The Initial Findings Shall Be Summarized and Forwarded to the Central Registry Unit (CRU)

DIVISION OF SENIOR AND DISABILITY SERVICES

Adult Protective Services Policy Manual

Joint Investigations 1703.30

Statutory authority to investigate and provide protective services to eligible adults has been given to the Department of Health and Senior Services, Division of Senior and Disability Services (DSDS). All specified mandated reporters are required to report suspected incidents to the department or face penalties for noncompliance. Primary responsibility for investigating reports lies with Adult Protective Services (APS) staff within DSDS. However, there are situations in which it is appropriate/recommended that staff conduct joint investigations with other agencies to maximize the thoroughness of the investigation and avoid duplication of efforts.

I. Accessing Department of Health and Senior Services, Office of General Counsel

If it is determined that a report indicates an investigation will warrant legal assistance from the Office of General Counsel (OGC), the appropriate department designee for OGC shall be contacted. Attorneys shall be involved at the earliest point in the investigation to facilitate thoroughness and minimize need for additional follow-up by staff. In every instance, the Adult Protective & Community Worker (APCW) shall inform the Adult Protective & Community Supervisor (APCS) as soon as it is determined a report indicates that it will be necessary to contact OGC. The APCS shall make all necessary contacts for legal assistance. The APCW may make this contact at the direction of the APCS.

OGC attorneys may be contacted to assist APCWs during the course of their investigation. Such assistance may include: information regarding courtroom procedure, advice from evidence experts, strategy advice, and general information which assists in deciding which way the investigation should proceed.

Involvement of an OGC attorney does not preclude notification of local law enforcement and the local prosecutor. However, when warranted, OGC may make a referral for prosecution, which would fulfill the APCW’s responsibility of notifying the prosecutor.

Any involvement of OGC shall be documented as a recording in Case Compass.

When necessary, to assure staff access to assistance without compromising the safety of a reported adult (RA), the following protocols shall be followed to obtain legal and/or investigative assistance:

Required Referrals to OGC: Involvement and/or referral to an attorney (OGC or local prosecutor) shall be required anytime the evidence indicates that the life of an RA may be in danger upon subsequent investigation by the division.

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A. Guardianship/Conservatorship

The APCS, in consultation with the Regional Manager (RM), shall authorize the APCW to make the necessary contact(s) for guardianship/conservatorship issues. OGC shall be contacted regarding all cases in which DSDS is recommending OGC file the petition for guardianship/conservatorship (see Policy 1704.48).

B. EDL

The Employee Disqualification List (EDL) program attorney in OGC (or his/her designee in Central Office) shall answer questions about cases that may result in a referral to the EDL (see Policy 1702.90). As required in statute, a referral to the EDL attorney shall be made on any investigation in which the APCW has found ‘reason to believe’ that one of the following has occurred: Ÿ abuse or neglect (including financial exploitation) of an in-home services participant by an in-home services employee (192.2475 RSMo); Ÿ abuse or neglect (including financial exploitation) of a Consumer Directed Services (CDS) participant by a CDS vendor or personal care attendant (208.912, RSMo); Ÿ misappropriation of property/funds or falsification of service delivery documents of an in-home service participant by an in-home service employee (192.2480 RSMo); or Ÿ misappropriation of property/funds or falsification of service delivery documents of a CDS participant by a CDS vendor or personal care attendant (208.915 RSMo).

Subpoenas

Questions regarding circuit/probate court subpoenas shall be directed to OGC. Upon receipt of a subpoena for testimony and/or a case record, the APCW shall upload the subpoena with the Subpoena Cover Sheet to the OGC case management system (see Policy 1703.80, Exhibit A). A copy of the subpoena and cover sheet shall be scanned and uploaded into the most recent case in Case Compass involving the subpoena (see Policy 1703.80). The APCW shall complete a Case Note Recording in all cases involving the subpoena to indicate into which case the subpoena was uploaded. If the subpoena is from a Public Administrator who is designated by the department to receive confidential information, the APCW shall provide OGC with this information (see Policy 1702.80).

II. Accessing Department of Health and Senior Services, Special Investigations Unit

The Special Investigations Unit (SIU) may assist APS staff in the investigation of reports of abuse, neglect, and exploitation by offering investigative assistance. This assistance may include, but is not limited to: consultation on the investigative procedure, determination of civil or criminal circumstances, assistance with gathering of evidence, referral and joint investigation.

If it is determined that a report indicates an investigation will warrant consultation with or referral/joint investigation with SIU, the APCW shall contact the APCS regarding the type of assistance needed. Cases appropriate for consultation or referral for joint investigation shall include, but are not limited to: Ÿ liaison with law enforcement where the investigation involves: . high profile cases

. access to evidence or information is being denied

. allegations of homicide

. missing persons

. unsuccessful attempts in involving or contacting law enforcement

. multiple jurisdictions; Ÿ reports indicating a substantial amount of evidence will need to be collected; Ÿ reports indicating professional preservation of physical evidence is necessary; Ÿ financial institution refuses to honor the Consent to Release Financial Records (DA- 6); Ÿ complex cases requiring extensive resources and/or time (those cases involving a significant number of witnesses, multiple RAs, victims, or alleged perpetrators (APs), but would not apply to routine EDL cases); or Ÿ cases warranting a referral for prosecution in which the referral cannot be made at the local level (see Policy 1703.72).

