A Critical Examination of State Agency Investigations into ...

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There is not proper and safe oversight of disabled children by Stateagencies of schools like the Anderson School, to help insure the safety ofthe children. OMRDD, CQC, and the State Education Department allfailed miserably in the handling of Jonathan’s abuse and neglect.In their letter, the Careys claimed they received “watered-down” reports fromboth OMRDD and CQC regarding their findings in an effort to “cover-up” Jonathan’sabuse and neglect at the Anderson School. The Careys were especially critical of themanner in which CQC conducted its investigation and made reference to the fact that theCQC investigator made only one site visit to Anderson School and did not conduct aface-to-face interview with them. They also complained they had made several attemptsto speak with former OMRDD Commissioner Maul and filed numerous Freedom ofInformation Law (FOIL) requests for documents regarding OMRDD’s investigation, butreceived repetitive denials. They further wrote that despite a statement to them fromTaconic regional office Investigator Searle that “in all the years he has been doing this, hehas never seen anything like this,” they later received “another very watered downofficial letter from OMRDD [Taconic regional office] of what happened to Jonathan.”The Careys wrote that after receiving the watered-down letter, they called Taconicregional office Director Mizerak to inquire “what has happened [as a result of theinvestigation] with the people involved with the abuse and neglect of Jonathan.”According to the Careys, Mizerak responded, “I do not know. It is up to the [Anderson]school to do disciplinary action within the school.” The Careys also wrote to GovernorPataki, “Neither...the Anderson School or any of the State agencies involved haveadmitted to any wrong doing. There must be proper accountability in the schools andwithin the State regulatory agencies for the safety of the children.”222
Governor Pataki’s Response to the Careys’ ComplaintsAccording to ORMDD and CQC records and e-mail correspondence betweenthose agencies and the Governor’s Office, former Governor Pataki’s staff had requestedthat OMRDD and CQC prepare a response to the Careys’ June 2, 2006 letter to thegovernor. The final joint response entitled “Confidential Draft – Internal Document(8/11/2006) Combined OMRDD and CQCAPD response to Michael Carey’s letter toGovernor Pataki of June 2, 2006” was provided to the Governor’s Office via e-mail onAugust 14, 2006. Although the document contained information from both agencies, anOMRDD Associate Commissioner Gatens combined the responses for transmission to theGovernor’s Office, as requested. The joint response identified 13 separate concernsraised by the Careys in their letter to Governor Pataki with point-by-point explanationsand/or rebuttals by CQC and OMRDD. In previous sections, this report has discussedsome inaccuracies or misrepresentations in the information provided by OMRDD andCQC to the Governor’s Office. The Inspector General found no evidence that theinformation in the document was disseminated beyond the Governor’s Office.In September 2006, the Careys were invited to the Governor’s Office to meet withseveral staff members of the Governor’s Office of Health and Humans Services. CQCGeneral Counsel Boehlert and an OMRDD representative also attended the meeting. TheDirector of Human Services for the Secretary of Health and Human Services told theInspector General that the Careys provided a “stack of documents that they wanted tobring to our attention, go over all of it, and see if there was anything that could be done.”She added that the Careys were upset that they “had not had the opportunity to meet with[OMRDD] Commissioner Maul and [CQC Chairman] O’Brien.” At the conclusion of223
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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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Jonathan’s “demeanor has change
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that the additional complaints of a
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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
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Page 198 and 199: ead, “If he wets again - take she
Page 200 and 201: Although the statement provided to
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Page 214 and 215: Restrictive Statutory LanguageAltho
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Page 232 and 233: VI. RECOMMENDATIONSThe Inspector Ge
Page 234 and 235: ehavior management (14 NYCRR § 633
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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 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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