A Critical Examination of State Agency Investigations into ...

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INVESTIGATION BY THE NEW YORK STATE POLICEThe Careys alleged to the Inspector General’s Office that state officials includingOMRDD Commissioner Maul and CQC Chairman O’Brien tampered with theinvestigation conducted by the State Police and the Dutchess County District Attorney’sOffice, and that there may have been political influence into the decision not tocriminally pursue the matter. The district attorneys of New York State are not within thejurisdiction of the State Inspector General. However, the Inspector General reviewed theinvestigation conducted by the State Police in conjunction with the district attorney andsought to determine whether the State Police or the district attorney discontinued theinvestigation or prosecution as a result of pressure from an agency or individual under theInspector General’ s jurisdiction. The Inspector General found no evidence that the StatePol ice or the district attorney was pressured to discontinue the investigation orprosecution of the case.On June 15, 2005, the State Police were contacted by an assistant district attorneywho is the Chief of the Special Victims Bureau of the Dutchess County’s DistrictAttorney’s Office. The assistant district attorney reported that Michael and Lisa Careyhad recently called her alleging child abuse involving their son while he was a resident atthe Anderson School.The Inspector General interviewed the assistant district attorney and State Policeinvestigator on several occasions and reviewed records obtained from the policeinvestigation. A program director for autism that the assistant district attorney hadconsulted was also interviewed. Additionally, the Inspector General interviewed218
executives from OMRDD, CQC, and the Taconic regional office regarding theirinteractions with the district attorney’s office and the State Police.Based on the Careys’ complaint, the State Police initiated an investigation, whichconsisted of an interview with the Careys and a review of the documents they provided,an interview with the Director of the Taconic regional office, and consultation with alocal program director at a private, not-for-profit program designed for children withspecial needs, including autism. In addition, the State Police investigator attempted tointerview Anderson School executives, but was met with resistance from the AndersonSchool attorney, who advised that Anderson School staff would not speak to him aboutthe matter.The State Police investigator conceded to the Inspector General’s Office that itwas difficult to move forward with the case due to the pending civil trial and the lack ofcooperation from the Anderson School. In addition, the investigator complained that thepolice received the allegations almost eight months after the alleged abuse occurred,stating, “We came onto the scene, the players and the stadium had emptied out by thetime we had got on the field.” To further encumber matters, he added, once preparationfor the Careys’ civil case commenced, all communication with the Anderson Schoolstopped. “That was our biggest hindrance here was that all doors were closed.”Initial State Police records listed possible misdemeanor charges of Assault in theThird Degree and Endangering the Welfare of a Child which were based on the Careys’original complaints. 45However, the State Police investigation of these charges did not45 Penal Law §120.00 and Penal Law § 260.10.219
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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
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While reports indicated that the An
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facilities like the Anderson School
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egistry, and then it seems there wa
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INVESTIGATION BY THE NEW YORK STATE
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target(s) of the complaint engaged
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arely used by CQC to substantiate a
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The second paragraph of the case su
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CQC Director of Quality Assurance a
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primarily to the provision of meals
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interview notes would have been exp
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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 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 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
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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,
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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
Page 252 and 253: Page 2Joseph FischJune 5, 2008conta
Page 254 and 255: Recommendations: The Inspector Gene
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