A Critical Examination of State Agency Investigations into ...

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Recommendations: The Inspector General recommends that OMRDD Central Officeensure compliance with its policy directing surveyors to examine all availableinformation, including pertinent documents and witness interviews.Response: This is the current expectation. However, I will direct the new OMRDDDeputy Commissioner for Quality Management to reinforce the expectation in trainingsessions and staff meetings to examine all pertinent documents and information whenconducting a survey.Recommendation: In instances when a survey related to a separate investigation by oneof OMRDD's regional offices is conducted, the Inspector General recommends thatOMRDD Central Office coordinate such efforts and obtain the investigative findings ofthe regional office.Response: I have already advised the Division of Quality Management of the need tocoordinate efforts with the internal investigative unit. In addition, I believe thenew organizational framework which I have adopted at OMRDD will help ensure theintegration of investigations and programmatic and licensure and fiscal reviews.Recommendation: In light of Jonathan's Law which provides families with greateraccess to certain investigatory records, the Inspector General encourages OMRDD to reevaluatethe language used in its Statement of Deficiencies to determine whether thedocument should indicate when many instances occurred, even if only one instance of aviolation is being cited.Response: I will advise the Division of Quality Management of the need to clarify thepolicy on how to address multiple deficiencies. There is significance to the number oftimes a deficiency occurs and this needs to be addressed when a survey takes place.Recommendation: The Inspector General reminds OMRDD Central Office of its ethicaland legal responsibility to provide thoroughly accurate information to the Governor'sOffice. OMRDD should take measures to ensure compliance with fulfillment of suchresponsibility.Responses: I have made transparency a hallmark of my administration. For reasons oftransparency, I have already made this position clear to my leadership team, managersand workforce in general and will remind my staff of the obligation to provide theGovernor's Office and all public officials and members of the public with accurateinformation.Recommendation: The Inspector General recommends that OMRDD review the conductof those responsible for providing a response to Governor Pataki's office that did notaccurately reflect OMRDD's actions in this matter.Response: It is difficult to reconcile what was written in the excerpts you cited and thegreater context of what the agency was doing and what the Governor's office knew the2
agency to be doing. We know that there was an investigation conducted and thatGovernor Pataki knew of the investigation. In addition, these comments were providedto the Governor Pataki almost two years ago, and unraveling the dynamics of therelationships and expectations that existed at that time would now be difficult. However,it is worth noting that the individual at OMRDD who prepared that response, inconjunction with CQC, is no longer with our agency. As to the other individuals whowere involved with the briefing of the Governor, I will discuss the matter further withthem.Recommendation: There is no justification for a child placed in a private, state-certifiedfacility to be afforded less protection from abuse than a child in a state-run facility. TheInspector General encourages OMRDD to re-examine draft regulations on behaviormanagement (14 NYCRR section 633.16) to ensure consistent safety and oversightprotections for all consumers statewide.Response: I have made the promulgation of the behavior management regulations apriority. You also recommend that OMRDD re-examine the behavior management draftregulations, which were never promulgated and therefore provide only guidance tovoluntary providers. As stated in the investigation, getting behavior managementregulations promulgated is a priority of my Administration. However, it is important thatthese regulation reflect OMRDD's mission and commitment to quality of care, and withthat in mind, I have directed that my staff take a diligent step backwards to make sure thatthe regulations are consistent with the overall mission and goals of OMRDD and itsperson centered perspective.Recommendation: The Inspector General recommends that OMRDD explicitlyrecommend agencies under its jurisdiction to review an employee's conduct and takeappropriate disciplinary action, when circumstances warrant such a recommendation.Response: I will advise all investigative staff that they should include, when appropriate,recommendations to voluntary providers that disciplinary action be taken againstemployees.Once again, I would like to thank you for the opportunity to comment on thisinvestigative report.3
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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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The oversight deficiencies were eve
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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
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Page 240 and 241: (ii) violent behavior exhibited by
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Page 250 and 251: incident is reported to have occurr
Page 252 and 253: Page 2Joseph FischJune 5, 2008conta
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