A Critical Examination of State Agency Investigations into ...

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(ii) violent behavior exhibited by either patients or employees;(iii) frequency and severity of injuries incurred by either patients or employees;(iv) frequency and severity of injuries occurring on individual wards or in buildings atsuch facility;(v) patient leave withou t consent; or(vi) medication errors.; and(vii) recommendations for corrective actions in response to incident reports toensure the care and safety of all patients.2. The establishment of cumulative record keeping of incident reports which identifiespatient and employee involvement.3. A compilation of uniform and measurable information, first on a facility basis, then onan office-wide basis, that will indicate where the greatest number and types of incidentsof violence and injury occur.4. That each Each facility shall aggregate its data monthly for the director and thataggregated information shall be submitted, at least semiannually to the commissioner ofthe office of mental health by facilities listed in section 7.17 of this chapter, and to thecommissioner of the office of mental retardation and developmental disabilities byfacilities listed in section 13.17 of this chapter.5. Such The commissioners shall transmit a copy of any report received pursuant tosubdivision four of this section to the state commission on quality of care for the mentallydisabled and advocacy for persons with disabilities.6. [FN1] Such commissioners shall promulgate regulations establishing standards for theprotection of children in residential care from abuse and maltreatment, includingprocedures for: (a) consistent with appropriate collective bargaining agreements andapplicable provisions of the civil service law, the review and evaluation of thebackgrounds of and information supplied by any person applying to be an employee, avolunteer or consultant, which shall include but not be limited to the followingrequirements: that the applicant set forth his or her employment history, provide personaland employment references and relevant experiential and educational information and,sign a sworn statement whether, to the best of his or her knowledge, he or she has everbeen convicted of a crime in this state or any other jurisdiction;(b) establishing for employees, minimal experiential and educational qualificationsconsistent with appropriate collective bargaining agreements and applicable provisions ofthe civil service law;Bold type indicates new language.Strike out type indicates deleted language. 236
(c) assuring adequate and appropriate supervision of employees, volunteers andconsultants;(d) demonstrating that appropriate action is taken to assure the safety of the child who isreported to the state central register as well as other children in care, immediately uponnotification that a report of child abuse or maltreatment has been made with respect to achild's custodian in a residential facility;(e) removing a child when it is determined that there is risk to such child if he or shecontinues to remain in a residential facility; and(f) appropriate preventive and remedial action to be taken including legal action,consistent with appropriate collective bargaining agreements and applicable provisions ofthe civil service law. Such standards shall also establish as a priority that:(i) subject to the amounts appropriated therefor, administrators, employees, volunteersand consultants receive training in at least the following: child abuse prevention andidentification, safety and security procedures, the principles of child development, thecharacteristics of children in care and techniques of group and child managementincluding crisis intervention, the laws, regulations and procedures governing theprotection of children from abuse and maltreatment, and other appropriate topicsprovided, however, that such offices may exempt administrators and consultants fromsuch requirements upon demonstration of substantially equivalent knowledge orexperience; and(ii) subject to the amounts appropriated therefor, children receive instruction, consistentwith their age, needs and circumstances as well as the needs and circumstances within thefacility or program, in techniques and procedures which will enable such children toprotect themselves from abuse and maltreatment.The commissioners shall take all reasonable and necessary actions to assure thatemployees, volunteers or consultants in residential care facilities are kept apprised on acurrent basis of all policies and procedures of the respective offices relating to theprotection of children from abuse and maltreatment, and shall monitor and supervise theprovision of training to such administrators, employees, volunteers, children andconsultants. Standards developed pursuant to this subdivision shall, to the extentpossible, be consistent with those promulgated by other state agencies for such purposes.7. Such commissioners shall provide necessary assistance to the state commission onquality of care for the mentally disabled in the conduct of investigations pursuant tosection 45.07 of this chapter, shall consider its recommendations for appropriatepreventive and remedial action including legal actions, and shall provide or direct aresidential facility licensed or operated by the office of mental health or office of mentalretardation and developmental disabilities to provide written reports thereon to thecommission as to the implementation of plans of prevention and remediation.Bold type indicates new language.Strike out type indicates deleted language. 237
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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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Jonathan’s casein-free diet, that
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treatment review to the Careys, the
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Documentation of investigatory acti
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As noted above, Bowser also failed
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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
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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 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 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
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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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