Mandated Reporting

An Overview of Reporting Requirements for Custodians

161 Delaware Avenue, Delmar, NY 12054

www.justicecenter.ny.gov

January 2019

Protection of People with Special Needs Act

The Justice Center was established by

the “Protection of People with Special

Needs Act”, enacted as Chapter 501 of

the Laws of 2012. The intent of the act

was to create a durable set of

consistent safeguards for all vulnerable

persons that will protect them against

abuse, neglect and other conduct that

may jeopardize their health, safety and

welfare, and to provide fair treatment to

the employees upon whom they

depend.

Further, the Protection of People with

Special Needs Act identifies certain

people who are defined as mandated

reporters and requires these people to

report reportable incidents involving

vulnerable persons to the Justice

Center’s Vulnerable Person’s Central

In addition to establishing the Justice

Center, the Protection of People with

Special Needs Act mandates that the

Justice Center operate a statewide

hotline, referred to as the Vulnerable

Persons’ Central Register or the

VPCR, to ensure that reportable

incidents are promptly reported and

fully investigated, that responsible

individuals are held accountable and

that providers implement corrective

action plans to prevent future incidents.

Who is a Mandated Reporter?

Human Services Professional | Human services professionals are those who may not see a person receiving services

on a daily basis, but who interact with the individual during the course of providing professional services. For a full list of

Human Services Professionals that are considered to be mandated reporters, please see the guidance document: An Over-

view of Reporting Requirements for Human Services Professionals. *Social Services Law, §488

Custodians | Custodians are individuals who are employed by, or volunteer at, state operated, licensed or certified facilities

or agencies under the Justice Center’s jurisdiction. Consultants, volunteers or contractors of organizations or companies that

contract with facilities and agencies under the Justice Center’s jurisdiction are also considered to be custodians if they have

regular and substantial contact with a person receiving services. *Social Services Law, §488(2)

Mandated reporters are required to report reportable incidents involving vulnerable persons.

What is a Reportable Incident?

Who is a Vulnerable Person?

There are three general types of reportable

incidents:

Abuse

Neglect

Significant Incident

Individuals who may be vulnerable to abuse and

neglect because of their reliance on professional

caregivers in state operated, licensed or certified

facilities, programs or agencies.

Vulnerable persons are not necessarily

individuals with disabilities, although many are.

State Oversight Agencies

Office for People With Developmental Disabilities

Office of Mental Health

Office of Addiction Services and Supports

Certain facilities and provider agencies licensed, operated or certified by the following State Oversight Agencies are

within the Justice Center’s jurisdiction.

Office of Children and Family Services

Department of Health

State Education Department

When is Reporting Required?

Immediately

Upon Discovery

Reasonable Cause

If you are a mandated reporter and have reasonable cause to suspect that a reportable incident has occurred and that

it was committed by a custodian, you must report it to the VPCR immediately upon discovery. The person receiving

services does not have to suffer harm for an incident to be reportable. The potential for harm must also be reported.

Even if the reportable incident occurred at a different facility or program from where you are employed, once you

become aware that something reportable has occurred, you are required to report the incident to the VPCR.

Immediately means right away.

Immediate reporting may be delayed

to take the necessary steps to call

9-1-1, implement safety measures to

protect the individual from further

harm, and to follow internal

facility procedures.

However, no internal procedure

should significantly delay a report to

the Justice Center. Staff going “off-

duty” does not justify a delay in

reporting. A report that is delayed

more than 24 hours may be

considered obstruction.

Discovery occurs when a

mandated reporter witnesses a

suspected reportable incident.

Discovery can also occur when

another person, including a person

receiving services or family member,

provides the mandated reporter with

reasonable cause to suspect that an

individual has been subjected to a

reportable incident.

When trying to determine if you have

reasonable cause to suspect an

incident has occurred, review the

circumstances, evidence and facts

known or readily available to you.

Consider your own observations,

trainings, experiences and common

sense in assessing:

• Was the individual injured or was

there potential for injury?

