Implementation Plan

Executive Order RP 33
Relating to Reforming the
Adult Protective Services Program

Health and Human Services Commission
July 12, 2004

Printable Adobe Acrobat (pdf) version of this report

HHSC News Release

Table of Contents

• Executive Summary
• Background
• Overview of the Reform Effort
• Findings of Fort Worth Case Reviews
• Current HHSC Efforts
• Establishing Desired Outcomes
• Actions Related to the APS Policy and Processes
• Actions Related to APS Organization and Administration
• Actions Related to Working with Community Partners
• Timelines
• Appendix A Combined Action Tables
• Appendix B Glossary of Terms

<<back to top>>

Executive Summary

Under Executive Order RP 33, 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.

HHSC began an intensive review of the APS program and issued a preliminary report on May 19, 2004, that included findings from case readings from the El Paso area. The report also included preliminary findings on program performance, functional review, and policy assessment of the APS program, including the Guardianship program. The preliminary investigation confirmed deficiencies, identified key issues, and listed performance outcome goals for each area. Immediate corrective actions were identified and the oversight process was described.

Executive Order RP 33 requires HHSC to submit an implementation plan that outlines the specific actions taken and to submit this report to the Governor no later than 90 days from the issuance of the order. This implementation plan will outline additional key deficiencies and corrective actions to reform the APS program to meet the protective needs to the elderly and adults with disabilities.

The APS program has been reviewed to:

• Ensure clearly defined outcomes at each step of the APS involvement with clients (the APS process), including partnering with community organizations to define and maintain ongoing services;
• Define management structure and support systems that are clearly aligned with the outcomes defined for the APS process; and
• Identify the current problems that prevent APS staff from achieving these outcomes.

Though APS investigates reported allegations in a variety of settings, this report focuses primarily on non-facility based investigations. Based on these parameters, a clear and definitive implementation plan has been developed. The implementation plan consists of actions that address issues identified for each key deficiency in the APS process, the management structure, and support systems.

From information obtained through the work sessions and groups, charts were developed that illustrate the APS process, desired outcomes, deficiencies, and corrective actions. These charts are included in Appendix A.

The implementation plan will require additional resources. HHSC is working to identify the funding needs to implement this plan for consideration by the Governor and legislative leaders. HHSC will ensure strict accountability for funding provided to programs.

Since the release of the preliminary report, 13 workgroups have been formed to examine all aspects of the APS program, identify deficiencies, and recommend corrective actions. Three underlying themes emerged during the workgroup process.

• The goals of APS are not well defined;
• There is not a clear delineation of the APS process steps; and
• There are few performance standards for the APS program.

This report describes corrective actions to be taken in each area of the APS program. The general timeline for implementation is in three phases.

First, policy must be developed, clarified, or revised to align with the desired outcomes for the APS program. Of particular concern are the policy issues related to the:

• Balance between self-determination and the agency's mandate for the protection of individuals at risk of abuse, neglect, and exploitation;
• Distinction between investigation and service delivery; and
• Responsibilities of the Guardianship program.

It is anticipated that these policy issues will be resolved by the fall of 2004.

Second, procedures must be developed to ensure established policy is effectively implemented. This will be accomplished by the following methods:

• Performance standards must be defined and adopted;
• Organizational structure must be uniformly defined;
• Mobile technology to streamline procedures must be deployed;
• Current APS in-home investigations handbook must be modified;
• New and effective training curriculum and processes must be implemented; and
• Community and judicial relationships reestablished and maintained.

These procedures will be fully developed by the spring of 2005.

Finally, the administrative structure and supporting technology must be implemented to ensure that:

• Staffing positions are filled;
• APS technology is modified to align with established policies and procedures; and
• Staff are retrained on new policies and procedures and APS support technology.

The administrative structure and supporting technology will be fully implemented by the summer of 2005.

HHSC is committed to implementing the corrective actions in this plan as quickly as possible within the timeframes indicated. Three critical areas are receiving the highest priority. One area is ensuring sufficient staff in critical areas of the state. HHSC is working with APS to identify needs and deploy necessary staff as quickly as possible. Another critical area is the development and deployment of a new risk assessment tool to replace the current capacity tool. Field-testing of this tool should begin this fall. Lastly, HHSC is working closely with state leaders to secure funding to expand the capacity of local Guardianship programs.

A full accounting of progress will be provided in the final report required by Executive Order RP 33 due November 1, 2004.

