A Critical Examination of State Agency Investigations into ...

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INVESTIGATION BY THE TACONIC REGIONAL OFFICE OF OMRDD....... .................. 94Background........................................................................................................ .................... 94Investigative Activities of the Taconic Regional Office ....................................................... 96Taconic Regional Office’s Findings.................................................................. .................. 100Taconic Regional Office’s Letter of Findings and Recommendations to the Anderson School............................................................................................................................................. 104Anderson School’s Response to Taconic Regional Office’s Recommendations ................ 109Taconic Regional Office’s Letter to the Careys .................................................................. 114Conclusion......................................................................................................... .................. 116SURVEY BY THE OMRDD CENTRAL OFFICE........................................... ................ 118Policies and Procedures Related to OMRDD Surveys ........................................................ 119Survey Activities of the OMRDD Central Office ............................................................... 119Findings of OMRDD Central Office’s Survey.................................................. .................. 123The Inspector General’s Findings Regarding OMRDD Central Office’s Survey ............... 128Acceptance of a Plan of Corrective Action Containing Factual Errors............. .................. 139Inaccurate Information Provided to the Governor’s Office............................... .................. 144Release of Records .............................................................................................................. 146Additional Monitoring of the Anderson School .................................................................. 147Differing Regulatory Standards for Consumers in State-Operated and Private Settings .... 149Conclusion......................................................................................................... .................. 153INVESTIGATION BY THE NEW YORK STATE COMMISSION ON QUALITY OF CARE ANDADVOCACY FOR PERSONS WITH DISABILITIES......................................... ................ 154CQC’s Child Abuse Investigation & Findings .................................................................... 155The Inspector General’s Analysis of CQC’s Child Abuse Investigation ............................ 160CQC’s Care and Treatment Investigation & Findings....................................... .................. 173Inspector General’s Analysis of CQC’s Care & Treatment Review ................................... 179Inaccurate Information Provided by CQC Officials.......................................... .................. 189Notification of Law Enforcement...................................................................... .................. 196Inadequate Investigative Oversight ..................................................................................... 197CQC’s Application of Child Abuse Statutes ....................................................................... 198Conclusion......................................................................................................... .................. 216INVESTIGATION BY THE NEW YORK STATE POLICE................................ ................ 218GOVERNOR PATAKI’S OFFICE .................................................................................. 221The Careys’ Complaints to the Governor.......................................................... .................. 221Governor Pataki’s Response to the Careys’ Complaints................................... .................. 223Governor Spitzer’s Response to the Careys’ Complaints.................................. .................. 225Inspector General’s Analysis of the Response by Governor Pataki’s Office ...................... 226Conclusion......................................................................................................... .................. 227VI. RECOMMENDATIONS........................................................................... ................ 228Taconic Developmental Disabilities Services Office ..........................................................228Office of Mental Retardation and Developmental Disabilities ........................................... 228Commission on Quality of Care and Advocacy for Persons with Disabilities.................... 230Legislative Recommendation .............................................................................................. 231Appendix ................................................................................................ 233Jonathan’s Law.................................................................................................................... 233Agency Responses to the Inspector General’s Report ..................... 244
