OPWDD’s commitment to protection from harm OPWDD’s mission is to help people with developmentaldisabilities live richer lives. OPWDD, in coordination withthe Justice Center for the Protection of People withSpecial Needs (Justice Center), has establishedrequirements and oversight procedures to protect peoplereceiving services from harm.

In order to support this mission, OPWDD and its provideragencies adhere to Title14 of New York Codes, Rules andRegulations Part 624 (14NYCRR Part 624), a regulationdesigned to protect people receiving OPWDD services.This regulation identifies steps to be taken when aperson receiving services experiences an incident, asdescribed on page 2, Types of Incidents. This regulationrequires all providers of services to do the following:

• Ensure that staff report untoward events, called"Reportable Incidents" and "Notable Occurrences," thataffect the well-being of people receiving services;

• Provide immediate care and protect the health, safety,and dignity of people with developmental disabilitiesinvolved in, or affected by, an incident;

• Investigate why incidents, including abuse and injuries,happen and take steps to prevent similar incidents fromhappening again;

• Establish an Incident Review Committee to reviewspecific incidents and examine trends; and

• Develop procedures and provide staff training andoversight, as needed, to prevent similar incidents in thefuture.

This brochure provides an overview of OPWDD’sexpectations regarding incidents and explains the rolesof qualified persons and other involved parties inadvocating on behalf of the people we serve. Pleaserefer to 14NYCRR Part 624 regulations for the completerequirements.

http://www.opwdd.ny.gov/regulations_guidance/opwdd_regulations

Who is able to receive noticeand ask about an incidentJonathan’s Law requires that qualified parties are to benotified of certain events involving parties receivingservices. Part 624 regulations, which include Jonathan'sLaw notifications, require that qualified parties arenotified of all incidents.

Qualified parties include an individual receivingservices, his or her legal guardian, or an involvedparent, spouse, adult child, or adult sibling who hasauthority to provide consent for care and treatment.

Part 624 regulations also require that a person whodoes not meet the definition of a qualified party, butwho serves as an advocate or correspondent for aperson receiving services, is to be notified of incidents.

Qualified parties, advocates, and correspondents mayrequest information about incidents.

There are additional OPWDD directives on notificationsinvolving Willowbrook class members.

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Learning About IncidentsOPWDD’s commitment to

protection from harm

How do agencies handle incident reports? Incidents must be reported, investigated, recorded, andreviewed by an Incident Review Committee, and actedupon to safeguard the wellbeing of people receivingservices.

Every provider must have a process for reporting thefollowing incidents to OPWDD:

• Reportable Incidents of Abuse and Neglect

• Reportable Significant Incidents

• Serious Notable Occurrences

Providers must also have systems to manage MinorNotable Occurrences and other potentially harmfulsituations that do not rise to the level of a ReportableIncident or Occurrence.

In addition, some incidents must be reported to theJustice Center. The Justice Center was created for theprotection of people receiving services from facilitiesand programs that are certified or operated by someState agencies, including OPWDD. Reportable Incidentsthat happen in programs and services certified oroperated by OPWDD are reported to the Justice Centeras well as OPWDD.

Types of incidents... Reportable Incidents of Abuse and Neglect include butare not limited to physical, sexual, and psychologicalabuse, as well other prohibited conduct such asdeliberate inappropriate use of restraint, and neglect.

Reportable Significant Incidents include but are notlimited to medication errors that result in adverse effects,use of seclusion, mistreatment, missing person, andchoking events.

Serious Notable Occurrences include sensitivesituations and deaths of people receiving services.

Minor Notable Occurrences include injuries that requiretreatment beyond first aid and theft and financialexploitation (involving$15 to $100).

When sharing the OPWDD 147 Form, OPWDD 148 Formand other records/documents pertaining to allegationsof abuse, providers are required by law to “redact” oredit to delete the names and identifying informationregarding other individuals receiving services andemployees.

How is an investigation conducted? • Every incident must be thoroughly investigated.

• The investigator will gather information from a varietyof sources and prepare a report that includes asummary of evidence, conclusions, andrecommendations. In the case of a report of Abuse orNeglect, the report will also include a finding of"substantiated" or "unsubstantiated."