<<back to top>>

Background

Under the Governor's Executive Order RP 33, 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). DFPS is charged with protecting children and adults who are elderly or have disabilities living in their home. APS is responsible for investigating abuse, neglect, and exploitation of adults who are elderly or have disabilities. The executive order was motivated by reports that indicated serious fundamental and systemic problems within the APS program.

HHSC began an intensive review of the APS program and issued a preliminary report on May 19, 2004, that included findings from case readings from the El Paso area. The report also included preliminary findings on program performance, functional review, and policy assessment of the APS program, including the Guardianship program. The preliminary investigation confirmed deficiencies, identified key issues, and listed performance outcome goals for each area. Immediate corrective actions were identified and the oversight process was described.

Executive Order RP 33 requires HHSC to submit an implementation plan that outlines the specific actions taken and to submit this report to the Governor no later than 90 days from the issuance of the order. This implementation plan outlines additional key deficiencies and corrective actions to reform the APS program to meet the protective needs of elderly and disabled persons.

<<back to top>>

Overview of the Reform Effort

The goal of the APS reform effort is to ensure the Texas Department of Family and Protective Services meets its legislative mandate to provide protective services to Texans with disabilities and the elderly who are at risk of abuse, neglect, and exploitation. The goal is guided by the principle that protective services represents only one aspect of the full array of services that individuals with disabilities and the elderly may need to ensure a high quality of life. An important component of meeting the needs of the clients is to identify the best resources, which may include services provided by local community groups.

The APS program has been reviewed to:

• Ensure clearly defined outcomes at each step of the APS involvement with clients (the APS process), including partnering with community organizations to define and maintain ongoing services;
• Define management structure and support systems that are clearly aligned with the outcomes defined for the APS process; and
• Identify the current problems that prevent APS staff from achieving these outcomes.

Though APS investigates reported allegations in a variety of settings, this report focuses primarily on non-facility based investigations in accordance with the Governor's Executive Order.

Based on these parameters, a clear and definitive implementation plan has been developed. The implementation plan consists of actions that address issues identified for each key deficiency in the APS process, the management structure, and support systems.

The implementation plan will require additional resources. HHSC is working to identify the funding needs to implement this plan for consideration by the state leadership. HHSC will ensure strict accountability for funding provided to programs.

<<back to top>>

Findings of Fort Worth Case Reviews

Using the same case reading strategy employed in El Paso in developing the preliminary findings, the Office of Inspector General (OIG) case review team continued their investigation with case readings from the Fort Worth area (Region 3). Their findings support the systemic nature of the problems within the APS program.

• In El Paso it was found that the investigation did not fully address all allegations of abuse, neglect, or exploitation in 35 percent of the cases read. That figure was 57 percent in Forth Worth.
• In El Paso it was found that in 30 percent of the cases read the actions (service plan) taken did not address all findings of abuse, neglect, or exploitation. In Fort Worth the comparable statistic was 47 percent.
• In El Paso it was found that in 41 percent of the cases appropriate action to prevent further abuse, neglect, or exploitation of the client was not taken. Case readings in Fort Worth revealed this outcome in 53 percent of cases.

The OIG review also indicates that each area of the state will vary in the quality of APS services. In El Paso, for example, community relations were weak and non-supportive. Fort Worth, in contrast, has a relatively strong community network to support APS efforts.

Overall, the Fort Worth case readings support the general finding of the preliminary report that APS does not establish accountability for positive outcomes.

<<back to top>>

Current HHSC Efforts

Since the release of the preliminary report, 13 workgroups have been formed to examine all aspects of the APS program, identify deficiencies, and recommend corrective actions. Three underlying themes emerged during the workgroup process.

The goals of APS are not well defined. Ill-defined goals result in various interpretations of the scope of APS activities and inconsistent application of policies and procedures. Internally, staff in one region may focus on determining capacity, while in other regions staff may focus on providing non-protective service delivery to clients (i.e., services which do not relate directly to the reduction of risk). Externally, this lack of clarity results in variations regarding how, and when, APS interacts with local community organizations.

There is not a clear delineation of the APS process steps. While each case referred to APS is different, the basic APS process should be the same for every case. The handbook offers minimal guidance for key decision points and even less for direction regarding the criteria and decision processes. Without such specificity in the decision making process, there is great variation in how decisions are reached and the appropriateness of these decisions. Clear, well-reasoned, and uniform decision-making criteria needs to be incorporated in each stage of the APS process and outlined in the APS handbook and training curriculum.

