TypeSizeNumberYearPublication
PDF81kbFOR0032013

Residential Crisis Treatment Program (RCTP) Follow-up Review

PDF1.2MbCQC0604132013

Commission Report: An Investigation into the Financial Practices of HOMEE Clinic, Inc.

The Commission’s investigation into this not-for-profit agency located in the Bronx found that the executive director diverted up to $100,000 in agency funds for her personal benefit.

PDF434KbCQC0515132013

Commission Report: Review of the Bernard Fineson Developmental Center Multiple Disabilities Unit

This report details significant care, treatment and safety deficiencies found by Commission investigators at the Bernard Fineson Developmental Center’s Multiple Disabilities Unit.  As a result of the Commission’s investigation, significant changes were implemented by the Office for People with Developmental Disabilities (OPWDD), which operates the facility.

PDF1.20MBCQC0506132013

"Fire Safety Study of State-Operated IRA’s.” 

PDF733KbCQC0419132013

Commission Report: People, Inc.

This report highlights the findings of a Commission investigation into deficiencies in the care and treatment of Elizabeth Bern (a pseudonym), a former resident of a facility operated by People, Inc. in Williamsville, NY.  Ms. Bern suffered serious injuries after a fall, but the Commission found delays in her treatment, falsification of records by staff, and a failure to adequately investigate the incident by both the facility and the Office for People with Developmental Disabilities (OPWDD), which licensed the program. 

PDF225KBCQC0411132013

“Lost in the Shadows: Willowbrook and the Era of Institutionalization” -- remarks of former Commission Chair Clarence J. Sundram presented at the conference “Willowbrook: Fulfilling the Promise” held at Albany Law School on March 22, 2013.

PDF1.79MBCQC0322132013

Commission Report:  A Review of Mental Health Screening Access to Mental Health Services and the Mental Health Status of People in Segregated Confinement in New York State Correctional Facilities.

This report covers a review of the mental health screening process for people entering the custody of the New York State Department of Corrections and Community Supervision (DOCCS) from county jails.  It includes their subsequent access to mental health services in state correctional facilities, as well as the mental health status of those who received segregated confinement sanctions within their first six months of incarceration.

PDF522KbCQC1230112011

In March 2011, Courtney Burke, then-Acting Commissioner of the New York State Office for People With Developmental Disabilities (OPWDD), requested that the New York State Inspector General investigate serious allegations of abuse of residents of the Valley Ridge Center for Intensive Treatment, an OPWDD facility in Norwich. 

PDF75KbCQC1214112011

Guidance for Service Providers on Responding to Reports from the Commission

PDF6MBCQC1128012011

An in-depth probe by CQC has uncovered schemes that allowed Medicaid to be overbilled thousands of dollars by a Yonkers-based program that assists people with disabilities.

PDF2.2MbAG001252011

Breach of Trust: An Investigation Into the Theft of Resident Funds at Academy Green Residences, Inc. This report describes how 16 residents with developmental disabilities had over $200,000 of personal funds misappropriated. 

 
PDF
3.2Mb  
 

 

FOR001 

 

2010  

Residential Crisis Treatment Programs (RCTPs)

The Commission conducted a review of Residential Crisis Treatment Programs (RCTPs) operating in state correctional facilities. Inmates in need of immediate mental health services are required to be transferred to one of the 16 RCTPs operating in DOCS facilities. Over, 5,500 inmates are transferred to RCTPs annually. The Commission reviewed utilization data from eight facilities serving over 4,500 inmates annually, individual inmate records and Department of Corrections and Office of Mental Health policies and procedures. The Commission also conducted face to face interviews with 52 inmates and surveyed inmates and staff in RCTPs regarding the quality of mental health care provided in RCTPs. The Commission found that while RCTPs were beneficial for many inmates, action should be taken to maximize the therapeutic nature of the RCTPs.

PDF
445Kb 
FOR002 
2010 

Residential Crisis Treatment Programs (RCTPs) :  DOCS & OMH Responses 

 PDF

704KbAR2009-102010

CQCAPD Annual Report SFY 2009-2010

 PDF20.9KbPPDLA0012010

PPDLA Summary 2nd Year

 PDF  

485Kb 

00170

2010 

Guest House Community Services   - Akumu Complaint  

 PDF 

 193Kb

 00171

2010

Guest House Community Services   - Akumu Indictment 

 PDF 

160Kb

00172

2010

Guest House Community Services  - Akumu Indict Press Release 

 PDF 

 999Kb

 00176

2010

CQC Best Practices in Board Governance Report

PDF / WORD 

 

 

 

1.3Kb / 14.5Kb 

 

 

 

00193 / 00194 

 

 

 

2010 

 

 

 

The Quality Initiative - The Quality Initiative was created to assist the Commission on Quality of Care and Advocacy for Person with Disabilities, other government agencies, and community based agencies to move beyond standard quality assurance measures to aspire to a higher level of providing services. The key components of this Initiative are to understand what people with disabilities think constitutes a good quality of life; what challenges were faced to get a good quality of life; and what still needs to change 

PDF / WORD 

70Kb / 103Kb 

00195 / 00196 

2010 

Quality Initiative Stories 

PPT1.33MbQI0092010

Quality Initiative PowerPoint

PDF30KbQI0102010

Quality Initiative Guidance

 PDF 

 545Kb

 00177

2010

CQC Ctr for Discovery Rpt May

 PDF

 2.7Mb

 00178

2010

Guest House Community Services FINAL Rpt 

 PDF 

2.8Mb

00174

2010

Response of the Board of Directors of The Center for Discovery

 PDF

 1.9Mb

EA2009

2009

Europa Associates

PDF

157Kb

HD2009

2009

Hospital Discharge Survey 2009

PDF

 

PDF

 

515Kb

 

295Kb

 

MHCMC2008

 

MCMCOMH08

 

2008

 

2008

 

Mental Health Comprehensive Medicaid Case Management:
A Review of Systems Coordination and Support for
People with Serious Mental Illness

Office of Mental Health's Response

 

PDF

860KB

ED2008

2008

Evelyn Douglin Center (SPIN)

PDF

640Kb

PS2008

2008

PSCH, Inc.: An Investigation into Financial Practices and
Corporate Governance

PDF

684Kb

AR2008

2008

CQCAPD Annual Report 2008

PDF187KbAR2006-072007

CQCAPD Annual Report 2006-2007

PDF

 

1.3Mb

84Kb

ALP2007

ALPDOH07

2007

2007

Assisted Living Programs

Department of Health Response

PDF

 

 

179KB

217KB

200KB

RTF2007

OMHRTF07

OMHRTF08

2007

2007

2008

Residential Treatment Facilities

Office of Mental Health's Response

Office of Mental Health Follow-up

PDF

40Kb

SP005

2007

Strategic Plan 2008 - 2010

PDF

 

447Kb

344Kb

CDT2006

OMHCDT06

2006

2006

Continuing Day Treatment

Office of Mental Health Response

PDF

 

 

82Kb

151Kb

137Kb

ADC2006

ADCDOH06

ADCOMH06

2006

2006

2006

Adult Home Closure Study

Department of Health Response

Office of Mental Health Response

PDF

 

47Kb

50Kb

HCAH2006

HCAHDOH06

2006

2006

Health Care in Impacted Adult Homes

Department of Health Response

PDF

78Kb

ATC2006

2006

A Review of the NYS Office of Alcoholism and Substance Abuse Services'
Addiction Treatment Centers

PDF

372Kb

TSI2006

2006

Transitional Services Inc. (TSI)

PDF

2.03 Mb

DW2006

2006

Disability Awareness Newsletter prepared by and for students 2006  

PDF95KbAR2004-052005

CQCAPD Annual Report 2004 - 2005

PDF

2.58 Mb

DW2005

2005

Disability Awareness Newsletter prepared by and for students 2005

PDF

49Kb

SP004

2004

Strategic Plan 2004 - 2006

PDF

2.48 Mb

DW2004

2004

Disability Awareness Newsletter prepared by and for students 2004

PDF

132Kb

AR022

2003

CQCAPD Annual Report 2002 - 2003 

PDF

968 Kb

DW2003

2003

Disability Awareness Newsletter prepared by and for students 2003

PDF

38Kb

SP003

2002

Strategic Plan 2000 - 2003

PDF354KbAR2000-012002

CQCAPD Annual Report 2000 - 2001

PDF

359Kb

00025

2002

Adult Homes Serving Residents with Mental Illness: A Study on Layering of Services, August 2002 This is a study of the cost and quality of the Medicaid-funded services provided to residents of adult homes serving residents with mental illness. The Commission chose the 11 largest adult homes in the greater New York City area in which some 90 percent of the residents are persons with histories of mental illness. Commission staff analyzed the cost of care for the residents who had continuously resided in these homes for at least the one-year period October 1999 to September 2000 by reviewing Medicaid cost data, auditing a sample of Medicaid claims to ensure the billings were supported by proper documentation, and visiting the homes to review the available medical and mental health records of 60 residents. The Commission found that the physical and mental health needs of the residents of these adult homes were addressed by a disjointed patchwork of publicly-funded services. The study found that, when SSI and Medicaid expenditures are combined, about $37,000 a year per resident was being spent on room and board, health and mental health services.

PDF

646 Kb

DW2002

2002

Disability Awareness Newsletter prepared by and for students 2002

PDF

54Kb

SP002

2001

Advancing the Commission's Strategic Goals (Dec. 2001)

PDF

39Kb

SP001

2001

Strategic Plan: Priorities for Action 2001

PDF

393Kb

AR021

2001

Annual Report: 2000 - 2001

PDF

787Kb

00026

2001

Exploiting Not-For-Profit Care in an Adult Home: The Story Behind Ocean House Center, Inc. December 2001 This report chronicles a Commission investigation into the exploitation of public funds for private gain at an Adult Home in Queens. The report documents how a former attorney used an intermediary to secretly obtain an operator's license and gain control of Ocean House, a not-for-profit home for adults with mental disabilities, and used the corporation as a conduit to transfer millions of dollars in public funds to himself and his family. The behind-thescenes control of Ocean House's multiple mortgages enabled him to exploit public funds intended for the care of residents of the facility. He avoided detection by arranging for family and business associates to be appointed as the corporation's officers and board of directors. The Commission investigation also alleges that the services available to Ocean House residents were "more revenue-driven than meaningful or necessary," and that, as a result, health-related services provided to residents by outside providers were "fragmented, costly, inefficient, and did not meet medical standards."

PDF

63Kb

00027

2001

Survey of the Provision of Electro-Convulsive Therapy (ECT) at New York State Psychiatric Centers by the Commission on Quality of Care, August 7, 2001 At the request of the Assembly Committee on Mental Health, the Commission conducted a survey of the provision of Electro-convulsive Therapy (ECT) at state psychiatric centers. The purpose of this survey was to obtain information about the frequency of administration of this treatment; facilities ' management of such, and the patients who undergo this treatment, but not to evaluate its efficacy. The Commission 's survey revealed that during the two-year period of the review, 164 individuals received ECT in state-operated facilities. The record review revealed that the clinical presentation of these individuals justified the use of ECT as a treatment modality. With respect to consent, excluding patients at Psychiatric Institute, approximately two out of five individuals in state facilities were receiving ECT pursuant to court order. Review of the policies and procedures revealed protocols which varied in detail regarding the procedure itself, physician privileging and consent issues.

