NYS Justice Center Annual Report 2025

2025 ANNUAL REPORT

New York State Justice Center for the Protection of People with Special Needs Annual Report to the Governor and Legislature www.justicecenter.ny.gov • 1 (800) 624-4143

CONTENTS

VISION, MISSION, GUIDING PRINCIPLES............ 4 INTRODUCTION...................................................... 6 HISTORY AND JURISDICTION................................ 7 2025 HIGHLIGHTS ............................................... 9 2025 PROGRAM UPDATES.................................. 14 Workforce and Stakeholder Outreach......................................15 Training and Safety Improvements..........................................20 Abuse Prevention and Quality Improvement..........................22 Diversity, Equity, Inclusion, and Accessibility.......................26 Incident Management...................................................................27 Mortality Reviews..........................................................................36 CONCLUSION........................................................ 39

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VISION, MISSION, GUIDING PRINCIPLES

LETTER FROM ACTING EXECUTIVE DIRECTOR

VISION, MISSION, GUIDING PRINCIPLES PROTECT. PREVENT. ADVOCATE.

LETTER FROM ACTING EXECUTIVE DIRECTOR Dear colleagues, advocates, and members of the legislature: THE JUSTICE CENTER’S PROMISE

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.

During the last year, my priority as Acting Executive Director of the NYS Justice Center was to listen, learn, and identify new ways to advance the agency’s mission.

Working directly with fellow State agencies, Advisory Council members, providers, people receiving services, their families, and, of course, my own staff, our goals for 2025 became clear: ¡ Prioritize process improvement and data sharing;

¡ Increase engagement and collaboration; and ¡ Heighten our focus on prevention and quality.

Thanks to the efforts of our staff, the Justice Center found powerful ways to adjust our work. Simple changes like implementing updates to our online reporting form and piloting new options for video interviewing helped us dramatically reduce administrative burdens. With quality and efficiency in mind, we also advanced larger initiatives like modifying our office structure and launching a new Quality Management Dashboard. These changes led to big results – helping us close 1,600 more cases in 2025. This is especially meaningful as each case closed represents not only resolution for people in care and their families, but also support for the provider communities who rely on our efficiencies to maintain a quality care workforce. To support the direct care workforce, we also launched new training programs in 2025. We expanded our law enforcement and first responder training offerings to include district attorneys’ offices and created a new trauma-informed investigations training. And, finally, to expand our broader abuse-prevention efforts, we launched a workgroup that leverages internal and external expertise to prevent abuse and neglect before they happen. I would like to thank the dedicated Justice Center team for moving this agency forward; the many agency, provider, advocate, and family groups that inform our direction; and Governor Hochul for her continued investment in our nation-leading protections. I am pleased to share the following summary of our work from 2025.

OUR VALUES AND 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 is paramount.

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

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.

Collaboration

Sincerely,

Maria Lisi-Murray, Esq. Acting Executive Director

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INTRODUCTION

HISTORY AND JURISDICTION

HISTORY AND 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:

INTRODUCTION The Justice Center for the Protection of People with Special Needs works in partnership with people receiving services, their families, direct care staff members, and provider organizations to protect the health, safety, and dignity of people receiving care from certain programs.

OVERSIGHT: State Agencies

Office for People with Developmental Disabilities (OPWDD)

112 added to SEL (1,137 total)

90,865 reports made to the Justice Center

Office of Mental Health (OMH)

2025 BY THE NUMBERS

Office of Addiction Services and Supports (OASAS)

300 Corrective Action Plan audits conducted

40% cases substantiated

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

Provided support to 4,000+ people and families

11,500 cases closed

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 and law enforcement to prosecute allegations that are criminal in nature. The agency also provides guidance, information, and support to victims and their families throughout the investigation process. Through its oversight and monitoring activities, the Justice Center identifies 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.

1 MILLION New Yorkers The Justice Center has jurisdiction over more than

This is done in a variety of ways, including: developing abuse prevention tools, providing education to stakeholders on agency operations, and ensuring high-quality investigations of all allegations of abuse and neglect under the Justice Center’s jurisdiction. 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.

JURISDICTION INFORMATION

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HISTORY AND JURISDICTION

2025 HIGHLIGHTS

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 has 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 in the service system, 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 support are valued.

