A Critical Examination of State Agency Investigations into ...

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INVESTIGATION BY THE TACONIC REGIONAL OFFICE OFOMRDDThe Inspector General found that the Taconic Developmental DisabilitiesServices Office (Taconic regional office) of OMRDD conducted a thorough investigationof the allegations with which it was presented. Of all the agencies investigating thismatter, the Taconic regional office performed the most interviews and site visits andproduced the most comprehensive report regarding Jonathan’s care. Using definitions setforth in agency regulations, the Taconic regional office found “evidence to support thatMistreatment…and Neglect…occurred with Jonathan” at the Anderson School.The Taconic regional office fully documented Jonathan’s care and addressedviolations with the Anderson School to ensure that the problems leading to its findingsthat mistreatment and neglect which occurred with Jonathan were corrected. TheTaconic regional office used the investigation as an opportunity to fully document thecircumstances surrounding Jonathan’s care and to require the Anderson School to reformand update its policies and practices to ensure better care for its service recipients. Thisreport notes a few areas in which the Taconic regional office could have improved itsoversight of the Anderson School, to ensure that the school was accurately informedabout the extent of the investigation and appropriately acknowledged problems so thatthey would not recur.BackgroundThe Taconic regional office provides services for individuals with developmentaldisabilities in Columbia, Dutchess, Greene, Putnam and Ulster counties. The Taconicregional office has direct administrative responsibility for OMRDD-operated facilities in94
the region, and also works closely with private voluntary agencies, including theAnderson School, providing them with technical assistance, training, and oversight.OMRDD regulations require that allegations of abuse or other serious incidents beimmediately investigated. 25For allegations pertaining to OMRDD-operated facilities,each regional developmental disabilities services office is responsible for coordinatinginvestigative activities. Allegations occurring in voluntary agencies like the AndersonSchool are typically investigated by the agencies themselves, after the agency hasnotified the OMRDD regional office of the allegation. Voluntary agencies are requiredby regulation to immediately notify their designated regional office of allegations ofabuse in their facilities.26As noted, the Anderson School first learned of the Careys’ allegations when itwas contacted by Jonathan’s OMRDD Medicaid Service Coordinator on October 22,2004. As required, the Anderson School notified the Taconic regional office of theallegations. Following this notification, the Anderson School Executive Directorcontacted the Taconic regional office and requested that the Taconic regional office,rather than the school, assume responsibility for the investigation, citing a conflict ofinterest in that the allegations implicated the school’s administrative staff.However,Taconic regional office Director Mizerak instructed the Anderson School to conduct itsown investigation, with “oversight” by the regional office. In explaining his decision,Mizerak told the Inspector General that voluntary agencies such as the Anderson School25 14 NYCRR Part 624.26 14 NYCRR Part 624.5 (b)(3).95
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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
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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
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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 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
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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
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Page 138 and 139: Seclusion / unauthorized time-out /
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Page 146 and 147: 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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