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.
2025 Annual Report 25
NYS JUSTICE CENTER 2025 Annual Report 24
NYS JUSTICE CENTER
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