PDF

1.7 Mb

DW2001

2001

Disability Awareness Newsletter prepared by and for students 2001

 PDF

373Kb

00192

2001

Transitional Services for New York Inc (TSI) Report 

PDF

1.05 Mb

DW2000

2000

Disability Awareness Newsletter prepared by and for students 2000

PDF

487Kb

AR020

1999

CQCAPD Annual Report SFY 1998 - 1999

PDF

143Kb

00028

1999

In The Matter of David Dix, November 1999 In January of 1999, David Dix (a pseudonym), an individual with an extensive history of psychiatric treatment, allegedly pushed a young woman to her death in front of a Manhattan subway train. The Commission and its Mental Hygiene Medical Review Board conducted an investigation to determine what mental health services Mr. Dix had received, to assess whether the services were adequate and appropriate, and whether they represented a cost effective expenditure of public funds. The investigation concluded with recommendations for improving the care of individuals who are seriously and persistently mentally ill, whose histories include behaviors dangerous to themselves or others, and who are uncooperative with outpatient mental health services. The passage of "Kendra 's Law" earlier in 1999 by the New York State Legislature was intended to address the problems presented by such individuals.

 

 

00029

1999

Watching Over the Children: A Review of 1998 Commission Activities on Behalf of Children with Mental Disabilities, August 1999 As required under the State 's Mental Hygiene Law, this report covers the Commission 's activities during 1998 in overseeing the care and treatment of children in New York State 's mental hygiene facilities. As the report indicates, the Commission 's role in conducting independent investigations of allegations of child abuse and neglect and of complaints about the quality of care; its systemic examination and comparison of practices among similar facilities; and its advocacy on behalf of children and families, have all contributed to improving the quality of services for children served by residential child care facilities.

 

 

00030

1999

A Report on Individuals with Developmental Disabilities Who are Possibly Homeless, August 1999 After media reports alleged approximately 135 individuals with developmental disabilities were homeless and known to be so by the State Office of Mental Retardation and Developmental Disabilities (OMRDD), which OMRDD disputed as largely inaccurate, the Commission was asked to investigate. Our review determined the media reports on the scope of the problem were inaccurate and inflated. Rather, OMRDD was found to have moved promptly and diligently to assist such individuals once identified as homeless. Indeed, in some regions of the state, OMRDD 's Developmental Disabilities Service Offices had developed model approaches to addressing the needs of such individuals. The Commission recommended OMRDD consider replicating such models elsewhere in the state. Given that many developmentally disabled homeless individuals also have substance abuse problems, the Commission recommended OMRDD explore treatment approaches with the State Office of Alcoholism and Substance Abuse Services.

 PDF

 1.78 Mbytes

00031

1999

Abandoning Its Not-For-Profit Purpose: The Case of Project Independence of Queens NY, Inc., June 1999 After receiving a detailed anonymous written complaint, the Commission found that the executive director of Project Independence of Queens NY, Inc. (PIQ) neglected and exploited its eight residents with developmental disabilities by depriving them of adequate food, services and shelter. The root cause was the PIQ's board of directors' failure to monitor the executive director's activities and hold her accountable for the management of this not-for-profit agency, which freed the executive director to place 15 of her relatives on the payroll, many who were of doubtful competence or unreliable, and to set her own salary which, at $114,000 in 1997, was more than double (235%) the average salary of 40 executive directors running similar-sized OMRDD-licensed programs. The Commission's investigation found that residents were living in a rundown, roach infested facility and fed inferior diets consisting of mostly government surplus foods. Aside from the poor quality, the diets were inappropriate for six of the residents who suffered from diabetes or high blood pressure. Other program deficiencies included inadequate hot water, lack of personal hygiene items, an overpowering urine smell, unsafe fire alarm system, and dirty and unsanitary facility conditions. The Commission's fiscal review found almost $50,000 in undocumented credit card purchases by the executive director and her relatives, a large portion of which was spent for personal items such as jewelry, pet grooming and trips to Florida, Haiti and the Dominican Republic. The executive director also misappropriated $35,000 which she used as a down payment to purchase a personal residence.

 

 

00032

1999

Exploiting Medicaid Through A Shell Not-For-Profit Corporation: The Case of Special Needs Program, Inc., January 1999 This report is on the Commission investigation of the programmatic and financial practices of the Special Needs Program, Inc. (SNP), a not-for-profit agency with a 10-bed group home near Hudson and other programs in Columbia County for individuals with autism and other disabilities, licensed by the Office of Mental Retardation and Developmental Disabilities (OMRDD). The husband and wife team running SNP diverted $752,000 of program funds for their personal use, operating it as a shell not-for-profit agency to conceal and distribute ill-gotten Medicaid proceeds. The Commission began its review in July 1997 after receiving an allegation that SNP was "over-diagnosing" residents to receive higher Medicaid residential and transportation reimbursement rates, and a complaint that the director, Dr. Joseph Fricano, was rarely seen at the agency. Investigation uncovered a serious potential conflict of interest in that a 1995 IRS form showed Fricano and his wife as the only members of the board of directors. The couple fled in 1997 ahead of the Commission's review. The Fricanos' scam at SNP was facilitated by a fake board, allowing them unfettered access to agency monies without need to approve their salaries or have their performance reviewed. SNP had been receiving about $1 million each year from Medicaid to run its OMRDD-licensed residence, and received $200,000-$300,000 annually from counties, school districts and day treatment providers to transport individuals with disabilities to and from educational facilities and day treatment programs. An excessive Medicaid rate of $100,000 annually for each of the 10 residentsallowed the Fricanos to "milk" the program while still delivering reasonably good services. But, SNP's finances were jeopardized by the Fricanos' removal of funds, with liens placed on the property because of unpaid payroll taxes, and the Fricanos sometimes needed to make loans to SNP, at 8 or 9 percent interest to keep it operating.

PDF

967 Kb

DW1999

1999

Disability Awareness Newsletter prepared by and for students 1999

 PDF

1.8Mb

00187

1999

Project Independence of Queens NY Inc PIQ Report

 PDF

2.0Mb

00191

1999

Special Needs Program SNP Report

PDF

325Kb

AR019

1998

CQCAPD Annual Report SFY 1997 - 1998

 

 

00033

1998

Diverting Public Funds: The Misguided Mission of the Independent Living Center of Amsterdam, Inc., August 1998 This is a report of the Commission's investigation of the programmatic and financial practices of the Independent Living Center of Amsterdam (ILC/A), a not-for-profit agency funded and overseen by the New York State Office of Vocational and Educational Services for Individuals with Disabilities (VESID). ILC/A received two-thirds of its monies from Medicaid to also provide services to individuals with developmental disabilities, including supervision and support for individuals in family care homes certified by the Office of Mental Retardation and Developmental Disabilities (OMRDD). The investigation determined ILCA/A illegally misapplied Medicaid funds to underwrite an ill-conceived and illegal housing development for the elderly, called Veddersburg Village, which brought both corporations to the brink of bankruptcy This dire situation necessitated action by several State agencies to end further diversion of funds, prevent a lapse in services to disabled clients, and protect elderly Veddersburg investors from the collapsing housing scheme, in which the entrance fees of $60,000 and $40,000 had been improperly collected. The report was also highly critical of the ILC/A board for failing to scrutinize the illegal and improper transactions which placed ILC/A's programs at risk and for allowing ILC/A and Veddersburg's financial conditions to deteriorate to near insolvency. The Commission recommended VESID and OMRDD examine their internal monitoring mechanisms, which failed to detect the improprieties and growing financial instability.

 

 

00034

1998

Watching Over the Children: A Review of 1997 Commission Activities on Behalf of Children with Mental Disabilities, March 1998 As required under the State's Mental Hygiene Law, this report covers the Commission's activities during 1997 in overseeing the care and treatment of children in New York State's mental hygiene facilities. As the report indicates, the Commission's role in conducting independent investigations of allegations of child abuse and neglect and of complaints about the quality of care; its systemic examination and comparison of practices among similar facilities; and its advocacy on behalf of children and families, have all contributed to improving the quality of services for children served by residential child care facilities.

 PDF

1.12Mb 

00035

1998

Could This Happen in Your Program? A Collection of Case Studies Provoking Reflection, Discussion, and Action, vol. II, 1998 Volume II of case studies, drawn from the Commission's investigation files, written in a style to promote a quick read and to engage direct care and management staff of agencies in a review of their own operations and, where needed, corrective or prevention action (e.g., additional training, policy or procedure reform, etc.) to improve services and better protect service recipients.

PDF

1.21Mb

DW1998

1998

Disability Awareness Newsletter prepared by and for students 1998

 PDF

 1.8Mb

 00180

1998

 Independent Living Center of Amsterdam Project

 

 

00036

1997

Incident Reporting and Management Practices at Five NYS Psychiatric Centers, May 1997 This Commission review of incident management practices at five state psychiatric centers surfaced several decidedly positive findings: episodes of patient elopements were reduced by more than 80% from 1994 to 1996. When incidents jeopardizing patient safety are identified, patients are provided prompt protective measures and/or treatment services; and incident investigations usually were timely and thorough, though some facilities need to improve in these areas and in the use and composition of Incident Review Committees (IRCs).

 PDF

 7.0Mb

00037

1997

Could This Happen in Your Program? A Collection of Case Studies Provoking Reflection, Discussion, and Action, vol. I, April 1997 This award-winning series was developed when the Commission realized that situations it encountered at individual facilities offered learning opportunities for staff of all service provider agencies. Each case study, drawn from the Commission's investigation files, is written in a style to promote a quick read and to engage direct care and management staff of agencies in a review of their own operations and, where needed, corrective or prevention action (e.g., additional training, policy or procedure reform, etc.) to improve services and better protect service recipients.

 

 

00038

1997

Watching Over the Children: A Review of 1996 Commission Activities on Behalf of Children with Mental Disabilities, February 1997 As required under the State's Mental Hygiene Law, this report covers the Commission's activities during 1996 in overseeing the care and treatment of children in New York State's mental hygiene facilities. As the report indicates, the Commission's role in conducting independent investigations of allegations of child abuse and neglect and of complaints about the quality of care; its systemic examination and comparison of practices among similar facilities; and its advocacy on behalf of children and families, have all contributed to improving the quality of services for children served by residential child care facilities.

PDF

656Kb

DW1997

1997

Disability Awareness Newsletter prepared by and for students 1997

PDF

900Kb

AR018

1996

Annual Report: 1995 - 1996

 PDF

 3.4Mb

00039

1996

Profit Making in Not-for-Profit Care: Part III The Case of Queens County Neuropsychiatric Institute, Inc., October 1996 While conducting a review of freestanding mental health clinics, Commission fiscal staff visited clinics throughout the state to look behind reported cost and productivity figures to gain an understanding of high and low-cost clinic operating practices. With the hope of replicating sound operating practices statewide, the Commission visited QCNI because it appeared to be one of the more efficient clinics licensed by OMH, with 1992 costs per 30-minute individual psychotherapy session at less than one-half of the statewide average, and clinician visits per day almost three times the statewide clinic average. But the Commission 's review determined that this seeming efficiency concealed a clinic program rife with serious problems in the quality of its high-volume services, improper billings to Medicaid accounting for almost one-fifth of its Medicaid income, diversion of agency assets to senior executives, failure of the board of directors to exercise its fiduciary responsibilities, and unprofessional conduct by the agency 's CPA who helped conceal financial irregularities from the board of directors and OMH.