• The investigative report is submitted to the agency’sIncident Review Committee for review. The Committeeis required to review and monitor investigatoryprocedures (except when the case is investigated bythe Justice Center or the Central Office of OPWDD) andmay in some cases, recommend further investigation.

How and when is the information available? • Qualified parties, advocates, and correspondents willreceive telephone notice as soon as reasonably possiblefollowing a report of an incident. They will also beprovided with an offer to meet with the director of theagency (or his or her designee) to discuss the incident.

• Qualified parties, advocates and correspondents whoreceive notice of an incident will automatically receivea Report on Actions Taken (OPWDD Form 148) within10 days of completion of the report.

• Qualified parties, advocates and correspondents whoreceive notice of an incident may submit a writtenrequest for a copy of the incident report and shouldreceive a redacted copy of the requested report within10 days after the request is made.

• Qualified parties (called "eligible requestors" in Part624 regulations) may also request additionalinformation on reportable incidents, such asinvestigative reports. These reports, which must beredacted, are provided to requestors within 21 daysafter the closure of an incident or within 21 daysfollowing the request if the incident is already closed.

• Written request for records or documents from thatinvestigation should be directed to the agency thatreported the incident.

• Requests may be made for information on incidentsthat occurred in the past. Part 624 regulations includerequirements regarding time frames applicable tothese requests.

• By law, all requested records and documentspertaining to incidents must be redacted (edited) sonames and identifying information about peopleinvolved in incidents are not available to those whorequest incident information.

Who can an advocate (includinga “qualified party” or correspon-dent) speak to for followup? An advocate should feel free to ask questions when heor she receives notice of an incident and may ask tospeak with a supervisor for more information. Theadvocate may also accept the offer to meet with theagency director or designee.

If not satisfied, the advocate may direct questions orconcerns to the director of the agency or other highlevel administrators.

For reports of Abuse or Neglect in a certified program,the Mental Hygiene Legal Services (MHLS) may also be aresource.

The OPWDD Incident Management Unit may also helpresolve outstanding issues.

There is an administrative appeal process for advocateswho have been denied incident records requested froman agency providing services.

Contact the OPWDD Incident Records Appeals Officer at44 Holland Avenue, Albany, NY 12229 for moreinformation.

If you are a member of the public who wants to reportabuse of an individual who receives services in theOPWDD system, there are several ways to do so:

• If you are aware of the name of the agency providingservices to the individual, you may contact the provideragency directly to report abuse.

• If information on the service provider of an individual isunknown, you may report abuse to OPWDD. You cancontact your local Incident Compliance Officer at 518-473-7032 during regular business hours, Mondaythrough Friday. The Incident Management Unit alsohas an off-hours contact number at 1-888-479-6763.

• The Justice Center operates a 24 hour hotline for thereporting of Abuse, Neglect and Significant Incidentsfor facilities and programs certified or operated byOPWDD at 1-855-373-2122.

How to advocate and protect individuals from harmThe qualified party or advocate and service providershould work together to ensure that the person is wellserved and safe. The partnership can begin at a teammeeting, where the person’s individualized plan ofservices and supports is reviewed; at that time, the team,including the qualified party or advocate, can discusssafeguards or interventions that may be required. Suchsafeguards often need to be individualized and specificto the person.

Particularly when unexplained injuries recur, the qualifiedparty or advocate might ask what steps are being takento protect the person from being exposed to the same orsimilar circumstances. While it is not always possible toanticipate the steps required, as they may be specific tothe incident, some possible areas for discussion include:

• changes in the person’s behavior or demeanor;

• the rhythm of the person’s day and week;

• use of/possible need for or change in adaptiveequipment;

• any physical care, health or hygiene problems needingattention;

• clinical/medical evaluation and/or intervention thatmay be helpful;

• level of supervision;

• staff training and re-training efforts; and/or

• conditions in the living or service environment.

Team meetings provide an invaluable forum for thequalified party or advocate and other members toadvocate for protection from injuries, especially thosethat are unexplained and recurring.

For clarification on the information contained in thisbrochure, please contact: OPWDD’s StatewideCommittee on Incident Review.opwdd.scir@opwdd.ny.gov

New York State Office for People With DevelopmentalDisabilities Statewide Committee on Incident Review44 Holland Avenue Albany, NY 12229