Selected Aspects of Incident Intake and Investigation

Issued Date
March 06, 2017
Justice Center for the Protection of People With Special Needs 


To determine whether the Justice Center for the Protection of People With Special Needs (Center) met its responsibility to operate a hotline, establish a database of reported allegations and a Staff Exclusion List, and ensure that all allegations are investigated fully and timely and are referred to law enforcement when appropriate. The audit covered the period July 1, 2013 through May 16, 2016.


The Center was established by the Protection of People With Special Needs Act (Chapter 501 of the Laws of 2012) and began operation on June 30, 2013. The Center has law enforcement authority to protect and advocate for people with special needs who are served by six State Oversight Agencies (SOAs) and more than 3,000 SOA licensees, facilities, providers, or entities certified by the SOAs.

Pursuant to Section 492 of the Social Services Law, the Center receives reports of allegations of reportable incidents involving persons receiving services in State facilities or provider agencies. The Center maintains an electronic database of reports accepted by the Vulnerable Persons Central Register (VPCR). The database is the Center’s electronic case file and reporting system and is used to document the receipt, investigation, and disposition of each allegation. Allegations are classified as either Abuse, Neglect, or other Significant Incidents. The Center directly investigates serious Abuse and Neglect reports, and delegates some less serious cases to SOAs for investigation.

The Center is also required to maintain a Staff Exclusion List (SEL), which is a register of persons about whom it has previously substantiated an allegation of the most serious types of Abuse or Neglect, also referred to as Category One offenses. Individuals listed on the SEL cannot hold positions that involve direct care of persons with special needs. The Center has a staff of over 400, which includes 136 investigators located across the State. As of September 2, 2015, Center records showed that, since its creation, it had received reports of over 113,000 incidents that were within its jurisdiction to investigate.

Key Findings

  • Although we were able to conclude that the Center does operate the required hotline and maintain the VPCR database and the SEL, we were unable to draw conclusions about several of the most important parts of our audit because the Center did not provide us with access to most of the relevant information needed to achieve our audit objective. Citing Section 496 of the Social Services Law, Center officials concluded that the Center is only authorized to provide the State Comptroller with case-specific information in substantiated cases. Consequently, we were unable to review more than 70 percent of the individual incidents reported in the VPCR database, including any cases where investigations have not been completed or where allegations were deemed to be unfounded.
  • We used the limited information we were provided to the extent possible to evaluate the Center’s compliance with its statutory mandates. Unfortunately, in most cases, the controls and compliance we were able to evaluate related more to ensuring that persons accused of (and subsequently found to have committed) serious instances of Abuse and Neglect received due process – and less to ensuring that all allegations of acts against vulnerable individuals had been investigated fully and timely and referred to law enforcement when appropriate.
  • Although our examination was severely limited, our tests identified three individuals who had been erroneously left off the SEL after committing serious acts of Abuse or Neglect. The names of two of the individuals should have been included on the SEL nine months before we identified them; the name of the third individual should have been included five months prior to our conclusions. These problems occurred because the Center lacked proper controls to periodically validate the accuracy of the SEL. Center officials promptly added these names once we brought the omissions to their attention.
  • Our limited testing also showed that the Center’s database of reported allegations contains numerous inaccuracies. For example, each suspected offender should have a unique identification number to, among other things, enable tracking of repeat offenders. Yet our analysis identified about 180 individuals who had multiple identification numbers assigned to them. We also identified about 220 substantiated offenses with inaccurate or blank fields for significant dates, including the date the incident was reported or when a finding was made. Such errors can result in inaccurate data being publicly reported by the Center. Officials told us they are implementing steps to correct the data inaccuracies and are also implementing a new reporting system.
  • Several Federal statutes, as well as the State Executive Law, include specific provisions for independent oversight of the Center, and access to its records, by a designated monitoring agency. Currently, the designated monitoring agency is Disability Rights New York (DRNY). However, we noted that DRNY has also been unable to obtain complete access to various aspects of Center operations and filed a lawsuit to compel disclosure and clarify its role and powers. While we take no position with respect to that action, we are concerned that there is a lack of independent oversight and public accountability for the Center’s performance of many aspects of its important responsibilities.

Key Recommendations

  • Develop and implement controls to ensure all subjects with substantiated Category One offenses are promptly added to the SEL.
  • Develop and implement procedures to provide reasonable assurance that data contained in the VPCR database is accurate, including procedures to periodically review and analyze the accuracy of the data and correct any inaccuracies discovered.

Other Related Audit/Report of Interest

Department of Health: Nursing Home Surveillance (2015-S-26)

John Buyce

State Government Accountability Contact Information:
Audit Director: John Buyce
Phone: (518) 474-3271; Email: [email protected]
Address: Office of the State Comptroller; Division of State Government Accountability; 110 State Street, 11th Floor; Albany, NY 12236