I. Executive SummaryINTRODUCTIONThis report presents the findings of a comprehensive examination by the NewYork State Inspector General of whether state agencies responded appropriately andsufficiently to allegations that Jonathan Carey, an 11-year-old child diagnosed withautism and mental retardation, was abused in 2004 while a resident at the AndersonSchool in Staatsburg, New York. The Inspector General’s Office commenced itsinvestigation of Jonathan’s care at the Anderson School in March 2007. Theinvestigation was initiated in response to requests from Governor Eliot Spitzer and StateSenate Majority Leader Joseph L. Bruno, as well as Jonathan’s parents, Michael and LisaCarey. Jonathan died under the care of workers at a state-run facility in February 2007.Both workers responsible were prosecuted by the Albany County District Attorney andlater convicted.This report primarily focuses on the investigations of the Commission on Qualityof Care and Advocacy for Persons with Disabilities (CQC) and the Office of MentalRetardation and Developmental Disabilities (OMRDD) in response to the allegations ofchild abuse at the Anderson School. The actions of the State Police and the DutchessCounty District Attorney, the State Education Department, and the Governor’s Office inresponse to these allegations were also reviewed. All responded to complaints byJonathan’s parents that their son had been abused and neglected at the Anderson School,a not-for-profit institution offering services to individuals with developmental disabilities.1
Page 2 and 3: Pursuant to Executive Law § 53, th
Page 6 and 7: The alleged abuse began in Septembe
Page 8 and 9: Michael and Lisa Carey. Along with
Page 10 and 11: The Careys filed a complaint with t
Page 12 and 13: The Taconic Regional Office’s Inv
Page 14 and 15: egulatory violations identified in
Page 16 and 17: compared to consumers in state-oper
Page 18 and 19: determined that Jonathan’s treatm
Page 20 and 21: Statements from CQC executives and
Page 22 and 23: investigating agencies or the Gover
Page 24 and 25: 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
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eally losing it, going bananas basi
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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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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
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Executive Director stated that arou
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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
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are responsible for conducting thei
Page 102 and 103:
School policies and procedures. Inv
Page 104 and 105:
Taconic Regional Office’s Finding
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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
Page 134 and 135:
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
Page 142 and 143:
Investigation of complaint by an in
Page 144 and 145:
and included supporting documentati
Page 146 and 147:
think they wanted him to have the r
Page 148 and 149:
Inaccurate Information Provided to
Page 150 and 151:
this allegation. The letter was tra
Page 152 and 153:
While reports indicated that the An
Page 154 and 155:
facilities like the Anderson School
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egistry, and then it seems there wa
Page 158 and 159:
INVESTIGATION BY THE NEW YORK STATE
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target(s) of the complaint engaged
Page 162 and 163:
arely used by CQC to substantiate a
Page 164 and 165:
The second paragraph of the case su
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CQC Director of Quality Assurance a
Page 168 and 169:
primarily to the provision of meals
Page 170 and 171:
interview notes would have been exp
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Jonathan’s “demeanor has change
Page 174 and 175:
that the additional complaints of a
Page 176 and 177:
and aggressive behavior related to
Page 178 and 179:
systemic significance.” In a hear
Page 180 and 181:
• Anderson School did not have co
Page 182 and 183:
Jonathan’s casein-free diet, that
Page 184 and 185:
treatment review to the Careys, the
Page 186 and 187:
Documentation of investigatory acti
Page 188 and 189:
As noted above, Bowser also failed
Page 190 and 191:
did not do a full care and treatmen
Page 192 and 193:
CQC’s progress notes indicate tha
Page 194 and 195:
epeatedly attempted to exaggerate t
Page 196 and 197:
focuses. “We did it at the same t
Page 198 and 199:
ead, “If he wets again - take she
Page 200 and 201:
Although the statement provided to
Page 202 and 203:
The oversight deficiencies were eve
Page 204 and 205:
that OCFS’s rate of indication is
Page 206 and 207:
In the following sections the Inspe
Page 208 and 209:
On at least one previous occasion,
Page 210 and 211:
emotional injury was impossible in
Page 212 and 213:
facility employee and CQC recommend
Page 214 and 215:
Restrictive Statutory LanguageAltho
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ecognizes that the determination of
Page 218 and 219:
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
Page 226 and 227:
There is not proper and safe oversi
Page 228 and 229:
the meeting, “We left it with the
Page 230 and 231:
this important matter. Your corresp
Page 232 and 233:
VI. RECOMMENDATIONSThe Inspector Ge
Page 234 and 235:
ehavior management (14 NYCRR § 633
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child in an institutional setting,
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(a) Records and documents pertainin
Page 240 and 241:
(ii) violent behavior exhibited by
Page 242 and 243:
8. Such commissioners shall provide
Page 244 and 245:
plan of prevention and remediation
Page 246 and 247:
the commission as to the implementa
Page 248 and 249:
Agency Responses to the Inspector G
Page 250 and 251:
incident is reported to have occurr
Page 252 and 253:
Page 2Joseph FischJune 5, 2008conta
Page 254 and 255:
Recommendations: The Inspector Gene
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