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Preliminary Report
Implementation of Executive Order
RP33 April 14, 2004
Relating to Reforming the
Adult Protective Services Program
Health and Human Services Commission
May 19, 2004
printable Adobe Acrobat version
Press
Release
Governor
Perry's Statement
Overview
Under Executive Order RP33, issued April 14, 2004, the Health and Human
Services Commission (HHSC) is directed to oversee the systemic reform of
the Adult Protective Services (APS) program of the Department of Family
and Protective Services (DFPS). The executive order was motivated by
reports that indicated serious fundamental and systemic problems within
the APS program
In response, the HHSC immediately deployed a team to El Paso to begin
case reviews of more than 1,200 cases involving 200 clients. The case
review focused on cases with referrals in the last two years and that had
more than three total referrals to APS. HHSC also began an examination of
operational, policy, and other aspects of the APS program.
Preliminary findings confirm that serious deficiencies exist in
virtually all aspects of the APS program. Subject matter experts have
identified key deficiencies in all the major areas of concern identified
in the Executive Order. These findings are consistent with case review
information focused in El Paso but suggest that problems with the APS
program may be fundamental and systemic. The preliminary findings for El
Paso regarding the APS program may be a visible manifestation of more
basic system-wide deficiencies.
This report is the first in a series of three. The Governor's Executive
Order requires that a report be issued within 90 days, followed by a final
report to be issued within 180 days. The findings in this initial report
are preliminary and contain recommendations for immediate corrective
action. Subsequent reports will address additional findings, will review
other areas of the state reporting similar issues (beginning with Fort
Worth), and will contain more comprehensive recommendations. Some of those
recommendations are likely to be longer-term solutions and may include
recommendations for statutory changes, if determined necessary.
Additionally, while this report focuses on El Paso, any corrective actions
with benefits beyond El Paso will be implemented statewide.
Preliminary Findings
A review team led by HHSC senior leadership arrived in El Paso on April
14, 2004, to begin case reviews and interviews with APS staff and
community stakeholders. The team consisted of HHSC executive staff and
staff from the Office of Inspector General and HHSC/DFPS Internal Audit.
Initial review of over 1,200 cases for 200 persons focused on cases within
the last two years that involved three or more referrals to APS-generally,
cases in which the individual and his or her situation was problematic.
| Case Readings: |
Serious problems exist in casework, including poorly
performed assessment, inadequate documentation, and lack of
appropriate follow-up activities. |
For all cases reviewed (Each question was asked for each case.
Percentages are not cumulative.):
- In 35 percent, the investigation did not fully address all
allegations of abuse, neglect or exploitation.
- In 32 percent, the caseworker did not obtain and document enough
evidence to reach a conclusion.
- In 30 percent, the actions (service plan) taken did not address all
findings of abuse, neglect, or exploitation.
- In 41 percent, appropriate action to prevent further abuse, neglect
or exploitation of the client was not taken.
- In 35 percent, where there was a threat or a risk to the client's
health or safety in the client's environment, the service plan did not
address the threat.
- In 41 percent, the client was determined to have mental illness.
- In 44 percent of the 41 percent where mental illness was identified,
no steps were taken to address any special needs related to the mental
illness.
- In 48 percent, there were other indications in the client's
behavior, environment, and history or in the testimony of others that
indicated capacity was questionable.
- In 71 percent of cases where mental illness was identified or
strongly indicated, the capacity questions were not asked of the client
nor was a clinical assessment of the client's capacity conducted.
- In 57 percent, where the cases were considered severe, client
contact was no more frequent than less severe cases.
- In addition, independent fact checking by audit staff indicates that
in many instances APS caseworkers did not verify information collected in
the investigations.
| Performance: |
Program performance levels in Region 10 compare poorly
with statewide averages.
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The following charts describe data on closed cases, service delivery,
caseload, and average days per investigation.
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| Region 1 |
Lubbock |
Region 2 |
Abilene |
Region 3 |
Arlington |
|
Region 4 |
Tyler |
Region 5 |
Beaumont |
Region 6 |
Houston |
|
Region 7 |
Austin |
Region 8 |
San Antonio |
Region 9 |
Midland |
|
Region 10 |
El Paso |
Region 11 |
Edinburg |
|
|
text link
text link
text link
| Policy: |
Process, policy, and law are not aligned to clearly defined
outcomes that protect individuals while recognizing self-determination.
