A Critical Examination of State Agency Investigations into ...
A Critical Examination of State Agency Investigations into ... A Critical Examination of State Agency Investigations into ...
The oversight deficiencies were even more pronounced in CQC’s so-called careand treatment investigation. Again, according to CQC care and treatment investigationpolicies, the CQC investigator is responsible for the completion of the case file and itscontents, while the Team Leader is responsible for reviewing the record to ensure it iscomplete and accurate. As in the child abuse investigation, the investigator assigned inthis case, Bowser, was the Team Leader. Since the docket sheet and progress notes wereblank, it appears that the oversight of the investigative case file was not sufficient.Keegan, who is Bowser’s supervisor, reported that she played both roles as investigatorand team leader and was responsible for checking her own work. Given this scenario,Keegan was asked by the Inspector General whether the responsibility for ensuring thecompleteness of the case file should have defaulted to him. He responded, “You canmake that argument that it should, but I’m actually much too busy to be able to lookat… case files…from the team leaders or investigators.”CQC’s Application of Child Abuse StatutesIn making their complaint to the Inspector General, Michael and Lisa Careyasserted that CQC has misinterpreted the definitions of child abuse and neglect containedin Social Services Law § 412(8)-(9) that are detailed earlier, and that thismisinterpretation results in a failure to identify and prevent child abuse throughout thesystem. The Careys cited as evidence of this misinterpretation the fact that CQCsubstantiates only approximately five percent of the child abuse allegations itinvestigates. The Inspector General found that CQC, in at least one case, used incorrectcriteria in determining whether a child has been placed at risk of physical injury. Inaddition, CQC makes little effort to evaluate whether the disabled children in its198
jurisdiction have experienced emotional injury as a result of abuse, and virtually no effortto evaluate whether they have been placed at risk of emotional injury. Finally, theInspector General found that CQC’s practice of designating certain unfounded cases as“institutional neglect” is contrary to the plain language of the Social Services Law andresults in requests to providers and OMRDD to review incidents that do not merit anyfurther attention.Different Rates of Substantiation Between CQC and OCFSAs noted earlier in this report, CQC is assigned only a small percentage of childabuse allegations state-wide. The State Central Register of Child Abuse andMaltreatment accepts more than 140,000 reports a year of suspected child abuse ormaltreatment, most of which occur within family settings rather than to children ininstitutions. Approximately one percent of reports per year deal with allegations of abuseor maltreatment in institutional settings. Of this one percent, CQC reviews allegationsagainst residential care facilities operated or certified by OMRDD or the State Office ofMental Health.Like CQC, the Office of Children and Family Services (OFCS) also reviewscertain child abuse allegations originating in institutional settings. OCFS is responsibleto review cases of OCFS operated or licensed residential care facilities and certainprograms under the jurisdiction of the State Education Department, such as schools forthe blind and schools for the deaf. When conducting investigations of alleged abuse andneglect of children in residential care, OCFS and CQC use the same definitions set forthin subdivisions (8) and (9) of § 412 of the Social Services Law. The chart below shows199
- 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 198 and 199: ead, “If he wets again - take she
- Page 200 and 201: Although the statement provided to
- 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
- Page 248 and 249: Agency Responses to the Inspector G
- Page 250 and 251: incident is reported to have occurr
The oversight deficiencies were even more pronounced in CQC’s so-called careand treatment investigation. Again, according to CQC care and treatment investigationpolicies, the CQC investigator is responsible for the completion <strong>of</strong> the case file and itscontents, while the Team Leader is responsible for reviewing the record to ensure it iscomplete and accurate. As in the child abuse investigation, the investigator assigned inthis case, Bowser, was the Team Leader. Since the docket sheet and progress notes wereblank, it appears that the oversight <strong>of</strong> the investigative case file was not sufficient.Keegan, who is Bowser’s supervisor, reported that she played both roles as investigatorand team leader and was responsible for checking her own work. Given this scenario,Keegan was asked by the Inspector General whether the responsibility for ensuring thecompleteness <strong>of</strong> the case file should have defaulted to him. He responded, “You canmake that argument that it should, but I’m actually much too busy to be able to lookat… case files…from the team leaders or investigators.”CQC’s Application <strong>of</strong> Child Abuse StatutesIn making their complaint to the Inspector General, Michael and Lisa Careyasserted that CQC has misinterpreted the definitions <strong>of</strong> child abuse and neglect containedin Social Services Law § 412(8)-(9) that are detailed earlier, and that thismisinterpretation results in a failure to identify and prevent child abuse throughout thesystem. The Careys cited as evidence <strong>of</strong> this misinterpretation the fact that CQCsubstantiates only approximately five percent <strong>of</strong> the child abuse allegations itinvestigates. The Inspector General found that CQC, in at least one case, used incorrectcriteria in determining whether a child has been placed at risk <strong>of</strong> physical injury. Inaddition, CQC makes little effort to evaluate whether the disabled children in its198
Change language