A Critical Examination of State Agency Investigations into ...

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focuses. “We did it at the same time, but they’re two separate activities. It was morethan what was required to do the child abuse investigation,” he said. He added that thesecond investigation had its own case file (albeit, the progress notes and docket sheet areblank as depicted earlier) and case number and generated a separate findings letter.However, he acknowledged that the second investigation consisted of the very sameinformation, interviews, and site visit as CQC’s child abuse investigation.As for the scope of the purported second investigation, or care and treatmentreview, Chairman O’Brien initially characterized it to the Inspector General’s Office as“very thorough,” “broader” than a child abuse investigation and “expansive.” Yet whenpressed by the Inspector General on the fact that no additional activities were conducted,Chairman O’Brien replied that it was actually a “focused, specific review.” “Wenarrowed what we were doing, that’s all I know.”Other Misleading or Inconsistent Information ProvidedGovernor’s Officeby CQC to theIn addition to the misleading information about the extent of CQC’s care andtreatment investigation, CQC provided further inaccurate information related to itsinvestigation of the Carey matter in a document transmitted to Governor Pataki’s Office.The information was requested by the Governor’s Office in response to the Careys’complaint about the investigations of their son’s case. The information was transmittedto the Governor’s Office by OMRDD Associate Commissioner Gatens, who wasresponsible for coordinating the responses of OMRDD and CQC to the Careys’complaint. CQC General Counsel Boehlert provided the information related to hisagency to Gatens. The Inspector General cautions CQC and all state agencies that192
information communicated to the governor should be factually accurate and verified assuch prior to transmission.Claim that CQC was unaware of certain allegationsAlthough the Inspector General found evidence to the contrary, CQC deniedhaving been informed of allegations regarding the conditions of Jonathan’s room andasserted that there was no documentary evidence to support the Careys’ claim. TheCareys claimed that:We personally found Jonathan on a visit lying naked on his bed, the bedalmost completely soaked with urine, no sheet to cover him (in October),urine on the floor, Jonathan’s only window blocked with special paper tolet light in, but he could not look out or anyone in. All of Jonathan’s toysand books were removed from his room. Jonathan’s pictures were also allremoved from his walls.The document transmitted to the Governor’s Office read:• There was no documentary evidence to support the allegation and noevidence that the parents ever reported this to OMR[DD], CQCAPD,or CPS.As previously addressed in the Taconic regional office analysis section of thisreport, the Inspector General’s Office identified numerous documents and AndersonSchool employee statements that lend support to this particular allegation.Furthermore,as previously stated, the October 13, 2004 handwritten “New Protocol” for Jonathan,which was signed by staff working with Jonathan, read, “Sometime tomorrow we will[be] having frosted adhesive put up on window to eliminate the reinforcer of looking outthe window. He should have No books, horse pillows, or anything he would findreinforcing in his room when he is non compliant” (emphasis original). In addition, it193
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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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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
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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 194 and 195: epeatedly attempted to exaggerate 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
Page 236 and 237: child in an institutional setting,
Page 238 and 239: (a) Records and documents pertainin
Page 240 and 241: (ii) violent behavior exhibited by
Page 242 and 243: 8. Such commissioners shall provide
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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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