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- Policy favors an individual's ability to refuse services and does
not provide appropriate or adequate guidance for intervention to prevent
abuse, neglect, or exploitation. APS literature states: "APS
philosophy, in most cases, is heavily weighted to client's liberty over
safety. The fifth APS casework principle…asserts that freedom to choose
is more important than safety." "An important principle of APS
casework is that adults who have the capacity to make informed life
decisions have the right to refuse protective services, even if they are
in a state of abuse, neglect, or exploitation."
- Guidance on decision-making does not adequately address abuse,
neglect, or exploitation issues.
- Policy does not provide flexibility to meet community standards
reflecting balance between self-determination and protection from abuse,
neglect, and exploitation.
- Policy, handbook, and practice are not aligned.
- Policy not maintained at a manageable level.
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Capacity Tools: |
The determination of capacity impacts almost every facet
of APS casework. With the capacity to choose, a person has the right of
self-determination. It is therefore critical to the success of APS to
correctly determine if an individual possesses this capacity. The current
capacity tool is ineffective and statistically weak.
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- Current tool focuses solely on mental and functional capacity,
without regard to any environmental issues or concerns.
- Tools provided to assess and/or diagnose abuse, neglect, and
exploitation are underutilized.
| Guardianship Program: |
Lack of clarity in law results in inconsistent
interpretation of the role and responsibility of APS.
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- Emphasis on self-determination results in fewer court intervention
requests to judges.
- Guardianship policy results in conflicts with the judicial system.
- Conflicts exist between guardianship and investigations residing
within the same agency.
- Community resources are underutilized.
| Technology: |
Opportunities exist to utilize technology more effectively.
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- Technology has not been fully developed or deployed to support and
enhance the investigative process, data collection, or training for field
staff.
- The current case management system (IMPACT) is reportedly dropping
cases and the associated supporting documentation.
- Telemedicine intervention techniques could be better utilized.
- Digital camera usage is sporadic, due in part to memory
deficiencies.
| Records: |
Compliance with documentation requirements is poor.
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- Records retention practices are not consistent with or supportive of
the investigative and/or judicial processes.
- Case documentation is generally incomplete and frequently
insufficient for the county attorney to pursue necessary action.
| Human Resources: |
Staff turnover in El Paso is twice the statewide
average.
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- Classification/pay levels of APS specialists and guardianship staff
may not appropriately reflect duties and responsibilities.
- Inadequate training and supervision may contribute to staff
turnover.
- The high turnover rate adversely affects the quality of
investigations and services.
| Training: |
Staff training is inadequate and inconsistently applied.
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- There are no specified outcomes measures for staff training.
- There is no formal linkage between formal classroom training and
prior or subsequent on-the-job training.
- Training does not ensure that staff are qualified to make
appropriate assessments, particularly in specialized areas such as
financial exploitation or self-neglect.
- Training does not ensure staff understand the process of a mental
health commitment under the Texas Health and Safety Code.
- Staff are not trained in how to appropriately engage community, such
as local mental health community, to assist.
- There is no annual continuing education required of APS
investigators or supervisors.
- Training is not readily accessible to staff in the field.
- Staff are often placed in the field without training.
| Procedures: |
Inconsistent application of procedures increases the risk
of poor outcomes.
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- Compliance with documentation requirements is inadequate.
- Investigators are not consistently addressing all allegations of
abuse, neglect or exploitation.
- The current capacity tool is not always applied, not applied
consistently, and inadequate to address areas of concern related to the
individual's ability to effectively deal with abuse, neglect, and
exploitation.
- Staff do not consistently provide independent verification of facts
presented by individuals under investigation.
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Community Resources: |
The lack of systemic partnerships with local offices
and community stakeholders hampers effective response to individuals with
documented needs.
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- Underdeveloped networking of community resources renders APS
ineffective in engaging support for individuals who are subject to abuse,
neglect, or exploitation.
- Lack of engagement with the community limits common understanding of
community standards and expectations.