 

 

00040

1996

A Brief Report on Active Programming in State Psychiatric Centers: Has Anything Changed? August 1996 While conducting a previous review and follow up on living conditions at all state psychiatric centers, the Commission had found that although conditions varied among facilities, a common factor eroding the quality of life for patients was idleness. Without meaningful activities, most patients spent their days either sitting in overcrowded dayrooms, wandering, sleeping or staring at television, with few opportunities to develop or retain skills necessary for maintaining a sense of worth and good mental health. Partly in response to the Commission 's published recommendations for constructive patient programming or daily activity, the Legislature in 1988 passed legislation requiring the Office of Mental Health (OMH) to establish standards for active programming, including consideration of the social, vocational, educational and recreational needs of each patient, and a minimum number of hours of activities to be provided each patient weekly unless exempted for medical or clinical reasons.

 

 

00041

1996

Why Do Psychiatric Clinics Costs Vary by 1030%: A Review of the Efficiency of Freestanding Clinics, May 1996 A study of outpatient mental health clinics operated by voluntary agencies and counties which found wide variations in the costs of clinic services, and identified the factors contributing to the high cost of the state's outpatient services.

 

 

00042

1996

Breaking with the Past: How New York's Private Psychiatric Hospitals Have Managed Since Managed Care, April 1996 This study of private psychiatric hospitals in New York State suggests that implementing successful managed care initiatives at private psychiatric hospitals may offer a cost-effective alternative for children and elderly patients housed in state institutions, while providing potential annual savings of some $14 million in reduced Medicaid payments through reduced lengths of stay, without adverse effect on patient care.

 

 

00043

1996

Watching Over the Children: A Review of 1995 Commission Activities on Behalf of Children with Mental Disabilities, March 1996 As required under the State's Mental Hygiene Law, this report covers the Commission's acclivities during 1995 in overseeing the care and treatment of children in New York State's mental hygiene facilities. As the report indicates, the Commission's role in conducting independent investigations of allegations of child abuse and neglect and of complaints about the quality of care; its systemic examination and comparison of practices among similar facilities; and its advocacy on behalf of children and families, have all contributed to improving the quality of services for children served by residential child care facilities.

 PDF

4.1Mb

00186

1996

PrivatePsychiatric HospitalStudy 

 PDF 

3.9Mb

00189

1996

Psychiatric Clinic Costs Study

 PDF

3.0Mb

00190

1996

QueensCountyNeuropsychiatric Institute Report

PDF

20Kb

AR017

1995

Annual Report: 1994 - 1995

 PDF

2.52Mb 

00127

1995

In the Matter of Jacob Gordon: Facing the Challenge of Supporting Individuals With Serious Mental Illness in the Community, August 1995 This report portrays the dilemmas and challenges posed by treatment-resistant patients living in the community, particularly when their care is fragmented among a host of service providers. The report presents the services rendered by the various care providers involved in Mr. Gordon's life and how he still fell through the cracks due to his resistiveness and the poor coordination of service, which cost more than $140,000 in Medicaid dollars alone in the last three years of his life.

 

 

00044

1995

Shifting Costs to Medicaid: The Case of Financing the OMRDD Comprehensive Case Management Program, December 1995 This report addresses the State Office of Mental Retardation and Developmental Disabilities' (OMRDD) implementation of a program for clients residing in the community which was intended to save the state money by shifting costs to Medicaid, which has resulted instead in millions of dollars of unnecessary costs through improper billings to Medicaid and duplicate payments to service providers.

 PDF

4.4Mb 

00045

1995

Governance of Restraint and Seclusion Practices by NYS Law, Regulation, and Policy, September 1995 The Commission's study of the use of restraint and seclusion in New York State psychiatric facilities, requested by the Legislature, outlines the confusion and gaps resulting from the four sets of inconsistent, contradictory, and duplicative directives on restraint and seclusion contained in state law, state regulations, the policies of the State Office of Mental Health (OMH), and in standards issued by the Joint Commission on Accreditation of Health Care Organizations (JCAHO). It concludes with recommendations to the Legislature and OMH to both streamline and improve the administration of restraint and seclusion in psychiatric facilities.

 

 

00046

1995

Patient Safety and Services at Kingsboro Psychiatric Center, July 1995 Investigation of conditions at Kingsboro Psychiatric Center prompted by the homicide of a patient in November 1994, allegedly at the hands of another patient who had escaped and returned, armed with a knife. The Commission's investigation found that the escape and homicide reflected lapses in security, search practices, communications and clinical judgment.

 

 

00047

1995

In the Matter of R.H.: A Patient at Manhattan Psychiatric Center, April 1995 A report of the Commission's investigation into the care and treatment of R.H., a patient at Manhattan Psychiatric Center who eloped from the facility several days before the homicide of a 63 year old woman he allegedly pushed in front of a subway train.

 PDF

 1.23Mb

00048

1995

Safeguarding Public Funds: A Review of Spending Practices in OMRDD Rate Appeals, January 1995 This report is on the State Office of Mental Retardation and Developmental Disabilities ' (OMRDD) system for processing appeals of medicaid rates for community-based programs, which does not adequately safeguard the expenditure of public funds or control costs. The system, which is intended to ensure that Medicaid rates are sufficient to cover the costs of efficiently-run facilities, granted appeal funding of $22 million in 1991, even though in many cases the money was not spent on the purpose for which it was claimed, or not spent at all. The Commission found that OMRDD failed to prevent the funding of excessive agency administrative costs, restrict spending to the purposes of the appeals, or recoup appeal monies that were not spent.

 PDF

2.8Mb

00183

1995

OMRDD Comprehensive Case Management Study

 PDF 

1.5Mb

00184

1995

OMRDD Rate Appeals Study 

PDF

21Kb

AR016

1994

Annual Report: 1993 - 1994

 PDF

 PDF

4.21Mb 

3.25Mb 

00049A

00049B

1994

(2 reports ) Restraint and Seclusion Practices in New York State Psychiatric Facilities, and Voices From the Frontline: Patients ' Perspectives of Restraint and Seclusion Use, September 1994 The use of restraint and seclusion in state psychiatric centers has almost doubled over the past decade (1984-1993) and has been associated with over 100 patients' deaths over that period. The Commission found wide variations in the frequency with which these interventions were used by psychiatric facilities in New York State. A second report containing the results of the largest survey of former psychiatric patients reported in the literature found that patients who were restrained or secluded during their inpatient stays overwhelmingly report these interventions were used illegally and that they were often poorly treated, abused or injured when restrained or secluded.

 

 

00050

1994

Care and Treatment for Persons with Multiple Disabilities: A Progress Report, August 1994 Care and treatment for individuals with both a developmental disability, such as mental retardation and a psychiatric diagnosis, have improved significantly over the years as many dually-diagnosed individuals have moved to special units called multiply-disabled units (MDUs), where they are better able to learn to control undesirable behavior and develop new skills. The Commission 's study of eight MDUs, in both state psychiatric centers operated by the State Office of Mental Health (OMH) and developmental centers operated by the State Office of Mental Retardation and Developmental Disabilities (OMRDD), indicates that since 1978 over 2,000 psychiatric center patients have been transferred to MDUs at developmental centers, which the Commission found better equipped to meet their needs and prepare them to live outside institutions. The Commission report recommended transfer of all dually-diagnosed individuals who are psychiatrically stable to the OMRDD programs.

 

 

00051

1994

Community Volunteer Advocacy in Group Homes: An Evaluation of the Westchester County Ombudsman Program, August 1994 A report on the evaluation of the Westchester County Ombudsman Program, a community volunteer advocacy program sponsored and coordinated by the Westchester County Department of Community Mental Health for individuals with developmental disabilities who live in local community residences and community-based intermediate care facilities (ICF-MRs).

 

 

00052

1994

Crossing the Line from Empowerment to Neglect: The Case of Project L.I.F.E., July 1994 The Commission's investigation identified serious problems affecting the health and safety of the residents of a supportive community residence program administered by Project L.I.F.E., which operates sixty apartments in Manhattan and the Bronx for seventytwo persons with developmental disabilities.

 PDF

960Kb 

00053

1994

Missing Accountability: The Case of Community Living Alternative, Inc., June 1994 The Commission's investigation uncovered diversion of approximately one-quarter of the public funds intended for the care of mentally disabled residents at a 10-bed facility in Queens, New York operated by Community Living Alternative (CLA), a not-for-profit corporation licensed by the New York State Office of Mental Retardation and Developmental Disabilities (OMRDD) to operate community residences. As a result of diversion of over one-half million dollars of the revenues during a five-year period by CLA's executive director and his wife who served as president of a phantom board of directors, residents of the only group home it operated lived in poor conditions without active treatment and recreation, and the home was chronically out-of-compliance with OMRDD regulations.

 PDF

2.79Mb 

00054

1994

Survey of Access to New York State Courts for Individuals with Disabilities, June 1994 Four years after passage of the national Americans with Disabilities Act (ADA) prohibiting discrimination in access to public accommodations, only 8 percent of the courtrooms in New York State are fully accessible to people with disabilities. A survey of 275 courts in 40 counties throughout the state by the Commission in conjunction with the State Bar Association Committee on Mental and Physical Disabilities found limited accessibility for persons with visual and hearing impairments, and few accommodations for persons with mental disabilities. The survey report makes recommendations for the court system to fully comply with the requirements of the ADA, which prohibit discrimination on the basis of disability in access to the services, programs and activities of state and local governments.

 

 

00055

1994

Watching Over the Children: A Review of 1993 Commission Activities on Behalf of Children with Mental Disabilities, March 1994 As required under the State's Mental Hygiene Law, this report covers the Commission's activities during 1993 in overseeing the care and treatment of children in New York State's mental hygiene facilities. As the report indicates, the Commission's role in conducting independent investigations of allegations of child abuse and neglect and of complaints about the quality of care; its systemic examination and comparison of practices among similar facilities; and its advocacy on behalf of children and families, have all contributed to improving the quality of services for children served by residential child care facilities.

 PDF 

3.0Mb

00175

1994

Community Living Alternative CLA Report

 PDF

2.2Mb

00188

1994

Project Life Report 

PDF

17Kb

AR015

1993

Annual Report: 1992 - 1993

 

 

00128

1993

In the Matter of Joan Stalker: A Study of the Need for Vigilant Monitoring of Family Care Homes, December 1993 This report chronicles the effects of the absence of proper monitoring by agencies which sponsor and certify individuals who undertake to serve mentally disabled persons. The agencies failed to detect an illegal and overcrowded family care home, as well as inappropriate discharges from State psychiatric centers to a home certified only for individuals with mental retardation, and failed to ensure the safety and well-being of residents at the home, where the deceased died under possibly abusive conditions, following earlier allegations of abuse.