There are few performance standards for the APS process. Appropriate performance criteria for what constitutes a good investigation or a good service delivery plan are lacking in the APS process. Current criteria appear to be subjective; therefore, it is difficult to measure staff performance. When management does have performance indicators, such as number of days an investigation is open, there are no clear standards for staff to follow. This lack of standards impairs the ability to effectively manage time and resources, to ensure quality investigations, and maintain accountability.

These three fundamental issues underlie virtually all deficiencies identified with the APS program. It is critical that deficiencies are remedied to ensure that the mission and goals of the program to protect the elderly and adults with disabilities is accomplished.

<<back to top>>

Establishing Desired Outcomes

To ensure an outcome driven process, HHSC convened a work session of stakeholders to help define successful outcomes in the investigative process. Stakeholders were invited from across the state, representing a broad array of groups. The participants in attendance represented various organizations dealing with issues on aging and disability, including judicial, legal, aging and disability advocates, and guardianship. Over 45 groups were contacted to send a representative to the work session.

Work session participants began by defining positive outcomes for individuals found to be at risk. These included such items as better access to services, working utilities, and ability to manage medication. Next, work session participants defined the critical elements of the investigation process, including desirable outcomes and best practices.

Guiding Principles

A number of guiding principles emerged from the desirable outcomes session and correspondence received by HHSC related to the APS reform efforts. The guiding principles identified were:

• Do no harm
• Maintain client dignity
• Maintain client's civil rights
• Perform tasks from a person-centered philosophy
• Preserve balance of personal rights and self-determination with mitigation of risk
• Maintain commitment to work with stakeholders

Mapping Outcomes to Process

A workgroup of business process engineers and policy specialists from HHSC reviewed the APS handbooks, work session outcomes, interviewed APS staff, and accompanied investigators on a number of investigations and site visits to collect process information. From the data collected, the APS process was mapped from start to finish. This map provides vital information for a comprehensive assessment of the APS process to ensure all aspects are analyzed during the development of corrective actions.

Identifying Deficiencies and Corrective Actions in the APS Program

Each workgroup researched the current APS process and compared it with the desired outcomes. The workgroups identified deficiencies and made recommendations for corrective actions.

While the majority of the deficiencies were connected to the various APS stages, a few were not. Several of the issues identified were overarching of the APS program or were tied to multiple steps in the APS process, such as administrative, organization, or support. For example, administrative organization of staff-the deployment of APS professionals, management, and support staff-will depend in large part on improvements in the APS process that clearly define the steps in investigation and service delivery. Once those steps are defined, the appropriate staff can be deployed to ensure successful outcomes.

From all the information obtained through the work sessions and groups, charts were developed that illustrate the APS process, desired outcomes, deficiencies, and corrective actions. These charts are shown in Appendix A.

<<back to top>>

Actions Related to the APS Policy and Processes

This section describes the actions in the implementation plan associated with each step in the APS process. The APS process includes these steps:

• Intake
• Investigation
• Risk Assessment
• Service Delivery
• Guardianship

For each step, a narrative provides an overview of the issues followed by a table that relates specific outcomes, issues, and actions.

Intake

Intake is a critical function for APS and plays several key roles. First, it is how the public accesses and provides information to the APS system. The intake process assures that all information necessary to initiate a case is received. The amount and type of information obtained are vital because they are used to classify, prioritize, and route cases to the field. To be effective, APS must help ensure that the public understands what constitutes abuse, neglect, and exploitation, and how to report it.

The number of calls that statewide intake can process effectively has been the subject of scrutiny in the recent past, in particular with regard to hold time. The wait time for callers has been reduced through the deployment of call center technology.

Each call is unique, and staff is trained to elicit information relevant to each allegation. There may be efficiencies gained by formally reviewing closed cases to determine whether certain information turns out to be more relevant than others and what additional information should be obtained to aid in investigations. The review would also be informative in assessing whether the appropriate notifications have gone to law enforcement, any special issues or requirements are identified, and if cases are being appropriately classified and prioritized.

While intake is responsible for routing cases, a routing protocol is followed to ensure appropriate staff is deployed to initiate the APS investigation. Issues concerning routing are covered in the investigation section of this report.

Corrective actions for improving the intake process include finalizing the roll-out of the public reporting website and reviewing closed cases to identify the importance of key variables to further enhance the intake, prioritizing, and routing of calls.

Investigation

The in-home investigation is the primary function of the APS caseworker in handling cases of abuse, neglect, and exploitation of elderly and disabled adults. Investigations must be conducted in a thorough and efficient manner to identify all issues that need corrective services. The purpose of investigations is to gain further knowledge of a situation, determine the priority of actions to be taken, and initiate any immediate intervention that may be required. Numerous deficiencies have been noted in the investigative process.

