ANDREW M. CUOMO
GOVERNOR

STATE OF NEW YORK
COMMISSION ON QUALITY OF CARE AND ADVOCACY
FOR PERSONS WITH DISABILITIES
401 STATE STREET
SCHENECTADY, NEW YORK 12305-2397

1-800-624-4143 (VoiceITTY/Spanish)
www.cqc.ny.goY

JANE G. LYNCH
CHIEF OPERATING OFFICER

BRUCE BLOWER
PATRICIA OKONIEWSKI

MEMBERS

January 6, 2011

Richard Miraglia
Associate Commissioner
Division of Forensic Services
44 Holland Ave.
Albany, NY 12229
Dear Mr. Miraglia:
The State Commission of Correction requested that this Commission review the mental
health evaluation and classification provided to
an inmate who died on March
12,2010 at the Downstate Correctional Facility..
~....
order to review the mental health evaluation and mental health classification provided
to _
we conducted a site visit to Central New York Psychiatric Center's, (CNYPC)
Risk Management Department to review.linical record and reviewed select CNYPC Policy
and Procedures.

While reviewing
record we noted that~answered in the affirmative to
item number one (Have you ever been in the hospital for emotional or mental health problems?)
on the CNYPC Mental Health Screening-Structured Interview form. According to Section V Disposition, if questiqn #1, 10 and/or # 11 are answered in the affirmative, a full mental health
evaluation is to be completed. Despite meeting this criteria, we found no evidence that an
, . I .
appropri
ealth evaluation was completed. This impacted the ability to accurately
classify
to ensure Ifreceived mental health services.
We recommend that policy # 1.2 - Reception Mental Health Screening be revised to
include; what more specific information regarding a full mental health evaluation consists of,
when a full mental health evaluation should be completed, and where a completed full mental
health evaluation is to be documented. This policy revision should also address oversight and
review of the CNYPC Mental Health Screening - Structured Interview forms to ensure they are
fully completed and that full mental health evaluations are conducted when required by CNYPC
Mental Health Screening criteria. A system should be implemented to ensure that supervision,
oversight and monitoring of the screening process results in the most appropriate outcome of
services. We also suggest that OMH staff at all reception centers be re-trained on conducting
reception mental health screenings.

We would appreciate a response to the above noted concerns by February 7, 20 II .
.rhank you for your continued cooperation with this Commission.
Under Article 6 of the Public. Officers Law, tinal agency determinations are required to
be available for public inspection. This letter will be deemed a tinal agency determination 30
days after the date of this letter, which affords you an opportunity to respond to our findings
prior to any disclosure pursuant to the Public Officers Law. Material which is required to be
kept confidential or which is protected from disclosure under the Public Officers Law or other
laws will be redacted prior to any such disclosure.
Respectfully,

r~~~-'-

H. A.

Michelle M.
.n, MA
Quality of Care Facility Review Specialist I
Division of Quality Assurance
and Investigations
518-388-2837
Michelle.guerin@cgc.ny.gov

ley
cc: Donald Sawyer, Executive Director, CNYPC
. Jayne Van Bramer, Director of Quality Management, NYS OMH
Brian Fischer, Commissioner, NYS DOCS
Diane VanBuren, Assistant Commissioner, NYS DOCS
Phyllis Harrison-Ross, MD, Cominissioner and Chair, MRB, NYS COC .

2

.

am

State of New York

.

. .. Andrew M. Cuomo
lI.lIOW
Governor

'i

OffIce of Mental Health

44 Holland Avenue
Albany, New York 12229
www.omh.ny.gov

January 31,2011

Michelle Guerin, MA
Division of Adult Quality Assurance & Investigations
New York State Commission on Quality of Care
and Advocacy for Persons with Disabilities
40 1 State Street
Schenectady, New York 12305-2397
Dear Ms. Guerin:
I am in receipt of your letter dated January 6, 2011, re~.
ommission's review
of the mental health evaluation and classification provided to