 

 

00129

1993

Life and Death at New Queen Esther Home for Adults, June 1993 The report illustrates the consequences of inappropriately discharging a psychiatric center inpatient to an adult home ill-equipped to provide the appropriate level of supervision and services. At an adult home with inadequate mental health services, a long history of assaults and acting out behavior by residents, pleas by staff for assistance with problem residents, calls to 911, and 12 years of citations for filthy and unsafe living conditions by the Department of Social Services, a known problem resident assaulted and critically injured another woman resident.

 PDF

4.21Mb 

0056A

1993

Serving Parents Who Are Mentally Retarded: A Review of Eight Parenting Programs in NYS, July 1993 For a growing number in New York State being a good parent is complicated by mental retardation, which can make learning and carrying out most parenting tasks more difficult. Until recently, these difficulties were considered inevitable and insurmountable, and within months, if not at birth, these parents would lose custody rights to their children, who would be placed in foster care and/or adoptive homes. In several New York communities, special pilot parenting programs, funded by the NYS Developmental Disabilities Planning Council (DDPC), are seeking to meet the needs of these families, helping mothers and fathers and sons and daughters to remain together. The Commission report documents the efforts of eight programs.

 PDF

3.74Mb 

0056B

1993

Parenting With Special Needs: Parents Who Are Mentally Retarded and Their Children July 1993

 

 

00057

1993

Falling Through the Safety Net: “Community Living” in Adult Homes for Patients Discharged from Psychiatric Hospitals, August 1993 A report on two deaths involving long-term psychiatric center residents discharged to chronically deficient adult homes prompted a call for psychiatric center staff to comply with laws on discharge planning and follow up, and for a coordinated "safety net" of residential and support services in the community for patients leaving state psychiatric centers.

 

 

00058

1993

Discharge Planning Practices of General Hospitals: Did Incentive Payments Improve Performance? April 1993 This report follows a yearlong study of the discharge practices of 10 hospitals across the state during which it retraced the experiences of a random sample of 100 patients admitted to and discharged from these facilities. The study was requested by the Office of Mental Health and the State Hospital Review and Planning Council to evaluate the effectiveness of new inpatient and outpatient reimbursement methodologies that provided incentive payments of approximately $20 million to hospitals and community mental health programs to improve the care of seriously mentally ill patients.

 PDF

5.02Mb 

00059

1993

NYS Residential Services for Children with Emotional Problems: A Call for Reform, February 1993 The Commission report called for significant structural reforms to serve children with emotional problems and their families more effectively, and to make more efficient use of the over $210 million a year spent by the State Office of Mental Health (OMH) alone on residential services.

PDF

17Kb

AR014

1992

Annual Report: 1991 - 1992

 

 

00060

1992

The Role of Psychotropic Medication in the Treatment of Children in NYS Mental Health Inpatient Settings, November 1992 The Commission found that the majority of parents/guardians are neither adequately informed, nor is their permission sought before their children are administered psychiatric drugs in state-operated children's psychiatric facilities. To protect patient rights and involve families in treatment planning, the Commission report strongly recommends to the State Office of Mental Health (OMH) that parents and guardians be given comprehensive information about psychoactive medication, and their written informed consent be obtained by psychiatric facilities before such medication is given to minor children.

 

 

00061

1992

A Review of Familial Abuse Allegations of Adults with Developmental Disabilities, July 1992 In this report the Commission called upon local Adult Protective Services offices to play a leadership role in coordinating investigation and protective intervention in response to allegations of abuse or neglect of developmentally disabled adults by family members.

 

 

00062

1992

Exploiting the Vulnerable: The Case of HI-LI Manor Home for the Aged and regulation by the NYS Department of Social Services, June 1992 A two-year-long investigation by the Commission uncovered the diversion of millions of dollars in public funds intended for the care of mentally ill residents of a 125-bed adult home in Queens operated by the Hebrew Academy of the Five Towns and Rockaway (HAFTR) and licensed by the New York State Department of Social Services.

 

 

00063

1992

Child Abuse and Neglect in NYS Office of Mental Health and Office of Mental Retardation and Developmental Disabilities Residential Programs, February 1992 This report of a three-year study called for greater efforts to be made to ensure the protection of children in residential mental hygiene facilities who surface as "repeat" alleged victims in child abuse and neglect reports to the State Central Register. At the same time, the Commission noted that, contrary to the common images of battered children, sadistic abuse or gross neglect of basic needs that the terms "child abuse and neglect" conjure up, in over two-thirds of the reports filed there was no reported physical injury to the child, and in another 25 percent of the cases the injury was treated with first aid. Six percent of the cases involved more serious injury and two cases involved the death of a child.

 

 

00130

1992

WayneThomas- A Resident of Parkview Home for Adults, April 1992 The suicide of an adult home resident occurred against a backdrop of failures by social services and mental health agencies to appropriately plan and coordinate his care after discharge from psychiatric hospitalization, and failure to address the treatment challenges he represented. Social services agencies allowed long-standing deficient conditions to persist at this problem home, including lax security which allowed the deceased to gain access to the roof from which he jumped.

 PDF

 3.9Mb

 00179

1992

 Hi Li Manor Report

PDF

17Kb

AR013

1991

Annual Report: 1990 - 1991

 

 

00131

1991

In the Matter of the Jacob Home: An Uncertified Adult Home Serving Residents with Mental Illness, August 1991 This report is on the investigation of an unlicensed adult home where two residents with mental illness died and residents lived under filthy and unsafe conditions, while the Department of Social Services failed repeatedly over several years to take effective enforcement action to protect residents and close the home. One resident died of hypothermia after the home lacked adequate heat, and neglect by the home 's operator of another resident 's medical needs resulted in his death from tuberculosis. Mental health clinic case mangers responsible for residents ' needs and services also did not maintain regular contact or respond to resident complaints about their treatment and obvious problems at the home.

 PDF

2.43Mb 

00064

1991

Sexuality and Developmental Disabilities: An Investigation of Sexual Incidents at Bernard Fineson Developmental Center, November 1991 This report is on a review of unreported sexual assaults and sexual abuse among mentally retarded adult residents at Bernard Fineson Developmental Center (BFDC) in Queens which prompted the State Office of Mental Retardation and Developmental Disabilities (OMRDD) to issue new guidelines regarding sexual activity among such residents. The investigation by the Commission revealed a breakdown in the facility's supervision of residents and in the handling of serious incidents of sexual assaults and sexual abuse which jeopardized residents' safety.

 PDF

2.37Mb 

00065

1991

TimothySmythe- A Patient at Central New York Psychiatric Center, August 1991 This report is of a review by the Commission of unreported incidents of extortion of patients enforced by physical and sexual assault at Central New York Psychiatric Center (CNYPC) revealing a breakdown in the facility's handling of such incidents which jeopardized patients' safety.

 PDF

870Kb 

00066

1991

In the Matter of Michael Goldstein: An Emergency Room Patient Discharged by Genesee Hospital, June 1991 Thirty-four-year-old Michael Goldstein (pseudonym) allegedly stabbed to death two persons in the residential hotel a few hours after discharge from Genesee Hospital's Emergency Room. During the emergency room assessment, Goldstein reported feeling suicidal and hearing voices telling him to kill people. Psychiatric social workers and an emergency room physician who interviewed Goldstein discussed their observations by telephone with the on-call psychiatrist. The report calls for new policies for hospital emergency rooms requiring that an experienced psychiatrist conduct a personal examination of patients likely to cause serious harm to themselves or others. The lack of such personal evaluations by experienced psychiatrists was a common factor in tragic incidents cited by the Commission.

PDF

3.91Mb

00067

1991

Inmates with Developmental Disabilities in NYS Correctional Facilities, March 1991 At the time this report was published, there were over 1,000 inmates in New York State's prison system who were developmentally disabled, representing, however, only about 2 percent of the approximately 53,400 inmates in custody. The Commission's study, the largest of its kind, was conducted in response to a request from the State Legislature, which had heard widely varying estimates of the incidence of developmental disabilities in the prison population.

 

 

AR012

1990

Annual Report: 1989 - 1990

 

 

00068

1990

Oversight of Transportation Services for Persons with Mental Disabilities, December 1990 The Commission's reviews of several deaths of mentally disabled clients in motor vehicle accidents during 1989 and 1990 revealed flaws in the oversight of transportation services among State agencies responsible for ensuring client safety. This Commission report indicates oversight is compromised by confusion over regulatory standards and omissions in monitoring and sharing of information among transportation carriers, resulting in unnecessary risks for people with mental disabilities who regularly rely upon such transportation to community residential and day programs.

 

PDF

 

5.52Mb

 

00123

 

1990

Adult Homes Serving Residents with Mental Illness: A Study of Conditions, Services and Regulations, October 1990 This Commission report, a study of adult homes serving a significant number of residents who are mentally ill, called for broad reforms in the regulation and enforcement practices of the State Department of Social Services (DSS) and in the mental health services provided to the residents. The study was mandated by the State Legislature.

PDF

4.06Mb

00070

1990

Special Education in New York State: Parents ' Perspective, April 1990 New York State has made progress in providing for the education of children with handicapping conditions, as reflected by the high level of satisfaction received by parents surveyed in a study conducted by the Commission, which administers the federally-funded Protection and Advocacy for the Developmentally Disabled (PADD) Program. The survey is the largest statewide study of the problems encountered by parents in securing the "free and appropriate" education guaranteed under law and was conducted under a grant from the State Developmental Disabilities Planning Council. Despite the satisfaction reported by parents, the Commission report states that there is much that needs to be done.

 

 

00071

1990

Investigation into Allegations of Child Abuse and Neglect at Western New York Children 's Psychiatric Center: Final Report, April 1990 This follow-up report by the Commission found that the safety, supervision and treatment of children at Western New York Children's Psychiatric Center (WNYCPC) improved significantly. The report closed out investigation of 32 allegations of child abuse and neglect at the Western New York facility, but noted, however, that many statewide corrective actions planned by the Office of Mental Health were still in the early stages of implementation.

 

 

00072

1990

Supervision and Care of Seriously Mentally Ill Children: A Case Study, February 1990 Citing long-standing problems with the safety, treatment and supervision of residents, this Commission report is of an investigation into a July 4, 1989 homicide of a 15-year-old girl at a residential program serving mentally ill children and youth. The report, regarding the Hawthorne Cedar Knolls (HCK) facility in Westchester County also questioned the effectiveness of existing models of care and treatment for seriously mentally ill children, who require a greater degree of structure and intensive treatment than such programs are designed to provide.

 

 

00132

1990

JosephConway- A Resident of Parkview Home for Adults, December 1990 A report on the investigation of an apparent suicide by an adult home resident with mental illness following arrest and incarceration for violating a court order to prevent him from harassing home residents. The bright and articulate resident, who exposed deficiencies and advocated for residents ' rights but also harassed residents and provoked staff, had become a target of staff mistreatment. Social services and mental health agencies were criticized for failure to intervene to manage his behavior.

