Division of Aging Services Adult Protective Services Case Review Guide – Investigation and Assessment

Rev. 8/27/19

Region:

Review Date:

Name of Supervisor:

Investigation ID:

Name of Client:

Name of Caseworker Assigned to Case:
Review Guide Question Yes No N/A Comments Documentation Needed In Record Where Found in the DAS Data System

1. Was client status in additional Aging Programs verified and documented? [P]

  • Search has been completed in DAS Data System to determine if client is currently participating in other Aging Programs.

  • Document entered regarding verification of program status

Intake report

Search within Consumer Tab (only use Filters – Last Name Contains, First Name Contains)

APS Investigation - Notes

2. Was there verification that the alleged victim is not duplicated in the Electronic Data Record? [P]

  • Search has been completed in the DAS Data System to determine if the client is duplicated in the system

  • Document entered that duplicates have been linked or request has been made to have records linked

Search within Investigation Tab (only use Filters – Last Name Contains, First Name Contains)

Search within Associated Investigations Subpage

APS Investigation - Notes

3. Was the intake report documented and copy sent to Law Enforcement?

APS Reports and Opening Cases 2.001 [P]

The documentation shows that the intake report was received, and notification sent to Law Enforcement

This review question is N/A if intake allegations are ONLY for self-neglect.

APS Investigation - Notes

4. Was the initial face to face contact made (or documentation to support that attempts were made) with the client within 10 calendar days of the date the report was received by Centralized Intake?

Contact and Documentation Standard 1.1 [C]

  • The first successful client contact recorded in DAS Data System was dated no later than 10 calendar days from the date of intake. The contact record indicates the CM had a face to face contact with the client on that date or

  • The documentation shows that reasonable attempts were made to make the initial client contact within 10 calendar days in the APS Investigation Contact Record(s). “Reasonable attempts” may include documentation of a) multiple contacts (2 or more) with the reporter and/or collaterals to determine the whereabouts of the client; b) repeated (2 or more) home visits/field visits/calls to the client’s residence including dates messages left; c) calls and/or visits to local medical facilities, jails, hotels, etc. to locate the client.

APS Investigation – Notes: 1st Face to Face

5. Is there documentation in the DAS Data System to indicate the client was interviewed in private or attempts were made to interview the client in private?

Contact and Documentation Standards 2.2 [C]

  • The documentation shows that the client was interviewed in private or

  • The documentation shows that an attempt was made to observe/interview the client in private. Note: N/A cannot be marked for this question.

APS Investigation – Notes: 1st Face to Face

6. Is there documentation of public benefits that the client is receiving (i.e. TANF, SSI, Food Stamps, VA funds, Medicaid, Medicare, etc.) [P]

The documentation indicates that an attempt was made to obtain public benefit information from the client or information obtained by intake was verified.

This review question is N/A if client refused to provide public benefit information.

Documentation should indicate that client refused to give information

APS Intake

APS Investigation - Notes

7. Did the documentation describe the impairments/unmet needs in the DON-R comments section if the DON-R ADL/IADL scores indicated the client had impairments and/or unmet needs that put him/her at risk for ANE?

Contact and Documentation Standards 2.8 [P]

Refer to your last DONR training when reviewing this element.

The documentation described specific issues the client had with ADLs/IADLs in the comments section of the DON-R.

This review question is N/A if scores did not indicate impairments and/or unmet needs.

APS Investigation – DON-R (Client) APS

8. Is there a HIPAA form in the client’s record that has been signed or if not signed, an explanation is noted in the client record why the record was not signed?

Contact and Documentation Standards 2.7 [P]

  1. A signed HIPAA form has been uploaded in the DAS Data System or is in the client’s hard record or

  2. A HIPAA form without the clients' signature is in the record (electronic or hard) and the record includes documentation on the reason why the form was not signed.

*If physical copy is kept, documentation should comply with record keeping standards

APS Investigation – Notes

9. Is there a Release of Information form in the client’s record that has been signed or if not signed, an explanation is noted in the client record why the record was not signed?