- APS is unable to successfully engage other health and human services
agencies, such as MHMR, in appropriate interventions.
| Legal: |
Current policies, practice and procedures reduce the number of
referrals to probate court.
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- The county attorney reports that APS referred 55 cases to the
probate court in fiscal year 2003. As of April 14, 2004, only four cases
had been referred in fiscal year 2004.
- The probate court indicates concern with the disclosure of
information by APS in response to requests by the court.
- Staff are inadequately trained on court proceedings with the result
that county attorney preparation for court hearings are adversely
affected.
- Poor quality of APS investigations, poor documentation of cases, and
understaffing has impaired the relationship with local prosecutors and
judges.
Key Issues and Performance Expectations
Based on HHSC's preliminary findings, performance outcome goals are
identified for these key deficiencies to focus and support APS reform.
Following is an initial, but not complete, set of performance standards
and possible future actions.
| Area |
Key Performance Standards
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Policy |
- Policy balances self-determination with protection from abuse,
neglect, or exploitation.
- Policy is sensitive to local conditions and
community standards within the law.
- Policy goals are clearly defined
based on desired outcomes.
- Performance benchmarks are defined and
monitored quarterly.
Future Actions:
- Review policies and include
recommendations for improved policies in the 90-day report to the
Governor.
- Review statutes biennially to ensure applicability and
relevance as more is known about the elderly and individuals with
disabilities.
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Capacity Tools |
- Capacity tools are designed to achieve well-defined
outcomes.
- Capacity tools are reliable and valid.
- The application of
capacity tools in decision-making is tempered with other evidence that may
present itself.
Future Actions:
- Revise outcomes and capacity tools
through multidisciplinary teams of stakeholders and subject matter experts
and implement statewide. The teams will be established within 60 days.
|
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Legal |
- Effective working relationships with local judicial officials are
established and maintained.
Future Actions:
- Examine the disclosure
issues in El Paso further. Develop appropriate procedures and criteria for
submission of information to probate court.
- Develop criteria to provide
reasonable timeframes to respond to such requests.
- Implement the
procedure in El Paso and consider its application statewide.
- Review
existing statutory limitations to disclosure of APS information.
- Examine
the prospects of assigning permanent on-site legal support for APS, as
well as other DFPS operations.
|
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Guardianship |
- Guardianship efforts are centered in community based
efforts and supported by APS program.
- Guardianship is viewed as one of
many tools in ensuring protection from abuse, neglect, or exploitation.
Future Actions:
- Restructure the guardianship program to be fully independent of investigations.
- Define local teams of stakeholders to
review exceptional cases prior to decisions to assume guardianship. The
teams will be established within 90 days and will meet monthly and move to
bi-monthly, or as needed.
|
|
Technology |
- Technology is used to collect and store data that can be
used to monitor performance and inform policy.
- Technology is used to
provide field staff the tools to be effective as they investigate, such as
having the APS manual stored electronically on a notepad computer.
- Training is readily available to field staff through the web.
Future Actions:
- Facilitate the use of instant communications, including digital
photography, to improve supervision and to ensure staff make appropriate
decisions.
- Utilize Telemedicine and related technology to quickly,
effectively, and efficiently bring subject matter experts to bear on
particular cases.
|
|
Records Retention |
- APS is in compliancy with state and federal law.
- APS and
guardianship record retention policies and relevant standards are
consistent.
Future Actions:
- Modify current practices to comply with appropriate standards.
- Develop
records retention policies to support information needs of investigators,
subject matter experts, and legal staff for the duration of case activity.
|
|
Case Documentation |
- Cases are documented properly.
- Documentation is secured by digital signature once entered by the caseworker.
- Digital pictures are used to enhance the quality of
documentation.
- Supervisors have read-only capability in cases.
Future Actions:
- Modify the system to accept digital signatures and pictures.
- Include
case documentation requirements in IMPACT training.
- Train supervisors to
review quality and quantity of work.
|
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Program Performance |
- Performance outcome measures and targets are established.
- Measures are linked to resource allocation.
- Measures are established for all levels of staff.
Future Actions:
- Monitor
performance monthly/quarterly to ensure adequate support is provided in
response to situational constraints and issues that arise.
|
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Human Resources |
- Positions are defined by skill sets.