 PDF

 6.4Mb

 00169

1990

 Adult Homes Study 

 

 

AR011

1989

Annual Report: 1988 - 1989

 PDF

1.8Kb

00133

1989

Francis Helms (Community Hospital of Western Suffolk), June 1989 This report demonstrates how unfocused service planning, poor interagency coordination, and a lack of follow up can subvert the mission of agencies responsible for protecting vulnerable adults. A mentally retarded beneficiary of a $200,000 trust fund under a conservatorship was kept locked in a small, filthy, barren room in a frail, elderly woman 's home for the last years of his life. He died as a result of neglect and deprivation because local social services and mental retardation offices, as well as court-appointed conservators and a community-based physician, all failed in their duties, leaving him to spend his last days sitting on a commode, with little or no stimulation, while his few social skills deteriorated from disuse.

PDF

2.2Mb

00073

1989

Profit-Making in Not-for-Profit Corporations: A Challenge to Regulators, December 1989 An investigation of the operators of one of the state's largest psychiatric clinic programs, which improperly billed the Medicaid program for over a million dollars, paid them grossly inflated salaries and perks, engaged in self-dealing with family-owned realty enterprises through which they received hundreds of thousands of dollars, and made large, unauthorized donations of funds to other charities.

 

 

00074

1989

Patient Leaves without Consent from New York State Psychiatric Centers: Myths vs. Facts, October 1989 Over the period 1981-87 there were an average of 7,242 incidents of patient leaves without consent annually from the state's 25 adult psychiatric centers. Together, these 25 centers served approximately 43,000 patients annually, with approximately 26,000 new admissions each year.

 

 

00075

1989

Outpatient Mental Health Services, July 1989 Citing total expenditures of over $800 million annually supporting 950 mental health outpatient programs, this Commission report maintains that existing problems in meeting the community service needs of the state's citizens with serious mental illness have less to do with the need for more money than the need to hold existing programs more accountable for providing them with necessary outpatient mental health services. The Commission report identified numerous weaknesses in accountability for mental health outpatient program performance and their cost-effective expenditure of public funds.

 PDF

2.06Mb 

00076

1989

Psychiatric Emergency Room Overcrowding: A Case Study, May 1989 This report concludes that the staggering demands placed on New York City's chronically overcrowded and understaffed hospital psychiatric emergency rooms (PERs) and "gridlocked" inpatient units may have been major factors affecting emergency evaluations, and admission and discharge decisions on a patient who later allegedly killed his parents.

PDF

2.23Mb

00077

1989

Preventing Inpatient Suicides: An Analysis of 84 Suicides by Hanging in New York State Psychiatric Facilities (1980-1985), May 1989 This study of all suicides by hanging in psychiatric facilities over a 6-year period from 1980-1985 concludes that such suicides are more than three times as likely to occur among psychiatric inpatients than in the general population. In releasing the findings of the study, the Commission urged greater attention to environmental safeguards and special suicide precautions at these facilities.

 

 

00078

1989

Investigation into Allegations of Child Abuse and Neglect at Western New York Children 's Psychiatric Center [Interim Report], January 1989 In a report based on a nine-month-long investigation, the Commission concluded that over a long period of time, many young children at Western New York Children's Psychiatric Center engaged in sexual activity with other children, and that many of these incidents occurred and persisted because of deficient management, clinical, and supervisory practices at the facility. Many children had been repeatedly involved in sexual activity with other children, and the highest incidence of this sexual activity occurred on the facility's unit serving the youngest children, aged 5-12.

 PDF

 2.0Mb

 00181

1989

 New York Psychotherapy and Counseling Center Report 

 PDF

2.0Mb

00182

1989

New York Psychotherapy and Counseling Center Report NYPCC

 PDF

4.8Mb

00185

1989

Outpatient Mental Health Services Study 

 

 

AR010

1988

Annual Report: 1987 - 1988

 PDF

 3.57Mb

00079

1988

A Review of 32 Office of Mental Health Supervised Community Residences, November 1988 This Commission report concludes that many community residences operated directly or certified by the State Office of Mental Health (OMH) provide safe, nurturing and rehabilitative places to live. Yet, other such residences have significant deficiencies, as in this report of unannounced review of 32 randomly chosen residences statewide.

 

 

00080

1988

Discharge Practices of Inpatient Psychiatric Facilities, August 1988 This Commission report concludes that, although inpatient psychiatric facilities devote considerable resources to discharge planning for patients, these efforts are often in vain because critical steps and follow up are not assured. As a result, discharged patients often do not receive the services they need and many lose contact with the mental health system. The Commission studied 60 patients discharged from five New York City metropolitan area inpatient psychiatric facilities who were followed for a six-month period.

 

 

00081

1988

Outpatient Suicide: A Descriptive Study of 172 Outpatient Suicides Reported by New York State Mental Health Programs in 1982, July 1988 The Commission report on its study of all 172 outpatient suicides reported for the year 1982 concludes that an increasing rate of reported suicides among psychiatric outpatients in the past several years suggests a need for more extensive, appropriate and effective community services. "Suicides represent the largest single category of unnatural deaths reported to the Commission and the numbers have been increasing," said Chairman Clarence J. Sundram when the report was released. "The number of outpatient suicides increased from 172 in 1982 to 243 in 1985."

 

 

00082

1988

Review of Living Conditions in NYS Developmental Centers, May 1988 Two decades after the deplorable conditions at now-closed Willowbrook Developmental Center were exposed, the Commission found basic living conditions for mentally retarded and developmentally disabled residents of developmental centers across the state greatly improved. Yet, this Commission report on a study of living conditions in State developmental centers states that expectations for the overall quality of life inside such institutions have also risen since Willowbrook and that some of these expectations remain unmet.

 

 

00083

1988

Admission and Discharge Practices of Psychiatric Hospitals: A Report to the New York State Legislature Pursuant to Chapter 50 of the Laws of 1987, April 1988 This study, mandated by the Legislature, of the admission and discharge practices of inpatient psychiatric facilities demonstrates how New York State spends more money on mental health services than any other state, yet it does not have a system that responds well to the needs of patients and their families.

 

 

00134

1988

RamonLuz- A Patient at Rockland Psychiatric Center July 1988 This case revealed a failure of psychiatric treatment and of supervision in the clinical care of a voluntary patient at a state psychiatric center who was subjected to polypharmacy despite his objections. The death was due to drug intoxication from multiple drug interactions, and facility supervision of his psychiatrist was faulted for failure to detect and address the physician 's lack of attempts to determine the cause of his symptoms or to review and modify his treatment plan.

 

 

AR009

1987

Annual Report: 1986 - 1987

 

 

00135

1987

Joseph Kirsh - A Resident of Craig Developmental Center, February 1987 The review found this mentally incompetent person was operated on without proper consent and died later of complications.

 

 

00084

1987

Child Abuse and Neglect in New York Mental Hygiene Facilities, December 1987 This report, on one of the first studies on reports of child abuse and neglect in State mental hygiene facilities, found that children residing in mental health facilities are a high risk group for abuse and neglect, with a rate of reports more than twice as high as for children in the general population.

 PDF

3.02Mb 

00085

1987

Institutional Child Abuse and Neglect: A Selected Annotated Bibliography, August 1987 This report, on one of the first studies on reports of child abuse and neglect in State mental hygiene facilities, found that children residing in mental health facilities are a high risk group for abuse and neglect, with a rate of reports more than twice as high as for children in the general population.

PDF1.46Mb

 

00086

 

1987

Abusing the Unprotected: A Study of the Misuse of Aversive Behavior Modification Techniques and Weaknesses in the Regulatory Structure, July 1987 This report is on the Commission's investigation of the misuse of aversive behavior modification techniques, resulting in mistreatment of residents at Opengate, Inc., an Intermediate Care Facility for the Mentally Retarded (ICF-MR) in Somers, New York.

 

 

00087

1987

Lisa Cohen - The Need for A Policy in the Developmental Disabilities Service System for Reporting Apparent Crimes to Law Enforcement Agencies, April 1987 The Commission's review of an incident of sexual abuse of a young mentally retarded woman which went unreported to police after she told staff at the State-operated facility where she lived in Broome County, despite state law requiring reporting of possible crimes.

 

 

00088

1987

Investigation into Conditions at Creedmoor Psychiatric Center, March 1987 This is a report on the Commission's review of incidents and overall conditions at the facility in the wake of homicides and escapes at Creedmoor Psychiatric Center. The report cites Creedmoor for lapses in security, together with long-standing deficiencies in patient supervision, patient medical care, and patient safety. The report concludes that the incidents of escapes and LWOCs, complaints about patient care and patient deaths studied collectively suggest "systemic breakdowns in the provision of appropriate care and treatment to patients, in training and supervision of staff, and in management's monitoring and oversight of the facility's performance despite repeated notification of deficiencies." The Commission makes a series of specific recommendations to the facility and to the State Office of Mental Health for changes in operational practices at Creedmoor and in state policies governing the discharge of patients. The Office of Mental Health appointed a Task Force of Experienced Managers to begin the process of change at Creedmoor.

 

 

00089

1987

Patient Living Conditions 1985-86, New York State Psychiatric Centers, February 1987 This report found that State psychiatric centers are capable of providing quality living conditions for patients, and many do; but many wards in a number of State institutions fail to provide appropriate custodial care. The most significant finding of the Commission was the wide variability in the quality of day-to-day living conditions observed among the State's 25 adult inpatient centers.

 

 

AR008

1986

Annual Report: 1985 - 1986

 PDF

2.9Mb 

00090

1986

Medication Practices in New York State Developmental Centers: A Post-Willowbrook Report of Practices at Five Developmental Centers, November 1986 After conducting one of the largest studies of the use of psychotropic and anti-convulsant medications in State centers serving the mentally retarded and other developmentally disabled persons, the Commission published this report which cited many improvements at the centers, while also finding significant deficiencies in monitoring of the use and side effects of such medications.

 

 

00091

1986

Profit Making in Not-for-Profit Care: A Review of the Operations and Financial Practices of Brooklyn Psychosocial Rehabilitation Institute, Inc., November 1986 A Commission investigation found that, despite its not-for-profit status, a Brooklyn mental health program was instrumental in generating hundreds of thousands of dollars in profits for its founder and his family through the diversion of public funds intended for patient care. As a result, the quality of patient care was deficient.

 

 

00092

1986

The Multiple Dilemmas of the Multiply Disabled: An Approach to Improving Services for the Mentally Ill Chemical Abuser, September 1986 This Commission policy paper reports that a high percentage of severely mentally ill individuals in New York State also abuse alcohol and/or drugs, but do not receive treatment for these additional problems. The critical lack of inpatient and community-based services for mentally ill persons with these multiple disabilities creates an enormous and costly gap, which results in increased psychiatric hospitalization rates and longer lengths of stay for such patients, substantially contributing to overcrowding of psychiatric admission units in voluntary, municipal, and State hospitals.

 PDF

515Kb 

00093

1986

Investigation of the Care and Treatment Provided to Juan Gonzalez by Presbyterian Medical Center Emergency Room July 3-5, 1986, July 1986 A report of the Commission's investigation into the care and treatment provided by Presbyterian Hospital to Juan Gonzalez between July 3-5, 1986. Mr. Gonzalez was arrested on July 7, 1986 after he allegedly killed two people and wounded several others with a sword, aboard the Staten Island ferry.

