A Critical Examination of State Agency Investigations into ...
A Critical Examination of State Agency Investigations into ... A Critical Examination of State Agency Investigations into ...
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
- 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
- Page 176 and 177: and aggressive behavior related to
- 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,
- 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
- Page 244 and 245: plan of prevention and remediation
- Page 246 and 247: the commission as to the implementa
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 <strong>of</strong> a logbook documenting Jonathan’s mealsAnother example <strong>of</strong> imprecise information contained in the joint response relatedto the Careys’ claim that:OMRDD, CQCAPD and the <strong>State</strong> Education Departmentmiserably in the handling <strong>of</strong> Jonathan’s abuse and neglect.all failedIn addition to asserting its claim <strong>of</strong> having conducted two full investigations,CQC responded to the accusation with the following:CQCAPD’s investigator has no recollection <strong>of</strong> having been told by theparents <strong>of</strong> a ‘logbook’ documenting withholding <strong>of</strong> food, nor <strong>of</strong> 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 <strong>of</strong> thelogbook during the course <strong>of</strong> 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 <strong>of</strong>fice] investigator about the logbook, but I did not look at itpersonally.”195
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