Contact and Documentation Standards 2.7 [P]

  1. A signed Release of Information form has been uploaded in the DAS Data System or is in the client’s hard record or

  2. A Release of Information form without the clients' signature is in the record (electronic or hard) and the record includes documentation on the reason why the form was not signed.

*If the unsigned copy is not uploaded, note should indicate reasons why the document was not signed by the client

APS Investigation – Notes

10. Is there documentation that one or more collateral contacts were made with individuals who are of benefit to the investigation?

Contact and Documentation Standards 2.4 [C]

The documentation indicated that one or more contacts were made with individuals who have knowledge of the client and/or the situation which could substantiate or not substantiate the allegation in the APS report (i.e., neighbors, non-household family, postal worker, employers, etc.)

This review question is N/A if no collaterals were listed on intake report and no collateral information was obtained

APS Investigation – Notes: Collateral Contact

11. Is there documentation in DAS Data System that the reporter was contacted, or an attempt was made to contact the reporter?

Contact and Documentation Standards 2.3 [P]

  • There is documentation in the DAS Data System that the original reporter was contacted or

  • At least one APS Investigation Contact or documentation in the Notes of the DAS Data System that shows an attempt was made to contact the reporter (Can be a successful or not successful APS Investigation Contact).

    If the reporter was anonymous, this review question is not applicable (N/A).

APS Investigation – Notes: Collateral Contact

12. Is there documentation in DAS Data System that the alleged perpetrator was interviewed or an attempt to interview was made?

Contact and Documentation Standards 2.6 [P]

  • Documentation in an APS Investigation Contact record shows that the alleged perpetrator was interviewed in person (if not reason why face to face was not possible) or

  • At least one attempted contact with “perpetrator” is recorded in an APS Investigation Contact record or an Investigation Contact record shows that an interview with the alleged perpetrator was not completed and the reason provided

    If there is no alleged perpetrator, this review question is N/A.

APS Investigation – Notes: Collateral Contact

13. Is there documentation in DAS Data System that the identified caregiver was interviewed, or an attempt was made to interview the caregiver?

Contact and Documentation Standards 2.4 [C]

  • Documentation in one or more APS Investigation contact record(s) shows that an identified caregiver was interviewed or

  • The documentation in an APS Investigation contact record indicates that an attempt was made to interview an identified caregiver.

    If there is no identified caregiver, this review question is N/A.

APS Investigation – Notes: Collateral Contact

14. Is there documentation in DAS Data System that adult household members were interviewed, or an attempt was made to interview other adult members of the household?

Contact and Documentation Standards 2.4 [C]

  • The documentation shows one or more APS investigation contact records where other members of the household were interviewed. (Note: If the individual is in a boarding home, PCH or NH, residents at these facilities could be included in this group) or

  • The documentation in the APS Investigation contact record(s) indicates that an attempt was made to interview other members of the household.

    If there are no adult household members, this review question is N/A.

APS Investigation – Notes: Collateral Contact

15. Were neighbors, friends and/or relatives in the community mentioned at the time of Intake and/or identified during the investigation interviewed or were attempts made to interview these collateral contacts?

Contact and Documentation Standards 2.4 [C]

  • One or more APS Investigation contacts indicate that contact was made with neighbors, friends and/or relatives not living in household who were collateral contacts or

  • The documentation in the APS Investigation contact record(s) indicates that an attempt was made to interview neighbors, friends and/or relatives in the community who are collateral contacts.

    If there were no neighbors, friends and/or relatives in the community mentioned at the time of Intake and/or identified during the investigation to be interviewed, this review question is N/A.

APS Investigation – Notes: Collateral Contact

16. Were formal service providers (e.g. staff employed by senior centers, day care centers, home health agencies, behavioral health case managers, etc.) interviewed or were attempts made to interview providers?