 

 

00136

1986

HildaNorton- A Patient at Central Islip Psychiatric Center, June 1986 In this case, a 70-year-old patient died in October 1983 of complications six months following surgery to correct a hip fracture. The report chronicles a six-month period of unexplained delays, inadequate pre- and post-operative medical care, and poor follow-up medical and nursing care at both Central Islip and Pilgrim Psychiatric Centers, during which the patient developed many severe and infected bedsores, and suffered a serious weight loss which was untreated. Fragmented care, with no single physician having responsibility for medically monitoring and coordinating the care of the patient, was found to have resulted in both the inattention to her medical needs which led to her progressive deterioration, and in the delay in transferring her back to Central Islip Psychiatric Center until it was too late to save her life.

 PDF 

1.7Mb

00173

1986

Brooklyn Psychosocial Rehabilition Report.

 

 

AR007

1985

Annual Report: 1984 - 1985

 

 

00137

1985

FlorenceAustin - An Outpatient at Elmira Psychiatric Center, September 1985 This investigation into the death of a mentally ill patient at a community hospital resulted in a recommendation that hospital should have internal processes to ensure careful decision-making when considering whether to forego aggressive efforts to sustain life. Such decisions should include informed consent by the patient, a guardian or the patient's surrogate.

 

 

00138

1985

Christopher Dugan - A Patient at South Beach Psychiatric Center, January 1985 There is an urgent need for the State Office of Mental Health to conduct clinical research on the phenomenon of sudden deaths among young and agitated, but otherwise healthy, psychiatric center patients, according to this Commission report on the death of a patient at South Beach Psychiatric Center (SBPC) during the process of being restrained. The Commission noted concern that eight able-bodied SBPC male staff trained in management of aggressive patients could not manage an out-of-control delusional patient.

 

 

00094

1985

Living Conditions in New York State Psychiatric Centers Revisited: A Report of Follow-up Visits to Nine Psychiatric Centers, November 1985 A follow-up review of living conditions at nine State psychiatric centers, (Kingsboro, Bronx, South Beach, Manhattan, Buffalo, Rochester, Middletown, Pilgrim and Binghamton) conducted in February 1985.

 PDF

1.98Mb 

00095

1985

Patient Abuse and Mistreatment in Psychiatric Centers: A Policy for Reporting Apparent Crimes to and Response by Law Enforcement Agencies, December 1985 There is significant noncompliance by State psychiatric centers with a requirement of the Mental Hygiene Law that acts of patient abuse or mistreatment, which may constitute crimes, be reported to appropriate law enforcement agencies, according to this Commission report. The Commission undertook a study of the problems associated with reporting possible crimes in psychiatric centers to law enforcement agencies at the request of the Governor's office, following a controversy over the lack of timely reporting of an act of sodomy between two male patients at a psychiatric center.

 

 

00096

1985

Enhancing Family Support Services for the Developmentally Disabled: Commission Comments on OMRDD Actions Pursuant to Chapter 50 of the Laws of 1984, March 1985  This is a report of the Commission's review, pursuant to Chapter 50 of the Laws of 1984, of action taken to implement the Legislature's mandate to New York State Office of Mental Retardation and Developmental Disabilities (OMRDD) to expand provision of State outpatient service delivery to clients living at home through the reallocation of existing outpatient resources. The Commission's review indicates that OMRDD has taken limited action to implement the Legislature's directives.

 

 

AR006

1984

Annual Report: 1983 - 1984

 PDF

 3.00Mb

00097

1984

Pitfalls in the Community-Based Care System: A Review of the Niagara County Chapter New York State Association for Retarded Children, Inc., and Agencies Responsible for Its Oversight, September 1984 Widespread mismanagement affecting the health and safety of clients of Niagara County Association for Retarded Children's (NCARC) residences and programs, together with questionable real estate transactions involving several hundred thousands of dollars and a lack of proper monitoring by State agencies were uncovered by the Commission and detailed in this report.

 

 

00098

1984

Shelter for Homeless Mentally Ill People: A Review of the Impact of the Queens Men 's Shelter on Creedmoor Psychiatric Center 's Operations, August 1984 Following a study of the Queens Men's Shelter established last fall on the grounds of Creedmoor Psychiatric Center (CPC) the Commission concluded that the shelter has had a minimal impact on patient care or CPC's operations and is a "reasonable response to the pressing problems that confront New York City and the State." Nevertheless, the report warned against expanding the shelter into an adjacent building at Creedmoor, stating that such an expansion "would create an overwhelming burden" on the participants in the specialized shelter initiative.

 

 

00099

1984

A Follow up of Implementation of Commission Recommendations to Improve Patient Care: South Beach Psychiatric Center, August 1984 South Beach Psychiatric Center made substantial and significant progress in upgrading the caliber of care afforded to patients, according to this follow-up report issued by the Commission. Four previous Commission reports on investigations of circumstances surrounding the unusual deaths of four patients at the psychiatric center had cited deficiencies in such vital areas of patient care as: medication administration practices; restraint and seclusion practices; the availability and working order of emergency medical equipment; and treatment and discharge planning practices.

PDF

1.71Mb

00100

1984

Facilities As Fiduciaries: A Review of the Management of Residents ' Funds by New York State Mental Hygiene Residential Facilities, June 1984 Criticizing certain inappropriate investment, management and expenditure practices of State mental hygiene residential facilities in managing over $35 million in personal funds of their residents, this Commission report called for legislative change and administrative action by the State's Office of Mental Health and Office of Mental Retardation and Developmental Disabilities.

 PDF

1.91Mb 

00101

1984

A Review of Living Conditions in Nine New York State Psychiatric Centers, May 1984 This Commission report reviews basic living conditions at nine State psychiatric centers, (Kingsboro, Bronx, South Beach, Manhattan, Buffalo, Rochester, Middletown, Pilgrim, and Binghamton) conducted in February 1985.

 

 

00102

1984

Managing Resources in the Mental Hygiene System: Promoting Equity in the Family of New York - A Review of Outpatient Services for Developmentally Disabled People, March 1984 That New York State can substantially increase support services to families of developmentally disabled children, including those who have "aged out" from the educational system, by better management and more effective targeting of the $126 million currently spent on outpatient services in the mental retardation system, was the overall conclusion of a ten-month long study conducted by the Commission at the direction of the State's Legislature.

 

 

00139

1984

JohnDawson- An Outpatient at the Albany County Mental Health Clinic, December 1984 There is an urgent need for mental health and law enforcement agencies statewide to cooperate and develop policies, training and information-sharing procedures to enable police officers to handle crises in the community involving the mentally ill, according to this Commission report. The report chronicles its review of the death of an outpatient of the Albany County Mental Health Clinic who was shot by Albany policy officers during a confrontation in his apartment.

 

 

00140

1984

Jerry Smith - A Resident of Fulton County, May 1984 This Commission report describes how a 21-year-old mentally retarded resident of Fulton County died as a result of physical abuse by his caretakers when Fulton County's Protective Services for Adults (PSA) was unable to intervene successfully, despite reports of severe and chronic abuse made several weeks earlier. The report noted that two of the assailants were convicted of manslaughter in the first degree and the third of assault in the first degree following the victim's death, which was found to be caused by toxemia due to extensive peritonitis, resulting from a perforation of the small intestine.

 

 

AR005

1983

Annual Report: 1982 - 1983

 

 

00141

1983

In the Matter of Simon Paz - A Patient at South Beach Psychiatric Center, October 1983 The Commission's investigation determined Mr. Paz was a difficult patient; but the Board noted such patients are not unique and manipulation, noncompliance, and lack of insight and judgment regarding their condition are not uncommon features of chronic "revolving door" patients. An increasing number of mentally disabled persons, particularly younger patients, are also alcohol and drug abusers. It is clear that a better effort needs to be made to confront the admittedly difficult challenge such patients present to State psychiatric facilities.

 

 

00142

1983

In the Matter of Henry McGee - A Resident of J. N. Adams Developmental Center, October 1983 This patient had several serious medical problems, was subjected to unnecessary major abdominal surgery at the age of 63 without benefit of a careful pre-operative diagnostic workup and a second surgical consultation. The major deficiency in this case, however, was the failure to effect a more timely transfer of the patient to a hospital when projectile vomiting, indication of intestinal obstruction, was noted.

 

 

00143

1983

In the Matter of Patrick White - A Resident of Oswald D. Heck Developmental Center, June 1983 The circumstances surrounding the death of this patient illustrate the consequences of making decisions on the medical condition of a client based primarily on the previous history without fully exploring the presenting symptomatology. The client's condition warranted more intensive medical surveillance than he received at O.D. Heck during his last four days of life.

 

 

00144

1983

In the Matter of Agnes Moro - A Patient at Manhattan Psychiatric Center, April 1983 The investigation by the Commission was undertaken as part of the Commission's and Board's ongoing responsibility to review all deaths of mentally disabled persons, and also as a follow up to the Commission's report on medical care practices at Manhattan Psychiatric Center [A Review of Selected Aspects of Patient Care, Manhattan Psychiatric Center 1979-81, May 1982].

 

 

00103

1983

Right at Home: A Review of Upstate Community Residences of the Mentally Disabled, November 1983 This is a report on the Commission's programmatic and fiscal review of 38 community residential programs serving developmentally disabled persons in upstate New York.

 

 

00104

1983

Psychotropic Drug Usage: An Rx for Improvement - A Study of Selected New York State Psychiatric Centers, August 1983 Citing significant deficiencies in controls on psychotropic drugs at six state mental hospitals, this Commission report called for legislative and administrative changes to improve patient care in this report. The Commission characterized the use of psychotherapeutic drugs as "the primary and predominant mode of treatment and management of the symptoms of mental illness in many, if not most, such facilities."

 

 

00105

1983

Managing Resources in the Mental Hygiene System - The Incident Reporting and Review System: More Process Than Is Due, March 1983 Calling for a major overhaul of the Incident Reporting and review System at State psychiatric and developmental centers, this Commission report indicated there are "fundamental flaws" in the system. The study concluded that the Incident Reporting and Review System produces approximately 100,000 reports annually, with multiple layers of internal review at the facility level, and of external review by Regional Offices, Central Offices, boards of visitors, Mental Health Information Service and, occasionally, by the Commission.

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3.65Mb 

00106

1983

A Review of Private Residential Facilities for the Mentally Retarded: Their Position in the Continuum of Care for Developmentally Disabled and Mentally Retarded Individuals, February 1983 Tremendous variations in the environmental quality, caliber of services provided and in specific areas of management at 10 private residential facilities serving significantly varying mentally retarded populations point to basic internal weaknesses in the regulatory process, according to this Commission report. The Commission's report on a review of 10 of New York State's 18 "private schools" for the mentally retarded, cites some programs as exceptional while highlighting others with significant deficiencies, in the areas of environment, medication administration practices and the assessment and programming of clients. All private schools are certified and regulated by the State's Office of Mental Retardation and Developmental Disabilities (OMRDD).