40% of agency staff have a personal connection to the mission

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ADVISORY COUNCIL MEMBERS

Having an impartial, objective organization come in and complete a thorough investigation can only lead to good...to safety. - Joe MacBeth President & CEO of the National Alliance for Direct Support Professionals, Justice Center Advisory Council Member

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2025 HIGHLIGHTS

Launched New Prevention Collaborative In 2025, the Justice Center launched a cross-functional Prevention Collaborative group that will aid in finding alternative strategies to prevent abuse and neglect. Using feedback directly from internal and external parties, the work of this group will promote: ¡ Increased partnerships with fellow State agencies, providers and families to ensure their feedback and needs are reflected in identifying priority topics and trends for prevention efforts. ¡ Decreased burden on providers by offering model policies, protocols and training programs they can easily implement. ¡ Increased knowledge and education for direct support workers on best practices in areas where abuse and neglect incidents are trending. ¡ Increased opportunities for the Justice Center to offer technical assistance and training to providers on best practices related to corrective action plan creation, implementation and follow-through.

Enhanced Focus on Workforce & Community Training In 2024, the Justice Center designed and launched a portfolio of free courses to educate first responders and law enforcement on respectful communications and investigative best practices for people with disabilities. The agency expanded its course offerings in 2025, offering new courses based on initial feedback.

VIEW OUR FULL PORTFOLIO

Promoted Process Improvements & Efficient Case Management In response to the growing need to reduce administrative burdens for providers, the Justice Center identified small-but-powerful ways to modify its work in 2025. The Justice Center implemented the following improvements to increase efficiencies for those who interact with the Justice Center throughout the lifecycle of a case. ¡ NEW REGION DOWNSTATE: Regional office locations are determined based on reporting volume within specific areas of the state. In 2025, the Justice Center opened a new region (including Richmond, New York, Bronx, and Kings counties) to better distribute the downstate caseload and improve response time downstate. ¡ NEW QUALITY MANAGEMENT DASHBOARD: This new dashboard was created specifically for State agencies to help identify when the Justice Center requires more information about an incident to move a case forward. This helps reduce delays in case processing. ¡ UPDATED WEBFORM STREAMLINES INCIDENT REPORTING: The Web Intake Reporting Form (Webform) used to submit incident reports electronically to the Justice Center was updated in response to feedback from providers. The changes improve user experience by more closely mirroring the agency’s live call center process and ensures more complete information is provided to the Justice Center for classification.

The agency also developed a new Trauma- Informed Investigator training for both internal and external staffs. The training explores what trauma is and how it impacts the mind and body in both primary and secondary trauma scenarios. The goal is to help training participants understand how their own personal trauma and the trauma of the victim or interview subject can alter the approach to an investigation.

TRAINING INFORMATION

Initiated Agency Strategic Planning Efforts As part of the strategic planning process, the Justice Center conducted statewide visits with providers under its jurisdiction to gather feedback on priority areas, reviewed input gathered from roundtables, and met with several New York State agencies to discuss opportunities for collaboration and improvement. The Justice Center also conducted regional listening sessions with direct care workers to get feedback directly from those who engage with people, families, providers, agencies, and Justice Center processes every day. This feedback, alongside the analysis of data from the past 10 years, helped the Justice Center team identify its strategic growth areas. The agency will release its strategic plan in 2026.

Pictured: Justice Center staff presenting at the Division of Criminal Justice Services Symposium

INCIDENT REPORT WEBFORM

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2025 HIGHLIGHTS

Engaged with Thousands at NYS Fair and Annual Summit Understanding the importance of engaging with stakeholders, 2025 marked the second year the Justice Center participated at the NYS Fair. More than 20,000 individuals stopped to speak with the Justice Center representatives to learn about the agency. This outreach opportunity not only promoted face-to-face interactions with the public but brought together Justice Center staff members from across the state, emphasizing the importance of collaboration. The Justice Center also continued its annual engagement event— the Justice Center Summit. This virtual, four-day conference covers topics such as investigations processed, criminal background checks, advocacy, and general updates from the executive staff. In 2025, more than 2,300 people registered for the Summit.

