A Critical Examination of State Agency Investigations into ...

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a snack such as cereal or verbal praise. The former Director of Clinical Services, whosupervised the implementation of Jonathan’s behavior plan at the time, wrote that“planned ignoring” is defined as a “non-exclusionary time out where social reinforcers[attention by others, verbal interaction] are removed…contingent upon the occurrence ofan inappropriate behavior.”Despite the fact that Jonathan’s daily behavior was disruptive, gains were stillfound in certain areas. Anderson School and his school district’s CSE records noted thatJonathan showed improvement throughout 2003 and into early 2004, and it appeared asthough his residential placement was meeting many of his needs.Michael and Lisa Carey agreed that during this period Jonathan showed signs ofimprovement in toilet training at the Anderson School. The Careys indicated thatJon athan was successfully using the toilet about 50 percent of the time and they werepleased with this progress.However, by the summer of 2004, Jonathan’s behavioral problems and non-An April-to-compliance escalated. Anderson School staff could not determine why.June 2004 quarterly progress report noted that Jonathan was disrobing more frequently.Jonathan’s removal of shirts, pants, shoes and socks presented a significant challenge tostaff, as they did not want Jonathan to perform daily activities in various states ofundress, especially in front of other students. Staff interviewed by the Inspector Generalcited “health” and “safety” concerns regarding Jonathan’s state of undress, especiallyduring mealtimes, particularly since he was urinating and defecating, sometimes in publicareas. Jonathan’s personal communication logbook, a journal of activities and behaviorsthat accompanies each resident throughout the day and is used to enhance60
communications between the residential and school staff, noted the increased incidenceof Jonathan’s aggressive behaviors. Many of the behaviors required the staff tophysically hold, restrain, or escort Jonathan in an effort to prevent him from harminghimself or others.Jonathan’s behaviors of flopping, attacking staff and students, removing clothes,and throwing things increased even more in September 2004. According to theResidence Manager, who oversees residence care staff, “He started spiraling out ofcontrol and they were frantically trying to come up with appropriate behavior plans andchanging meds.”On September 11, 2004, the Careys visited Jonathan to celebrate his 11 th birthday,which fell on the following day. His log entry states:Jonathan had a good morning he was playing with cars, andalso…walking. Their parents came at 11:30 a.m. When he saw them hewas very happy. They came for …Festival. He had fun time there. Heate breakfast and lunch well…Jonathan had a great afternoon. He enjoyedall the parents visiting, the festival, his birthday party, etc. He seemedvery happy and peaceful.Two days later, on September 13, he had a very rough day, staff wrote. “Not verymany toileting issues but he ‘flopped’ for about 85% of the day. He was very aggressivetoward students and female staff in the classroom…He had to be restrained afterattacking some students & staff.’’The Careys, too, observed Jonathan’s increased maladaptive behaviors. “I couldhardly even manage him,” Michael Carey told the Inspector General’s office, describinga late September home visit. Lisa Carey added, “Yeah, it was like a nightmare all61
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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
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 54 and 55: The reports are shared with the fam
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 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
Page 106 and 107: an entry on an October 4, 2004, Beh
Page 108 and 109: When questioned about the Taconic r
Page 110 and 111: involved “fully in the program pl
Page 112 and 113: 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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that OCFS’s rate of indication is
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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
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Recommendations: The Inspector Gene
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