 

 

00107

1983

Managing Resources in the Mental Hygiene System: The Evolution of Discrete Mental Retardation Units, February 1983 A report on the Discrete Mental Retardation Units (DMRUs), located on the grounds of State psychiatric centers and staffed by developmental centers. Though initially failures at providing appropriate care to persons inappropriately retained at psychiatric centers, over a three-year period DMRUs overcame many of the problems associated with their inauspicious beginnings. While significant progress has been noted at the six downstate locations, the Commission report chronicles three years of monitoring and recommended specific continued action to ensure a uniformly high caliber of care.

 

 

00108

1983

Managing Resources in the Mental Hygiene System: A Study of Deployment of Staff to Community Hospitals, February 1983 The practices of sending staff to accompany mentally disabled patients needing medical treatment at community hospitals are costing the State at least $1.2 million annually, while exacerbating chronic staff shortages and disrupting care and treatment at State mental hygiene facilities, according to this Commission report.

 

 

AR004

1982

Annual Report: 1981 - 1982

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3.25Mb 

00109

1982

Willowbrook: From Institution to the Community; A Fiscal and Programmatic Review of Selected Community Residences in New York City, August 1982 This report concluded that the vast majority of community residences established in the seven years since Governor Hugh L. Carey signed the Willowbrook Consent Decree are providing safe, attractive, comfortable and homelike environments in which more personalized care is delivered to severely and profoundly retarded residents than was available in State institutions in New York City. And, on the average, this care is provided at lower costs than the cost of care in those institutions. These were the leading conclusions of a two-year long Commission study. At the same time the Commission criticized the operations of two- and three-bed apartment residences for such clients, established pursuant to a federal court order, as "programmatically and fiscally misguided" and urged their discontinuance.

 

 

00110

1982

A Follow up of Implementation of Commission Recommendations To Improve Medical Care: Craig Developmental Center, July 1982 This review of medical care at Craig Developmental Center was undertaken by the Commission as an outgrowth of our long-standing concern over the quality of medical services available to residents of that facility. Our concern stems from investigations into deaths of residents of Craig Developmental Center conducted by the Commission and the Mental Hygiene Medical Review Board, as required by law.

 

 

00111

1982

A Review of Selected Aspects of Patient Care: Manhattan Psychiatric Center 1979-81, May 1982 This is a report on the Commission's review of conditions at Manhattan Psychiatric Center (MPC). This review began as an outgrowth of the Commission's Mental Hygiene Medical Review Board reviews of patient deaths at MPC in 1979, which raised questions regarding management and treatment practices at the facility. In April of 1980 our findings were shared with the Office of Mental Health and MPC and a plan of correction was developed. During 1981, Commission staff conducted a follow up on the implementation through a second in-depth review at Manhattan Psychiatric Center.

 

 

00112

1982

Financing the Deficits of Community Mental Health Centers: A Case of Misplaced Incentives, May 1982 Criticizing the State laws requiring the allocation of State aid to community mental health programs based on their operating deficits as inherently inefficient and replete with incentives for diversion of public funds away from their intended purpose, this Commission report urged the State to abandon its present method of annually distributing almost $100 million in mental health local assistance funds to municipalities.

 

 

00113

1982

An Investigation of Selected Incidents at the Otsego School, January 1982 This is a report of the Commission on its investigation into allegations and incidents at the Otsego School (now known as Pathfinder Village), a private school certified by the Office of Mental Retardation and Developmental Disabilities. The investigation by the Commission was undertaken following allegations of abuse and other irregularities in the school's operations by a former employee of the school.

 

 

00145

1982

In the Matter of Mia Martine - A Patient at Mid-Hudson Psychiatric Center, December 1982 The case presented perplexing medical questions, as well as questions about the performance of physicians in managing and documenting the medical care of this patient. The Board also was concerned over the lack of a Mortality Review Committee assessment of the death.

 

 

00146

1982

In the Matter of John Meginn - A Resident at Craig Developmental Center, December 1982 The Board criticized not only the surgeon for his recalcitrant attitude in accepting this case, but also the Craig Developmental Center physician, and stated that as a licensed practicing physician, he had a responsibility to assure that his patient was receiving the appropriate level of care. The Board observed that it is not accepted medical practice that permission be sought from attending physicians in order to utilize a hospital's emergency service, and he abrogated his responsibility as an advocate for the mentally disabled by knowingly allowing a lesser level of care to be afforded this client than he would have tolerated with private patients.

 

 

00147

1982

In the Matter of Pedro Montez - A Patient at Manhattan Psychiatric Center, December 1982 The report illustrates the inevitable and unfortunate outcome of having inadequately trained staff and trainees assigned to cope with violent patients presenting the most severe treatment problems.

 

 

00148

1982

In the Matter of Samuel Ricci - A Patient at Central Islip Psychiatric Center, November 1982 This patient was sent to CIPC's special medical/surgical unit for the express purpose of definitive diagnosis and treatment. He received neither and was medically neglected. The failure of CIPC physicians to obtain a surgical consultation, despite the need for such being noted three times in the record, appears inexcusable. No rational for treating Mr. Ricci conservatively is ever noted by physicians in the record, save for the single entry by the resident that he would be treated conservatively without any further explanation.

 

 

00149

1982

In the Matter of Leonard Gray - A Patient at Rochester Psychiatric Center, November 1982 Leonard Gray did not require psychiatric hospitalization on an acute ward of a State hospital, and he was not given proper care and attention. His “treatment plan” did not state his needs, and the use of various psychotropic medications on this patient was questionable. Mr. Gray spent the bulk of his time at RPC awaiting placement or being treated for injuries sustained there. A neurological exam apparently was not done for lack of completion of a consultation form in this neurologically-injured individual, and no assessment was done of whether a compression fracture and other injuries sustained at RPC had impacted on his neurological status. Too intelligent to be labeled retarded, and thus shunted from that service delivery system, Mr. Gray was never diagnosed as psychotic and only his depression--in reaction to his accident and his friend 's and father 's deaths—served as a valid reason for entry into the psychiatric center. The treatment plan lacked any strategies to deal with basic needs of this patient—toileting, ambulation training, safety, behavioral management strategies, skin care due to a brace, etc. There was never a nurse assigned to the ward on evenings or nights. This case also illustrates an apparently casual attitude toward medication administration, as well as the potential for problems with the lack of accountability of the stock drug system.

 

 

00150

1982

In the Matter of Jason Price - A Patient of Brookdale Hospital Medical Center, October 1982 The Medical Review Board noted that this death was one of more than a dozen undetermined deaths across the state of young agitated persons receiving psychotropic medication.

 

 

00151

1982

In the Matter of Rita Finn - A Client of Rensselaer County Department of Mental Health Unified Services, July 1982 Inept police investigation of the unusual circumstances surrounding the 1980 death of a Rensselaer County Department of Mental Health Unified Services patient, and the "casual attitude" of a former Rensselaer County Medical Examiner in reviewing the death, were castigated in this Commission report.

 

 

00152

1982

In the Matter of Alex Zolla - A Patient at South Beach Psychiatric Center, May 1982 This patient died in restraint. The patient was a 17 year old obese male with previous psychiatric admissions and a history of resistance to treatment including violent outbursts. However, the patient died within two days of his admission without any prior indication that he was suffering a from life-threatening condition. The cause of death was determined to be myocarditis, acute heart failure.

 

 

00153

1982

In the Matter of Faye Trina - A Resident of Brooklyn Community Residence Operated by Brooklyn School for Special Children, March 1982 The Commission report illustrates the consequences of permitting untrained and unqualified persons to operate and staff a residential program for the developmentally disabled. Investigation findings disclosed that 9 developmentally disabled residents were left in the sole custody of an untrained 18 year old relief staff person who was working a 16-hour shift and whose only previous work experience had been with the physically handicapped. All other staff of this residence had received little or no training after being hired. This was compounded by a lack of supervision of such staff and the lack of a formal supervisory on-call system for emergencies.

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818Kb 

00154

1982

In the Matter of Molly Reed - A Client of Two Oliver Street Residence Operated by Manhattan Developmental Center, March 1982 This is a report on the Commission's and its Mental Hygiene Medical Review Board's investigation into the death of a 31 year-old client who died after she was admitted to a hospital for treatment of severe burns sustained while at the community residence.

 

 

00155

1982

In the Matter of Janice Sherman - A Patient at South Beach Psychiatric Center, February 1982 This is a report on the Commission's and its Mental Hygiene Medical Review Board's investigation into the death of Janice Sherman [a pseudonym], a 19 year old patient at South Beach Psychiatric Center who died in restraint for agitation. She had a history of multiple psychiatric hospitalizations since the age of 15 following a suicide attempt, and unquestionably posed a severe treatment challenge to the staff of the psychiatric center. But, in attempting to cope with the patient's agitated behavior, on numerous occasions both the State Mental Hygiene Laws and the Office of Mental Health regulations governing the use of restraints and seclusion were disregarded.

 

 

AR003

1981

Annual Report: 1980 - 1981

 

 

00156

1981

In the Matter of Jeffrey Roland - A Patient at Rochester Psychiatric Center, October 1981 In their review, the Mental Hygiene Medical Review Board stated this unfortunate case was representative of "a series of errors back and forth...a problem of communication." The physicians on the Board noted that this case also raises questions about patients who decompensate frequently and postulated that, "treating them from a base in a hospital rather than returning them to the community" might prove to be more beneficial. This case depicts clinical chaos which culminated in a patient's falling through the cracks despite an overabundance of therapists and a variety of services.

 

 

00157

1981

In the Matter of Richard Sanders - A Resident of Newark Developmental Center, October 1981 Richard Sanders was a likable resident with a cadre of friends on the staff; his nemesis was a unilateral surgical decision and the swift processing of this decision which found him in surgery before interventions could be initiated. The changing of the preoperative diagnosis by the surgeon less than 24 hours before surgery, without notification to NDC officials, and the surgeon 's previous intent to include permission for possible orchiectomy without rationale lends credence to the Commission's and Mental Hygiene Medical Review Board 's belief that the surgeon 's actions in this case were questionable. Further, the intervention and deficient workup by the medical specialist and anesthetist exemplify the poor medical care delivered to this patient. There appeared to be a casual attitude towards unnecessary surgery among some medical practitioners at the facility.

 

 

00158

1981

In the Matter of Mark Monroe - A Patient of St. Lawrence Psychiatric Center, September 1981 This is a report on the Commission's and its Mental Hygiene Medical Review Board's investigation into the death of Mark Monroe [a pseudonym], a patient on convalescent care status at St. Lawrence Psychiatric Center, while living at an ARC community residence. The major breakdown in communication, in the absence of proper medication protocol, directly led to the death of this client.

 

 

00159

1981

In the Matter of Eileen Alenza - A Resident of Bronx Developmental Center, September 1981 The Commission concluded the death could have been avoided. Responsibility was shared by the direct care staff on duty the day she died. Staff's failure to monitor her closely, even after her third disappearance within a relatively brief period of time, was one factor responsible for Miss Alenza being able to leave the unit undetected and for her eventual fall from the fifth floor terrace to her death.

