2023

ANNUAL
REPORT
to the Governor
and Legislature

justicecenter.ny.gov | 1 (800) 624-4143 2023 Annual Report

 NYS Justice Center
2023 Annual Report 2

CONTENTS

Mission, Vision, Guiding Principles 3

Cover Letter 4
Introduction 5
2023 Highlights & Initiatives 7
Workforce & Stakeholder Outreach 10
Training & Safety Improvements 13
Abuse Prevention & Quality Improvement 14
Diversity Equity & Inclusion 20
Incident Management 21
Mortality Reviews 31
Conclusion 34
OUR VISION
People with special needs shall be protected from abuse, neglect, and mistreatment.
This will be accomplished by assuring that New York State maintains the nation’s
highest standards of health, safety, and dignity; and by supporting the dedicated
people who provide services.

OUR MISSION
The Justice Center is committed to supporting and protecting the health, safety, and
dignity of all people with special needs and disabilities through advocacy of their
civil rights, prevention of mistreatment, and investigation of all allegations of abuse
and neglect so that appropriate actions are taken.

OUR GUIDING PRINCIPLES

Integrity: The Justice Center believes that all people with special needs deserve to
be treated with respect and that people’s rights should be protected.

Quality: The Justice Center is committed to providing superior services and to

ensuring that people with special needs receive quality care.

Accountability: The Justice Center understands that accountability to the people

we serve, and the public is paramount.

Education: The Justice Center believes that outreach, training, and the promotion of
best practices are critical to affect systems change.

Collaboration: Safeguarding people with special needs is a shared responsibility,

and the Justice Center is successful because it works with agencies, providers,
people who provide direct services, and people with special needs to prevent abuse
and neglect.
 NYS Justice Center
2023 Annual Report 4
COVER LETTER

To the Governor and Legislature:

I am pleased to provide you with the 2023 Annual Report of

the Justice Center for the Protection of People with Special
Needs, as required by Executive Law § 560. This report
summarizes the agency’s activities and accomplishments
from January 1 through December 31, 2023. It includes, but
is not limited to, the following statistics and information:

• Number of reports received by the Vulnerable Persons’

Central Register (VPCR);
• Results of investigations by types of facilities and
programs;
• Corrective actions taken;
• Summary of patterns and trends in the reporting of and
response to reportable incidents, and recommendations for
appropriate preventative and corrective actions;
• Training provided in 2023; and
• Summary of the Justice Center’s HALT monitoring of the
use of segregated confinement and the provision of mental
health services to incarcerated individuals.

Additional information about the Justice Center can be

found on the agency’s website at www.justicecenter.ny.gov.

Respectfully submitted,

Maria Lisi-Murray
Acting Executive Director
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2023 Annual Report 5
INTRODUCTION

The Justice Center for the Protection of People with Special Needs works in
partnership with individuals receiving services, their families, direct care staff, and
provider organizations to protect the health, safety, and dignity of people with
special needs and disabilities. This is done in a variety of ways, including:
developing abuse prevention tools, providing education to stakeholders on Justice
Center operations, and ensuring high-quality investigations of all allegations of
abuse and neglect.

To achieve its mission, the Justice Center standardized the state’s systems for
incident reporting, investigations, disciplinary processes for state employees,
corrective and preventive actions, and pre-employment background checks. The
outcome of these activities is outlined in this report. In addition, the Justice Center
has implemented several strategic initiatives to improve agency functions and
address concerns with agency stakeholders. These initiatives ensure the Justice
Center is protecting New York’s most vulnerable citizens while also supporting the
dedicated people who care for them.

HISTORY & JURISDICTION

The Protection of People with Special Needs Act (Ch. 501, L. 2012) established the
Justice Center for the Protection of People with Special Needs as an executive
agency responsible for protecting the safety and well-being of the approximately 1
million adults and children who, due to physical or cognitive disabilities, or the
need for services or placement, are receiving care from certain facilities or
provider agencies that are licensed, operated, or certified by six state agencies.
These agencies include:

OVERSIGHT
JURISDICTION INFORMATION
State Agencies
Office for People with Developmental Disabilities (OPWDD)
Office of Mental Health (OMH)
Office of Addiction Services and Supports (OASAS)
Office of Children and Family Services (OCFS) (State-operated programs/facilities
and certain residential programs)
Department of Health (DOH) (Summer camps and adult homes that meet certain
criteria)
State Education Department (SED) (Certified residential schools and programs)
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2023 Annual Report 6
The agency, which became operational on June 30, 2013, serves as the state’s
central repository for all reports of allegations of abuse, neglect and significant
incidents involving vulnerable individuals as defined in Social Services Law (SSL) §
488(1). The Justice Center maintains a case management system that tracks all
reported cases of abuse and neglect to resolution, ensures all allegations are fully
investigated, and makes final legal determinations on all allegations. The Justice
Center works with county district attorneys to prosecute allegations that are criminal
in nature. The agency also provides guidance, information, and support to victims
and their families throughout the investigative process.

Through its oversight and monitoring activities, the Justice Center identifies durable
corrective and preventive actions to address the conditions that cause or contribute
to the occurrence of abuse and neglect. In consultation with its Advisory Council,
the Justice Center also works collaboratively with a broad array of stakeholders to
promote prevention strategies and to develop guidance and tools to help provider
agencies better protect people receiving services.

ADVISORY COUNCIL INFORMATION

The Justice Center operates with a staff of nearly 500 committed professionals. The
agency’s front-line staff, which includes call center representatives, investigators,
attorneys, and individual and family support advocates have collectively
accumulated decades of experience working with special populations at state and
private provider agencies and in other service systems prior to joining the Justice
Center. Notably, a recent agency survey revealed that more than one third of the
agency’s staff has a loved one with special needs, which only enhances the
collective commitment of our workforce to the mission of the agency.

