A Critical Examination of State Agency Investigations into ...

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The reports are shared with the family and the school district. The IEP is reviewedannually by the school district and the parents to chart the progress of the student anddevelop a plan for the coming year.Once admitted, children are assigned to residences, based on age and level offunctioning. The residential component of the Anderson School is supervised by aDirector of Children’s Residential Services, who oversees daily operations andcoordinators of the residences. Birch Cottage, where Jonathan resided, was supervisedby a residence manager who oversaw the residential care staff and residents and acted asthe primary liaison with parents, nursing staff, and the school. The cottage utilized theservices of approximately 22 Anderson School employees, direct care aides and others, tomeet the daily needs of the children.The residence component seeks to strengthen skills such as personal care,communication, social interaction, recreation and community integration. Residentsparticipate in community activities such as visits to parks and festivals. They also join incottage activities, such as arts and crafts and games.Students attend classes at the Anderson School’s private school, which is locatedon the grounds. Teachers’ assistants escort students to and from the residence andsupport teachers in their lessons and activities. Elementary-age classes address schoolreadiness behaviors (sitting, listening to a speaker, taking turns, etc.), academicfunctioning and social skills development. Behavior specialists and speech andoccupational therapists provide assistance in implementing and developing these skills.In response to maladaptive and defiant behaviors by residents, the AndersonSchool may employ a Behavior Support Plan, which attempts to address and manage50
these behaviors; to foster more positive, appropriate, and pro-social behavior; and toensure the safety of the residents and their peers. The development of a BehaviorSupport Plan commences with the identification by staff of maladaptive behaviors to betargeted and the recording of the frequency and intensity of the behaviors, which aredocumented in a Behavioral Report Form.A clinician identifies a pattern of behavior from the review of these BehavioralReport Forms, and with team input, decides if a behavior plan is required or a currentplan needs to be modified. A Functional Behavior Assessment is then conducted toidentify contributing factors and formulate a hypothesis about the conditions under whichthe behavior occurs and the consequences that maintain it.After evaluating the behavior, a treatment team creates a plan. Team memberscould include a behavioral specialist, a case manager, and the directors of clinicalservices, education, children’s residential services, and health services. This team meetsto review assessments and to determine if the individual’s behavior plan needs to bemodified. Behavior support management techniques can range from verbal persuasion tophysical interventions. Policies dictate that the techniques employ the least restrictivealternatives possible to ensure the safety of all parties. The facility’s clinician also isresp onsible for providing in-service training to all staff involved so that the plan will beconsistently implemented. The overall implementation of the behavior plan is theresponsibility of the Director of Clinical Services.On an as-needed basis, supplemental forms are used to capture important clinicalinformation such as a child’s urinary output, caloric intake, and refusal to dress, whichwas done in Jonathan’s case. Anderson School Weekly Body Check Forms document a51
Page 2 and 3:
Pursuant to Executive Law § 53, th
Page 4 and 5: INVESTIGATION BY THE TACONIC REGION
Page 6 and 7: The alleged abuse began in Septembe
Page 8 and 9: Michael and Lisa Carey. Along with
Page 10 and 11: The Careys filed a complaint with t
Page 12 and 13: The Taconic Regional Office’s Inv
Page 14 and 15: egulatory violations identified in
Page 16 and 17: compared to consumers in state-oper
Page 18 and 19: determined that Jonathan’s treatm
Page 20 and 21: Statements from CQC executives and
Page 22 and 23: investigating agencies or the Gover
Page 24 and 25: 7. There is no justification for a
Page 26 and 27: Legislative RecommendationThe Inspe
Page 28 and 29: and give positive reinforcement for
Page 30 and 31: separate reports. Taconic’s was i
Page 32 and 33: 4. Did the investigating agencies e
Page 34 and 35: in the Department of Special Educat
Page 36 and 37: III. BackgroundNEW YORK STATE SERVI
Page 38 and 39: abuse or maltreatment within New Yo
Page 40 and 41: certain OMRDD-certified facilities,
Page 42 and 43: instances in which the Anderson Sch
Page 44 and 45: appropriateness of the Dutchess Cou
Page 46 and 47: Diagram of the Anderson School camp
Page 48 and 49: Additionally, the Mental Hygiene La
Page 50 and 51: Among the protections offered in th
Page 52 and 53: To ensure the safety of the residen
Page 56 and 57: esident’s physical condition, inc
Page 58 and 59: He could also become physically agg
Page 60 and 61: RESIDENCY AT THE ANDERSON SCHOOLIn
Page 62 and 63: Shortly after his admission, Jonath
Page 64 and 65: a snack such as cereal or verbal pr
Page 66 and 67: weekend, his behavior was so bad, s
Page 68 and 69: Experts retained by the Inspector G
Page 70 and 71: The October 9, 2004, Anderson Schoo
Page 72 and 73: eally losing it, going bananas basi
Page 74 and 75: document indicated that Jonathan at
Page 76 and 77: notified and she consented to the m
Page 78 and 79: The Anderson School Executive Direc
Page 80 and 81: naked to prevent him from leaving t
Page 82 and 83: Anderson School Weekly Body Check F
Page 84 and 85: continues. Does he take a multivita
Page 86 and 87: Executive Director stated that arou
Page 88 and 89: OMRDD regulations, OMRDD called the
Page 90 and 91: CQC investigator’s notes reflecte
Page 92 and 93: the psychiatrist wrote (in part),
Page 94 and 95: V. State Agency Investigations of A
Page 96 and 97: On October 25, 2004, the Careys att
Page 98 and 99: INVESTIGATION BY THE TACONIC REGION
Page 100 and 101: are responsible for conducting thei
Page 102 and 103: School policies and procedures. Inv
Page 104 and 105:
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
Page 128 and 129:
that is absent from the Statement o
Page 130 and 131:
clinical director role, psychiatris
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the table contingent on appropriate
Page 134 and 135:
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
Page 148 and 149:
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
Page 158 and 159:
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
Page 164 and 165:
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
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
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
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On at least one previous occasion,
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emotional injury was impossible in
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facility employee and CQC recommend
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Restrictive Statutory LanguageAltho
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ecognizes that the determination of
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CQC policy does not require further
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CQC wrote in its unfounded notifica
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INVESTIGATION BY THE NEW YORK STATE
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develop sufficient evidence to supp
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There is not proper and safe oversi
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the meeting, “We left it with the
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this important matter. Your corresp
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VI. RECOMMENDATIONSThe Inspector Ge
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ehavior management (14 NYCRR § 633
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child in an institutional setting,
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(a) Records and documents pertainin
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(ii) violent behavior exhibited by
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8. Such commissioners shall provide
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plan of prevention and remediation
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the commission as to the implementa
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Agency Responses to the Inspector G
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incident is reported to have occurr
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Page 2Joseph FischJune 5, 2008conta
Page 254 and 255:
Recommendations: The Inspector Gene
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