A Critical Examination of State Agency Investigations into ...

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Although the statement provided to the Governor implies that CQC did not knowof the logbook, CQC General Counsel Boehlert claimed we “never suggested that weweren’t aware of the existence [of the logbook.] We said that the parents did not bringthis to our attention….I think we got [the logbook] a couple of ways: via their attorney inNovember [2004] and via the folks at OMRDD.” CQC Director Keegan added, “I don’tknow; I didn’t write it [the response]….It says that the investigator has no knowledge ofit. Now that’s probably in error, because I know that she did. I don’t know who wrote it.I don’t know what basis it was. I don’t know, but you know we all know that she wastold by [the Taconic regional office investigator] that there was a logbook.”The Inspector General’s Office questioned Chairman O’Brien regarding themisleading information provided to the Governor’s Office. Despite the fact that theintended recipient of the response was the Governor, O’Brien did not recall reviewing thedocument until he was preparing to meet with the Inspector General’s Office, over oneyear after the document was drafted.The joint response developed by both OMRDD and CQC contained factual errors,misrepresentations, and misleading information to the Governor’s Office.Notification of Law EnforcementCQC did not notify a law enforcement agency regarding Jonathan’s abuse. NewYork State Mental Hygiene Law reads, “If it appears that a crime may have beencommitted, the commission [CQC] shall give notice thereof to the district attorney orother appropriate law enforcement official.” 44A CQC document, entitled “Checklist for44 Mental Hygiene Law § 45.07(f)(2).196
SCR Intake/Follow-up,” that is completed by CQC to ensure all initial activities are takenwhen a case is received, indicated that the police were not informed of the allegationwhen it was first received, in late October 2004. Investigator Bowser reported that it isstandard practice for CQC to ensure that law enforcement has been notified when it isbelieved that a crime may have been committed. When asked why the police were notcontacted immediately, Bowser said, “We didn’t see anything that would…necessitate acall to the police. I mean, apparently the parents had called the police. I don’t knowwhat happened with that.” General Counsel Boehlert also stated, “If we had seenevidence of what we thought was criminal conduct, we would have reported that. Wedidn’t see that.”Given CQC’s findings, the Inspector General does not criticize its decision not tonotify the district attorney or law enforcement.Inadequate Investigative OversightThe Inspector General’s Office found deficiencies in case supervision andoversight at CQC. CQC child abuse policies note that its investigators are responsible forensuring that child abuse investigations are complete and that the investigator’s TeamLeader is responsible for ensuring the record “is complete and accurate.” Theinvestigator assigned to this case, Bowser, was also the Team Leader. Finalresponsibility for ensuring that the information is complete rests with the Director ofQuality Assurance and Investigations, according to policy. Since two memos to the casefile were never completed by Bowser, it appears that Keegan did not adequately reviewthe file to ensure it was complete when it was submitted for review.197
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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
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Inaccurate Information Provided to
Page 150 and 151: this allegation. The letter was tra
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Page 156 and 157: egistry, and then it seems there wa
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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
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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 198 and 199: ead, “If he wets again - take she
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 220 and 221: CQC wrote in its unfounded notifica
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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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Page 246 and 247: the commission as to the implementa
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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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