When the APCS has questions regarding the situation or needs clarification regarding whether a referral to or joint investigation with SIU is necessary, it may be appropriate to contact SIU for consultation. This contact may be made by the APCS and/or the APCW.

If an investigation warrants referral to SIU and/or joint investigation with SIU, the APCW and/or the APCS shall complete an SIU Request for Investigation form (see Policy 1703.30 Exhibit A). This form includes the following: Ÿ victim’s (RA’s) name and report number Ÿ suspect’s (AP’s) name Ÿ the nature of the request (crime involved abuse, neglect, or exploitation) Ÿ a brief synopsis of the case investigation to date The APCS shall send this form via e-mail through the RM and HCS Bureau Chief to SIU. A copy of this form shall be scanned and uploaded into the Reported Adult’s (RA’s) electronic record in Case Compass. If the investigation involves more than one case, the form shall be uploaded into the most recent case. The APCW shall complete a Case Note in all cases involving the request to indicate into which case the SIU request was uploaded.

Along with the form, the email to SIU referring a case for joint investigation shall include the reason SIU’s involvement is being requested.

When a case has been accepted by SIU the following shall occur: Ÿ The APCS shall enter the appropriate Disposition Code, “SIU Involved”, in the Dispostion Tab in Case Compass and shall leave the case in open status while SIU continues the investigation (see Policy 1703.70). Ÿ The assigned SIU Investigator shall contact the referring RM, APCS or APCW as appropriate to obtain evidence collected prior to referral (see Policy 1703.72) and coordinate with them to exchange information as appropriate.

The APCW will continue to investigate, assess, address and/or monitor the RA’s situation which may include unmet needs, whether physical, emotional, or social in nature, that require assistance or interventions on the part of the APCW. Questions or concerns regarding the involvement of SIU shall be discussed with the HCS Bureau Chief when appropriate.

Upon the conclusion of an investigation of a case referred to SIU or jointly investigated with SIU, written notification of the disposition of the case will be sent from SIU by email to the referring RM, HCS Bureau Chief, APCS and APCW. The APCW shall update the Allegations tab as appropriate. The APCW shall also complete the Investigation Summary on the Dispostion tab in Case Compass according to SIU’s findings and shall update the status and disposition of the report as indicated by SIU.

NOTE: In certain circumstances, it may be necessary for SIU to delay a written summary or provide only minimal information for the summary due to ongoing investigations by law enforcement or specific instructions by a prosecutor.

III. Law Enforcement

The APCW shall involve local law enforcement or the court system when necessary (see Policy 1704.40). The APCW shall inform the APCS of joint investigations with law enforcement. Contact with law enforcement authorities will be expected any time allegations or information is obtained which causes reason to believe and/or suspect that: Ÿ emergency entry of the premises is needed; Ÿ emergency removal of the RA from the premises is needed; Ÿ caregiver or other party will (allegedly) refuse to allow the investigation to be conducted; Ÿ the life of the RA may be in danger upon (subsequent) investigation by the division; Ÿ the RA faces the likelihood of serious physical harm if not placed in a medical treatment facility; Ÿ abuse or neglect meeting the statutory definition of the Crime of Elder Abuse has occurred (see Policy 1702.40); Ÿ report indicates physical evidence needs to be professionally gathered or preserved; Ÿ information indicates the eligible adult is being held against his/her will; Ÿ homicide or reported suicidal threats have occurred; Ÿ misappropriation of a Home and Community Based Services (HCBS) participant’s property or funds or falsification of service delivery documentation that has placed the participant at risk has occurred; or Ÿ information suggests substantial risk or danger to the APCW (see Policy 1703.10). Other circumstances in which the APCW may involve law enforcement prior to a face-to-face visit with the reported adult include: Ÿ to obtain background information about subjects in the report (e.g. past law enforcement involvement, potential threat to the APCW, reported adult, etc.) Ÿ the report indicates an unrelated serious crime may have been committed Ÿ there is reason to believe the AP will flee if the APCW is not accompanied by law enforcement

Ÿ notification of law enforcement is needed to preserve the peace Ÿ it is believed that law enforcement may have relevant information about the situation (for example, a past involvement in disputes, a party to the situation having previously been jailed, etc.)

The APCW shall cooperate with law enforcement during the investigation as requested. The degree of involvement by DSDS in the gathering of evidence shall be at the discretion of the law enforcement agency.

When appropriate, the APCW shall coordinate with law enforcement to interview the AP. This may involve a joint interview, the APCW witnessing the interview, or the APCW obtaining documentation of the interview conducted solely by law enforcement. If the AP interview will be conducted solely by law enforcement, the APCW shall request that the APCS waive the AP interview and shall request a copy of the AP interview from law enforcement.