First, there is a clear need to improve the process for assigning and prioritizing cases to improve responses to reports and to minimize administrative costs. APS can utilize information from past cases to better estimate priorities and staffing needs for future cases. In addition, a lack of adequate administrative personnel exists to handle issues of routing, maintaining call lists, and appropriately assigning cases. Supervisors are performing administrative tasks in addition to their regular case management duties.

Second, reports of abuse, neglect, and exploitation have not been fully or appropriately investigated and documented. The current assessment tool focuses exclusively on capacity and does not identify and document potential physical and psychological harm, medical issues, environmental conditions, personal relationships, and the client's risk to self or others. The current practice is to identify these areas of need in the service delivery phase and not the investigative phase, blurring the critical distinction between validating the allegation(s) and assessing the potential for risk through investigation, and reducing risk through service delivery. The client must agree to accept services for this assessment to be completed. Creating a new assessment tool to replace the current capacity tool is dealt with in a separate section of this report. Currently, under-utilization of legal and judicial avenues for gathering supporting evidence limits staff ability to assess risk.

Third, the investigative phase is specifically designed to support subsequent actions, many of which may require legal decision-making. Legal decisions require well-documented facts. There are clear deficiencies in documentation and variation in staff understanding of what documentation is required.

Finally, processes and standards for APS in-home investigations need to be expanded and clarified. Caseworkers are faced with situations for which no clear guidance is provided in the handbook. Without clear guidelines, practices vary widely by region.

Corrective actions for improving the investigative process are to review and enhance current guidelines on prioritization and appropriate routing to trained caseworkers, delineate and separate the investigative phase from the service delivery phase of the process, and more effectively allocate administrative personnel to relieve supervisors and allow them to focus on case management. Perhaps the most important corrective action is the replacement of the current capacity questions with a more comprehensive risk assessment tool and the retraining of caseworkers to properly utilize that tool.

Risk Assessment Tool

The law simultaneously gives APS the mandate to provide for the protection of individuals with disabilities and the elderly and provides the client the option to refuse the investigation or any services. The capacity assessment used by APS is a limited decision-making tool that does not take into account the complexities in cases in which appropriate balance must be found.

The current assessment tool focuses solely on mental and functional capacity without regard to environmental issues or concerns. Caseworkers must focus too narrowly on how the client answers the capacity questions without consideration of factors that may indicate continued or further exposure to risk. In many cases, caseworkers will skip the capacity assessment if they determine that capacity is not an issue related to the primary reported allegations, thus prematurely closing the investigation.

APS must develop a comprehensive risk assessment tool to replace the current capability questions. This tool should cover all areas of risk, including an assessment of environmental, social, medical, mental health, and financial conditions found. It should provide for ways to assess risk in the absence of the client's cooperation and should ensure that clear criteria for referrals are made when warranted. Most importantly, this tool should reveal the client's capacities as they are evidenced in various aspects of their life.

This comprehensive risk assessment tool should appropriately refer clients to professionals for assessment of capacity, ensure that complex cases have extended but rapid review, and direct the investigator to initiate and appropriately document removal proceedings.

A particular deficiency was noted in the ability of APS staff to detect financial exploitation. APS must work to develop explicit guidelines for staff to follow to detect financial exploitation and train staff accordingly. A multidisciplinary team should be formed to help develop these guidelines and review the more complex and difficult cases.

Corrective actions include implementation of a new assessment tool, establishing clear rules for the acquisition of medical or mental health determinations of capacity and internal quality assurance teams to review cases of questionable risk and establish guidelines for scheduled supervisor case reviews. HHSC considers the development of the risk assessment tool a high priority and expects to pilot the tool in the fall of 2004.

Service Delivery

The scope of APS is that it shall conduct investigations of abuse, neglect, and exploitation and may provide protective services to minimize further risk. APS caseworkers provide protective services to an elderly or disabled person who has been determined by APS to be in a state of abuse, neglect, or exploitation. These services may include case management, arranging for psychiatric evaluations, home care, adult day care, social services, health care, and other services. These services differ from guardianship activities in that the client retains legal control over his/her situation but is assisted in these efforts by APS caseworkers.

A major issue is the lack of distinction between the investigative stage and the service delivery stage. In life-threatening or emergency situations service delivery must begin immediately and concurrently with the investigative process. Although, in the majority of cases, the primary allegations do not necessarily warrant immediate action, and service delivery activity should not commence until the investigative stage is complete. Since provision of services is a major factor of the funding allocation, there appears to be an undue emphasis on service delivery at the expense of a thorough investigation.