20,000+ individuals stopped to engage with Justice Center staff at the NYS Fair

In June 2025, in recognition of National Safety Month, the Justice Center hosted a special event, Partnering to Protect, to honor four individuals whose quick thinking and decisive actions helped save a life. The event underscored the critical importance of vigilance, collaboration, and a shared commitment to safety across New York’s care systems. It also featured a dynamic panel of representatives from across the state who regularly interact with the systems under the Justice Center’s jurisdiction, offering diverse perspectives on strengthening protections and improving outcomes for people in care. PARTNERING TO PROTECT IN NEW WAYS

2,300+ people registered for the Justice Center summit

SUBSCRIBE TO THE JUSTICE CENTER YOUTUBE CHANNEL

Complementing this effort, the Justice Center launched a new podcast in June titled “Could This Happen in Your Program?”. The podcast examines case scenarios and brings together subject matter experts in safety to explore how incidents unfold and, more importantly, how they can be prevented. Designed as a practical learning tool for direct care staff, the series provides actionable insights to help identify risks early and implement safeguards that reduce the likelihood of abuse and neglect. Together, these initiatives reflect the Justice Center’s continued commitment to prevention, protection, and advocacy.

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2025 PROGRAM UPDATES

WORKFORCE AND STAKEHOLDER OUTREACH

2025 PROGRAM UPDATES

WORKFORCE AND STAKEHOLDER OUTREACH The Justice Center makes protecting the rights of the dedicated workers who provide direct care to people who are vulnerable to abuse a top priority.

2025 PROGRAM UPDATES

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 and 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. More than 28,000 individuals and family members have contacted advocates for assistance since 2013. In 2025, the Justice Center provided 4,078 individuals and family members with advocacy and support. Advocates provide information about the reporting and investigative process, case status updates, and records access. In 2025, the Justice Center corresponded with individuals and families regarding records access needs 420 times. Justice Center advocates may also accompany victims to interviews or court proceedings. In 2025, advocates conducted 1,000 victim and witness accompaniment support efforts in Justice Center-led investigations, a 24% increase from 2024. Justice Center advocates also help with questions or concerns involving State agencies. The Justice Center participates in conferences and informational events throughout the state, offering materials and answering questions about the agency. Advocates presented at, or participated in, 71 such events in 2025. During the agency’s annual Family Engagement Series, the Justice Center provided valuable information and education on the role of the Justice Center and offered tools to help families advocate for a loved one with a disability. The Justice Center provided resources focused on enhancing communication, explaining what to expect when an incident of abuse or neglect is reported to the Justice Center, and promoting caregiver wellness. Approximately 215 attendees joined these virtual family engagement sessions.

28,000+ individuals and family members provided with advocacy and support since 2013

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WORKFORCE AND STAKEHOLDER OUTREACH

Champion and Code of Conduct Awards Each year, the Justice Center spotlights members of the direct care workforce who display a strong commitment to the Code of Conduct and serve as an inspiration to their colleagues. The Justice Center understands the impact staffing shortages are having across the direct care workforce, which makes these awards even more meaningful. In total, the Justice Center selected six individuals for the 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. What is the Code of Conduct? The Code of Conduct is a framework for certain employees to help people with special needs “live self-directed, meaningful lives in their communities, free from abuse and neglect, and protected from harm”. Certain employees must read and sign the code upon employment, and annually.

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 responding to systemic issues facing people receiving services at two OPWDD Developmental Centers in New York State: Sunmount DDSO and Valley Ridge. Through direct collaboration with people 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. In 2025, the Ombudsman supported people receiving services and their families more than 892 times, a 37 percent increase from 2024.

In 2025, the ombudsman supported people receiving services and their families more than 892 TIMES

Please see our full list of winners below. Click their names or faces to read about their inspiring stories.

MINA PORTER Direct Support Professional at The Arc Lexington SHAUNICE FAINES Assistant Director of Residential Services at East End Disability Associates CRYSTAL JOHN Vice President, Behavioral Health Residential Services at WellLife Network LAURA ROCCHIO Director of Direct Services at Helen Keller National Center KRISTIN COPELAND Peer Bridger at Alliance for Rights & Recovery MOHAMED EL SHOWKI Direct Support Professional at Community Resources Staten Island

LEARN MORE ABOUT THE CODE OF CONDUCT

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WORKFORCE AND STAKEHOLDER OUTREACH

TRAID Program The Technology-Related Assistance for Individuals with Disabilities (TRAID) Program provides assistive technology to New Yorkers with disabilities 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 federal and state partners. TRAID Centers loan a variety of devices for use in different settings such as at home, school, or work. The 12 regional TRAID Centers provided 1,030 device demonstrations in 2025. A demonstration is conducted when staff members 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.

