A Critical Examination of State Agency Investigations into ...

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Agency Responses to the Inspector General’s ReportThe two primary agencies reviewed in this report, OMRDD and CQC, were askedto respond to the Inspector General’s findings and recommendations. Those responsesare included in the following pages.244
DAVID A. PATERSONGOVERNORSTATE OF NEW YORKCOMMISSION ON QUALITY OF CARE & ADVOCACYFOR PERSONS WITH DISABILITIES401 STATE STREETSCHENECTADY, NY 12305-23971-800-624-4143 (Voice/TTY/Spanish)www.cqcapd.state.ny.usJANE G. LYNCHCHIEF OPERATING OFFICERBRUCE BLOWERPATRICIA OKONIEWSKIMEMBERSJune 2, 2008William HebertChief InvestigatorOffice of the Inspector GeneralEmpire State PlazaAgency Building 2, 16 th FloorAlbany, NY 12223Dear Mr. Hebert:I was appointed Chief Operating Officer of the Commission, effective Tuesday, May 27, 2008,upon the resignation of Gary O’Brien as Commissioner and Chair. As such, I have had a limitedopportunity to review the draft findings and recommendations of the Inspector Generalconcerning the various investigations of the allegations of abuse of Jonathan Carey at theAnderson School in 2004. Notwithstanding that limitation, I have determined I can best respondto the draft report by describing the affirmative steps which the Commission has taken, and willtake, to improve the quality and scope of its investigations into allegations of child abuse andmaltreatment. This approach will address issues and concerns raised in the report and betterserve and protect children with disabilities and their families.First, the Commission acknowledges that the demarcation between Commission SCRinvestigations and care and treatment reviews is not clearly articulated. This has contributed to alack of clarity regarding the nature and scope of both types of Commission reviews. I havedirected senior staff to revise protocols and train employees to better delineate and documentactivities when conducting SCR investigations and/or care and treatment reviews. Further, Ihave instructed senior staff to ensure that an independent supervisory review of each SCRinvestigation and/or care and treatment review is completed and documented. In addition, I canassure the Inspector General that a site visit to the residential program in which the SCR incidentis reported to have occurred is now conducted as part of every SCR investigation. Also, OCFShas been conducting a detailed review of each SCR investigation summary completed by theCommission since December 2007, and I am pleased to note that OCFS has confirmed all 111Commission findings reviewed to date.Second, the Commission will develop a plan for the phased implementation of a new protocol forthe investigation of allegations of child abuse or maltreatment. Currently, every SCR allegationreferred to the Commission must trigger a review by the residential program in which theAN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYERREASONABLE ACCOMMODATION WILL BE PROVIDED ON REQUESTPRINTED ON RECYCLED PAPER
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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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did not do a full care and treatmen
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CQC’s progress notes indicate tha
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epeatedly attempted to exaggerate t
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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 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,
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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 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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