Another issue is the lack of clarity around what constitutes protective services. Protective services are those services that remove a client from risk of abuse, neglect, or exploitation. Protective services are only one of an entire array of life-enhancing services available to individuals with disabilities and the elderly. Without this clarity, service plans may include services that more appropriately belong to other public or private social service organizations, such as the Area Agencies on Aging. APS' collaboration with local community groups may not result in attaining appropriate resources, and service delivery may extend far past the assurance of protection. Further, there may be confusion about whether and what types of guardianship services are needed. Also, as with the investigation process, there is a lack of clear guidelines for service delivery resulting in plans differing for similar risks and indefinite service delivery for multi-needs or multi-handicapped individuals.

There appear to be issues surrounding the identification of client resources. Clear standards do not exist for ensuring that staff have identified client resources that need to be utilized prior to any outside funding. This includes whether or not clients are currently enrolled in state and federal programs.

Finally, there seems to be inadequate coordination and referral with other state agencies that provide non-protective services. This is due, in part, to unclear cooperative agreements between APS and other health and human services agencies.

Corrective actions include evaluation of the need to separate investigative staff from service delivery staff and identify those workers as social services aides, decision criteria to determine when to initiate guardianship proceedings, and improved inter-agency cooperation.

Guardianship

Guardianship is pursued when a client is deemed to be at continued risk of abuse, neglect, and/or exploitation, and the client has been shown to lack capacity and a less-restrictive alternative is not available. APS staff ensure the case record provides the information a judge will need to make this determination, including the identification of an appropriate guardian for consideration.

APS makes every effort to find an appropriate guardian. APS policy requires staff to consider family members or other trusted individuals for primary consideration. If such an individual cannot be identified, APS considers attorneys, financial institutions, private professional guardians, or Guardianship programs. If no other entity can be identified, a referral is made to a contracted guardianship provider if available in the area. The court may also identify an appropriate guardian. APS provides case information and support to the proposed guardian, the attorney, and the court as needed during the guardianship proceedings.

If no other appropriate guardian can be found for the client, APS may be directed by the court to take temporary guardianship while efforts are made to continue to identify a guardian or, ultimately, take guardianship responsibility for the client. Guardianship is determined by a judge.

Since the 1995 repeal of a statute that designated APS as "guardian of last resort" in Texas, there is presently no "guardian of last resort" in Texas. There is, in some areas of the state, a difference between APS guardianship policies and the judges' interpretation of the law. This issue needs clarification and may need legislative remedy.

Several issues are identified with the Guardianship program. First, the problems identified with determining capacity contribute to the Guardianship program being underutilized. The department's emphasis on self-determination and deficiencies found in the capacity tool are leaving some clients at continued risk to health and safety. These clients cannot adequately protect themselves from risk and should more appropriately be in a Guardianship program. Development of a risk assessment tool in place of the current capacity tool and appropriate training will help resolve this issue.

Second, there is a lack of contractors offering guardianship services. In some areas the capacity of existing local Guardianship programs is limited, while in other areas there are no local programs. Additional funding provided to ensure guardianship services would help build a more solid infrastructure of guardian support. HHSC will work with state leadership to identify and provide seed money as quickly as possible to help build capacity for local Guardianship programs across the state.

The issue is further compounded due to the fact that some contractors may lose money providing guardianship services. Guardianship programs may collect money from estates for private-pay clients. Some programs also have other funding sources such as Area Agencies on Aging, United Way, county funds, and other sources that pay for services to their wards. Programs contracting with DFPS cannot use money from the client's estate. Guardianship programs are less motivated to accept private-pay wards with relatively small estates. This inadvertently results in APS retaining clients that are more resource intensive.

Third, the Guardianship program is located within APS, creating a conflict of interest. Clients in the Guardianship program who are reported at risk would be the subject of an investigation carried out by the same program. HHSC will examine the appropriateness of moving the Guardianship program in fiscal year 2005.

Finally, guardianship duties and responsibilities for incapacitated adults are carried out by two health and human services agencies, DFPS and HHSC. The DFPS guardianship-related statutes are contained in Chapter 48 of the Human Resources Code, and the HHSC guardianship-related duties are contained in Chapter 531 of the Government Code. The HHSC Guardianship program administers the local Guardianship program grants. HHSC also receives recommendations for program improvement from the HHSC Guardianship Advisory Board.

