A Critical Examination of State Agency Investigations into ...

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VI. RECOMMENDATIONSThe Inspector General has provided copies of this report to the relevant stateagencies. In addition, copies have been provided to the Albany, Schenectady, andDutchess County district attorneys’ offices for information and review.Taconic Developmental Disabilities Services Office1. The Inspector General recommends that the Taconic regional office of OMRDD,or any regional office, take primary responsibility for an investigation regarding achild’s care at a facility within its jurisdiction whenever the facility discloses aconflict of interest or an appearance of such a conflict that would interfere with aninternal investigation.2. The Inspector General recommends that the Taconic regional office take steps toensure full cooperation of employees in state-certified facilities with OMRDDinvestigations, as required by law. These steps could include notification of thefacility’s Executive Director or Board of Directors of an employee’s failure tocomply with this obligation, as well as a referral of the matter to OMRDD CentralOffice to review the provider’s certification to operate in New York.Office of Mental Retardation and Developmental Disabilities1. The Inspector General recommends that OMRDD Central Office ensurecompliance with its policy directing surveyors to fully incorporate all regulatoryviolations into a Statements of Deficiencies.228
2. The Inspector General recommends that OMRDD Central Office ensurecompliance with its policy directing surveyors to examine all availableinformation, including pertinent documents and witness interviews.3. In instances when a survey related to a separate investigation by one ofOMRDD’s regional offices is conducted, the Inspector General recommends thatOMRDD Central Office coordinate such efforts and obtain the investigativefindings of the regional office.4. In light of Jonathan’s Law which provides families with greater access to certaininvestigatory records, the Inspector General encourages OMRDD to re-evaluatethe language used in its Statements of Deficiencies to determine whether thedocument should indicate when many instances occurred, even if only oneinstance of a violation is being cited.5. The Inspector General reminds OMRDD Central Office of its ethical and legalresponsibility to provide thoroughly accurate information to the Governor’sOffice. OMRDD should take measures to ensure compliance with the fulfillmentof such responsibility.6. The Inspector General recommends that OMRDD review the conduct of thoseresponsible for providing a response to Governor Pataki’s office that did notaccurately reflect OMRDD’s actions in this matter.7. There is no justification for a child placed in a private, state-certified facility to beafforded less protection from abuse than a child in a state-run facility. TheInspector General encourages OMRDD to re-examine draft regulations on229
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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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systemic significance.” In a hear
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• Anderson School did not have co
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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
Page 216 and 217: ecognizes that the determination of
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Page 220 and 221: CQC wrote in its unfounded notifica
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Page 226 and 227: There is not proper and safe oversi
Page 228 and 229: the meeting, “We left it with the
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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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