Objective

To assess the extent of implementation of the three recommendations included in our initial audit report, Compliance With Jonathan’s Law (Report 2017-S-67).

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 Addiction Services and Supports. 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.”)

Our initial audit report, issued on November 18, 2019, sought to determine whether OPWDD was complying with the requirements established under Jonathan’s Law. We determined that OPWDD did not implement processes to effectively monitor whether Facilities are complying with Jonathan’s Law. While Facilities established practices for notifying qualified persons within the required time frame, 11 percent of the incidents we reviewed lacked support that the requisite 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. We also found that Facilities did not always provide records to qualified persons when requested or did not provide 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 Finding

OPWDD officials made limited progress in addressing the problems identified in the initial audit report. Of the initial report’s three audit recommendations, one was implemented and two were not implemented.

Key Recommendation

Officials are given 30 days after the issuance of the follow-up review to provide information on any actions that are planned to address the unresolved issues discussed in this review.