.-...r

The CQC review did not find evidence that an appropriate mental health evaluation was
completed as required by CNYPC policy. This was despite the fact that one of the trigger
questions, which should lead to a full evaluation, was checked. We agree with the Commission's
findings and the need to complete the required evaluation was reinforced with the employee in
question and all reception staff.
The Commission recommended that policy #1.2-Reception Mental Health Screening be
revised to· include additional information on full mental health evaluations such as exactly when
they should be completed and where this should be documented. In response to this
recommendation, a thorough review of the CNYPC policies will be conducted and necessary
policy changes will occur. Training on policy changes will be part of the implementation of the
revised approach.
In addition, a standardized "training manual" is being developed as a guide and reference
tooI for all clinicians in Reception Centers. This manual will include all 'of CNYPC's reception
policies and direction as to when a full mental health evaluation must be completed and where it
must be documented. This "training manual" will be finalized and available by March 1, 2011.
It was also recommended that policy be revised, putting into a system which would
provide oversight, supervision, monitoring and review of the. screenings. As the Commission is
acutely aware, these are difficult fiscal times requiring the judicious allocation of resources.
Accordingly, we are not in a position to revise our current monitoring and supervision protocols
in response to one adverse event. Moreover, with the upcoming review by the Commission of
the OMHIDOCS Reception Protocols, we question the timing of the Commission's
recommendation. It seems prudent to us that we await the Cdmmission's Final Report of its
review before we render a decision to modify or revise our monitoring or supervision protocols.

AN EQUAL OPPORTUNllY/AFFIRMATIVE ACTION EMPLOYER

o

OMH 26.01 (' 21'~

It was also recommended that all OMH statf at reception centers be re-trained on
conducting reception mental health screenings. We agree with this suggestion and all clinicians
at reception centers will be re-trained by June 1, 2011. Education and training sheets will be
available upon request.

We thank you again for your review and hope this information is helpful.
Sincerely,

gfglia,LCSW

Associate Commissioner .
Division of Forensic Services

cc:

Donald Sawyer, Executive Director, CNYPC
Brian Fischer, Commissioner, NYSDOCS

ANDREW

M. CUOMO

GOVERNOR

STATE Of NEW YORK
COMMISSION ON QUALITY Of CARE AND AOVOCACY
FOR PERSONS WITH DISABILITIES
401 STATE STREET
SCHENECTADY, NEW YORK 12305·2397
1·800-624-4143 (VoicelTTYISpanish)

JANE G. LYNCH
Cr!IEF OPERATING OFFICEH

BRUCE BLOWER
PATRICIA OKONIEWSKI
MEMBERS

www.cqc.ny.goY

February 11,2011

Richard P. Miraglia; LCSW
Associate Commissioner
New York State Office of Mental Health
44 Holland Avenue
Albany, NY 12229
Dear Mr. Miraglia:
The Commission ha~ January 31,2011 response to our
letter of findings regarding _ _
We appreciate that policies regarding the mental health screening process
. will be reviewed, revised and training will be part of the implementation process
and that a standardized training manual for clinicians in the Reception Centers
will be developed. We are pleased that these actions are being taken and
request that you forward a copy of your Reception Center Training Manual to our
office upon completion.
With regard to your reluctance to revise or modify your monitoring and
supervision protocols due to the Commission's upcoming review at the Reception
Centers, it is the Commission's protocol to make recommendations as concerns
are identified during investigative reviews, and we stand by that
recommendation. We believe that best practice includes thoroughly reviewing
the systems in place after an adverse event such as a suicide.
At this time, the Commission considers this matter closed. Thank you for
your continued cooperation with this Commission.
Please be reminded that all correspondence related to this matter will be
available for public inspection under Article 6 of the Public Officers Law. Material
which is required to be kept confidential or which is protected from disclosure

under the Public Officers Law or other laws will be redacted prior to any such
disclosure.
Respectfully,

'iltULuvV~(.~ IL{.A.
Michelle M. Gueri , MA
Quality of Car~ cility
Review Specialist I
Division of Quality Assurance
and Investigations

518-388-2837
Michelle.guerin@cqc.ny.gov

lip
cc:

Jane Lynch, COO, CQCAPD
Donald Sawyer, Executive Director, CNYPC
Michael Hogan, Commissioner, NYS OMH
Jayne VanBramer, Director of Quality Management, NYS OMH
Brian Fischer, Commissioner, NYS DOCS
Diane Van Buren, Assistant Commissioner, NYS DOCS
Phyllis Harrison-Ross, MD., Commissioner and Chair, MRB, NYS COC