SDMC Program The Surrogate Decision-Making Committee (SDMC) is a volunteer-driven program supported by the staff at the Justice Center and contracted regional organizations. SDMC provides a personalized approach to medical decision-making for non-emergency major medical treatment and end-of-life care for qualified people with disabilities who are unable to give their own informed consent and do not have someone to do so for them. The first program of its kind in the country, SDMC has served as an alternative to the court system for such decisions for over 30 years. Instead of going to court for consent, a request for decision is submitted to SDMC and an online hearing is held with the person in need of services and those who support them, including a representative of Mental Hygiene Legal Service, who provide legal support. The SDMC panel asks questions about the person’s capacity, surrogate availability, and the proposed treatment and issues an informed decision on the request. SDMC has over 300 volunteers—including health care professionals, attorneys, family members of people with disabilities and advocates—spread across every county in the state. SDMC held over 800 proceedings in 2025 and served more than 700 individuals. SDMC is actively recruiting new volunteers. If you are interested in applying, click below.

3,000+ short-term assistive technology device loans provided by the TRAID centers

300 SDMC volunteers across every county in New York

700+ individuals served in 2025

The TRAID Centers provided 3,386 short-term assistive technology device loans in 2025. A short-term loan is typically for 60 days or less. This gives 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, the TRAID Center can provide a long-term loan. The TRAID program receives donated devices from members of the community, which they clean and then provide to individuals who need them long-term. The TRAID Centers loaned 1,456 devices on a long-term basis this year. Because individuals are sometimes able to receive donated devices rather than spending money on a new one, the cost-savings for these New Yorkers totaled nearly $402,000 in 2025.

BECOME A VOLUNTEER

STORIES FROM THE FIELD

A woman who had lived in a facility setting for many years started the process of transitioning into a community-based home. The TRAID Center worked with her support team to provide her with the necessary devices to help her live independently.

A regional TRAID Center loaned a wheelchair and bedside commode to a woman so she could return home safely following a stroke.

A parent contacted their local TRAID Center to obtain a posterior walker to help improve their child’s mobility. Following the device loan, the child’s independence and participation increased significantly.

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TRAINING AND SAFETY IMPROVEMENTS

TRAINING AND SAFETY IMPROVEMENTS Outreach, training, and the promotion of best practices are critical to effect systemic changes. That is why the Justice Center made a substantial investment in training its own staff and external audiences. The Justice Center offers a variety of training and support materials including Forensic Interviewing Best Practices for Vulnerable Populations, Code of Conduct and Maintaining Professional Boundaries.

Justice Center In-Service Training As part of the Justice Center’s commitment to continuous improvement, the agency offers an annual in-service training for all staff members. The theme was “Shaping Our Future Together” and included presentations from state agency partners and other external presenters. Topics included: ¡ Young Lives, Lasting Impact: Addressing Trauma in the Investigations Process- A Panel Discussion ¡ Investigating Injuries of Unknown Origin ¡ Identifying and Supporting Pillars of Category 4 Findings ¡ Trends in Administrative Appeals Decisions ¡ Neurodiversity 101 In total, more than 300 Justice Center staff members attended the training.

300+ Justice Center staff members attended the in-service training

State Agency Collaborative Trainings The Justice Center provides investigation training to state and provider agencies. In 2025, the agency provided three Investigation Basics training sessions, which were attended by 692 provider and state agency investigators. The agency also continued its online training series covering investigative topics such as the elements of psychological abuse, injuries of unknown origin, and trauma-informed approach to investigations. The Justice Center presented the series to 859 state and provider agency staff members. In 2025, the Justice Center also introduced an online series covering abuse-prevention topics. The agency produced two sessions reaching nearly 600 professionals offering guidance on corrective action plan audits and choking prevention. In addition, the Justice Center provides a professional boundaries training, which is now approved for Credentialed Alcoholism and Substance Abuse Counselor (CASAC) credits and Continuing Education Credits for licensed social workers and psychiatrists. The Justice Center offered this training 10 times to 548 staff members from OASAS and OMH-licensed and certified programs throughout the year. Finally, in collaboration with the National Alliance for Direct Support Professionals, the Justice Center held four training sessions for 116 provider trainers. These “train-the-trainer” sessions provide guidance and resources on how to help direct support professionals understand and embrace the Code of Conduct.

