A Critical Examination of State Agency Investigations into ...

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Page 2Joseph FischJune 5, 2008containing greater detail about the investigative findings. I believe that this report should reflect thatthis information was subsequently provided at my direction.The past 15 months have been difficult for the OMRDD system; for its many, many dedicated workers,the families of people served by the OMRDD system and the individuals themselves. All are hurt whenthe system is tainted. There is much that is good in the system, and of course, still much that can beimproved. Thank you for providing resolution to this outstanding matter and for providing me anopportunity to further advance my agenda for greater quality of care at the Anderson School andapplying lessons learned across my entire service system.Attached you will find OMRDD's responses to the specific recommendations provided in the report.Again, thank you for bringing closure to this matter.Sincerely,na Jones RitterCommissioner
DETAILED OMRDD COMMENTS IN RESPONSE TO OIGRECOMMENDATIONSThe following are our point by point comments to OIG's recommendations to OMRDD:Taconic:Recommendation: The Inspector General recommends that the Taconic regional officeof OMRDD, or any regional office, take primary responsibility for an investigationregarding a child's care at a facility within its jurisdiction whenever the facility disclosesa conflict of interest or an appearance of such a conflict that would interfere with aninternal investigation.Response: I intend to advise all DDSOs of their obligation to assume responsibility foran investigation of a voluntary provider whenever it would present a conflict of interestfor the voluntary provider to investigate incidents or abuse at its own facilities orprograms, such as when the administration of a provider is the target of an investigation.As the report notes, this is OMRDD's policy now, and it should be consistentlyfollowed.Recommendation: The Inspector General recommends that the Taconic regional officetake steps to ensure full cooperation of employees in state-certified facilities withOMRDD investigations, as required by law. These steps could include notification of thefacility's Executive Director or Board of Directors of an employee's failure to complywith this obligation, as well as a referral of the matter to OMRDD Central Office toreview the provider's certification to operate in New York.Response: I intend to advise all DDSOs that they must persist if they do not getcooperation by a witness at a voluntary provider and that this might include seeking theassistance of OMRDD Central Office and/or the Executive Director or the Board of thevoluntary provider. In fact, OMRDD has already included this admonition in itscommunications to voluntary providers as part of its focus on improving boardgovernance.OMRDD:Recommendation: The Inspector General recommends that OMRDD Central Officeensure compliance with its policy directing surveyors to fully incorporate all regulatoryviolations into a Statements of Deficiencies.Response: I will advise the Division of Quality Management that all violations found ina survey should be included in a Statement of Deficiency, even if the survey wastriggered by the care of a particular individual.1
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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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Although the statement provided to
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Page 212 and 213: facility employee and CQC recommend
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Page 216 and 217: ecognizes that the determination of
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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 248 and 249: Agency Responses to the Inspector G
Page 250 and 251: incident is reported to have occurr
Page 254 and 255: Recommendations: The Inspector Gene
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