Objective

To determine whether the Office for People With Developmental Disabilities is complying with the requirements established under Jonathan’s Law. This audit covers the period April 1, 2015 through April 25, 2019.

About the Program

In February 2007, Jonathan Carey, a 13-year-old non-verbal autistic and developmentally disabled boy, died while in the care of a State facility operated by the Office of Mental Retardation and Developmental Disabilities (subsequently renamed the Office for People With Developmental Disabilities, or OPWDD). Jonathan’s parents attempted multiple times to obtain information concerning several unexplained injuries, unauthorized changes in treatment, and suspected abuse and neglect while at a privately run facility and then at a State-run facility. In May 2007, “Jonathan’s Law” was enacted to expand parents’, guardians’, and other qualified persons’ access to records relating to incidents involving family members residing in facilities operated, licensed, or certified by OPWDD, the Office of Mental Health, or the Office of Alcoholism and Substance Abuse Services. Under Jonathan’s Law, facility directors are required to do the following in response to any incident involving a patient receiving care and treatment:

• Provide telephone notification to a qualified person within 24 hours of the initial reporting of an incident;
• Upon request by a qualified person, promptly provide a copy of the written incident report;
• Offer to hold a meeting with a qualified person to further discuss the incident;
• Within ten days, provide the qualified person with a written report on the actions taken to address the incident (Actions Taken Report).

In addition, upon written request to the provider, qualified persons may obtain records and documents related to reportable incidents within 21 days of either the conclusion of the investigation or the written request, whichever is later.

OPWDD operates 13 Developmental Disabilities State Operations Offices in six regions across the State to oversee over 1,100 certified programs. OPWDD also regulates, certifies, sponsors, and oversees approximately 650 community-based service providers subject to Jonathan’s Law requirements. (The State- and community-operated programs are hereafter referred to collectively as “Facilities.”)

Key Findings

• OPWDD has not implemented processes to effectively monitor whether Facilities are complying with Jonathan’s Law. While Facilities have established practices for notifying qualified persons within the required time frame, 11 percent of the incidents we reviewed lacked support that the required notification was made within the required time frames and 7 percent lacked support that an Actions Taken Report had been issued within the required time frames.
• Facilities do not always provide records to qualified persons when requested or are not providing them within 21 days of the request or the conclusion of the investigation (whichever is later), as required. In a sample of 63 record requests, 32 percent (20) were either not provided on time or not provided at all. In addition, Facilities provided inconsistent information – with some offering more detail than others – to qualified persons in response to record requests.

Key Recommendation

• Provide updated guidance to Facilities on their responsibilities related to Jonathan’s Law requirements – including clear and consistent implementation procedures – and require Facilities to follow procedures.