A Critical Examination of State Agency Investigations into ...

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notified and she consented to the medication increase the next day, according to clinicalcontact records.On October 12, 2004, Jonathan’s logbook and behavioral reports showed thatJonathan was “relatively cheerful” but was without his pants while in his room. Jonathanrefused all prompts to get dressed for snacks, dinner, or walks. Staff noted new bruiseson Jonathan’s back and under his chin. The nurse and pediatrician examined him. Thepediatrician wrote that Jonathan had been in behavioral crisis, with some improvementafter Michael Carey’s visit two days earlier. He was eating and drinking better,according to progress notes. The pediatrician also documented that Jonathan hadmultiple bruises due to self-injurious behavior and recommended that Jonathan beweighed weekly and that Jonathan’s intake and output be recorded.On October 13, 2004, Jonathan refused to use the toilet or leave his bedroomalmost the entire day, even needing to be carried out for a fire drill in the morning hours,according to his personal communication logbook and the Birch Residence log, which ismaintained in the residence and is used to document daily and significant events there.In response, a Treatment Team Problem Solving Meeting was held that day with12 Anderson School administrators and clinical staff. It was noted that Jonathan hadmany marks on his body from “escorting him immediately after flopping, attempting torun out of the house and throwing himself into the railings on the front porch at theresidence.”Concerns were raised about Jonathan’s intense behaviors and discussions ensuedregarding appropriate services, including questioning whether the Anderson School was72
the suitable placement for Jonathan. Jonathan’s Behavior Specialist told the InspectorGeneral that she was:Very concerned overall with what was going on….It got to the pointwhere it just wasn’t working and we didn’t have the tools to provide forhim. And I think what happened was it just, it went too far. And therewas just no going back.According to the minutes from the October 13 meeting, “At this time, Jonathan’sbehaviors are surpassing our ability to ‘bring him back’ to his usual self. In the past hehas responded to favorite staff and his [sic] is not doing that right now and reinforcers arenot motivating for him.” It was suggested by Anderson School Treatment Teammembers that Jonathan may be receiving some positive reinforcement in his bedroom orfrom looking out the window. The minutes noted that, “Jonathan needs a plan of PlannedIgnore. At Anderson School, the facilities are not set-up for this type of plan.”Following this October 13 meeting, Jonathan’s Behavior Support Plan was againaltered and immediately implemented. This new plan called for Anderson School staffto:• Add “frosted adhesive” paper to Jonathan’s bedroom windows to“eliminate the reinforcer of looking out the window.”• “Truly ignore” Jonathan in his room.• “Change Jonathan’s sheets once in the a.m. when he gets up (if bed iswet). If wets again take sheets off and don’t put clean ones on until heleaves for school. If he doesn’t go to school leave bed unmade (untilbedtime).”• Remove all books, “horse pillows,” or anything else that “he wouldfind reinforcing in his room when he is non compliant.”• Require that Jonathan “not go to school” and “remain in residence” ifhe does not follow verbal prompts to get dressed.73
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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
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 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 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
Page 120 and 121: it is not his office’s policy to
Page 122 and 123: SURVEY BY THE OMRDD CENTRAL OFFICEA
Page 124 and 125: 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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