1500+ state and provider

investigators trained with training program

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ABUSEPREVENTIONANDQUALITYIMPROVEMENT

ABUSE PREVENTION AND QUALITY IMPROVEMENT

ABUSE PREVENTION AND QUALITY IMPROVEMENT A core element of the Justice Center’s mission is to develop tools to help prevent mistreatment of people who are vulnerable to abuse. The agency accomplishes this through a number of practices including:

APPLICANTS DENIED APPROVAL FOR EMPLOYMENT CONSIDERATION

AGENCY

TOTAL DENIED

395 applicants

OPWDD

229

OMH OCFS

98 68

were denied approval for employment consideration in 2025

Pre-employment checks to ensure the safety of both people receiving services and the workforce, data analysis of trends, issuance of guidance, best practices that promote positive outcomes, and quality improvement reviews.

At times, The Justice Center’s Criminal Background Check determines an individual’s criminal history makes them unsuitable to work with populations under Justice Center jurisdiction. In 2025, this occured 395 times. STAFF EXCLUSION LIST The first line of defense against system-wide abuse is the Justice Center’s Staff Exclusion List (SEL). The Justice Center places all subjects substantiated for Category One conduct, which includes serious or repeated acts of abuse or neglect, on the SEL. Placement on the SEL permanently bars an individual from working in all settings under the Justice Center’s jurisdiction. The total number of individuals on the SEL at the end of 2025 was 1,137, an increase of 112 from 2024. Preventing Abusers from Re-entering the Service System 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 a person with special needs. In 2025, providers checked the SEL 31,000 times per month on average. Since 2014, there have been 472 instances where an individual on the SEL attempted to re-enter the service system and were denied due to their placement on the SEL. This vital check prevents staff members who have committed serious or repeated acts of abuse and neglect from obtaining employment in a service setting under Justice Center jurisdiction.

1,137 total individuals were on the SEL at the end of 2025

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 people receiving services while at the same time mitigates risk for employers and the dedicated workforce. CRIMINAL BACKGROUND CHECKS, FINGERPRINTS PROCESSED & APPLICANTS REVIEWED

The Justice Center processes upwards of 100,000 fingerprints annually Since Justice Center operations began, the agency has performed close to 1 MILLION criminal background checks

AGENCY

TOTAL FINGERPRINTS PROCESSED

The SEL is truly the first line of defense when protecting people receiving care in New York. - Maria Lisi-Murray Acting Executive Director

OPWDD

85,476 30,872

OMH OCFS

8,129 Applicants Reviewed 18,982 Applicants Flagged for Additional Information 992

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ABUSEPREVENTIONANDQUALITYIMPROVEMENT

ABUSE PREVENTION AND QUALITY IMPROVEMENT

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. The Justice Center does this through reviews and audits of corrective action plans and 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 providers 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 take the necessary steps to prevent incidents of abuse and neglect in the future. Corrective action plan (CAP) audits are most often completed after finding that a systemic issue caused the abuse or neglect. In 2025, the Justice Center conducted 300 audits of facility and agency CAPs which included assessing 1,911 corrective actions, identifying 654 additional findings, and providing 959 resources. Examples of the audits and results are below. The Justice Center conducted several audits following investigations to evaluate safety practices, compliance with policies, and the effectiveness of corrective actions.

SYSTEMIC REVIEW The Justice Center reviewed agency responses to allegations of sexual abuse and professional boundary violations in OPWDD settings, analyzing substantiated case trends across 20 providers. The review identified opportunities for system-wide improvements, particularly in safeguards, policy development, and training on professional boundaries.

VIEW SYSTEMIC REVIEW

As a result, OPWDD collaborated with the Justice Center to begin developing a targeted training on maintaining professional boundaries in care settings. The training will emphasize recognizing early warning signs, appropriate staff intervention, and reporting requirements. OPWDD will also reinforce the importance of implementing immediate safeguards following allegations through its quarterly provider training series. HALT Monitoring As required by the Humane Alternatives to Long-Term Solitary Confinement (HALT) Act, the Justice Center monitors and makes recommendations regarding 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 19 facilities in 2025. In total, the Justice Center completed 786 cell-side and 162 private interviews with incarcerated individuals and referred 133 of those individuals to be evaluated by OMH. In accordance with the law, the agency reviewed the quality of mental health care for 285 incarcerated individuals placed in segregated confinement and Residential Rehabilitation Units. Reports on all monitoring efforts from 2025 are posted on the Justice Center website.

