A Critical Examination of State Agency Investigations into ...

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Anderson School Weekly Body Check Forms dated October 14 and 15 noted theexistence of “old” bruise marks. On October 14, the Anderson School implemented anew form entitled “Jonathan Carey Refusal to Dress Tracking.”It listed the times thatJonathan refused to put on clothes or remain clothed, from October 14 to 22.October 15 was another difficult day for Jonathan, according to his logbook,clinical records, and e-mail correspondence. Although he ate a full breakfast, hisbehavioral issues increased later in the day, requiring physical escorts. He refused to eatlunch, dinner, or any substitutes and he would not dress. The log stated that he “spent therest of the day in the quiet room.” A second shift entry on October 15 noted, “He spentall day curled up on his bed.”On Saturday, October 16, 2004, Michael and Lisa Carey visited Jonathan.According to the Careys, Jonathan was gaunt, naked, and bruised atop urine-soakedsheets on his bed, monitored by an aide who sat outside his door, which was slightly ajar.Lisa Carey stated, “Jonathan was laying there totally naked on his bed, and he looked upand he looked very dazed, very shell-shocked look, and he did finally recognize that itwas us.” Lisa Carey added that Jonathan was in a “round pool of urine and he was layingdirectly in it.”“We noticed Jonathan’s face starting to sink in…we started noticing ribs showingmore and his arms thinner,” Michael Carey stated. He also recalled seeing the windowscovered with paper. Lisa Carey confirmed her husband’s description and added, “Whenwe walked in, I noticed right away all of his pictures were removed, all of his toys, all ofhis books, the entire room had been stripped bare…and all of his bedding was stacked upon an open shelf; none of it was on his bed except the fitted sheet once again.” Lisa78
Carey added that this was “on a totally different scale” from what she thought a plannedignore entailed, which was the mere disregarding of an attention-seeking behavior in thehope that it would pass.The Careys told the Inspector General’s office that they dressed Jonathan andbrought him to a McDonald’s restaurant for lunch. According to Lisa Carey, theydiscussed their options as to what to do with Jonathan, given what they had observed. AnAnderson School e-mail noted that Lisa Carey reported to the school that Jonathan ate “2hamburgers, fries, soda, ½ a donut, Fritos, and 2 meatballs from Dad’s sandwich.”According to this e-mail and the October 16 entry in Jonathan’s logbook,Jonathan refused to get dressed for breakfast before his parents arrived and refused to sitat the dinner table after he returned from their outing.Staff had discussed, in problem solving meetings, their concerns that the Careysinterfered with programming during visits and that their nightly phone calls could“trigger” some of Jonathan’s behaviors.The next day, October 17, 2004, Jonathan stayed in his bedroom all day, exceptfor a brief moment when he came out, took two bites of a peanut butter and jellysandwich and flopped to the floor, Anderson School records state. He refused all otherregular meals. That same day, Anderson School administrators discussed having adietician consult on Jonathan’s meal program. An e-mail from the Anderson SchoolDirector of Children’s Residential Services to Jonathan’s Residence Manager on October17 stated:Have we been weighing Jon regularly to monitor any weight loss? If not,I think we should, maybe every other day or so as long as this cycle79
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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
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Legislative RecommendationThe Inspe
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and give positive reinforcement for
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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 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 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
Page 126 and 127: 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
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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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