The activities and accomplishments highlighted in this report reflect the work of the
Justice Center in partnership with state agencies, non-profit provider agencies, and
individuals and families who effectively promote positive change. These changes
have resulted in a system of care where people who receive services are treated with
dignity and respect and those who provide services and supports are valued and
supported.
 NYS Justice Center
2023 Annual Report 7
2023 HIGHLIGHTS & INITIATIVES

10 YEAR ANNIVERSARY
The Justice Center commemorated its 10-year
anniversary in 2023. To mark the occasion,
the agency issued an anniversary report
highlighting the Justice Center’s impact on the
service system. The report is an in-depth look
at the work of the Justice Center over the past
decade including data analysis, prevention
efforts, supports and services, what makes the
agency’s expertise unique, and where the
agency will focus efforts in the next decade.
The report features clips of interviews with
staff members who have spent the entirety of
the agency’s existence with the Justice Center
as well as with stakeholders who have helped
CLICK TO ACCESS REPORT
shape the evolution of the agency.

Additionally, the Justice Center launched a series of videos with staff and
stakeholders. These feature more in-depth interviews about the agency, its impact
over the last decade, and what makes the Justice Center a great place to work.
These videos were part of a robust digital marketing campaign aimed at raising
awareness of the agency’s work for individuals with special needs.

ANNIVERSARY WEBPAGE

Finally, Executive Director Miranda wrote an op-ed published in The Buffalo News
calling on other states to follow New York’s lead and take steps to protect their
vulnerable populations. The Executive Director was also featured in a podcast series
the explored the events that led to the creation of the Justice Center, the agency’s
first years of service, and where the service system goes from here.

INCIDENT MANAGEMENT ROUNDTABLES

The Justice Center held five incident management roundtables with providers
and five different state oversight agencies (OCFS, SED, OPWDD, OMH and
OASAS) between March and June. These small group discussions provided an
opportunity for the Justice Center to receive feedback from stakeholders on how
to improve processes.
 NYS Justice Center
2023 Annual Report 8
Participants also discussed how to assist provider agencies in spreading awareness
of the protections afforded to their loved ones in care and in creating processes
that ensure that families receive timely notification of incidents of abuse and
neglect when they happen.

Overall feedback about the Justice Center’s ability to respond to concerns and
operational needs of provider agencies was positive. The Justice Center is working
with state agency partners to address the concerns and recommendations
identified during the roundtable discussions. Some examples of this work include:

• Establishing a workgroup with OPWDD to develop resources for agencies to help

families understand the incident management process. This work has resulted in
a guide for providers on effective communication and a guide for families on
effective advocacy.
• Eliminating redundancies in reporting and CAP audits.
• Changing the online reporting form for reporting incidents to make it easier to
use.

FAMILY OUTREACH
The Justice Center understands that family members may have information that
can assist an investigation. In 2023, the Justice Center instituted a new policy to
ensure that families are notified at the beginning of a Justice Center
investigation. This policy improves the communication between family members
and the Justice Center and provides them with an opportunity to convey any
information they think may be relevant to an investigation. In addition, this first
contact allows the Justice Center to connect families with agency resources that
can help them understand the investigatory process and gives them a point of
contact for questions or concerns.

FAMILY OUTREACH

JUSTICE CENTER/OPWDD WORKGROUP

The Justice Center and the Office for People With Development Disabilities
(OPWDD) held a series of roundtables with provider agencies to identify the pain
points they were experiencing with the incident management process. After
compiling the results of the roundtables, the Justice Center and OPWDD have
come together to form a multi-disciplinary workgroup tasked with developing a
short list of projects aimed at alleviating the providers’ pain points. The
workgroup has created a draft list of projects that will focus on reducing
duplication and improving clarity for provider agencies on the investigatory
process. They are currently working on outlining high level implementation plans,
timeframes, and measures of success for each project. As the plan for each
project is finalized, team members will begin working on implementing them.
 NYS Justice Center
2023 Annual Report 9
AUTOMATED STRATEGY MEMOS
The Justice Center continually searches for opportunities to make the
investigatory process more efficient, recognizing the impact investigations have
on the workforce crisis. The agency started sending strategy memos with each
delegated investigation in 2022 to help improve the quality of these
investigations and reduce investigative cycle time. These memos help guide
State Agency/private provider investigators in how to structure their investigation
to make sure all required elements are submitted when an investigation is sent
back to the Justice Center for review. Feedback indicated the memos could be
hard to read because of the method used to distribute them so in 2023, the
agency changed the distribution method to a hyperlink, bringing the investigator
to a user-friendly page where all the tools, evidence requirements, and
components needed for completion are outlined. This tool is helpful to newer
provider investigators and seasoned staff alike.

TELEHEALTH VIDEO SERIES

Recognizing the expansion of telehealth
services and how they help individuals with
disabilities easily access healthcare, the Justice
Center produced a series of videos that help
people understand how to facilitate a telehealth
appointment. The series includes two videos for
individuals receiving services: an introduction to
the iPad for telehealth and an overview of
telehealth appointments. A third video for health
care providers features tips for making
telehealth accessible to everyone. The series
was completed in both English and Spanish and
was paid for using American Rescue Plan funds
distributed through the Administration for
VIEW FULL SERIES
Community Living.

EXPANSION OF DIVERSITY EQUITY & INCLUSION WORK

The Justice Center continued to expand its work to both create an inclusive
environment at the agency as well as employ a diverse workforce that is reflective
of the individuals served. Executive Director Miranda’s vision for diversity, equity,
and inclusion (DEI) expanded in several ways in 2023. The Justice Center
launched “lunch and learns,” opportunities for staff to learn from each other about
a variety of topics including Veterans’ Month, Pride Month, Eid al-Fitr, and
Passover. Additionally, the agency launched or enhanced the following in its DEI
initiatives: diversity calendars, diversity and inclusion newsletters, community
sessions, anonymous employee feedback box, participation and co-sponsorship of
interagency cultural and heritage celebration events, DEI trainings and workshops.
 NYS Justice Center
2023 Annual Report 10
WORKFORCE & STAEKHOLDER OUTREACH

The Justice Center makes protecting the rights of the dedicated workers who
provide direct care to vulnerable individuals a top priority. The agency also
recognizes its responsibility in supporting victims in an investigation. As such, the
Justice Center has developed several initiatives to support the workforce, victims,
providers, families, and other stakeholders.

INDIVIDUAL & FAMILY SUPPORT

The Justice Center provides guidance and support to victims of abuse or neglect,
their families, personal representatives, and guardians throughout the course of
an investigation. Nearly 21,500 individuals and family members have contacted
advocates for assistance since 2013. In 2023, 3,608 individuals and family
members were provided with advocacy and support.