300 CAP audits were conducted by the Justice Center

VIEW REPORTS

Supervision and Staffing An audit identified concerns related to staff supervision, training, and environmental safety within a residential program. Following a site visit, the Justice Center shared its findings with the relevant state licensing agency. The licensing agency subsequently determined that conditions posed a threat to the health and safety of people receiving services, requiring the provider to implement an immediate remediation plan.

Food Preparation and Choking Prevention An audit examining food preparation practices found that staff members were not consistently following required food consistency modifications outlined in individuals’ plans of care. The Justice Center intervened during a site visit to ensure proper preparation and provided guidance and resources to strengthen choking prevention practices. No additional choking incidents have been reported by the provider since the visit and re-education.

Professional Boundaries and Incident Reporting An audit also identified concerns related to professional boundaries and the provider’s handling of incident reporting requirements. The Justice Center provided technical assistance and recommendations to strengthen policies, staff training, and compliance with mandated reporting obligations.

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DIVERSITY,EQUITY,INCLUSION,ANDACCESSIBILITY(DEIA)

INCIDENT MANAGEMENT

DIVERSITY, EQUITY, INCLUSION, AND ACCESSIBILITY (DEIA)

INCIDENT MANAGEMENT

In 2025, the Justice Center continued implementation of its Diversity, Equity, Inclusion, and Accessibility (DEIA) strategic plan in a collective effort to improve the experiences of staff members and constituents across New York State. Supported by an informed and committed leadership team, a dedicated staff, and continuous policy review and development, the Justice Center achieved the following objectives:

PROSECUTIONS

JUSTICE CENTER

Criminal cases are managed by

INVESTIGATION

Justice Center prosecutions in

coordination with district attorney .

INCIDENT

Serious allegations

CASE CLOSURE

APPEAL

MANAGEMENT

of abuse and

neglect and all

abuse and neglect

allegations in

Training ¡ Achieved a completion rate of more than 90% on the agency’s full-day Diversity, Equity, and Inclusion training. ¡ Achieved a participation rate of more than 90% in trainings related to discrimination prevention, language access, and neurodiversity. ¡ Developed a new Disability Awareness training series for all agency staff members. Language Access ¡ Increased agency utilization of interpretation and translation-related services. ¡ Expanded language access resources for staff members. Culture and Diversity Recognition ¡ Cosponsored all 2025 cultural/heritage recognition events with the New York State Department of Civil Service and the New York State Office of General Services. ¡ Collaborated on DEIA panels in partnership with New York State agencies including the Department of Public Service, Office of Child and Family Services, Worker’s Compensation Board, and the Governor’s Diversity, Equity, and Inclusion Office. ¡ Cosponsored 2025 New York State Diversity, Equity, Inclusion, and Accessibility Symposium

certain state -

operated facilities

The JC reviews

all

abuse and neglect

Subjects of

A report is made to

STATE AGENCY

investigations

substantiated

the Justice

INVESTIGATION

( regardless of

cases have 30

Center ’ s hotline

delegation )

days to appeal if

and classified

determine the case

desired

outc

ome

INDIVIDUAL

FAMILY SUPPORT

Less serious

The Justice Center has a group of specialized

allegations of

employees dedicated solely to individual and

abuse and neglect

family support .

This team supports these

groups throughout the investigation process .

Process of a Justice Center Investigation INTAKE

Anyone, including a parent or guardian, advocate, or person receiving services can make a report to the Vulnerable Persons Central Register (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 members 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 is also available for use. 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.

in partnership with the Governor’s Diversity, Equity, and Inclusion Office. Minority and Women-Owned Business (MWBE) & Service Disabled Veteran Owned Business

90,000+ reports were made to the VPCR in 2025

¡ Achieved utilization rate of 73.57%, well above the Governor’s MWBE utilization goal of 30%. ¡ Justice Center spent approximately $95,000 (4% utilization) on SDVOB products and services between January 1, 2025 and December 31, 2025.* *Fiscal Year 2025 SDVOB utilization was 2.2% of Justice center total discretionary expenditures.

