Audit Report on the Safety and Wellbeing of Infants Residing in Sampled Department of Homeless Services Shelters

Executive Summary

The mission of the New York City Department of Homeless Services (DHS) is to prevent homelessness, address street homelessness, provide safe temporary shelter, and connect New Yorkers experiencing homelessness to suitable housing. To accomplish these goals, DHS collaborates with not-for-profit partners to provide temporary shelter and various services that homeless New Yorkers need to transition to permanent housing. These providers connect homeless families and individuals with a range of resources, including case management, housing placement assistance, mental health services, and other critical types of assistance.

According to DHS, approximately 50 infants in New York City die from preventable, sleep-related injuries each year. DHS participates in a Safe Sleep Initiative that the City’s Administration for Children’s Services (ACS) and Department of Health and Mental Hygiene (DOHMH) initiated in or around 2015. As part of that initiative, in 2018, DHS issued DHS-PB-2018-01, titled “Safe Sleep Policy on Infants in Shelters for Families with Children” (Safe Sleep Policy), a policy intended to provide shelters with guidelines for safe sleep practices for infants. The Safe Sleep Policy includes provisions (such as the use of stationary or portable crib) for the safety and wellbeing of infants whose families reside at a shelter.  DHS also requires shelters to show families a safe sleep video within 48 hours of their arrival. Shelter staff are required to have each family sign a Safe Sleep Education Acknowledgment and Crib Acceptance/Refusal Form (safe sleep form). If a family decides to use its own crib, shelter staff must obtain approval from DHS.

DHS also requires shelter staff to conduct weekly unit inspections for families with infants. Shelter staff document such inspections by entering a unit inspection note in the Client Assistance and Rehousing Enterprise System (CARES) maintained by DHS and maintaining hard copies of the completed inspection forms within each client’s physical file. DHS monitors shelters by conducting semiannual reviews of all shelters using a checklist drawn from State and local regulations to assess and ensure compliance.  At the conclusion of the evaluation, DHS issues a letter to each provider, outlining the issues noted during the evaluation and requiring shelters to take action to remedy the deficiencies the evaluation identified, if any.

During Fiscal Year 2019, DHS managed 2 City-operated and 155 provider-operated shelters that served families with children.^[1] According to DHS officials, during Fiscal Year 2019, DHS provided shelter to approximately 25,661 families with approximately 46,454 children including 4,824 infants.

Audit Findings and Conclusions

The providers of sampled homeless shelters for families with children do not adequately ensure the safety and wellbeing of infants residing at their shelters. Our inspection of 91 randomly selected units with infants at 13 shelters, during the period of December 9, 2019 through March 12, 2020, revealed 264 deficiencies in two broad categories—(1) unsafe sleep conditions and (2) inadequate unit conditions—that raised concerns about infants’ safety and health. The unsafe sleep conditions we observed involved crib-related deficiencies and the absence of required safe sleep posters. Inadequate unit conditions included defects such as exposed electrical outlets, mold and mildew, vermin infestation, and accessible hazardous substances. We found deficiencies in all 13 shelters we visited and found 4 or more safety concerns in 32 units in 11 of those shelters. In reviewing DHS records, we also found that shelter management often did not update CARES timely to reflect the arrival of newborn infants in families residing in their shelters, which may reduce DHS’s ability to effectively monitor infants residing in shelter.

Two factors contributed to both the unsafe conditions for infants we found at these shelters and the shelters’ failures to report the presence of newborns in CARES timely: (1) shelters did not diligently inform families of safe sleep protocols; and (2) shelters did not consistently perform or document the required unit inspections. As a result of the above-mentioned unsafe conditions and lack of timely recordkeeping, risks to the safety and wellbeing of infants residing in these shelters were significantly increased. Subsequent to our shelter inspections, which were conducted with shelter staff, we asked DHS what, if any, actions had been taken to correct the conditions we had observed. DHS’ response indicates that of the 264 deficiencies we observed, 22 deficiencies pertained to two shelters that had been closed in June 2020, subsequent to our observations. Nearly half of the issues (3 at one shelter and 7 at the other one) remained unresolved prior to the closings. Of the remaining 242 deficiencies, according to DHS, 104 (43 percent) had been addressed prior to our inquiry with DHS; 118 (49 percent) were addressed after we followed up with DHS; 7 (3 percent) were scheduled to be addressed by the end of October 2020; and 13 (5 percent) had not been addressed either by the date of the client’s departure from the shelter or as of November 2, 2020, the last date DHS provided us with information. These 13 issues had been outstanding from 15 through 329 days since the time we first observed them.

The above-mentioned performance failures raise particular concerns because there were no apparent consequences for noncompliant shelter operators. Despite poor performance evaluation scores for 5 of the 13 shelters in our sample, all 5 shelters were nevertheless offered opportunities to continue doing business with the City.  If the conditions we found at these sampled shelters are consistent with conditions at the remaining shelters contracted by DHS, the City faces an increased risk that providers managing shelters throughout the City are offering inadequate housing to homeless families.

Audit Recommendations

To address the issues raised by this audit, we make 10 recommendations, including that:

• DHS should ensure that the shelter providers promptly inspect and correct the conditions that raise safety and health concerns in the 13 sampled shelters identified in this report.
• DHS should update, and enforce, its written policies and procedures to include a specific timeframe in which shelters must update their records in CARES, any successor system, and other records to account for the presence of all infants. The written policies and procedures should cover, at a minimum, updates to the family composition records, and a standard, readily searchable, contemporaneous record of the date every infant, including every newborn, begins residing in the shelter.
• Shelter staff should ensure that they play the prescribed safe sleep instructional video for all families with infants and then obtain properly completed Safe Sleep Education/Acknowledgment and Crib Acceptance/Refusal Forms on time from all families with infants and that they use only the updated form DHS prescribes.
• Shelter staff should ensure that they perform the required weekly unit inspections, that they document the results in a timely manner, and that they take prompt corrective action to address the deficiencies they find.
• DHS should establish and enforce consequences for noncompliance with infant safety policies.

Agency Response

The audit made ten recommendations to DHS. In its response, DHS generally agreed with nine recommendations, although it contends that it was already in compliance with three of them. DHS disagreed with the remaining recommendation (#9) that it reassess the degree to which its semiannual review adequately addresses issues of infant safety and reconsider the detail in which it reports the deficiencies identified through its reviews in letters to providers. In its response, DHS listed the positive attributes it believes it has incorporated within its semiannual review, effectively rejecting the auditors’ recommendations that its current practices need to be improved.

DHS’ response also included objections to our methodology. After carefully reviewing DHS’ arguments, we found no basis to change any of the report’s findings or conclusions. The full text of DHS’ response is included as an addendum to this report.

[1] The 155 provider-operated shelters consisted of 306 locations and were operated by 51 providers. Two additional locations were City-operated.