Contact and Documentation Standards 2.4 [C]

  • One or more APS Investigation contacts indicate that contact was made with formal service providers, as indicated in the AIMS Investigation Contact Record or hard copy record or

  • The documentation in the APS Investigation contact record(s) indicates that attempt(s) were made to interview formal service providers who were collateral contacts.

    If there were no formal service providers mentioned in the Intake and/or identified during the investigation, this review question is N/A.

APS Investigation – Notes: Collateral Contact

17. Were medical providers interviewed or were attempts made to interview the medical providers?

Contact and Documentation Standards 2.4 [C]

  • One or more APS Investigation contacts or documentation in the hard copy record (e.g., medical statements) indicates that contact was made with medical providers or

  • The documentation in the APS Investigation contact record(s) indicates that attempt(s) were made to interview medical providers who were collateral contacts.

    If there were no medical providers are mentioned in the Intake and/or identified during the investigation, this review question is N/A.

APS Investigation – Notes: Collateral Contact

18. Was a contact made to a financial institution, conservator and/or other individuals who have knowledge of and/or manage the financial affairs of the client or were attempts made to interview these collaterals if financial exploitation and/or exploitation of property was alleged or uncovered during the investigation?

Contact and Documentation Standards 2.4 [C]

  • One or more successful collateral contacts in DAS Data System indicate that a contact was made with a financial institution and/or other who have knowledge of the clients' financial circumstances and/or the hard copy record contains documentation from the financial institution or others who have financial information/records.

  • The documentation in the APS Investigation contact record(s) indicates that attempt(s) were made to interview individuals who had knowledge of and/or financial exploitation/exploitation of the property of the client.

    If no allegation or evidence uncovered to indicate financial exploitation and/or exploitation of the property occurred, this review question is N/A.

APS Investigation – Notes: Collateral Contact

19. Was an income worksheet completed and in the DAS Data System? [P]

  • The documentation indicates that the income worksheet was completed, or attempts were made to complete the income worksheet with the client

  • A request was made for ERF and the income worksheet was completed to justify the needs for the funds

    If no allegation or evidence uncovered to indicate financial exploitation and/or exploitation of the property occurred, and/or there was no request for ERF, this review question is N/A.

APS Investigation - Notes

20. Was a SLUMS Examination Assessment completed for clients where cognitive impairment is alleged or suspected? [P]

  • The documentation in the APS Investigation contact record indicate that there are questions or concerns regarding client’s capacity

  • The documentation indicates that there is no medical provider or contact was made or attempts were made to interview medical providers and capacity remains in question

  • Client was assessed, or attempts were made to complete examination with client

    If capacity is not in question and/or there is documentation from medical provider to refute concerns regarding capacity, this review question is N/A

APS Investigation – Notes

APS Investigation - Documentation

21. Was a Diligent Effort to Locate form completed and documented if there was an unsuccessful effort to locate the client?

Contact and Documentation Standards 2.2 [C]

  • The documentation in the DAS Data System indicates that reasonable attempts were made to locate client

APS Investigation - Documentation

17. Was the APS ANE Risk Assessment completed and indicated the following: insurance status, health and functional status, social/emotional support, mental health treatment/history and services offered/requested

[C&P]

  • Investigation completed, and results of the investigation documented in the APS ANE Risk Assessment.

  • The Risk Assessment indicates that information was obtained or an attempt was made to gather information regarding insurance status, health and functional status, source of social/emotional support, mental health treatment/history, services offered/requested

APS Investigation – Documentation: APS ANE Risk Assessment

Insurance Status (Medical Problems), Health and Functional Status (Personal and Social Vulnerability and Medical Problems), Source of social/emotional support (Mental/Emotional Characteristics), Mental health treatment/history (Mental/Emotional Characteristics), Services offered/requested (Social Services)

22. Was the investigation completed within 30 business days/45 calendar days of receipt of the initial APS report?

Contact and Documentation Standards 2.8 [C]

  1. The APS Assessment “Complete Date” will be within 30 business days/45 calendar days from the date of Intake if the CM successfully made face to face contact with the client and the investigation is complete or

  2. A Diligent Effort to Locate form indicates that no successful client contact was made (i.e., the client was not seen) and

  3. The DAS Data System record indicates that the APS Investigation/Assessment was closed within 30 business days/45 calendar days of the date of Intake.

