A Critical Examination of State Agency Investigations into ...

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On October 25, 2004, the Careys attended a meeting of the Bethlehem CentralSchool District’s Committee for Special Education (CSE). During the meeting, LisaCarey read a 16-page written statement outlining their numerous complaints, as notedabove. On October 26, 2004, CQC advised OMRDD Central Office that it had receivedthe Careys’ allegations through the State Central Register and that it had opened aninvestigation. As noted, OMRDD had been previously apprised of the allegations onOctober 22, 2004, when Michael Carey contacted the OMRDD Medicaid ServiceCoordinator.On November 2, 2004, an attorney representing the Careys faxed a letter datedNovember 1, 2004, to the Taconic regional office, requesting an investigation of theCareys’ allegations by the Taconic regional office. A copy of the letter was sent to CQC.Enclosed with the letter was a copy of the statement presented by the Careys at theOctober 25 CSE meeting. In addition, the letter cited two occasions, October 10 and 16,2004, on which Michael Carey arrived at the Anderson School to pick up Jonathan anddiscovered that he was naked in his room, lying in urine, atop his bed. According to theletter, the Careys claimed that although they had received prior reports from theAnderson School of some behavioral problems involving Jonathan, they had not receivednotification about any modification to Jonathan’s Behavior Support Plan, and thus, hadnot consented to such plans.The attorney’s letter further stated that the Careys had discovered Jonathan in acondition they described as “gaunt and dazed,” and they claimed that although Jonathanhad gained several inches in height between June and October 2004, he had lost onepound during that same period. “The Carey’s [sic] discovered that not only had the92
Anderson School staff been instructed to let Jonathan remain in his room naked, butJonathan had been deprived of food for at least one week, and on more than [one]occasion during that period of time.” Additionally, the letter said that Jonathan wassupposed to be on a casein-free diet, but Lisa Carey learned from one of the direct carestaff that Jonathan was provided lactose-free, fat-free milk, which was not casein-freemilk. The Careys also alleged that Jonathan had a great number of bruises on his backand legs and that he had been left to lie naked for a period of thirty-six hours or more.On that same date, November 2, 2004, after receiving the letter, Taconic regionaloffice Director Mizerak decided, contrary to his earlier determination, that the Taconicregional office, and not the Anderson School, would assume responsibility for theinvestigation. Advised of Mizerak’ s decision, the Anderson School provided theTaconic regional office the investigative materials it had gathered to that point.In response to the Careys’ allegations, OMRDD Central Office decided it wouldexamine broader, systemic issues at the Anderson School and the Anderson School’sregulatory compliance through what is termed a survey. OMRDD’s survey commencedon November 3, 2004.Thus, as of November 3, 2004, 12 days after the Careys withdrew Jonathan fromthe Anderson School, three state entities had begun active investigations or reviews ofissues related directly or indirectly to Jonathan’s stay at the school.93
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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
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in the Department of Special Educat
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III. BackgroundNEW YORK STATE SERVI
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abuse or maltreatment within New Yo
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certain OMRDD-certified facilities,
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instances in which the Anderson Sch
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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 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
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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
Page 134 and 135: Former Regional Director Articola s
Page 136 and 137: BruisingAlthough the Careys noted t
Page 138 and 139: Seclusion / unauthorized time-out /
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Page 142 and 143: Investigation of complaint by an in
Page 144 and 145: 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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