Advocates provide information about the reporting and investigative process,

case status updates, and records access. In 2023, the Justice Center provided
assistance to individuals and families regarding records access 1,133 times.
Justice Center advocates may also accompany victims to interviews or court
proceedings. In 2023, advocates provided victim and witness accompaniment in
Justice Center-led investigations on 617 occasions. Justice Center advocates
can also help with questions or concerns involving State agencies. The Justice
Center attends conferences and informational events throughout the state,
offering materials and answering questions about the agency. Advocates
presented at or participated in 47 such events in 2023.

Virtual conference appearances have allowed more people to be able to

participate in Justice Center outreach events. Over the past year, the Justice
Center provided valuable information and education to external stakeholders on
the role of the advocate and engaging in self-care. The agency did this by
offering multiple virtual family engagement sessions with 320 people taking part.

In addition to these responsibilities, the Justice Center is part of the multi-agency

Trauma Champions Collaborative (TCC), led by the Division of Criminal Justice
Services (DCJS) to advance the integration of trauma-informed practices in state
agencies and in community-based organizations throughout the state.

Finally, the Justice Center has an Ombudsman responsible for advising and
responding to questions and concerns raised by more than 200 individuals
receiving services at two OPWDD Developmental Centers in New York State:
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2023 Annual Report 11

Sunmount DDSO and Valley Ridge. The Ombudsman helps address systemic trends
by supporting self-advocacy initiatives through participation in more than 1,000
committee and treatment team meetings on an annual basis. Through direct
collaboration with individuals receiving services, Mental Hygiene Legal Services,
the NYS Department of Health and OPWDD, the Ombudsman plays an integral role
in advocating for improved conditions overall.

CODE OF CONDUCT & CHAMPION AWARDS

The Justice Center understands the importance of recognizing individuals who
demonstrate a commitment to people with special needs. The agency has created
two awards: the Justice Center Champion Award and the Justice Center Code of
Conduct Award. This year was the seventh consecutive annual award presentation.
The agency handed out 10 awards this year, a nod to the 10-year anniversary of the
Justice Center.

The Champion Award honors New Yorkers who have displayed exemplary dedication
to people with special needs. The honorees in 2023 included two individuals, Meg
Adams from OPWDD and Rebecca Cooper from OASAS, who have tirelessly
supported Justice Center investigations as well as two organizations, the Southern
Adirondack Independent Living Center and the New York State ID/DD Nurses
Association.

The Justice Center also spotlights staff at provider agencies who display a strong
commitment to the Code of Conduct and serve as an inspiration to their colleagues.
We understand the impact staffing shortages are having across the direct care
workforce, which makes these awards even more meaningful. Winners included one
staff member who had worked in the field for 20 years and another who had done so
for 40 years! In total, six individuals were presented with the Justice Centers Code of
Conduct award. Each exemplifies the highest standard of direct care and shows the
State how one person can make a difference in someone else’s life.

VIEW THE CEREMONY

STAKEHOLDER BRIEFINGS
The Justice Center spends considerable time engaging with provider agencies, the
direct care workforce, family members, local government, and other interested
stakeholders. The agency understands that partnerships formed with these
stakeholders are crucial to the success of the Justice Center. In 2023, the agency
conducted nearly 100 presentations, the majority of which were to provider
agencies under the Justice Center’s jurisdiction as well as their staff. The Justice
Center also conducted outreach presentations to local government agencies,
attorneys, and people receiving services and their families.
 NYS Justice Center
2023 Annual Report 12
TRAID
The Technology-Related Assistance for Individuals with Disabilities (TRAID) Program
provides access to assistive technology to any New Yorker with a disability through
Regional TRAID Centers. These centers provide device loans and hands-on training to
people with disabilities. The Justice Center administers TRAID through grants from the
US Department of Health and Human Services Administration for Community Living
(ACL), the NYS Department of Health, and ACCES-VR to 12 Regional TRAID Centers. A
variety of devices are loaned out for use in different settings such as at home, school,
or work.

The 12 regional TRAID Centers demonstrated devices to approximately 1,900 people

in the 2022-2023 data year. Demonstrations are conducted when staff show
individuals two or more similar devices so they can ask questions, compare
specifications, and make an informed choice on what might work best for them.
Individuals can then choose to borrow the devices to try them in real world settings.

The TRAID Centers provided 8,200 short-term assistive technology device loans to
5,730 individuals. A short-term loan is typically for 60 days or less. These give
individuals the opportunity to try out a device before purchasing it and provides
access to devices that may only be needed for a short period of time.

If an individual needs a device for longer than 60 days, then TRAID staff can provide a
long-term loan. TRAID receives donated devices from members of the community,
after which they clean the devices and give them to individuals who need them
long-term. The TRAID Centers loaned 3,428 devices to 2,150 individuals. Because
individuals are sometimes able to receive donated devices rather than spending
money on a new one, cost-savings is calculated. The cost-savings in 2022-2023 was
nearly $785,000.

TRAID Program Impact LEARN ABOUT TRAID

Stories from the Field
A therapist from a local school district A school nurse reached out to their local TRAID
reached out to Upstate Caring center about a new student that had recently started
Partners (Utica) TRAID Center. She classes. They were looking for a device to help the
was working with a new student who student stand while at school. The TRAID Center had
was non-verbal, and she wanted to a supine stander available and loaned it to the
see if any text to speech apps might school. The nurse sent the following feedback;
work for them. The TRAID staff "Borrowing the supine stander from [TRAID] has
showed the therapist a few options, been an amazing experience. [The student] can
and the student made good progress participate in activities that allow him to stand with
using an iPad and Proloquo2go app his classmates and not feel so isolated. Thank you
for communication. for helping [him] fit in with the rest of the students."
 NYS Justice Center
2023 Annual Report 13
TRAINING & SAFETY IMPROVEMENTS

The Justice Center believes that outreach, training, and the promotion of best
practices are critical to affect systemic changes. That is why the agency has made
a substantial investment in training of both internal staff and external stakeholders.
The Justice Center offers a variety of training and support materials to ensure the
health, safety, and dignity of people with special needs. Trainings include Forensic
Interviewing Best Practices for Vulnerable Populations, Code of Conduct and
Maintaining Professional Boundaries.

