Mortality Review

The deaths of certain individuals receiving services under Justice Center jurisdiction are required to be reported to the Vulnerable Persons Central Register (VPCR) Mortality Review Line.  The agency screens all death reports to determine if further investigation is warranted. 

The Justice Center may conduct an on-site investigation when: 

• An individual commits suicide, either while in a hospital or licensed residential facility, or shortly after discharge from the facility; 
• There is an allegation of abuse; 
• A death appears to be the result of restraint or seclusion; and/or
• A death appears to be a result of inadequate supervision or medical care from a residential setting.

Administrative Reporting Requirement

1. All deaths of individuals receiving services from a residential facility or residential program operated, licensed or certified by the Office for People with Developmental Disabilities (OPWDD), the Office of Mental Health (OMH), the Office of Addiction Services and Supports (OASAS), or the Office of Children & Family Services (OCFS) must be reported to the Justice Center.  In addition, known deaths of individuals who had received services from such a facility or program within 30 days of their death must also be reported. 
2. Providers must call the Justice Center Mortality Review Line at (855) 373- 2124 to make an initial report, and then submit a Report of Death form in writing (OPWDD and OMH programs will continue to be able to utilize IRMA or NIMRS to electronically submit the required information).
3. The Justice Center will review all reports of death under its jurisdiction and may conduct its own investigation.
4. State and private providers should continue to review/investigate deaths in their programs, unless informed otherwise by the Justice Center.

Abuse & Neglect Reporting Requirement

1. If there is any reason to suspect abuse or neglect related to a death,  a report must be made to the VPCR in addition to the administrative death report. Non-residential programs must continue to report suspected abuse or neglect related to a death to the VPCR Hotline. 

• The individual was receiving services from an Office for People With Developmental Disabilities (OPWDD) operated, licensed, or certified residential facility or residential program at the time of their death, or had received services within 30 days of their death.
• The individual was receiving services from anOffice of Mental Health (OMH) operated, licensed, or certified residential facility or residential program, or had been admitted to a Comprehensive Psychiatric Emergency Program (CPEP) at the time of their death, or had received services within 30 days of their death.
• The individual was receiving services from an Office of Addiction Services and Supports (OASAS) licensed or certified residential facility or residential program at the time of their death, or had received services within 30 days of their death.
• The individual was receiving services at the time of their death, or had received services within 30 days of their death from the following: an Office of Children and Family Services (OCFS) operated residential facility or residential program for youth placed in the custody of the Commissioner of OCFS; was receiving services from an OCFS licensed or certified residential facility serving abandoned children, abused children, neglected children, dependent children, persons In need of supervision, or juvenile delinquents; was receiving services from an OCFS Family Type Home for Adults; was receiving services from an OCFS certified runaway and homeless youth program; or was receiving services from an OCFS certified youth detention facility.
• In instances in which an individual received services from more than one provider agency, even if the provider agencies are licensed or certified by the same State Oversight Agency, only the residential provider agency must report the death to the Justice Center. (Example: an individual received residential services from Provider Agency A, and received mental health clinic services from Provider Agency B; only Provider Agency A is required to report the individual’s death to the best of their ability).
• Directors (or their designee) should submit the Justice Center Report of Death to the Executive Secretary, Mental Hygiene Medical Review Board. It is preferred that these forms be received via fax, but can be submitted by mail to the NYS Justice Center for the Protection of People with Special Needs. 

All facilities or programs should also ensure compliance with other applicable rules and regulations.

Who reviews death reports?

Each and every report is reviewed by investigators with human service program experience and health care professionals, including nurses.  The Justice Center is also assisted by its Medical Review Board whenever a medical opinion is required to determine the standard of care.

What does the Justice Center do with reports of death?

The Justice Center receives information about the cause and manner of death as well as specific information about the person's medical, psychiatric, and behavioral presentation 90 days prior to their death.  

The circumstances surrounding the death of a person are examined to assess whether quality of care issues may have contributed and to make recommendations to improve care with the goal of preventing the recurrence of similar issues.

After completion of this assessment, a notification letter is sent to the director of the facility or provider agency and the legal guardian or personal representative notifying them that the assessment is closed.

If there are any concerns regarding the quality of care, the Justice Center will make a report and, where appropriate, make recommendations to prevent future lapses in care.  The report is issued to the director of the facility or provider agency, the State Oversight Agency, and the legal guardian/personal representative.

What if there is an allegation of abuse or neglect?

The Justice Center notifies the appropriate district attorney and medical examiner if there is any reason to suspect abuse or neglect.  The Justice Center also launches its own investigation in the same manner as any other abuse or neglect allegation.

Do parents, guardians, and/or personal representatives receive notification when a death has been reported?

The program or provider agency is required to notify the legal guardian or personal representative after learning of a death or learning of an allegation that was reported to the Justice Center.

Step 1: Make a report

Call the death into the VPCR at 855-373-2124

Step 2: Fill out form

Every Director (or their designee) should complete the Justice Center Report of Death form as thoroughly as possible within five (5) working days of the discovery of the death.  Instructions for the Report of Death form should be reviewed.  When complete, forms should be submitted to:

Mortality Review

NYS Justice Center for the Protection of People with Special Needs

401 State Street Schenectady, NY 12305

Reports can also be faxed to 518-457-3503.