Corrective actions include providing additional resources to build the guardianship infrastructure at the local level, transferring the Guardianship program, and strengthening the training of APS staff on the appropriate use of guardianship. HHSC has placed a high priority on strengthening the Guardianship program as quickly as possible.

<<back to top>>

Actions Related to APS Organization and Administration

This section describes the actions in the implementation plan associated with the organization and administration of the APS program, including:

• Staffing
• Funding
• Performance Management
• Technology
• Mobile Technology
• Records Retention
• Training

For each area, a narrative provides an overview of the issues, followed by a table that relates specific outcomes, issues, and actions.

Staffing

The effective and efficient deployment of staff is critical in maximizing the limited resources available to the program. APS is not deploying staff to best meet the needs of clients.

Of immediate concern is ensuring that staff are deployed to areas in the state to alleviate chronic staff shortages that are having a negative impact on clients. HHSC is working with APS to immediately identify these areas and develop staffing remedies. HHSC considers this a high priority and is acting quickly to implement this corrective action.

The basic APS caseworker is, at the same time, service delivery planner, service provider, community relations specialist, records retention staff, and legal support rolled into one. Critical distinction must be made between the roles of investigator and service delivery staff. In prior times when there were fewer complexities associated with investigation and service delivery, an individual may have been able to do a competent job for both functions. Today, each function is so specialized and complicated that each requires particular skills.

Financial exploitation and self-neglect require highly specialized skills beyond what can be expected of all APS caseworkers. The array of medical conditions present also requires specialized consultation and efficient procedures for acquiring that consultation.

Additionally, supervisors must be able to provide guidance to workers on those cases that are complex and present unique problems. This is a key responsibility for supervisors that is not consistently applied in the field.

More efficiency may be gained by separating the development of a service plan from routine administrative tasks of arranging for and delivering those services. In a similar manner, the community relations, judicial relations, and other support functions are likely best provided by designated staff rather than incorporated into a general APS caseworker position.

Finally, the frustration of staff in having to do all these functions may contribute to the high turnover rates in this program. It is important that a realistic job preview for applicants shows how they can succeed and thereby provide incentive to participate in this important work.

Corrective actions to staffing include examining the need for creating positions designed specifically to identify service needs of clients and allow caseworkers and supervisors to focus their efforts of conducting thorough investigations. These "social service aides" will improve overall program efficiency and assist in managing excessive caseloads. Additional corrective actions are to redesign selection and training criteria to improve retention rates.

Funding

Funding for field operations in APS is based on the equity of service statement (ESS), a model that attempts to equalize funding for services across regions. Based on indicators of workload, the goal of ESS is to provide each region an equitable distribution of available funds. The cost of providing services is primarily a function of the number of staff that can be afforded. The ESS formula, therefore, in effect determines the number of staff for each region.

The APS ESS formula has four components: intake, investigation, service delivery and guardianship. A workload study is performed to identify the average time for each component. Then the number of intake, investigation, service delivery and guardianship cases are computed for each region. Finally, the number of staff hours for each component is computed and totaled by region. The ratio of regional staff hours to the total statewide hours is the percentage of funding allocated.

Weakness or flaws in the indicators upon which the ESS is based cause distortions in the distribution of funding.

One weakness is the lack of definition of what constitutes a case. The distinction between cases investigated and those in service delivery is blurred by the lack of clarity in policy and, as a result, the lack of clarity in IMPACT.

The level of effort involved in each phase of investigation and service delivery cannot be determined at the regional level and is not part of the work measurement study. Moreover, without some system of profiling cases, it cannot be determined which cases are complex and require more time and which are relatively simple and do not.

DFPS conducts work measurement studies to determine how much time is spent on cases. Currently the work measurement study for APS focuses on the statewide average of time to complete a case. Complex cases take more time and there are indications that regions may differ such that some regions have a higher rate of these cases than others. The use of a statewide average in the formula for determining regional funding allocations may be inappropriate if regions differ in their ratio of complex cases.

Current average caseloads vary widely by region. This may be the result of differing caseload demands between regions. The lack of regional time information prevents informed decision making regarding how similar caseload sizes should be. There is no way to determine if the observed variation in caseloads is equitable or not.

The target population of APS services is relatively well defined, yet demographic information is not used in the ESS to anticipate future caseload trends.

Finally, the lack of clarity on what constitutes protective services results in a misallocation of resources into non-protective services. This lowers the funding available for protective services and shifts the cost for non-protective services to DFPS.

