A Critical Examination of State Agency Investigations into ...

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The October 9, 2004, Anderson School Student Injury/Illness Report, completed by a nurse,documenting Jonathan’s bruising. (Note – “SIB” stands for Self Injurious Behavior)Also on October 9, Anderson School officials made two telephone calls toMichael Carey to advise him of the new situation. Medical notes and interviews ofAnderson School staff reflected that Michael Carey was informed about the seriousness66
of Jonathan’s condition and that Michael Carey acknowledged that Jonathan’s bruisingwas a result of physical interventions. Contemporaneous Anderson School MedicalProgress Notes read, “[Michael Carey] understands that bruises are self-caused & thatstaff is doing their best to protect Jon from the acts which caused this bruising.”Anderson School administrators stated that they recommended to Michael Careythat Jonathan be seen at a hospital because of his behaviors and bruising. They claimedthat Michael Carey denied their request to send Jonathan to the hospital. Michael Careydisputes this claim. Contemporaneous Medical Progress Notes read, “[Hospital]Admission was discussed but the feeling was this would not be needed at this time.”Medical notes also indicated that Mr. Carey was made aware that Jonathan wasgoing to be given substitute foods in his room, as he had not eaten the previous day. Thenurse wrote that Michael Carey was pleased that there was a plan “to continuenourishment while Jon remains in his room and understands that full meals cannot bebrought to room which might encourage this behavior.” The Executive Director alsorecalled telling Michael Carey about the food issue and that he had been told by staff thatJonathan was eating nutritional substitute foods. According to the Executive Director,Michael Carey purportedly responded, “What would you do if you feed him the standardmeal that everyone else is having in the house? You would be rewarding bad behavior.”Michael and Lisa Carey contend that October 9, 2004, was the first time theywere informed in any detail about the extent of the crisis situation involving their son,and that they previously were not informed of the changes to Jonathan’s meal or behaviorplan, his removal of clothing, or the source of the bruising. The Careys claimed that theyreceived a call on this date from the Executive Director who said that Jonathan “was67
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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
Page 20 and 21: Statements from CQC executives and
Page 22 and 23: investigating agencies or the Gover
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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 66 and 67: weekend, his behavior was so bad, s
Page 68 and 69: Experts retained by the Inspector G
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
Page 116 and 117: acknowledged there was a “propose
Page 118 and 119: 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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