• Do you believe the explanation of

how the injury occurred?

• How reliable is your information?

Each mandated reporter has a personal obligation to report a suspected reportable incident individually to the

Justice Center unless multiple reports regarding the same incident would be made to the VPCR and the “Multiple

Reporting Exception” is met.

Under the “Multiple Reporting Exception”, the only time you are not required to report an allegation to the VPCR is if:

• You know that the incident was already reported to the VPCR; AND

• You know that you were named in the report as a person of knowledge of the incident

If you are unsure whether you have reasonable cause to suspect a reportable incident has occurred or you are not

certain the “Multiple Reporting Exception” has been met, we encourage you to report the incident to the VPCR.

Obligation to Notify Your Provider Agency

Your employer or supervisor cannot tell you that you may not report if you believe that you are required to

do so. You are not obligated by the Justice Center to tell your employer that you made a report to the

VPCR. However, your employer, may require you to also make an internal report of an incident.

We encourage you to speak to your supervisor about your internal reporting procedures and

responsibilities.

Is it Reportable?

State Central Register Example

A 14-year old boy lives at an Office of Mental Health

residential treatment facility and spends the weekends

at home with his family. On Monday, his parents

return him to the residential treatment facility where

staff discover a cigarette burn on his neck, that was

not there on Friday.

Is this reportable to the Justice Center?

NO. In this case, because there is no basis to

believe that the burn was caused by a custodian, this

incident would NOT be reportable to the Justice

Center.

However, it would be reportable to the State Central

of child abuse and neglect of children under the age

of 18 in a daycare setting, foster home or within a

family home, must continue to be reported to the

Statewide Central Register of Child Abuse and

Maltreatment by calling 1-800-635-1522.

Different Facility or Program Example

A 25 year-old woman shows up at the day habilitation

program with a bleeding gash on her arm. She lives in

a facility certified by the Office for People With

Developmental Disabilities as an Individual

Residential Alternative. She is transported between

the facility and the day habilitation program by a

transportation company under contract with the

facility.

Is this reportable to the Justice Center?

YES. This incident is reportable to the VPCR, even if

staff at the day habilitation don’t know if the individual

was injured at the Individual Residential

Alternative or on the van. Both are settings under the

jurisdiction of the Justice Center and staff are

custodians.

If you become aware that an individual has been

subjected to a reportable incident at a different facility

or program, you are required to report the incident to

the VPCR.

Driving Example

You are riding in the agency van with people receiving

services and another staff member, who is driving the

van. The driver was eating a large breakfast sandwich

while driving. In order to eat the sandwich, the driver

used both his hands and steered with his knees. He

was driving 10 miles over the speed limit in a

well-populated area with lots of vehicular and

pedestrian traffic. He stopped abruptly frequently.

After returning to the house, some of the people riding

in the van told you they were afraid they were going to

get into an accident.

Is this reportable to the Justice Center?

YES. Even though there was no accident and people

receiving services didn’t suffer a physical injury, there

was potential for harm because of the way the van was

being driven.

When deciding whether there is a reasonable cause to

suspect that a reportable incident occurred, you should

consider your own observations, training, experience

and common sense in assessing the situation. Driving

with your knees and speeding in well-populated areas

puts people receiving services at risk of being in a car

accident. In this case, some of the people riding in the

van said they were afraid they while they were riding in

the van.

Is it Reportable?

Report from Person Receiving Services

A person receiving services reports that a staff

member placed his hands on her neck and squeezed

it during a restraint that occurred on the previous day.

You observe bruises on the individual’s neck.

Is this reportable to the Justice Center?

YES. You have reasonable cause to suspect that a

reportable incident occurred because the person

receiving services reported to you that a staff member

placed his hands on her neck and you observe bruises

there.

Observation Example

You observe a staff person placing a person receiving

services in an authorized restraint, using the proper

technique. During the restraint, the individual begins

to scream “rape”.

