A Critical Examination of State Agency Investigations into ...

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continues. Does he take a multivitamin at all? That might helpnutritionally. [Name] is our consulting dietician; has she been brought inon this at all? If not, now is the time, and Mrs. Carey needs to know thatwe will be asking [the dietician] to do a nutritional assessment of Jon’sstatus this Thursday [October 21, 2004] when she is here....She would bethe expert on what to offer Jon in addition to the soy milk as well as haverecommendations on any multivitamins.... [The dietician] needs to beadvised of this situation and involved in it to help all members of the teamensure Jon remains healthy. P.S. [Staff Name]: What is your assessment ofhis weight loss/appearance?The Careys spent October 17 mulling their options for Jonathan. “I justremember my husband and I at length discussing what to do next, having a lot ofconversation about going into the school the following day and who to confront and whatto do,” Lisa Carey said.On October 18, 2004, Michael and Lisa Carey visited the Anderson School toconfront Jonathan’s treatment team about their concerns and to take Jonathan to a dentistappointment. They spoke with several treatment team members, but claimed they weretold they would not be allowed to attend an upcoming team meeting to discuss Jonathan’scrisis. Their interactions were documented on an Anderson School Clinical TeamContact log, which indicated that Lisa Carey voiced concerns about Jonathan only eatingsoy milk and yogurt: “[Lisa Carey] stated that she wants him to eat solid food regardlessof what he is wearing and where he is. She also indicated that she was concerned aboutfamily visitation being restricted in the new plan.”Lisa Carey reported that she had heard that the Anderson School was consideringrestricting their visitation rights for a period of time. “There is no way we would everconsent to not be able to visit Jonathan,” she stated to the Inspector General.80
When the Careys took Jonathan to the dentist, they claimed that they discoveredJonathan’s personal communication logbook in his clothing bag. The next day, theyprovided the logbook to their attorney.Following team meetings on October 19 and October 20, the school launched yetanother Behavior Support Plan for Jonathan, dated October 20, 2004. It was notfinalized, according to Anderson School staff, but it had been forwarded to theBethlehem School District and Jonathan’s parents in preparation for the October 21 CSEmeeting. It contained many techniques already in place such as planned ignore, removalof all reinforcers inside Jonathan’s bedroom, and mealtime protocols including the offerof nutritional supplements when he “refused” meals. The plan further directed staff tohold the doorknob to Jonathan’s room when he was in the room to prevent him frompulling or shaking the door handle.The proposed plan also added a new factor: the suspension of home visits or visitsfrom the family for four weeks to allow for “intense programming” with Jonathan.Communication between Jonathan and his parents would be limited to telephone callsfrom Jonathan to his parents twice a week.Although Anderson School administrators claimed the October 20 BehaviorSupport Plan had not been finalized, many of the instructions delineated in the plan werealready being implemented by Anderson School staff. For example, the Careys reportedto the Inspector General that they made multiple telephone calls to the Anderson Schooland were told by staff who answered the phone that they had been instructed not to speakto them when they called the facility. One staffer informed investigators that theResidence Manager had instructed her not to answer the phone. The Anderson School81
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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
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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 82 and 83: Anderson School Weekly Body Check F
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
Page 132 and 133: 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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