Oversight and Monitoring

OASAS collects and reviews corrective action plans following reported incidents and Justice Center determinations.


The Justice Center is a state oversight agency charged with taking reports of, investigating and prosecuting allegations of abuse and neglect. After investigation, the Justice Center makes a determination that the abuse and/or neglect is either substantiated or unsubstantiated. These determinations are maintained within the Vulnerable Persons Central Registry (VPCR). OASAS, as the state oversight agency, collects and reviews provider corrective actions taken in response to both the initial incident and the Justice Center’s determination.


Corrective Action Plan

To complete the oversight and monitoring process, the provider must create and implement a corrective action plan. Any action taken in response to an allegation of abuse and neglect is considered a corrective or preventative action. Areas of systemic concern are issues identified that are not specific to one staff member, but require attention and correction across the program.

Whether substantiated or unsubstantiated, a provider should review all incidents involving credentialed/licensed staff to determine the need to file a complaint with the appropriate oversight authority where there is a reason to believe a credentialed/licensed professional has violated ethical or professional standards. Credentialed/licensed staff should also be mindful of their own ethical and professional obligation to report the misconduct of other professional colleagues.




Actions recommended to establish additional services or treatment and/or to improve services to meet an individual receiving services needs/wishes. Actions recommended to meet standards set by treatment/service plan, regulations and/or facility policies.


Actions recommended to implement or improve administrative oversight of staff supervision, staffing patterns, and/or staff training to meet regulatory requirements and facility policies.


Actions recommended to implement or improve policy/procedure in order to meet regulatory requirements.

Incident Management

Actions recommended to improve the incident management practices of the provider. This may include internal and/or external reporting, investigation procedures or reports and/or incident review activities

Physical Plant/Environmental

Actions recommended for correction of identified physical plant/environmental issues (e.g., fire safety; improvement of sanitation; environmental controls; heating & cooling).


Actions recommended to address missing or incomplete documentation.

Safety/Basic Needs/Patient Rights

Actions recommended to make corrections to meet basic needs such as clothing, food, shelter, protection of individual’s rights guaranteed by law/regulation.


Regardless of the outcome (substantiated or unsubstantiated), a Justice Center finding may make recommendations to address and correct the allegations and/or areas of systemic concern identified during the Justice Center investigation. Upon receipt of a Justice Center determination, any steps taken to address and correct the allegations and/or areas of systemic concern identified by the Justice Center, or the provider, as a result of an incident of abuse and neglect must be documented in a corrective action plan (CAP) and submitted to OASAS on the Justice Center Determination Corrective Action Plan form (SQA-55) below.

Providers should submit the corrective action plan (CAP) and supporting documentation to [email protected] within 10 days.


Effective October 13, 2017 any administrative actions taken by a provider related to a custodian with a substantiated category 1-3 allegation of abuse or neglect must be entered into the Administrative Action Reporting Mechanism (AARM). A “Quick Reference Guide,” FAQs, and a “Job Aid” for training may be found on the Justice Center website.

Instructions are contained in the Quick Reference Guide below.