STATE AGENCY COLLABORATIVE TRAININGS

The Justice Center is mandated to provide investigation training to state and
provider agency staff. In 2023, we provided five Investigation Basics trainings,
which were attended by 430 provider and state agency investigators. The agency
has also continued its online training series covering investigative topics such
effective medical interviews, investigating lapses in professional boundaries, and
on the development of corrective action plans. The series was presented to more
than 200 state and provider agency staff. In addition, the Justice Center provides a
professional boundaries training, which is now approved for CASAC credits and
Continuing Education Credits for licensed social workers and psychiatrists. This
training was offered seven times to 150 staff from OASAS and OMH-licensed and
certified programs throughout the year.

JUSTICE CENTER IN-SERVICE TRAININGS

As part of the Justice Center’s commitment to continuous improvement, the
agency offers an annual in-service training for all staff members. This year was the
first in-person session since 2019. The theme was “Planning for What’s Ahead” and
included the following topics:

• Post Pandemic: A Workforce Panel Discussion

• What are the Justice Center Implications for the Challenges Faced by Providers
• Interviewing Individuals with Autism
• Trends in Administrative Appeals Decisions
• OPWDD’s Use of Lytx DriveCam System for Passenger Safety

In total, more than 320 Justice Center staff attended the training.
 NYS Justice Center
2023 Annual Report 14
ABUSE PREVENTION & QUALITY IMPROVEMENT

A core element of the Justice Center’s mission is to develop tools to help prevent
mistreatment of individuals with special needs. There are several ways the agency
works toward the prevention of abuse and neglect. Examples include
pre-employment checks to ensure the safety of both individuals receiving services
and the workforce, data analysis of trends, issuance of guidance on how to stop
practices that might endanger vulnerable populations, and quality improvement
reviews. The Justice Center’s actions encourage provider agencies, stakeholders,
and staff members to take a proactive approach to establishing safe, supportive,
and abuse-free environments.

PREVENTION
Criminal Background Checks
The Justice Center reviews and evaluates the criminal history of all prospective
employees or volunteers applying for jobs at provider agencies under its
jurisdiction and advises about the individual’s suitability for employment. This
comprehensive review provides a safety net for individuals receiving services
while at the same time mitigates risk for employers and the dedicated workforce.

FINGERPRINTS PROCESSED

OPWDD 73,856

OMH 22,507

OCFS 10,483

TOTAL: 106,846

APPLICANTS REVIEWED: 12,753

APPLICANTS FLAGGED FOR MORE
885
INFORMATION:
DENIED APPROVAL FOR EMPLOYMENT

OPWDD 161

OMH 106

OCFS 49

TOTAL: 316
EXAMPLE DENIALS

At times, The Justice Center’s Criminal Background Check determines an

individual’s criminal history makes them unsuitable to work with vulnerable
populations. In 2023, there were 316 times this occurred.

Applicants Denied Clearance for Employment

An applicant was being considered for direct care employment as a Case
Manager. The applicant’s criminal history included numerous convictions
for rape, sodomy, sexual abuse, robbery, and criminal use of a firearm.
The criminal background check further revealed that the applicant was
convicted of the violent rape of 13 teenagers between the ages of 14 and
19 years of age. The criminal background check revealed that the
applicant utilized a firearm during the offenses. The Justice Center
denied employment consideration for this individual.

Another applicant was being considered for direct care employment as a

supervisor in a program for individuals with developmental disabilities.
Their criminal history included convictions for sexual abuse, forcible
touching, and endangering the welfare of a child. The criminal
background check revealed that the applicant exploited a position of
trust and supervision to sexually abuse two teenaged victims. The
Justice Center denied clearance for employment consideration.

An applicant was being considered for direct care employment involving

transportation. The criminal history included sexual abuse of a minor
where the applicant physically overpowered and sexually assaulted a
10-year-old victim after being a guest at a birthday party at the victim’s
home. The applicant was an off-duty New York City emergency services
employee at the time of the crime. The Justice Center denied clearance
for employment consideration.
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2023 Annual Report 16
STAFF EXCLUSION LIST (SEL)
Protecting the Ser vice System
Another tool used to prevent those who have a history of abusing vulnerable
populations from continuing to work with and have access to individuals receiving
services is the Justice Center’s Staff Exclusion List (SEL). All subjects substantiated
for Category One conduct, which includes serious or repeated acts of abuse or
neglect are placed on the SEL. Placement on the SEL bars an individual from
working in all settings under the Justice Center’s jurisdiction forever.

Cases Substantiated for LEARN ABOUT THE SEL

Categor y 1 conduct:
1 2

A young adult was placed in handcuffs at an An individual receiving services at an

OCFS facility after a restraint. As the staff OPWDD facility was taken to a staff
member was removing the handcuffs, another member’s house after being told they could
physical altercation began. The staff member play video games there. Instead, the staff
punched the victim several times which member engaged in inappropriate touching
resulted in them falling to the floor. The staff and performed oral sex on the victim. This
member then hit and kicked the victim. happened on four separate occasions. The
Finally, the victim was put back in handcuffs staff member was substantiated for
and then hit in the face while restrained. The Category One Sexual Abuse and put on the
staff member was substantiated for Category SEL. In addition, criminal charges were
One Physical Abuse and put on the SEL. filed.

Preventing Abusers from Working with Vulnerable Populations

Provider agencies under the Justice Center’s jurisdiction, as well as other providers
identified in statute, are required to check the SEL before hiring someone who will
have regular and substantial contact with an individual with special needs. In 2023,
the SEL was checked roughly 30,000 times per month.

Since 2014, there have been 320 instances where an SEL check has resulted in a
match and a provider has been notified that the applicant was on, or pending
placement on, the Staff Exclusion List.

This means individuals who have been substantiated for serious acts of abuse and
neglect were stopped from being hired into settings where they would have regular
and substantial contact with vulnerable people again.

The total number of individuals on the SEL at the end of 2023 was 931, an increase
of 61 from 2022.
 NYS Justice Center
2023 Annual Report 17
QUALITY IMPROVEMENT
The Justice Center has the authority and responsibility to make recommendations
on improving the quality of care at provider agencies under its jurisdiction. This is
done through reviews and audits of corrective action plans and can include visits to
and inspections of provider agencies. Additionally, the Justice Center can engage
in a systemic review of programs under its jurisdiction. This important audit function
allows the Justice Center to make recommendations to provider agencies and the
state agencies that license or certify them so that they can improve quality of care
and protect the people they serve from harm.