- Hiring process
ensures successful applicants demonstrate appropriate application of
skills.
- Skill set definitions are regularly compared to those found to
be desirable by successful performers on the job.
- Leadership and
supervisor job descriptions are defined by advanced skill sets.
Future Actions:
- Create staff specialists in particular aspects of abuse,
neglect, or exploitation and assign to provide support in ongoing
investigations immediately.
- Implement a retention plan to retain
qualified staff.
|
|
Procedures |
- Quality control processes monitor quality of documentation
and inform appropriate interventions and training.
Future Actions:
- Monitor staff performance monthly during the six-month probation period
and then annually to ensure integrity of casework.
- Ensure that
procedures are flexible to allow staff to respond to unique aspects of
cases.
|
|
Training |
- Training is aligned with desirable outcomes as defined in
policy.
- Minimum performance standards are established as defined skill
sets of staff.
- Impact of training is assessed to ensure staff have
acquired the skill sets associated with the training.
- On-the-job
training is clearly and formally linked to classroom training.
- All staff
have training in financial exploitation to recognize its presence and take
corrective actions.
Future Actions:
- Develop a training curriculum within
180 days and establish an annual review by multidisciplinary teams of
subject matter experts.
- Conduct assessments during the training, at the
end of training, and after some determined interval after skills have been
applied on the job. Pre-tests and post-tests will be developed and
administered. The tests will be included in the overall assessment of the
skill set to determine if the staff have successfully acquired the skills
to complete the job.
- Require that training on specific aspects of
investigations-abuse, neglect, and exploitation-is completed before staff
can investigate those aspects.
|
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Community Resources |
- Strong community networks ensure support for those
identified at risk for or experiencing abuse, neglect, or exploitation.
Future Actions:
- Recruit subject matter experts to volunteer
for consultation on an as-needed basis.
- Engage local teams to review
alternatives for guardianship.
- Develop interagency working relationships
and MOUs to ensure resources are appropriately deployed to assist
individuals found to be abused, neglected, or exploited.
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Immediate Corrective Action and Oversight
Immediate Corrective Action
- Capacity Tool: APS workers will be properly trained on the
appropriate next step or referral to be made if a determination of
capacity is unclear. APS investigators will be provided adequate training,
tools, and understanding to accurately assess capacity. Any capacity
assessment tool put into use at APS will include a wide variety of
factors, including environmental factors.
- Staffing and Supervision: Several strategic personnel actions in El
Paso (including hiring additional investigative staff, one additional
supervisor, and a program administrator) are being taken to quickly
address performance issues there. These jobs have already been posted for
hiring.
- Community Relations: The new El Paso program administrator will also
be charged with establishing and building the community network that
supports APS service delivery.
- Improving Casework Quality and Quantity: Because of the critical
nature of the evaluation tools to the investigative process, HHSC will act
quickly to define clear investigative outcomes and identify or develop
tools to measure mental and functional capacity, as well as to assess risk
of abuse, neglect, and exploitation. A reengineered and useful training
program built around the effective use of these tools, that measures
performance and ties classroom and on-the-job training, is also a high
priority.
- Judicial Relations: HHSC legal staff are working with El Paso
judicial officials to strengthen working relationships, including
revitalizing training recently developed but underutilized. Temporary
on-site legal support staff have been assigned to the El Paso APS office
as longer-term strategies are implemented. A deputization from the Office
of the Attorney General to authorize DFPS attorneys to appear in court on
behalf of caseworkers subpoenaed to testify has also been obtained. HHSC
will also work quickly to ensure that performance standards support
positive working relationships with judicial officials statewide.
- Technology: Strategies for integrating technology into the
investigative process are being actively pursued and will be implemented
aggressively on an ongoing basis. An information systems audit on IMPACT
will be conducted.
- Guardianship: The guardianship program will be transferred from APS
and significant steps taken to sharpen its mission, strengthen its
effectiveness, and build community-led capacity.
- Training: Training deficiencies will be addressed immediately. No
APS caseworker will assume a caseload without demonstration of success in
training.