The request to the APCS and the reason for the request must be documented in the Recordings in Case Compass. If the APCW is requesting a waiver of the AP interview, the APCW shall “Request an Exception” in Case Compass, selecting the “Waiver” exception type and the appropriate exception reason. This will generate a notification to the APCS. The decision to waive the AP interview must be clearly documented in Case Compass and include justification for the waiver of the AP interview. Sufficient information must be presented by the APCW in order for the APCS to approve the exception request.

Any involvement of law enforcement shall be documented in the Recordings in Case Compass. On those cases in which a police report has been filed, the APCW shall obtain a copy of this report as documentary evidence (see Policy 1703.20). The Police Report Request (DA-19) shall be completed to provide a written request for this document when necessary (see Policy 1707.45). The copy of the police report and/or the copy of the AP interview shall be scanned and uploaded to the most recent case relevant to the police report/interview in Case Compass. The APCW shall complete a Case Note recording in all cases involving the police report/interview to indicate into which case the documentation was uploaded. Anytime a document containing pertinent information to the report is too large to be uploaded into Case Compass, pedigree information regarding that document, including the location of the document, shall be noted in the Recordings tab (see Policy 1703.20).

Required Referrals: Notification of law enforcement and the prosecutor is required by law on all reports alleging elder abuse by a perpetrator other than self with a final determination of ‘reason to believe’ (565.186, RSMo).

IV. Licensing Authority

A. Division of Regulation and Licensure, Section for Long Term Care Regulation (SLCR)

Reports received by the toll-free Elder Abuse Hotline that allege that a resident of a state-licensed facility has been abused or neglected by an owner, operator, or employee of such facility will be forwarded by the Central Registry Unit (CRU) to SLCR for investigation. Reports that allege that a resident of a state-licensed facility has been abused, neglected, and/or exploited by an outside perpetrator will be forwarded to DSDS for investigation. Based on feedback combined with the information contained in the report, the APCW, in consultation with the APCS, shall consult with SLCR and follow the lead of SLCR staff in ensuring the protection of the resident in the facility.

During the course of an investigation, APCWs may observe situations within a facility, although residents are not in immediate danger, which may be in violation of regulatory requirements. Potential regulatory violations shall be reported to CRU to ensure appropriate handling and recording. These violations include, but are not limited to: Ÿ cleanliness problems; including sanitation, infection control, pests, general housekeeping, building, equipment, and maintenance problems Ÿ inadequate staffing Ÿ insufficient nutritional services or practices Ÿ personal hygiene regarding residents or staff Ÿ residents within a Residential Care Facility (RCF) or Assisted Living Facility (ALF) who are unable to negotiate a pathway to safety with or without assistive devices EXCEPTIONS: 1) a person is temporarily incapacitated (not to exceed forty-five days) due to illness, surgery or injury 2) an ALF I allows residents who require minimal assistance to evacuate the facility and an ALF II allows residents who require more than minimal assistance to evacuate the facility Ÿ missing records or significant lack of documentation

Ÿ facility’s failure or refusal to allow residents to exercise their legal rights Good communication is essential between DSDS and SLCR. Therefore, the APCW, in consultation with the APCS, shall contact the SLCR Complaint Unit in the appropriate regions when investigating complaints related to a resident residing in a long term care facility. SLCR may contact the appropriate RM for the exchange of information and request for assistance such as in the closing of a facility and relocation of residents.

B. Other Licensing Entities:

Upon request, APCWs shall conduct joint investigations with the appropriate agencies on behalf of RAs cared for by licensed entities (see Policy 1702.15).

V. Office of the Missouri Long-term Care Ombudsman 1/800-309-3282

Reports that allege a violation of Resident Rights shall be referred to the Office of the State Long-term Care Ombudsman. The APCW shall follow the lead of the ombudsman office and assist in the investigation, as necessary, to ensure protection of the resident. The Ombudsman should be contacted whenever a resident is in need of an advocate or there are questions regarding resident rights (for additional information regarding Resident Rights, see the following website: http://health.mo.gov/seniors/ombudsman/pdf/ResidentRightsforLongTermCareInMissouriPD F.pdf

VI. Missouri Medicaid Audit and Compliance Unit

The Missouri Medicaid Audit and Compliance Unit (MMAC) investigates cases of provider fraud, participant fraud and/or consumer fraud. If MMAC discovers evidence of participant fraud that could lead to a consumer’s disqualification from the Consumer Directed Services (CDS) program or discovers consumer fraud that could lead to an EDL case, MMAC notifies DSDS through the Central Registry Unit (CRU). If provider fraud, participant fraud and/or consumer fraud is found by an APCW during an investigation, DSDS notifies MMAC. The sharing of this pertinent information helps to minimize each organization's duplication of efforts as well as protect the program and its recipients (see Policy 1703.24).

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