Corrective Action Plan Audits

As part of the Justice Center’s oversight and monitoring function, the agency
reviews and conducts audits of corrective actions that stem from abuse and neglect
cases to ensure facilities and provider agencies are taking the necessary steps to
prevent incidents of abuse and neglect in the future. Corrective action plan (CAP)
audits are most often completed after a finding that abuse or neglect was caused by
a systemic issue. In 2023, the Justice Center conducted 446 audits of facility and
agency CAPs which included assessing 2,603 corrective actions, identifying 1,034
additional findings, and providing 660 resources. Examples of the audits and results
are below.

Examples

Nutrition Concerns

A person receiving services lost a significant amount of weight, which had gone
unnoticed by staff. The investigation found concerns with training, supervision, and
communication at the program. The CAP audit included an on-site visit which
revealed serious concerns regarding the provider’s ability to safely care for the
people receiving services, many of whom had unique needs for the program type,
including enhanced mealtime supports, modified food diets, and repositioning
requirements.

The findings from the audit were discussed with the agency which developed a plan
to address the deficiencies. This plan included using a dietician to provide training
to staff on mealtime supports. The dietician provided educational materials related
to preventing choking on each unit, worked with the food vendor to ensure food
was prepared to the right consistency, and purchased additional blenders to make
mealtimes more efficient.

Supervision and Assignments

A person receiving services choked on food and the investigation revealed issues
with supervision. Specifically, staff who were assigned to provide line of sight
supervision were also assigned tasks such as serving meals and cleaning the
 NYS Justice Center
2023 Annual Report 18

kitchen. Additionally, there were issues with the completion of body checks and the
corresponding forms.

The findings from the audit were shared with OPWDD, who sent a team on-site, at
which time numerous issues were identified and a statement of deficiency was
issued. Additionally, the program indicated a plan to correct the insufficient findings
from the audit, including providing guidance to staff on the completion of body
checks and staff training regarding providing enhanced supervision and not being
assigned additional tasks.

Professional Boundaries

A staff member was alleged to be having inappropriate communication with a

person receiving services. The investigation revealed the agency did not have a
policy on professional boundaries. The CAP audit included insufficient findings for
failing to train staff on the new professional boundaries policy as well as failing to
implement a system to monitor compliance with required training.

Upon receipt of the CAP audit findings letter, OASAS requested the agency develop
a plan for addressing the insufficient findings. In response, the agency shared their
plan, which entailed including the professional boundaries policy as part of the new
hire process, the development of a new mechanism to monitor staff training, and
training staff who had not previously been trained, on the new professional
boundaries policy.

Systemic Review

The Justice Center completed a project involving providers who have had incidents
of people receiving services choking on food in OPWDD residential and day
programs. This project used a “follow the person” model and included site visits
during mealtimes to ensure food was prepared to the proper consistency and other
mealtime supports were being provided. Site visits included nine providers and 17
locations and individual findings letters were shared with each agency. At the end
of the project, a comprehensive findings letter was sent to the OPWDD
Commissioner.

In response, OPWDD developed a plan to provide the field with updated guidance
and annual training on choking prevention, update contact information for ordering
OPWDD cutting boards/visual guides to use in meal preparation, and links to
resources addressing dining safety on the choking prevention webpage.
 NYS Justice Center
2023 Annual Report 19

HALT Monitoring
2023 was the first full year of the Humane Alternatives to Long-Term Solitary
Confinement (HALT) Act, of which the Justice Center monitors and makes
recommendations regarding the quality of care provided to inmates with serious
mental illness. This involves monitoring the quality of mental health care provided
by the Office of Mental Health (OMH) to people who are incarcerated in state
prisons.

The Justice Center reviewed the quality of mental health care at 21 facilities in
2023. In total, the Justice Center completed 1,854 cell-side and 118 private
interviews with incarcerated individuals and referred 150 of those individuals to be
evaluated by OMH. The agency also reviewed the quality of mental health care for
290 incarcerated individuals. In addition, the agency reviewed the records of over
352 incarcerated individuals placed in solitary confinement and Residential
Rehabilitation Units in accordance with the law. There were 16 reviews completed in
2023.

The Justice Center also publishes a separate HALT Annual Report with in-depth
information regarding the agency’s findings.

VIEW HALT MONITORING

VIEW HALT ANNUAL REPORT

 NYS Justice Center
2023 Annual Report 20
DIVERSITY EQUITY & INCLUSION

The Justice Center’s work of supporting and protecting individuals with special
needs is inseparable from our commitment to diversity, equity, and inclusion. It is
central to the agency’s mission that each member of our diverse community feels
valued and represented no matter their identities, cultures, experiences,
backgrounds, and characteristics. This is recognized as crucial to the
organization's continued success, and most importantly, what staff members,
volunteers and the community deserves.

In 2023, the Justice Center expanded the scope of this initiative and developed a
five-year DEI plan to chart a path forward for cultivating culture change throughout
the agency and beyond. The plan outlines specific critical success factors that
include informed and committed leadership, clearly articulated roles and
responsibilities, continuous policy review and development among others. Each
factor has an associated goal, strategy, and action step.

To coincide with the release of the five-year DEI plan, the agency launched its first
DEI climate survey. The purpose of the survey was to understand the Justice
Center’s current climate and inform future decisions in supporting a diverse,
equitable, and inclusive workspace. Survey results are being used to create
meaningful programming and outreach for our workforce with respect to social
justice issues.

The Justice Center also continued the critical work of its Anti-Racism Workgroup.
This group supports the agency’s commitment to DEI by identifying and
recommending anti-racism and DEI best practices. It also supports the
dissemination and implementation of new DEI practices across business units
while creating opportunity for members to address DEI-based concerns.

The agency is also committed to offering the public language access services and
has dedicated a portion of the annual budget for the interpretation and translation
of key documents.

