A Critical Examination of State Agency Investigations into ...

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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
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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
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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 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
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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
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Page 2Joseph FischJune 5, 2008conta
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Recommendations: The Inspector Gene
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A Critical Examination of State Agency Investigations into ...

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