A Critical Examination of State Agency Investigations into ...

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weekend, his behavior was so bad, so it wasn't just the school…This carried right over tohome -- the change -- there is no doubt in our mind.”Entries in Jonathan’s personal communication logbook around this time revealedthe confusion that staff had over his casein-free diet. One employee wrote that Jonathanreceived milk for lunch and reminded staff to follow his casein-free diet. Another stafferresponded that Jonathan was drinking lactose-free milk. However, Jonathan should havebeen given soy milk, not lactose-free milk, which contains casein.On September 23, 2004, Anderson School staff launched a new Behavior SupportPlan. This plan reiterated the use of planned ignore and directed staff to ignore all ofJonathan’s bad behaviors, while attempting to redirect his focus to the task or activity athand. It also authorized staff to remove Jonathan from the classroom to a vacant roomwhen he disturbed other children in school. If he displayed maladaptive behaviors in theresidence, staff members were instructed to escort Jonathan to his bedroom. WhenJonathan was in his bedroom, the plan directed staff to remove all of his “reinforcers,”such as toys, books, and cars.Four days later, on September 27, 2004, nine clinical staffers at the AndersonSchool held a Team Problem Solving Meeting to discuss Jonathan’s extreme difficulties.At the meeting, staffers noted that Jonathan’s behaviors were preventing him from doingany work at school, where he was “targeting other students in the classroom” and werecausing problems in the residence and during home visits. The staff attributed some ofJonathan’s negative behaviors to attention-seeking and defiance. That afternoon, forexample, Jonathan required a two-person escort from the school to the residence, where62
he stripped off all his clothes and repeatedly lunged for an exit door handle to set off thealarm, according to a logbook entry.In response, staff developed another Behavior Support Plan. The September 27plan, implemented immediately, added more restrictions. For the first time, Jonathan’sBehavior Support Plan included restrictions on Jonathan’s access to regular meals. Theplan required Jonathan to be dressed and seated in a dining table chair before he could eathis regular meal. Staff would give one verbal prompt that it was time to eat and place hismeal on the dining room table in front of him. At school, Jonathan’s classroom deskwould be used for meals when he acted appropriately. If he failed to comply, Jonathanwould be removed to an adjacent room to eat. Nursing staff directed that his food intakeat all meals be documented. However, the new plan did not specify how staff membersshould react if Jonathan refused to come to the table or dress to eat. It did not state whatalternative foods, if any, should be provided.There is no evidence that the Careys were aware of this new Behavior SupportPlan. Despite instructions to record Jonathan’s food intake, documentation of mealsduring this period was inconsistent or missing altogether. Therefore, the InspectorGeneral could not determine what Jonathan did or did not eat during this time or whatfood he was provided.However, some documents indicated that Jonathan “refused to eat.” The notationthat Jonathan “refused to eat” was interpreted by staff in two ways. One was that hephysically shunned the food placed before him; the other was that Jonathan refused tocomply with the directive to put his clothes on and, therefore, was not permitted to eat aregular meal with other children in the school or the residence.63
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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
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 64 and 65: a snack such as cereal or verbal pr
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
Page 114 and 115: 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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A Critical Examination of State Agency Investigations into ...

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