 

 

00160

1981

In the Matter of Frank Darby - A Resident at Craig Developmental Center, August 1981 The report recommends: that the State Office of Mental Retardation and Developmental Disabilities retain independent consultation to review the quality of medical care at Craig Developmental Center; that developmental center physicians seek hospital consultation promptly on behalf of seriously ill developmental center clients; that the developmental center create a mechanism to assure the transfer of patient information in a more thorough manner, to include client medical care; that mortality reviews include all staff, especially physicians, involved in a client's care and treatment; and, that the conduct of physicians who failed to provide adequate medical attention to the deceased in this case be referred to the Board of Professional Medical Conduct of the Department of Health for review.

 

 

00161

1981

In the Matter of Fred Zimmer - A Patient at Kingsboro Psychiatric Center, June 1981 Although the patient died as a direct result of being restrained following an assault upon staff of the facility, the Commission report concludes that "there was no evidence of intent to abuse or to inflict harm upon the deceased patient."

 

 

00162

1981

In the Matter of Alphonse Rio - A Patient at South Beach Psychiatric Center, March 1981 The Commission and its Mental Hygiene Medical Review Board investigation into this case found that, while there may have been a necessity to place this patient in a camisole for prolonged periods during his stay on the intensive care unit, there was no documentation by a physician justifying its use. More disturbing was the evident failure of the psychiatric resident to examine the patient prior to authorizing the use of a camisole. This physician had attended to the patient earlier in the day when he was found to be perspiring, hyperventilating and agitated. He knew, or should have known, of the temperature control problems being experienced by the unit. In this case the medical rationale for medication doses exceeding Department of Mental Hygiene Drug Manual guidelines also was not subject to appropriate consultation, consent and documentation; medication orders were not clearly written and conditions for administration were not coordinated with nursing staff.

 

 

00163

1981

In the Matter of Peter Breen - A Patient at St. Lawrence Psychiatric Center, February 1981 In the process of staff restraining this patient and placing him in a tray chair, the patient apparently suffered fractures of the ribs and sternum. The report determined that the facility staff lacked a team approach and consistency in their interactions with the patients, and improper methods were used in restraining this violent patient with the tray chair, an unauthorized restraint, in violation of the Mental Hygiene Law. No responsibility was clearly assigned to one treating physician as the focal point for all patient-related communications and continuity of care responsibility for this patient who was undergoing an acute medical episode.

 

 

00114

1981

The Endless Quest: The Autistic and Their Families, August 1981 This report describes the struggles of families with autistic children both in trying to understand this enigmatic syndrome and the difficulty in finding adequate and appropriate services for their children. The 1981 report is divided into five sections: 1) Autism: An Enigmatic Syndrome; 2) Parenting and Autistic Child; 3) A Look at New York State's Institutional Care Network for the Autistic; 4) Perspectives from Professional Spokespersons on Autism; and 5) Looking Toward the Future: Mapping the First Steps.

 

 

00115

1981

Family Care Revisited: Buffalo Psychiatric Center Family Care Follow-up Study, March 1981 This Commission report is on its follow up of the family care program at Buffalo Psychiatric Center (BPC). For nine months during 1979, the Commission conducted a comprehensive review of BPC's family care program in response to both expressions of community concern at Commission hearings and the Office of Mental Health request for independent scrutiny of the program following published reports of various problems affecting the quality of care.

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 5.00Mb

00116

1981

Profit vs. Care: A Review of Greenwood Rehabilitation Center, Inc., A Private School for the Mentally Retarded, and Related Regulatory Processes, March 1981 This Commission report is on a 21-month-long investigation into the financial and program practices of the Greenwood Rehabilitation Center, Inc., a private school for the mentally retarded located near Ellenville, New York (with administrative offices in Hicksville, Long Island), and into the regulation of this school by the Office of Mental Retardation and Developmental Disabilities and the former Department of Mental Hygiene. It is the conclusion of this report, with respect to the Greenwood Rehabilitation Center, public funds in the form of Supplemental Security Income (SSI) payments, intended primarily for the care of the residents, have been diverted, through a variety of means, to the personal and corporate enrichment of the owners, their families and associates--to the detriment of the mentally retarded residents the corporation was ostensibly created to serve.

 

 

AR002

1980

Annual Report: 1979 - 1980

 PDF

3.01Mb 

00117

1980

Converting Community Residences into Intermediate Care Facilities for the Mentally Retarded: Some Cautionary Notes, (ICF-MR), October 1980 This is a Commission report on a fiscal and programmatic review of the Office of Mental Retardation and Developmental Disabilities' initiative to convert community residences into Intermediate Care Facilities for the Mentally Retarded (ICF/MR).

 PDF

1.99Mb 

00118

1980

Protecting the Rights of Developmentally Disabled Persons: Establishing a Statewide System of Advocacy Services, July 1980 This Commission report is on a survey funded by the New York State Advisory Council on Mental Retardation and Developmental Disabilities to survey the independent advocacy agencies throughout the State.

 PDF

3.03Mb 

00119

1980

A Study of the Delays in the Receipt of Medicaid Cards by Patients Discharged from Mental Hygiene Facilities, July 1980 Medicaid-eligible individuals released from State psychiatric and developmental centers have experienced lengthy delays in the receipt of Medicaid cards, which adversely affect their access to needed services in the community and, at the same time, inappropriately reduce federal financial participation in the cost of these services. This Commission study is of the Medicaid card issuance process to determine the causes and effects of such delays. The report reflects conditions found to exist from 1976 through early 1979 -- the period in which the sample population experienced delays in the receipt of Medicaid cards.

PDF

2.8 Mb

00120

1980

A Review of the Barbara Downes Family Care Home, June 1980 The Commission undertook the review of the Barbara Downes family care home, supervised by Binghamton Psychiatric Center, following the death of Cleo B., a resident of the home who was struck by a truck while crossing the road on the morning of October 8, 1979. Allegations of inadequate supervision and inappropriate medication practices in the home prompted the Commission to initiate a separate review of the home itself. These allegations were brought to the Commission 's attention by Binghamton Psychiatric Center 's Board of Visitors, which raised concerns over the supervision and medication practices in the home.

PDF

7.1 Mb

00121

1980

Strengthening Patient Advocacy (MHIS): A Review of the Mental Health Information Service, May 1980 This is a report on the Commission study of the organization and operations of the Mental Health Information Service with a view to providing the Executive, Legislative and Judicial branches of government with recommendations for improving the effectiveness of the Service.

 

 

00122

1980

A Review of Syracuse Developmental Services, March 1980 This Commission undertook the review of Syracuse Developmental Center in response to complaints by a nurse at the facility, and investigated what was alleged to be the deteriorating quality of resident care and programming. The major issues which emerged were associated with staffing and philosophies of resident care.

PDF

5.3Mb

00164

1980

In the Matter of Aaron Maxwell - A Resident of Rome Developmental Center, November 1980 This is a report of a resident of Rome Developmental Center (RDC) who died following surgery. The report recommends that RDC take steps to ensure coordination among treating physicians of various specialties whenever elective surgery upon a resident is contemplated, and that all standard diagnostic procedures be utilized in deciding upon the course of treatment for mentally retarded patients. The report also recommends: that facility physicians, including the treating psychiatrist, meet with the consulting surgeon in cases involving elective surgery and reach agreement on the need for surgery; that second opinions be obtained in cases of elective surgery; that assessments by outside consultants be based upon more than a single patient visit; and, that following the recommendation of an outside consultant, surgery be done in a timely manner, with the need for surgery to be reassessed in cases of significant time lapse.

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930Kb 

00165

1980

In the Matter of Joseph C. - A Resident of Craig Developmental Center, August 1980 The report recommends that the developmental center take steps to ensure coordination and communication among medical staff charged with care of clients who are seriously ill. Specifically, the report recommends: that clients deemed ill enough to be sent to an emergency room should be promptly evaluated by a facility physician upon return; and, that facility nurses document decisions to deviate from established client treatment regimens. In addition, the report recommends that a transfer form be developed to include information, regarding the special needs of handicapped clients, for use whenever such clients are sent to other facilities or to outside practitioners, to increase communication between facility and community physicians. The report further recommends that the developmental center administration proceed, through education and direct intervention, to ensure that local general hospital physicians provide the same emergency care to developmental center clients as is afforded to the general public, and not misconstrue the developmental center's medical unit as comparable to a hospital's acute care surgical unit. Finally, the Commission report recommends that, following the unanticipated death of a client, there should be a forum for staff of all levels to exchange information, identify problem areas and plan for future intervention to prevent the recurrence of such deaths.

PDF

9.7Mb

00166

1980

In the Matter of Alice S. - A Resident of Craig Developmental Center, July 1980 The report recommends that the developmental center negotiate with the local general hospital, upon which it relies for medical care, to ensure provision of proper postoperative care for the developmental center clients. The developmental center was also urged to clarify use of its medical unit as an infirmary providing skilled nursing care, rather than an acute medical care hospital. It was further recommended that the developmental center work with the general hospital to dispel myths and provide education about the nature of both retardation and epilepsy.

 

 

00167

1980

In the Matter of William S. - A Resident of Capital District Psychiatric Center, April 1980 This is a report on the Commission's and its Mental Hygiene Medical Review Board's investigation into the death of William S. [a pseudonym], a patient at Capital District Psychiatric Center who committed suicide in the Albany Police Lockup.

 

 

00168

1980

In the Matter of Cheryl J. - A Patient at Greenwood Rehabilitation Center, April 1980 This is a report on the Commission's and its Mental Hygiene Medical Review Board's investigation into the death of Cheryl J. [a pseudonym], a patient at Greenwood Rehabilitation Center, a private school for the mentally retarded. The report recommends that the Greenwood Rehabilitation Center provide its staff with adequate training in resuscitation and first aid, and that emergency equipment be made more accessible. It was recommended that the Office of Mental Retardation and Developmental Disabilities review the medical emergency response capabilities of each of the State's private schools for the mentally retarded.

 

 

AR001

1979

Annual Report: 1978 - 1979

 

PDF

 

3.39Mb 

 

00069

 

1979

Family Care for the Mentally Ill: The Unfulfilled Promise, October 1979 Criticizing the Buffalo family care program for psychiatric patients as unrealistic and poorly administered, this Commission report asserted that for most psychiatric patients at that facility family care is a dead end where the quality of patient care can best be characterized as neglectful.

PDF

8.3 Mb

00124

1979

A Review of Broome Developmental Services, April 1979 This report is the result of visits to Broome Developmental Center (BDC) in response to concerns and allegations raised by the Board of Visitors, the Parents Group, a local assemblyman, facility staff members, members of the community and newspaper reports. The major issues that emerged were associated with staffing.

 PDF

2.31Mb 

00125

1979

Allegations without Substantiation: An Investigation into Charges by the Rockland County Medical Examiner, March 1979 This investigation by the Commission determined that charges of numerous drug-related deaths at Rockland Psychiatric Center and Letchworth Village Developmental Center are "totally without substantiation and made with no basis in medical examination or fact."

 

 

00126

1978

The Establishment of Priorities: Public Hearings Held by the Commission on Quality of Care, October 1978  

 

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