A Critical Examination of State Agency Investigations into ...

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the meeting, “We left it with them that we would review what they [Careys] had given usand see what we should do, or could do, if anything.” She noted that the joint responseprovided to the Governor’s Office by CQC and OMRDD in reply to the Careys’ writtencomplaint was not discussed at the meeting.Subsequently, the Governor’s Office arranged a meeting between the Careys andCQC Chairman O’Brien and then-OMRDD Commissioner Maul. No one from theGovernor’s staff attended the meeting, which was held on October 20, 2006. CQCChairman O’Brien told the Inspector General’s Office that the “Governor’s Officedirected both of us [OMRDD and CQC] to meet together with them.You know, so theywere asking us to meet and help.” Maul reported to the Inspector General’s Office thathe thought the meeting was really to discuss confidentiality over quality assurancedocuments and the parents’ frustrations with this. He said that both CQC and OMRDDwere dealing with the same confidentiality issues, so “it seemed appropriate” to him todiscuss the issue with both agencies in attendance. Following the meeting, the Careys’attorney sent a letter to Boehlert, with a copy to former OMRDD General CounselKietzman, thanking them for meeting and enclosed a copy of the aforementionedlogbook, which the Careys believed provided crucial evidence that Jonathan was abusedat the Anderson School. As noted above, neither CQC nor OMRDD Central Office hadreviewed the logbook during their investigations.The Former Director of Human Services told the Inspector General’s Office thatfollowing the October 20, 2006, meeting, Michael Carey made an unannounced visit toher office and expressed his dissatisfaction with Maul and O’Brien. She advised, “Iheard from them, [the Careys] that they weren’t real happy with the meeting and they felt224
they weren’t taken seriously.” She did not recall receiving a written report from eitherOMRDD or CQC regarding the meeting; however, she recalled both OMRDD and CQCexpressed to her verbally that they advised the Careys they stood by their investigations.According to the Careys, after receiving a copy of Jonathan’s logbook, CQCreaffirmed its conclusion that the allegations concerning Jonathan’s abuse wasunsubstantiated, stating, “In our judgment, the information in the logbook does notsupport such an allegation or indication.” They received no response from OMRDD.Michael Carey reported to the Inspector General that, having been dissatisfiedwith the results of his meetings and with the agencies’ response to the logbook, herequested to meet with the governor personally. He reported, “For the next two months, Iwas either in person or calling almost every day the Governor’s Office to get in with thegovernor, and was denied every time.”Around this time, the Careys also contacted the Inspector General’s Office withtheir concerns. In a preliminary assessment, the Inspector General’s Office concludedthat their concerns were being addressed by the Governor’s Office and top managementin the relevant state agencies. In March 2007, under a new governor and new InspectorGeneral, this office re-opened its investigation.Governor Spitzer’s Response to the Careys’ ComplaintsFollowing the 2006 gubernatorial election and change of administration, theCareys sent a letter to former Governor Eliot Spitzer’s office on January 19, 2007.Michael Carey advised he received a response from Spitzer’s office but it stated,“Although it is not possible to schedule a meeting, we appreciate you writing to us about225
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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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and aggressive behavior related to
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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
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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
Page 216 and 217: ecognizes that the determination of
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Page 226 and 227: There is not proper and safe oversi
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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
Page 252 and 253: Page 2Joseph FischJune 5, 2008conta
Page 254 and 255: Recommendations: The Inspector Gene
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