APS Investigation – Documentation: APS ANE Risk Assessment (date Investigation ended)

APS Investigation – Determination: Completion Date

23. Was the investigation determination documented in the DAS Data System?

Contact and Documentation Standards 2.8 [P]

The APS Assessment Justification/Closure Statement will be in the client Electronic Data Record. The statement will:

  1. Summarize the findings from the Investigation.

  2. If the case needs to be opened for on-going services, the CM will indicate that the client is personally and socially vulnerable, and is at continued risk for further A/N/E (endangered), cannot protect him/herself from further A/N/E and is in need of APS On-going services

  3. If the case is closed at the conclusion of the investigation, documentation should indicate the reasons for closure, if the client is or is not personally and socially vulnerable and may be or may not be at continued risk for further A/N/E (endangerment).

  4. The documentation should indicate if, at the time of closure, the client is at risk for serious injury and/or death, the reason for the closure (e.g., client declined APS services, etc.)

APS Investigation – Documentation: APS ANE Risk Assessment

APS Investigation – Allegations

APS Investigation – Determination

24. Does the documentation indicate that a report was sent to the District Attorney and/or law enforcement on all cases involving abuse, neglect and/or exploitation prior to or upon substantiation of the allegations in the case?

Contact and Documentation Standards 2.10 [C]

The Disabled Adult and Elder Persons \Report should be entered and saved in a WORD document. The report should indicate the name of the person/agency to who it is directed and the case findings & disposition of the case (e.g., opened for on-going APS services). The date of the LE report should be on or before the DAS Data System investigation completed date for substantiated cases of abuse, neglect and/or exploitation. A copy of the report should be uploaded into the Electronic Data Record, if maintaining physical records, a copy should be placed in the client’s hard record and a copy sent to the District Manager

APS Investigation - Notes

25. Is there evidence of supervisory approval of the investigation, assessment and case disposition in DAS Data System through the case staffing at the close of the investigation?

Contact and Documentation Standards 2.9 [C]

Staffing with supervisor documented in the DAS Data System.

APS Investigation – Notes

APS Investigation – Determination Notes

Check one:

  • Supervisor

  • District Mgr. 2nd level review

  • 2 Ptree Staff/Special Review

  • P & I Review

Case Corrections or Other Follow Up Needed?

  • No

  • Yes

If yes, date due _________

Date discussed with CM _________

Date Case Corrections/Follow Up Completed: (if sent back for corrections or Closure was denied)

Case Review Comments:
Emergency Relocation Funds (ERF) – Use if applicable for the case

1. Is there documentation in the DAS Data System to indicate the need for ERF?

  • The documentation in the APS Investigation Record indicates the need for ERF (Emergency Relocation Funds)

  • Information has been provided to indicate that all other resources have been used or attempts to use prior to requested ERF

APS Investigation – Notes

APS Investigation – Documentation: APS ERF Application and Approval Form

2. Is the ERF request/authorization documented in the Electronic Data Record?

Contact and Documentation Standards 3.16 [P]

A copy of the APS ERF Application and Approval Form, ADPOR (Authorization for Disbursement/Purchase Order) to DFCS Regional Accounting, along with all required and supporting documentation is in the Electronic Data Record.

The Supervisor, the District Manager and/or State Office Representative has approved the request by completing the ERF Decision in the DAS Data System and signing off on the APS ERF Application and Approval Form, ADPOR to DFCS Regional Accounting, and supporting documentation.

APS Investigation – Notes

APS Investigation – Documentation: APS ERF Application and Approval Form

3. Was an income worksheet completed and in the Electronic Data Record?

Contact and Documentation Standards 3.16 [P]

The Income Worksheet was completed and provides justification or supporting need for ERF.

APS Investigation – Notes

Case Management Review – Quality Review regarding documentation standards within the case