Corrective actions are to redesign funding allocations to more accurately consider regional geographic and demographic needs, analyze current workloads after modifying the work measurement study (WMS), and assess more appropriate resource allocations in terms of funding and staff.

Performance Management

Many, if not most, of the problems identified in the APS reform occurred due to a lack of established performance management tools and processes. First, there are few, if any, performance standards. Staff do not have clear, program-wide standards to guide them in handling particular cases or to manage their caseload. The lack of available policies and procedures in handling cases also contributes to this problem. Staff do have performance standards associated with their annual performance review, but the reviews are not always done in a timely manner.

This lack of clear program-wide performance standards makes it difficult to appropriately monitor and supervise staff. Performance standards vary by supervisor, making it difficult to consistently monitor program performance.

Second, and as a result of the first, the current management reporting system is inadequate and underutilized. The absence of clearly stated performance measures makes it difficult to identify problems and tailor solutions to address issues in a timely manner. As a result, problems arise in the form of high profile cases that are brought to the attention of management from outside the agency. These types of cases generate specific solutions that may not address the underlying problems that created them. The ability to resolve these high profile cases does not address the underlying fundamental problem.

Development of performance standards tied to clear policies and procedures is just one of the corrective actions required for the APS program. Consistent with H.B. 2292 and the vision for health and human service delivery, APS must develop and implement a quality assurance program to identify current issues, anticipate potential problems, and design corrective action plans to correct those problems immediately.

Technology (IMPACT)

The technology supporting the APS program is the Information Management Protecting Adults and Children in Texas (IMPACT) system. IMPACT is a case tracking and reporting system that also supports the Child Protective Services and Child Care Licensing programs at DFPS. Three problem areas were identified during evaluation of the system.

The first issue occurs in developing caseload reports. Standard caseload reports are currently generated from summary tables. These tables are built using rules for classifying and sorting service delivery data. On the other hand, when service delivery data is accessed directly, rather than through the summary tables, conflicting reports are generated.

This issue seems to be based on rules for coding and summarizing data that lack clarity regarding specific decision-making points in the intake, investigative, and service delivery phases of the APS process. An information systems audit is planned to assess the scope of this problem.

The second issue relates to compliance with records retention policy. Records retention policy is tied to the date a case is closed. Records are being kept longer than necessary due to a lack of clarity in policies and procedures for closing cases. Additionally, a lack of staff resources has resulted in a backlog of case records that need to be merged or purged. This corrective action will require extra staff effort and resources to implement. Once the retention policy has been clarified, IMPACT will be modified.

APS supervisors should more fully utilize existing IMPACT data warehouse reports and ad-hoc reports that provide detailed information on caseloads at regional, unit, and worker level for quality assurance and performance management. Existing reports should include drill-down capability to more readily identify outlying cases to create the development of key performance indicator (KPI) reports that record the performance of workers.

Finally, it was reported that IMPACT was "dropping" cases that had been entered into the system. Further research indicated the identified cases had not actually been entered into the system, due in large part, to staff error in the data entry process. The Department of Family and Protective Services identified the staff error and implemented an adjustment to the system to disallow inappropriate data entry. HHSC found no evidence to support that IMPACT has dropped cases.

Corrective actions include performing an information systems audit regarding the rules for coding and summarizing data, modifying IMPACT according to new records retention policies and procedures, and retraining staff in advanced uses of IMPACT.

Mobile Technology

Technology is critical in the overall operation of the APS program. When used to its full potential, it can provide staff with efficient and effective tools to carry out their jobs. It can also provide supervisors and management with the tools necessary to create and implement revised performance standards and quality assurance measures.

A complete and through review of all current technology being used by APS was conducted. Technology was identified that can be more consistently and efficiently employed, such as the use of digital cameras by caseworkers. Computer based training is not fully utilized but could be to provide information and training to staff in the field.

The lack of real time access to policies and key APS tools and forms was also identified as an issue. The delay of inputting case notes into IMPACT results in misreporting and loss of data. Mobile technology will address this issue.

APS should deploy wireless technologies and handheld devices with electronic reporting capabilities to caseworkers. A case wizard prototype that integrates policies, procedures and application tasks to guide a user should be developed. For example, wizards for the step-by-step performance of critical tasks, such as Chapter 48 removals and risk assessments, would expedite reporting and improve caseworker efficiency. Supporting evidence should also be scanned into the case file. These improvements will require an increase in storage capabilities of field office computer systems.

