A Critical Examination of State Agency Investigations into ...

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ead, “If he wets again – take sheets off and don’t put clean ones on.” Hence, based onthe above-referenced documents alone, the Inspector General’s Office questions theveracity of CQC’s response.Further, the Inspector General’s Office finds the statement referencing noevidence of the Careys ever reporting this to CQC to be erroneous. The November 1,2004, letter from the Carey’s attorney to Taconic regional office, which was copied toCQC Investigator Bowser, explained the aforementioned allegations. Attached to thisletter was a copy of Lisa Carey’s handwritten statement read during the October 25,2004, CSE meeting which expounded on the allegations in greater detail. Furthermore, acop y of the November 1, 2004, correspondence was again provided to CQC DirectorKeegan by OMRDD officials via facsimile on November 3, 2004.When confronted with this seemingly inaccurate response, CQC ChairmanO’Brien offered, “Yeah, I don’t know what to say about that. You know, you’d have tospecifically ask Mark [Keegan] or Doreen [Bowser] if they would have gotten thatinformation. You know, I was not involved, so I don’t know.” O’Brien’s response thathe “was not involved” in CQC’s formal response to the governor, despite his position ashead of the agency, is startling. General Counsel Boehlert was also shown evidence inbehavior plans from CQC’s own files that seemingly supported the original allegation bythe Careys. He responded, “We did not do the investigation of that allegation.”Moreover, the Inspector General’s Office asked Director Keegan about the accuracy ofthe joint response statement that, “There was no documentary evidence to support theallegation and no evidence that the parents ever reported this to OMR[DD], CQCAPD, or194
CPS.” Keegan acknowledged that it was not accurate and that CQC did know about theconditions in Jonathan’s bedroom at that time.Cla im that CQC was unaware of a logbook documenting Jonathan’s mealsAnother example of imprecise information contained in the joint response relatedto the Careys’ claim that:OMRDD, CQCAPD and the State Education Departmentmiserably in the handling of Jonathan’s abuse and neglect.all failedIn addition to asserting its claim of having conducted two full investigations,CQC responded to the accusation with the following:CQCAPD’s investigator has no recollection of having been told by theparents of a ‘logbook’ documenting withholding of food, nor of havingtold the parents that ‘she absolutely considered what happened to Jonathanabuse and neglect.’As previously noted, Michael Carey told the Inspector General’s Office that heinformed Investigator Bowser during an October 29, 2004 telephone conversation that hehad in his possession a “logbook” which clearly said, according to Michael Carey, “mealswere being withheld.” When questioned by the Inspector General’s Office, almost threeyears later, Bowser said that she could not recall Michael Carey informing her about alogbook. Since Bowser failed to document the conversation, the Inspector Generalcannot verify these statements. However, she admitted that she was made aware of thelogbook during the course of the child abuse investigation in 2004, but not by the Careys.Nevertheless, she chose not to review it. She told the Inspector General, “I talked to theOMRDD [Taconic regional office] investigator about the logbook, but I did not look at itpersonally.”195
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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
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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 196 and 197: focuses. “We did it at the same t
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,
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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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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