DEI WEBPAGE
 NYS Justice Center
2023 Annual Report 21
INCIDENT MANAGEMENT

CASE MANAGEMENT PROCESS

PROSECUTIONS
Criminal cases are
JUSTICE CENTER managed by JC
INVESTIGATION prosecutions in
coordination with DA

INCIDENT
MANAGEMENT Most State-op cases CASE CLOSURE APPEAL
and more serious
non-State-op cases
are investigated by
the JC

Review & close JC

A report is made led and SOA led Subjects of
to the Justice STATE AGENCY substantiated cases substantiated
Center’s hotline INVESTIGATION and special cases have 30
and classified circumstance cases days to appeal if
(e.g. sexual abuse) desired

Less serious allegations INDIVIDUAL & FAMILY SUPPORT

are delegated to SOA -
All delegated cases The Justice Center staffs a unique group of
come back tot he JC for specialized employees dedicated solely to individual
triage and case closure and family support. This team supports these groups
throughout the investigation process.

Intake
Anyone, including a parent or guardian, advocate, or individual receiving services
can make a report to the VPCR when they have knowledge or have reason to believe
that a person receiving services has been abused, neglected or mistreated. Some
people are required by law to report to the VPCR. These “mandated reporters”
include provider agency staff and human services professionals who, by nature of
their job, must report allegations of abuse or neglect.

Call center representatives are available 24 hours a day, seven days a week, 365
days a year. The number to contact the toll-free hotline to make a report is
855-373-2122. A web-based reporting form and a mobile application are also
available for use.
 NYS Justice Center
2023 Annual Report 22

The call center representative will first assess whether an emergency responder is
necessary and/or if the person receiving services is in danger or needs immediate
assistance. If that is the case, the caller is instructed to hang up and call 9-1-1. The
reporter should then call back once the emergency is over to file the report. If no
emergency exists, the call center representative will collect information from the
reporter and assign an incident number.

Classification
Once the allegation is assigned an incident number, it is then classified into one of
the following categories: abuse/neglect, death, significant incident or non-NYJC.

Once the allegation is assigned an incident number, it is then classified into one of
the following categories: abuse/neglect, death, significant incident or non-NYJC.

Abuse
• Physical: intentional contact (hitting, kicking, shoving, etc.), corporal punishment,
injury which cannot be explained and is suspicious due to extent or location, the
number of injuries at one time or the frequency over time
• Psychological: taunting, name calling, using threatening words or gestures
• Sexual: includes inappropriate touching, sexual assault, and sexual contact with a
person incapable of consent
• Deliberate misuse of restraint: use of these interventions with excessive force, as a
punishment or for the convenience of staff
• Controlled substances: using, administering, or providing any controlled
substance contrary to the law
• Aversive conditioning: unpleasant physical stimulus used to modify behavior
without person-specific legal authorization.

Neglect
• Any breach of a direct care employee’s duty which includes action, inaction, or
lack of attention on the part of the employee that results in or is likely to result in
physical injury or serious impairment to the person’s physical, mental, or
emotional condition.

Death
• The Protection of People with Special Needs Act requires certain deaths be
reported to the Justice Center. These include the death of an individual receiving
services from a residential facility or program that is licensed, certified, or
operated by OPWDD, OCFS, OMH and OASAS.

Significant Incident
• Incident other than an incident of abuse or neglect that, because of its severity or
the sensitivity of the situation, may result in or has the reasonably foreseeable
potential to result in harm to the health, safety or welfare of a person receiving
services. Examples include conduct between persons receiving services and
conduct of an employee that is inconsistent with an individual’s treatment plan.
 NYS Justice Center
2023 Annual Report 23
Non-NYJC Incident
• The nature of the incident is not reportable to the Justice Center because the
incident is not a reportable incident or because it did not occur at a provider over
which the Justice Center has jurisdiction. These can vary widely and may include
concerns about a provider, or complaints about food. Cases that require follow-up
are referred to the appropriate State Agency.

Not an Incident
• Calls that do not allege any type of incident but instead may be general inquiries
or incorrectly routed calls. The Justice Center will refer to a relevant agency or
entity if available.

REPORTS MADE TO THE JUSTICE CENTER

Classification Total Number Percentage

Abuse & Neglect 13,050 15.3%

Death 1,650 2%

Significant Incident 27,866 32.7%

Non-NYJC Incident 31,473 36.9%

Not an Incident 11,173 13.1%

THE REPORTING PROCESS

Three-Business Day Review of Incidents

The JThe Justice Center has implemented a review process for allegations where
appropriate classification of an incident may initially be difficult to accurately
determine. The three-business day assessment allows the agency to conduct a
preliminary review of allegations lacking specificity by obtaining additional
information from the facility or provider agency. This involves the collection of a
minimum amount of documentation to accurately classify and assign a case. This
additional short step allows classification to be better informed and therefore a
more accurate incident classification and a better use of investigative resources.

The three-business day review is available to all OPWDD, OMH, OCFS, OASAS, and
SED providers.
 NYS Justice Center
2023 Annual Report 24
THREE-BUSINESS DAY REVIEW OF INCIDENTS IN 2023

878 878

584

448

272 257
244 243
160
133 149
101
62 55 75
37 33 36
0 0

Criminal vs. Administrative Cases

Once a case is classified as abuse or neglect, that case is next characterized as

either criminal or administrative.

Criminal Cases
The Justice Center’s Special Prosecutor works with county district attorneys to
bring criminal charges in cases that allege that a crime has occurred against an
individual receiving services by an employee of a facility or provider agency. The
Justice Center notifies district attorneys of all allegations of abuse and neglect.
Cases involving potential criminal charges can be investigated by the Justice
Center, the local police, or both.

In 2023, 91 arrests were made in connection to Justice Center cases.

While a criminal case is being investigated and prosecuted, the same case is also
investigated through the Justice Center administrative investigation process.

Administrative Cases
The first step in the administrative investigation of allegations of abuse and/or
neglect is appropriate classification and assignment for investigation. The Justice
Center investigates allegations in state-operated programs as well as the most
 NYS Justice Center
2023 Annual Report 25
serious allegations in non-state operated settings. Less serious allegations of abuse
and neglect in non-state operated settings are delegated to the State Agency for
investigation, which in turn may delegate to the provider. The Justice Center
reviews all investigations regardless of which delegate investigative agency
conducts them and makes all final determinations regarding whether a case will be
substantiated or unsubstantiated. Significant incidents are referred to the
appropriate State Agency for investigation.