Is this reportable to the Justice Center?

NO. You observed that a staff member using the

proper technique in a restraint and was merely holding

the individual’s legs. You witnessed a proper restraint,

which is not a reportable incident.

Leaving People Receiving Services

Alone in a Vehicle Example

A person receiving services tells you that when he

was being driven to a medical appointment by another

staff person, the staff person stopped at her house

and left him alone in the car for five minutes. The

person receiving services regularly engages in

self-injurious behavior and requires line of sight

supervision while awake.

Is this reportable to the Justice Center?

YES. Whenever a person receiving services is placed

in a situation in which there is potential for harm, the

incident should be reported.

In this case, the person receiving services requires

line-of-sight supervision while awake because of

self-injurious behaviors.

Custodian Not Identified Example

A person receiving services has a swollen, bloody

nose and “fresh” bruises on her face, chest, back and

arms. The individual cannot, or will not, explain how

these injuries occurred, and no other persons

receiving services or staff on duty at the time can

explain the injuries.

Is this reportable to the Justice Center?

YES. When deciding whether there is reasonable

cause to suspect that a reportable incident occurred,

you should consider your own observations, training,

experience and common sense in assessing the

information presented to you.

In this case, the individual has multiple injuries and no

one is able or willing to provide an explanation for the

injuries. Remember, conclusive evidence that the

injuries were caused by a custodian is not required.

Identifying who caused the injuries is also not a

requirement when making a call to the VPCR.

Is it Reportable?

Supervisor States Not to Report

Example

A person receiving services tells you that a staff

member kicked him on his back approximately one

week ago. You discover a number of bruises on his

back, but are not sure if they were caused by a kick. A

supervisor tells you that you do not need to report this

incident to the Justice Center.

Is this reportable to the Justice Center?

YES. Remember, your employer or supervisor

cannot tell you that you may not make a report to the

VPCR if you believe that you are required to do so.

Further, you are no obligated from the Justice Center to

tell your employer that you made a report to the VPCR.

However, your employer, may require you to also make

an internal report of an incident.

Car Accident Example

A staff person takes one of the agency vehicles for an

oil change. The staff person drove by herself and there

was no one who received services in the vehicle. The

staff person was talking on her cell phone when she ran

a red light and was hit by oncoming traffic. The staff

person was taken to the hospital and issued a traffic

ticket.

Is this reportable to the Justice Center?

NO. Incidents are only reportable if people receiving

services are harmed or there was potential for harm.

In this case, there were no people receiving services

riding in the vehicle when the accident occurred.

How to Report

Information You Will Be Asked to Provide

Mandated reporters can call the toll-free VPCR 24-hour hotline at 1-855-373-2122. For individuals using New York

Relay Service, dial 7-1-1 and give the operator the phone number 1-855-373-2122. There is also a web form, as well

as a mobile application, that are available for reporting abuse and neglect. For more information, visit the Justice

Center’s website at www.justicecenter.ny.gov.

• Confirmation that immediate protections are in place for the victim; was 9-1-1 called, if necessary

• Details regarding the victim, subjects and witnesses

• Details of the incident, including the date, time, location, description of incident

• Responsible State Oversight Agency

• Name and address of the provider agency, facility and/or program

• Name, title and contact information of others who may have the same information as you

• Any other information that may assist with the investigation or review of the incident

• You do not have to know all of the answers to these questions to make a report

TOLL-FREE VPCR 24-HOUR HOTLINE

1-855-373-2122

What to Report

Abuse

Neglect

Significant Incident

Abuse is an action by a custodian against a

person receiving services that causes or

has the potential to cause injury or serious

protracted impairment of the physical,

mental or emotional condition of a service

recipient.

There are seven categories of abuse:

physical abuse; sexual abuse;

psychological abuse; deliberate

inappropriate use of restraints; use of

aversive conditioning; obstruction of reports

of reportable incidents; and unlawful use or

administration of a controlled substance.

