by Jake Pearson, illustrations by Dominic Bodden, special to ProPublica

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The temperature was plummeting on Thanksgiving eve when Judith Zbiegniewicz wrapped herself in a blanket, picked up her phone and tapped out yet another plea for help to New York Guardianship Services. It was 2018, and for the previous five years the company, whose slogan is “caring that makes a difference,” had overseen nearly every major decision in her life, as it did for hundreds of New Yorkers deemed incapable by the courts of looking after themselves.

The organization had repeatedly maintained in court filings that Zbiegniewicz, who was 65 and suffered from depression and anxiety, was doing well under its supervision and that the Queens apartment it had placed her in was the “best and only place for her.” Each year, court examiners reviewed the reports and a judge signed off on their assessments.

In truth, though, Zbiegniewicz lived in squalor on the second floor of a dilapidated home whose roof had partially collapsed. She’d complained when her mattress teemed with bedbugs and when rats gnawed the legs of her kitchen chairs. Yet every month, her legally appointed guardian had taken $450 in compensation from her bank account as her living conditions deteriorated.

Now, with no heat and a cold front barreling down on the city, she stuffed bath towels under a door to block the draft and again appealed to NYGS.

“While you and every one at the guardianship are home in a warm house and having Thanksgiving dinner think of me. In a apartment without heat and can’t,cook. And rats in the kitchen,” she wrote on the evening of Nov. 21, 2018. “So much for where caring makes a difference.”

Three decades ago, New York was at the vanguard of a national movement to prevent such exploitation. State lawmakers passed progressive legislation to codify wards’ civil rights and maximize their independence. Under the law, guardianships were supposed to be tailored to the needs of the individual, with regular court examination to safeguard their welfare.

But today, the system is in shambles, leaving thousands of vulnerable New Yorkers sequestered, voiceless and forgotten while the officials who oversee their care struggle to ensure it, according to a ProPublica investigation. In New York City, there are just over a dozen judges to handle the 17,411 people in guardianships, data provided by the courts show. With that load, cases can sit for years without any kind of meaningful oversight. The hardest hit are poor New Yorkers like Zbiegniewicz, whom the state has entrusted to a network of loosely regulated nonprofits. The outcomes for some of these individuals — known in industry parlance as the “unbefriended,” because they have no family or anyone else to help them — have been dire.

In one case, a guardian didn’t notice his ward had died and continued to collect payments for the man’s care even after his death. In another, a guardian told the court in a report that they didn’t know where their ward was for a year. Case managers had visited her apartment but never went in. Eventually a utility worker discovered the woman’s corpse, covered in maggots, decomposing in her own bed.

That the 1990s reforms have failed has been an open secret for years among advocates, lawyers and judges, who have repeatedly called for an overhaul. But the state lawmakers and judicial leaders who have the power to improve it have not done so — even as cases like that of Britney Spears have brought national attention to the issue of guardianships.

ProPublica reviewed hundreds of pages of court records, interviewed dozens of lawyers and experts and talked to the wards who are least equipped to advocate for themselves. What we found is that some of the remedies that policymakers introduced 30 years ago to bolster care and curb abuse, like minimum qualifications for guardians and court examination of their reports, are in dire need of an upgrade.

Today, for example, it is far easier in New York to become a guardian than a nail technician. Parties need only complete a day-long course — far less training than is required in some other states, including California, Texas and Florida. And oversight of their work is similarly threadbare, consisting primarily of a court-appointed examiner who focuses almost exclusively on financial paperwork and a judge who signs off on the examination. But with thin ranks of reviewers, annual assessments can take years to complete. And officials rarely, if ever, see the wards in person.

The easy entry and lack of oversight, critics say, has helped attract unscrupulous nonprofits that take advantage of the wards they are supposed to protect.

In 2015, the chief financial officer of one nonprofit was convicted for stealing more than $50,000 from a ward’s accounts, government documents show. That same year, state regulators found that another nonprofit improperly loaned its top officials more than $250,000 while wards were unnecessarily kept in nursing homes.

Today, even those who helped write the state’s main guardianship statute, known as Article 81 of the Mental Hygiene Law, concede the yawning gap between its promise and its practice has rendered it, in the words of one, “basically pointless.”

“Keeping people out of guardianship in the first place is the single most important thing to do, because once you’re in it, it’s the toilet you get flushed down,” said Kristin Booth Glen, a former judge who helped craft the law and has called for reform for years. New York’s oversight of guardianships has been “a total and utter disaster,” she said.

Few groups illustrate the consequences of that failure better than NYGS, the organization that was supposed to care for Zbiegniewicz. Over the past decade, the company has grown to become one of the largest providers in the business, drawing $450 in monthly compensation each from hundreds of wards’ accounts while providing as few services as possible, according to court documents and six people familiar with the company’s operations, including former employees.

“Everybody is shirking responsibility,” said Carla Billini, the former director of case management for NYGS. She resigned last April after a decade in the job, saying she was fearful that the company’s practices would result in harm to wards. “How is there nobody above the guardian who watches all the guardians?”

A spokesperson for the Office of Court Administration, which runs New York’s court system, said that judges face “extremely challenging circumstances” but do the best they can under the law. “The caseloads are extremely high and individual cases can persist for decades,” he said. “Yet, the courts never give up in searching for solutions to ensure the well-being of some of society’s most underserved populations.”

NYGS executives declined to be interviewed for this story. In a statement, Sam Blau, the company’s chief financial officer, said that as a fiduciary he was barred from answering questions “about any specific client.” However, he noted, “we are accountable to the Court and our annual accounts and reports are scrutinized by Court appointed examiners and any issues would be addressed.” NYGS did not answer written questions about the company’s broader business practices.

In his statement, Blau called ProPublica’s reporting “misguided, without full and proper context, filled with omissions and less than accurate information.” But when asked to specify his concerns, he did not respond.

Zbiegniewicz’s decadelong experience as a NYGS ward serves as a road map to how Article 81 fails New Yorkers who are least able to protect themselves.

Zbiegniewicz’s introduction to guardianship came as it does for thousands of others in the city each year: through a call to the city Adult Protective Services program by someone concerned about her well-being.

It was November 2008, and Zbiegniewicz was struggling financially and emotionally. Her father had died suddenly from a heart attack a year and a half earlier, leaving her the family’s Maspeth, Queens, home — and, to her surprise, a reverse mortgage. The outstanding debt was $266,532.95.

Zbiegniewicz had no job and no way to pay. She had been dependent on her father all of her adult life, the result of an early trauma: At 18, she was raped leaving the subway on her way to work at Queens’ Welbilt Stove plant. Her world became small, as her devastated parents shielded her. She never sought therapy, never returned to work and rarely ventured beyond the comfort of her block.

Now, with the house in foreclosure, someone called........

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