The investigation process proceeds with examination of the evidence and

interviews of witnesses, victims and subjects. Witnesses and subjects of Justice
Center investigations can have legal counsel or a union representative present
when being interviewed, unless an applicable union contract, or Collective
Bargaining Agreement, provides differently. Individuals receiving services who are
the victim of or witness to abuse and neglect may have a personal representative or
an advocate from the Justice Center’s Individual and Family Services Unit
accompany them during an interview.

Determination
Administrative cases conclude by either being substantiated or unsubstantiated.
The Justice Center makes the final determination regardless of which agency
completed the investigation. The standard of proof for a Justice Center
administrative case is a preponderance of the evidence. This means a review of the
evidence shows the allegation of abuse or neglect was more likely than not to have
occurred.

PERCENTAGE OF INVESTIGATION OUTCOME FOR ABUSE & NEGLECT CASES IN 2023

STATE OPERATED NON-STATE OPERATED

No JC Jurisdiction
0% (1) (30)

(2,556)

(1,015)

(1,372)

(4,642)
 NYS Justice Center
2023 Annual Report 26
Determination Categories

Unsubstantiated
The case is sealed (not made public and cannot be accessed by future employers)
and a letter of determination is sent to the subject, victim and provider agency
letting them know the finding.

Substantiated
The case is classified into one of four categories depending on the severity:

• Category 1: Serious physical abuse, sexual abuse, or other severe conduct.

Category 1 substantiations place subjects on the Staff Exclusion List (SEL).
Subjects on the SEL are banned from working in any setting under the jurisdiction
of the Justice Center and remain on the list forever.

• Category 2: Conduct that seriously endangers the health, safety, or welfare of a

service recipient by committing an act of abuse or neglect. Two Category 2
substantiations within three years will result in placement on the SEL. Category 2
offenses are sealed after five years.

• Category 3: Less serious incidents of abuse or neglect. Reports are sealed after
five years.

• Category 4: Incidents of abuse or neglect that are mitigated by systemic

conditions at a program or facility that increased the likelihood of such abuse or
neglect, such as inadequate training, staffing, or supervision. Category 4 also
includes instances in which an individual receiving services has suffered abuse or
neglect, but a perpetrator cannot be identified.

FAST FACT
Most (75%) of substantiated abuse and neglect
findings are classified as Category 3 conduct.

The Justice Center makes several parties aware of the findings of an investigation.
The victim or their personal representative will be issued a “letter of determination”
(LOD), making them aware of the outcome of the allegations. A LOD is also issued
to the director of the facility or program, the SOA that licenses or certifies the facility
or program, and the subject of the investigation.
 NYS Justice Center
2023 Annual Report 27

CLOSED ABUSE & NEGLECT CASES 2023

Total Closed 3,571

State Operated Total 1,015 28.4%

Non-State Operated 2,556 71.6%

CLOSED ABUSE & NEGLECT CASES 2023 - BY CATEGORY

STATE OPERATED
NON-STATE OPERATED

Category 1
Category 1
0.7%
2%

CLOSED ABUSE & NEGLECT CASES 2023 - BY ALLEGATION TYPE

STATE OPERATED NON-STATE OPERATED

The 1,015 total closed state operated cases in 2023 can be broken down by the The 2,556 total closed non-state operated cases in 2023 can be broken down by the
following allegation types. Note, one case can have multiple allegation types following allegation types. Note, one case can have multiple allegation types
depending on findings. depending on findings.

Deliberate Deliberate
6.4% 8.8%
Inappropriate Restraint Inappropriate Restraint
Neglect 92.9% Neglect 87.0%

Obstruction 1.8% Obstruction 4.5%

Other 0.2% Other 1.1%

Physical Abuse 9.5% Physical Abuse 17.6%

Pyschological Abuse 1.2% Pyschological Abuse 2.0%

Sexual Abuse 0.3% Sexual Abuse 1.5%
 NYS Justice Center
2023 Annual Report 28

Appeals
An appeals process (called a “request for amendment”) is available to subjects of
substantiated reports to ensure due process. Subjects have 30 days to challenge
Justice Center findings. Upon receipt of an appeal request, the Justice Center
reviews the investigative file, the substantiated report, the request for amendment
and any additional information provided by the subject. A determination is then
made as to whether there is a preponderance of evidence to support the
substantiation as well as proper category assignment.

If the substantiated finding is upheld, subjects can proceed to a hearing before an

Administrative Law Judge. The judge considers all the evidence presented by both
the Justice Center and the subject or their legal representative and makes a
recommended decision that is reviewed by the Justice Center’s Executive Director.
One of three outcomes is then possible:

• The Executive Director finds the Justice Center met its burden to prove the
allegation and the correct category level was assigned. The substantiated finding
remains against the subject.
• The Executive Director finds the Justice Center met its burden to prove the
allegation, but a lesser category level was inappropriate. The substantiated
finding remains with a new category level.
• The Executive Director finds the Justice Center did not meet its burden to prove
the allegation. The report is unsubstantiated, and the record is sealed.

In 2023, the Justice Center received 763 requests for amendment, made 854 de
novo determinations, and held 58 hearings.

Discipline
Disciplinary or other employment actions resulting from a substantiated finding are
at the discretion of the employing provider agency (State Agency or private
provider) in accordance with established rules and collective bargaining
agreements, the exception being Category 1 findings which result in placement on
the Staff Exclusion List (SEL). This means in most of the cases, the Justice Center is
not involved in any decisions regarding the discipline of a subject. The notable
exception occurs with state employees, where Justice Center attorneys work
collaboratively with the State Agencies to achieve appropriate disciplinary
outcomes.

Justice Center attorneys represent the State at disciplinary proceedings brought

against State employees, protected under Collective Bargaining Agreements, in all
cases of substantiated abuse or neglect. In 2023, 166 State employees were
separated from service for various reasons including probationary status,
resignations, or upheld disciplinary charges. In addition, the Justice Center
 NYS Justice Center
2023 Annual Report 29

reviewed and approved 619 Notices of Discipline seeking to impose written

reprimand, suspension without pay, fine, loss of accrued leave credits, reduction in
grade, or dismissal from service. Further, the Justice Center participated in 458
expedited reviews and 23 full arbitration hearings.