Neglect is any action, inaction or lack of

attention that breaches a custodian's duty

and that results in or is likely to result in

death, physical injury or serious or

protracted impairment of the physical,

mental or emotional condition of a person

receiving services.

Most commonly, neglect is the result of a

custodian’s lack of attention or failure to act

as required by his or her responsibilities.

Neglect can include, but is not limited

to: failure to provide proper supervision;

failure to provide adequate food, clothing,

shelter, medical, dental, optometric or

surgical care; and failure to provide access

to educational instruction.

Any 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.

Types of significant incidents identified

in statute:

1. Conduct on the part of a custodian that is

inconsistent with an individual’s treatment

plan, educational program or generally

accepted treatment practices.

2. Conduct between persons receiving

services resulting in harm or the potential

for harm.

3. ANY other conduct identified in

regulations of the State Oversight Agencies.

The Protection of People with Special Needs Act defines three types of incidents that must be reported: abuse,

neglect and significant incidents. You are not required to know what type of incident has occurred in order to make a

report.

What Happens to a Report

A trained staff person takes a full report and carefully

enters all details of the incident into the VPCR. All calls

are recorded and an incident number is assigned at the

end of each call. The incident number gives proof that

the incident was reported. This number should also be

referenced by the reporter if he or she needs to add

more information at a later time.

Intake

Classification

Assignment

Final

Determination

After the call, a reportable incident is classified as

abuse, neglect or significant incident.

Once the report in classified, a case is created and

assigned to the appropriate entity for investigation.

Once assigned, the investigation begins.

Regardless of who is conducting the investigation, the

Justice Center reviews all abuse and neglect

investigations and makes the final determination about

whether or not the allegation is substantiated or

unsubstantiated.

Once a determination is made, the Justice Center notifies the victim and his or her personal representative, the

subject in the case and the provider agency director, of the outcome. Mandated reporters and witnesses are not

notified of the outcome of the investigation.

The Justice Center does not make a determination regarding significant incidents, however, a State Oversight Agency

may request that a provider agency develop a corrective action plan if there is an issue of concern.

Mandated Reporter Obligations

If you have a reasonable cause to suspect that a reportable incident has occurred:

• You must make a report immediately upon discovery

• Your supervisor cannot tell you that you can not report an incident

• Report individually unless the “Multiple Reporting Exception” applies

Resources and Contact Information

For additional resources and information on the Justice Center, please visit our website at:

www.justicecenter.ny.gov

Report Abuse or Neglect: 1-855-373-2122

Report Abuse or Neglect TTY: 1-855-373-2123

Confidentiality of Reporting

As a mandated reporter, your identity is confidential and

may not be publicly disclosed. You may ask that your

identity not be disclosed but it may be necessary to

disclose your identity to the person investigating the

reported incident, in order to ensure that an incident is

thoroughly investigated. The Justice Center makes every

reasonable effort to protect the identity of mandated

reporters, especially when a reporter is alleging that he or

she is the victim of retaliation for making a report.

The law grants immunity to mandated reporters from a

legal claim which may arise from a good faith act of

providing information to the VPCR. For example, if you

make a report to the VPCR because you had reasonable

cause to suspect a reportable incident has occurred, the

subject of the report may not sue you if the allegation is not

substantiated. Immunity will not be granted to someone

found making an intentionally false report.

Immunity from Liability

Failure to Report

A mandated reporter who knowingly and willfully fails to

report suspected abuse or neglect to the VPCR, may be

subject to termination and may be sued in civil court for

monetary damages for any harm caused by the failure

to make a report.

Protection from Retaliation

State laws protect mandated reporters from retaliation.

A state agency, facility or provider agency, school,

medical or other public or private institution, cannot take

any retaliatory personnel action, as defined in the Labor

Law, Section 740 (1)(e), against an employee or agent

because that person, acting in good faith, makes a

report to the VPCR.

If you believe that you are being retaliated against for

making a report, you should call the VPCR.