Oversight
The reform of APS will be guided by a reform oversight committee
consisting of: the HHSC Executive Commissioner; HHSC Deputy Executive
Commissioners for Social Services, Health Services, Financial Services and
System Support Services; HHS Inspector General; and HHSC Chief of Staff.
HHSC will lead an independent task force that will include subject
matter experts in regulation, administration, organization, technology,
policy, community relations, and legal. The task force will be organized
into four primary teams consistent with Executive Order RP33.
A Case Review Team will continue to review closed cases to identify
deficiencies and issues. The Case Review Team will also expand its scope
of review to include other areas of the state producing reports of similar
issues.
A Program Review Team will examine the organizational, administrative,
and technical aspects of the APS program and take appropriate action.
A Policy Review Team will reexamine existing policies and practices
within APS, as well as statutory requirements of APS to ensure the
reprioritization of its public safety mission. New rules, policies, and
practices shall be implemented as soon as possible and recommended
statutory changes reported to the Office of the Governor by November 1,
2004.
A Community Relations Review Team will examine and provide policy and
process guidance on collaborative working relationship with stakeholders
and partners to meet the goals of the state. This team will focus both on
developing models for integrating APS activity into local integrated
services for the elderly and persons with disability and for a statewide
infrastructure that supports localized efforts. Capacity building will be
an important component of this team's effort.
Each team may establish one or more multidisciplinary workgroups to
review specific areas of concern, develop appropriate performance
standards, and make recommendations for improvement.
Reporting
HHSC will supplement this preliminary report by providing a full
implementation plan by July 12, 2004, and a final report by November 1,
2004.
Appendix A
Executive Order RP33 - April 14, 2004
Relating to reforming the Adult Protective Services Program
BY
THE GOVERNOR OF THE STATE OF TEXAS
Executive Department
Austin, Texas
April 14, 2004
WHEREAS, the State of Texas values older Texans and persons with
disabilities, and is committed to ensuring that these Texans, particularly
as the number of older adults increases, can live in a safe and healthy
environment; and
WHEREAS, the mission of the Adult Protective Services program is to
protect older adults and persons with disabilities from abuse, neglect,
and exploitation by investigating and providing or arranging for services
necessary to prevent or alleviate maltreatment; and
WHEREAS, concerns about self-determination not withstanding, it is equally
important to ensure the state's commitment to helping individuals who have
lost the ability to provide for themselves the goods and services which
are necessary to avoid physical harm, mental anguish, or mental illness;
and
WHEREAS, the most effective way to prevent and address the abuse, neglect,
or exploitation of adults is to ensure that Adult Protective Services is
closely working and coordinating with every community stakeholder in
preventing and investigating elder abuse, including the medical community,
the mental health community, victims rights associations, advocate groups,
legal experts, courts, law enforcement, and others; and
WHEREAS, the full participation of municipal, county, and state law
enforcement is key to identifying, investigating, and stopping elder
abuse, neglect, and exploitation; and
WHEREAS, the administration and organization of the Adult Protective
Services program should operate efficiently and be accountable for the
protection and safety of older Texans and persons with disabilities; and
WHEREAS, under House Bill No. 2292 of the 78th Legislature, the Health and
Human Services Commission was charged to provide policy direction,
oversight, administrative support, and accountability for the health and
human services agencies, including the Department of Family and Protective
Services; and
WHEREAS, reports of cases of potential elder abuse and neglect in El Paso
prompt the necessity of extraordinary measures;
NOW, THEREFORE, I, Rick Perry, Governor of Texas, by virtue of the power
and authority vested in me by the Constitution and laws of the State of
Texas, do hereby order the following:
Systemic Reform. The Health and Human Services Commission, considering
this effort of the highest priority, shall direct and oversee the systemic
reform of the Adult Protective Services program, focusing on the need to
protect older adults and persons with disabilities from abuse, neglect,
and exploitation. The Commission shall request assistance from additional
state agencies as needed to ensure an appropriate and comprehensive reform
of the program.
