A Critical Examination of State Agency Investigations into ...

CQC wrote in its unfounded notification letter to the facility, “Unfortunately, seriousincidents of patients engaging in sexual contact continue to occur.” Although theInspector General notes that CQC did perform additional activity on this case, itnevertheless was classified as “unfounded” rather than “institutional neglect” despite thesignificant and serious systemic deficiencies identified at the facility. Even the case ofJonathan Carey’s treatment at the Anderson School may have been a candidate for aninstitutional neglect designation. Because CQC’s policies regarding institutional neglectrequire a determination within seven days, many cases that involve institutionaldeficiencies are not designated as such, and thus may not receive the follow-upenvisioned by the law’s sponsors.ConclusionWhen asked to characterize the quality and thoroughness of CQC’s investigationsof Jonathan’s alleged abuse, CQC Chairman O’Brien stated, “I think it was verythorough. We defined what we were going to do and we did it.” Similarly, CQC’sGeneral Counsel characterized the child abuse investigation as “incredibly thorough, asall of our investigations are.” To the contrary, the Inspector General found the childabuse investigation was incomplete, and the care and treatment review simply did nothappen.CQC failed to conduct a thorough investigation and made dubious claims abouthaving conducted two separate investigations. Although the investigative shortcomingsin this case were serious and numerous, the investigator does not bear full responsibilityin this matter. This case also demonstrates failures throughout CQC, from investigativeoversight and case supervision to overall leadership and general philosophy.216