caselooking at…a separate…a separate situation or whatever, so no. I didn’t.”CQC management claimed that Bowser was mistaken in her testimony in theInspector General’s investigation. Director Keegan, Bowser’s supervisor, said that hewas surprised that Bowser said she did not do a second investigation because she did doone. He claimed that the two investigations were done simultaneously but with different191
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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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Former Regional Director Articola s
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BruisingAlthough the Careys noted t
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Seclusion / unauthorized time-out /
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monitoring or supervision by clinic
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Investigation of complaint by an in
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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
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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
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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 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 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
Page 216 and 217: ecognizes that the determination of
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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
Page 236 and 237: child in an institutional setting,
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Page 240 and 241: (ii) violent behavior exhibited by
Page 242 and 243: 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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