Review of Case Files. The Health and Human Services Commission shall
immediately begin an independent review of previously closed cases in the
Adult Protective Services program, prioritizing cases for review,
determining whether regulations have been consistently followed, and
taking immediate corrective measures in cases where needed. The Commission
shall ensure that any necessary and appropriate disciplinary action be
taken in response to all cases identified as having been mishandled,
particularly if injury or death resulted from inappropriate action. The
Commission shall use information collected from these case reviews to
ensure the reforms to the Adult Protective Services program promote the
continued health and safety of older Texans.
Administrative Reform. The Health and Human Services Commission shall
conduct a comprehensive administrative reform of the Adult Protective
Services program, including developing new training procedures, developing
minimum qualifications for caseworkers and supervisors, and ensuring the
effective application of all state statutes and policy requirements to
protect the safety and well-being of older adults and persons with
disabilities.
Organizational Reform. The Health and Human Services Commission shall
conduct a comprehensive organizational reform of the Adult Protective
Services program to ensure the appropriate placement of state resources
and program supervisors for proper and sufficient regional oversight and
communication, the effective application of all state statutes and policy
requirements, and the most appropriate outcomes for older adults and
persons with disabilities.
Increase Use of Technology. The Adult Protective Services program shall
consistently take advantage of new technology, such as digital cameras and
wireless communication devices, to improve the quality of services,
monitoring and investigation of cases.
Partner with Law Enforcement. The Texas Department of Public Safety is
directed to give high priority to investigating and addressing any
potential criminal cases of elder abuse and neglect. Additionally, the
Department of Public Safety shall coordinate with municipal and county law
enforcement and the Health and Human Services Commission staff members to
provide assistance as needed in conducting home and institutional visits
of elders and persons with disabilities and to develop appropriate
training on investigative techniques for these cases.
Partner with Local Communities. The Adult Protective Services program
shall work with community partners to establish permanent cooperative
relationships in local communities to prevent and raise awareness of the
abuse, neglect, and exploitation of older Texans and persons with
disabilities. These partnerships shall include the primary care and
geriatric medical community, the mental health community, local area
agencies on aging, victims? rights groups, advocate groups, legal experts,
courts, law enforcement as well as any other local or unique community
resources necessary.
Review of State Policy. The Health and Human Services Commission and the
Adult Protective Services program shall review and adopt new rules and
policies, including the development of a new and appropriate screening
tool, which may be necessary to implement this Executive Order. These
policies shall take into consideration all aspects of the person's
situation from their cognitive abilities to the environment in which they
live, so that the rights of the individual are balanced with the
requirement that they live in a healthy and safe environment.
Review of Statute. The Health and Human Services Commission and the Adult
Protective Services program shall review and make recommendations
regarding any changes in statute which may be required.
Report of Compliance. The Health and Human Services Commission shall
oversee the development and submission of an implementation plan and a
final report of the implementation of this order. The implementation plan
shall outline the specific actions taken to implement this order and shall
be submitted no later than 90 days of the date of this order. The final
report shall review all actions taken, as well as the recommended
statutory changes developed in compliance with the Order, and shall submit
this report to the Office of the Governor no later than November 1, 2004.
Full Cooperation. All affected agencies and other public entities shall
cooperate fully with the Health and Human Services Commission during the
research, analysis, and implementation of this order.
This executive order supersedes all previous executive orders on Adult
Protective Services. This order shall remain in effect until modified,
amended, rescinded, or superseded by me or by a succeeding Governor.
Given under my hand this the 14th day of April, 2004.
RICK PERRY
Governor
Appendix B
Case Review
Review of Case Files
- HHSC Independent Review
- Prioritized
- Consistent application of regulations
- Accountability
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Policy Review
State Policy
- Overall Review
- Screening Tools
Statute
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Program Review
Organization
- Resource Allocation
- Funds
- Supervisors
- Caseworkers
Administration
- Supervisor Qualifications
- Caseworker Qualifications
- Training - initial and on-going
- Application of Statute and Policy
Technology
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Community Relations
Relations with Community Partners
- Awareness and Prevention
- Primary Care & Geriatric Medical Community
- Mental Health Community
- Local Area Agencies on Aging
- Victim's Rights Groups
- Advocate Groups
- Legal Experts
- Courts
- Law Enforcement
- Other Community Resources
Relations with Law Enforcement
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Report of Compliance
- Implementation Plan (90 days)
- Final Report (November 1, 2004)
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