A Critical Examination of State Agency Investigations into ...

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incident is reported to have occurred. In some cases, a separate review may be undertaken by thecertifying agency (OMH or OMRDD). Going forward, every such allegation will result in: (1) aCommission investigation of the SCR allegation, with the consistent application of all relevantprovisions of the Social Services and Mental Hygiene Laws, including those requiring evaluationof the risk of physical and emotional injury and recommendations that employee discipline beconsidered, where warranted; and (2) a broader review, which will look at all of the criteria andfactors which affect the care of the child named in the SCR report, not only those which arespecifically referenced in the SCR allegation, and also issues which may affect the care of otherchildren in the program and/or which may have wider systemic impact. This review will becompleted after all other relevant investigations by other entities (e.g., the facility and/orcertifying agency) have been finalized, and will evaluate the adequacy of other investigationsand the extent to which any recommended corrective action have been implemented. The reviewwill be conducted by an experienced investigator, and not by the same investigator assigned toconduct the SCR investigation. As we proceed, I will be reaching out to a variety ofstakeholders, within and outside of State government, to seek their advice and counsel to assurethe efficacy of this approachReflecting the high priority which I have assigned to this issue, the Commission has establishedcriteria to guide the phased implementation of this protocol, beginning with allegations whichraise the most serious concerns. We will be training staff to carry out this new protocol, withparticular attention to several of the issues raised in the Inspector General’s report; e.g., adheringto investigative policies and protocols; securing and reviewing all relevant information; and,thoroughly documenting investigative activities; etc. The protocol will be initially implementedthrough the realignment of existing staff resources. I am in the process of preparing a plan whichwill address options for identifying the resources necessary to support full implementation.I believe that the implementation of this protocol will better serve the interests of children andfamilies throughout the system. Equally important, it will afford greater transparency andaccountability in oversight.In closing, I want to express my appreciation for the thoroughness of your investigation. Iwelcome the opportunity which this review has afforded the Commission to analyze itsoperations and take steps to improve the quality of the oversight and advocacy which it providesto New Yorkers with disabilities, their families, advocates and service providers.Sincerely yours,Jane G. Lynch
David A. PatersonGovernorDiana Jones RitterCommissionerSTATE OF NEW YORKOFFICE OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES44 HOLLAND AVENUEALBANY, NEW YORK 12229-0001www.omr.state.ny.us(518) 473-1997 • TDD (518) 474-3694June 5, 2008Joseph Fisch, Inspector GeneralEmpire State PlazaAgency Building 2, 16 th FloorAlbany, New York 12223Thank you for the opportunity to comment on the Office of the State Inspector General (OSIG) DraftReport, "A Critical Examination of State Agency Investigation into Allegations of Abuse of JonathanCarey". I have waited with great anticipation for the results of this comprehensive and in-depthinvestigation of activities and conduct which occurred prior to the start of my administration. I amcommitted to thoroughly analyzing the results of this report to identify opportunities for improvement inmission-driven, quality management and outcomes.This independent investigation, while providing assurances that work performed by the Office of MentalRetardation and Developmental Disabilities (OMRDD) Central Office and its Taconic DevelopmentalDisabilities Services Office (DDSO) was conducted completely and in compliance with rules andregulations then in place, indicates that there are still opportunities to improve our approach toinvestigations and our quality reviews. I can not help, however, being disturbed by the information andfindings related to the standard and practice of care for Jonathan Carey while at the school and continueto appreciate the family's frustration and sadness, now amplified in the context of the subsequent tragicdeath of their son. While I was particularly relieved with the conclusion that there was no evidence tocorroborate allegations of a cover-up of information, I know we should continue to work to do better.Accordingly, over the last year, OMRDD has advanced a number of improvements in qualitymanagement, oversight and transparency and we will be aggressive in addressing the additionalrecommendations so thoughtfully provided by you in this report.Turning specifically to the OIG's findings as they relate to OMRDD, I agree with the finding that theTaconic investigation was "comprehensive and competently executed" and that it "addressed everyallegation raised," finding "mistreatment" and "neglect" at the Anderson School. I also agree that theCentral Office quality assurance survey was adequate and the follow-up extensive.The report does question the adequacy of the information which was provided to the Carey's concerningthe findings of the investigation of the Anderson School by Taconic. After I became Commissioner, Idid ask my Counsel to examine that particular issue and we decided that OMRDD could have done abetter job of sharing information with Jonathan's parents. Consequently, on May 25 th of last year, myCounsel sent the Carey's a copy of the letter which had been previously sent to the Anderson SchoolProviding supports and services for people with developmental disabilities and their families.recycled paperOMR 26.04 13/08)
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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
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ead, “If he wets again - take she
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Page 212 and 213: facility employee and CQC recommend
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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
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Page 246 and 247: the commission as to the implementa
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Page 252 and 253: Page 2Joseph FischJune 5, 2008conta
Page 254 and 255: Recommendations: The Inspector Gene
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