STATE OPERATED EMPLOYEE DISCIPLINE

Termination Total 166

Loss of Leave Credits or Other Privleges 162

Suspension 98

No Penalty 294

Counsel or Train 235

Letter of Reprimand 157

Resigned 91

Fine 58

Probation Terminated 51

Upheld at Arbitration 6

Exclusion or Other 10

Retired 15

Other Penalty 1

Administrative Action Reporting Mechanism

State Agencies require provider agencies under the jurisdiction of the Justice
Center to submit information about what administrative actions have been taken
with respect to subjects of substantiated allegations of abuse or neglect in
non-state operated settings. The information is submitted to the Justice Center
through a web application. The requirement allows State Agencies to ensure
providers that they license or certify are responding to substantiated allegations of
abuse or neglect with appropriate corrective action. The chart below indicates the
type of disciplinary action taken by private providers, and the number of times that
action was taken in 2023.
 NYS Justice Center
2023 Annual Report 30

NON-STATE OPERATED EMPLOYEE DISCIPLINE

Termination Total 897

Counseling (Formal-Written) 701

Re-Training 645

Resignation/Retirement 204

Counseling (Informal / Verbal) 181

Training 168

Suspension (1-14 Days) 125

Suspension (30 or More Days) 115

Staff Ressignment / Relocation 107

Letter of Reprimand 106

Additional Staff Supervision 56

No Action 47

Suspension (15-30 Days) 37

Placed on Probation 31

Demotion 14

Employee Assistance Referral 10

Fine (Monetary Accruals) 2

 NYS Justice Center
2023 Annual Report 31
MORTALITY REVIEWS

The ProtThe Protection of People with Special Needs Act requires the deaths of all
individuals receiving services from a residential facility or program licensed,
certified, or operated by OPWDD, OMH, OASAS or OCFS to be reported to the
Justice Center. In addition, the death of any individual who received services from
the above facilities in the 30 days prior to their death must also be reported. Any
time a death is reported to the Justice Center where there is an allegation of abuse
or neglect, a separate notification is sent to both the district attorney and the
medical examiner.

PROCESS OF AN ASSESSMENT OR INVESTIGATION

The requirement to report a death is not exclusive to those that may have been
caused by abuse or neglect. Instead, the death of every service recipient in these
residential settings, regardless of the circumstances, must be reported to the
Justice Center. For this reason, the agency has broken the investigations into two
separate categories.

Executive Law § 556 Reviews

Most of the death reports received by the Justice Center fall under Executive Law
§ 556. This section of law requires administrators of residential programs licensed,
operated or certified by OPWDD, OMH, OASAS, and OCFS to report all deaths of
residents to the Justice Center, regardless of whether the death is unusual or
expected. The purpose of this reporting is twofold: to monitor and examine
whether quality of care issues may have contributed to an individual’s death and
to make recommendations to improve future care of individuals receiving services
and prevent the recurrence of similar issues.

All deaths reported under Executive Law § 556 are reviewed by investigators with
program experience as well as health care professionals, including registered
nurses. Through these reviews, the Justice Center can make recommendations to
providers on how to improve quality of care. Letters are sent to both providers and
the appropriate state agency for monitoring of recommended corrective actions.

EXECUTIVE LAW § 556 REVIEWS

Total Reviews 1,609

State Operated 365

Non-State Operated 1,244

 NYS Justice Center
2023 Annual Report 32

MORTALITY INVESTIGATIONS
Mandated reporters under Justice Center jurisdiction are required to report any
death for which they have reasonable cause to suspect abuse, neglect, or a
significant incident may have been involved. Any death report potentially involving
abuse or neglect follows the same investigative process as other abuse or neglect
reports: classification and assignment of unique case number, investigation, and
determination. Medical examiners and district attorneys are notified of a death
through electronic means as well as by telephone.

The Justice Center has developed a specific protocol that it follows for reviewing
abuse or neglect cases where a death is involved. Initial review involves input from
a supervising investigator, a criminal investigator, a lead Justice Center investigator,
the regional nurse, the Assistant Special Prosecutor for the region and a
representative from the Office of General Counsel. This comprehensive approach
allows team members with varied backgrounds to advise on the approach for the
investigation. The team is presented with information including medical and clinical
history of the individual receiving services, a synopsis of the circumstances
surrounding the death, involvement by local law enforcement, medical examiner or
district attorney and history of any concerns regarding the program or facility.

Cases of abuse or neglect involving the death of a service recipient do not

necessarily mean the abuse or neglect caused the death. The Justice Center
evaluates causational versus corresponding links when assigning category levels of
substantiated cases.

Cases of abuse or neglect with death involved are also reviewed by the Justice
Center’s Special Prosecutor in addition to the notifications sent to the local district
attorney.

MEDICAL REVIEW BOARD

The Justice Center Medical Review Board (MRB) advises on cases as needed or
requested. The Board consists of up to 15 physicians with expertise in forensic
pathology, psychiatry, internal medicine, and addiction medicine. In 2023, 16 cases
were referred to the MRB.

The MRB is called upon for all full death reviews to give an opinion on whether the
standard of care was met for the deceased. The designated primary reviewer of the
MRB for each case is given all information pertinent to the case (documents,
summary reports, interviews/interrogations). The case is presented at the next
regularly scheduled MRB meeting. The primary reviewer provides their expert
opinion and other members of the MRB can weigh in on the discussion.
 NYS Justice Center
2023 Annual Report 33
The MRB can also consult or perform a full review for all abuse and neglect cases
with death involved as needed upon request of an investigator. A consult routinely
relates to a specific question while a full MRB review happens after the completion
of the investigation and the investigatory question of whether abuse or neglect
occurred remains. The MRB also reviews trend reports on completed mortality
assessments at least annually.
 NYS Justice Center
2023 Annual Report 34
CONCLUSION

It is unequivocal that people with special needs are safer today than before the
inception of the Justice Center. Under the guidance of Governor Hochul and in
partnership with State and private provider agencies, individuals with disabilities,
family members, and advocates, the Justice Center will build upon the
accomplishments detailed in this report in the year ahead. The agency continues
to explore and develop new approaches to strengthen the Justice Center’s ability
to safeguard New York’s most vulnerable citizens.
justicecenter.ny.gov | 1 (800) 624-4143