2025 Annual Report 27

NYS JUSTICE CENTER 2025 Annual Report 26

NYS JUSTICE CENTER

INCIDENT MANAGEMENT

CLASSIFICATION Once the allegation is assigned an incident number, it is then classified into one of the following categories: 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 members 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 the reporting of certain deaths to the Justice Center. These include the death of a person 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. NON-NYJC INCIDENT The details provided suggest the incident does not legally qualify as a “Reportable Incident” or 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. The Justice Center refers cases that require follow-up 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 IN 2025 BY CLASSIFICATION

2025

2024

35,000

32,206

31,211

30,608

30,516

30,000

25,000

20,000

14,525

14,261

15,000

11,269

10,900

10,000

5,000

1,654

1,609

80% of offense findings involve neglect

Abuse and Neglect

Death

Significant Incident

Non-NYJC Incident

Not an Incident

90,865 total reports were made to the Justice Center in 2025

+3% increase from 2024

14,525 reports launched an abuse and/or neglect investigation

NYS JUSTICE CENTER 2025 Annual Report 29

NYS JUSTICE CENTER 2025 Annual Report 28

INCIDENT MANAGEMENT

THREE-BUSINESS DAY REVIEW OF INCIDENTS The Justice Center has 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.

Criminal Cases The Justice Center’s Special Prosecutor works with local law enforcement and county district attorneys to bring criminal charges in cases that allege that a crime has occurred against a person 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 2025, 107 arrests were made in connection to Justice Center cases (this is a 28 percent increase from 2024). While a criminal case is being investigated and prosecuted, the same case is also investigated through the Justice Center administrative investigation process. 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.

28% more arrests made in connection with the Justice Center in 2025

2025

2024

THREE BUSINESS DAY REVIEW (3BDR) VOLUME

90,865

87,894

TOTAL REPORTS TO THE JC

1,600 more cases closed than in 2024 due to improvements in case processing

6,218

Reports Reviewed by 3BDR

5,760

10,783

2025 4,570

2024

10,706

TOTAL CASES OPENED/CREATED

INVESTIGATION OUTCOME FOR ABUSE AND NEGLECT CASES

2,722

Cases Opened/Created from 3BDR Reviewed Reports

2,189

Substantiated Unsubstantiated

3,866

6,930 11,500

5,952

ADMINISTRATIVE VS. CRIMINAL CASES Once a case is classified as abuse or neglect, that case is next characterized as either criminal or administrative. 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 serious allegations in non-state operated settings. The Justice Center delegates less serious allegations of abuse and neglect in non-state operated settings 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. The Justice Center also refers significant incidents 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. People 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.

9,818

TOTAL CLOSED ABUSE AND NEGLECT CASES

¡ 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.

40% Substantiated

60%

¡ SUBSTANTIATED: the case is classified into one of four categories depending on the severity.

Unsubstantiated

2025 Annual Report 31

NYS JUSTICE CENTER 2025 Annual Report 30

NYS JUSTICE CENTER

INCIDENT MANAGEMENT

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. An LOD is also issued to the director of the facility or program, the State agency that licenses or certifies the facility or program, and the subject of the investigation.

¡ 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 person receiving services 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.

MOST EGREGIOUS OFFENSES

TOTAL ABUSE & NEGLECT CASES CLOSED/SUBSTANTIATED BY OFFENSE TYPE

The below chart indicates the type of offenses found as a result of investigations.

2025

2024

1000 1500 2000 2500 3000 3500 4000 4500 5000

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

4289

LESS SERIOUS OFFENSES

3,583

¡ 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 a person receiving services has suffered abuse or neglect, but a perpetrator cannot be identified.

SYSTEMIC ISSUES

695

582

307

218

117

230

0 500

136

TOTAL ABUSE & NEGLECT CASES CLOSED/SUBSTANTIATED BY CATEGORY

Deliberate Inappropriate Restraint Deliberate Inappropriate Restraint

Neglect Neglect

Obstruction Obstruction

Other Reportable Other Reportable

Physical Abuse Physical Abuse

Psychological Abuse Psychological Abuse

Sexual Abuse Sexual Abuse

4% 2% Category 1 Category 4

The below chart indicates the severity of the substantiated offenses.

2025

2024

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:

113

Category 1 Category 2 Category 3 Category 4

22% Category 2

984

818

773 appeal requests received in 2025

3,277

2,736

72% Category 3

196

217

TOTAL CLOSED ABUSE AND NEGLECT CASES

4,570

3,865

2025 Annual Report 33

NYS JUSTICE CENTER 2025 Annual Report 32

NYS JUSTICE CENTER

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