In all, the deployment of wireless technologies, tablet PCs, and digital recording media would greatly enhance the documentation, efficiency, and thoroughness of investigations. The availability of these devices would also facilitate the implementation of telemedicine consultations should this pilot prove successful. With such technologies, upgrades to IMPACT and increased training would be necessary.

Records Retention

Records retention is a vital support component of the investigative and service delivery phases of the APS process. Proper records retention provides justification and substantiates the decisions made through the duration of the case. It is critical to the success of a case if referred to the courts.

Several areas of concern have been identified within the APS records retention processes that need corrective actions. One area of concern is that records retention practices are not consistent with or supportive of the investigative and/or judicial processes.

APS case files are not retained in accordance with state approved policies, and the DFPS records management program has no standard electronic tracking system for monitoring records management activities and agency compliance. According to the records retention policies, DFPS is behind schedule on destruction of case files, creating a legal liability for the agency. At the current destruction rate, DFPS will not be in compliance with records retention policy for several years.

Agency policies regarding merging of case files within IMPACT are unclear and inconsistently applied throughout the state. If the case is not merged correctly, the information may appear to be lost due to the difficulty of maneuvering through multiple electronic cases. Quality assurance measures are not in place to ensure that retention policies are consistently applied throughout the state.

Training regarding records retention is not regularly provided to APS staff. Understaffing in the field also creates a problem with performing records management activities.

Corrective actions include developing a uniform case file merging policy, implementing a system of organized automated records (SOAR), and purging the backlog of electronic files.

Training

Training provides the tools for APS staff to efficiently carry out the investigative mandates of APS. It is critical to every aspect of program operations.

APS training is deficient. One reason for this is the lack of specific policies and procedures in investigation, service delivery, and community and judicial relations. Changes in policies and procedures will improve training dramatically. A complete overhaul of the APS curriculum will then be necessary.

Current training practices do not ensure all staff have the skills necessary to perform their jobs. The training is too brief for the amount of material that must be mastered by the new worker. Pre- and post-tests are not used to evaluate staff learning. There is no requirement for annual training for caseworkers. A certification process is available but voluntary for staff. Although this practice has been discontinued, new APS caseworkers were allowed to investigate cases without formal training.

A number of areas in training must be improved. Better training on building and maintaining community relations is needed, as well as training on the law enforcement and judicial aspects of investigations and casework.

APS must provide specialized training in complex areas, such as financial exploitation, mental health, and self-neglect. Basic training should include significant coverage of these topics, including criteria for when to consult with subject matter experts.

Supervisor training should focus more in-depth on decision-making regarding complex cases to ensure supervisors are able to provide appropriate guidance to staff.

Finally, training needs to be more readily available to staff. This includes access to the standard training curriculum via computer-based training and to ongoing refresher training.

Corrective actions include a complete revision of the basic service delivery curricula, developing performance standards for learning, and developing computer-based training for easy access by field staff.

<<back to top>>

Actions Related to Working with Community Partners

To ensure community involvement and establish best practices in building and maintaining relationships with community partners, HHSC convened a work session of stakeholders. Stakeholders were invited from across the state representing a broad array of groups. The participants in attendance represented various organizations dealing with issues on aging and disability, including judicial, legal, aging, and disability advocates and guardianship. Over 100 groups were contacted to send a representative to the work session.

Work session participants began by defining positive community relationships that would assist APS in meeting its goals. These included such items as better access to services, improving communication, and steps to successfully building relationships in each region.

This section describes the actions in the implementation plan associated with the collaborations needed to ensure the success of the APS program.

• Community Relations
• Judicial Relations

For each area, a narrative provides an overview of the issues followed by a table that relates specific outcomes, issues, and actions.

Community Relations

Community relationship building is a significant part of the APS program. A collaborative working relationship with local community groups ensures that client needs identified in APS investigations can be effectively met.

APS should play a critical role in developing and maintaining local community networks. There is a large variation in the quality of such networks across the state. Staff should receive clear direction from management about the essential components necessary to support community networks. Staff should also be provided the tools, in the form of a handbook, to be successful in their efforts. Additionally, the APS basic training should include a section on building and maintaining strong community relations.

APS should strategically and consistently develop and maintain community resources to ensure services are available for clients. Local community resource books should be created and maintained. APS staff should be dedicated to ensure they are current.

Community networks should be the vehicles for a coordinated, comprehensive public awareness campaign. Community partners can help effectively translate the message in terms of their respective community cultures.

The engagement of volunteer coordinators varies significantly across the state. Volunteer services are an important piece of the APS service model, and dedicated staff should be deployed to ensure effective volunteer programs in all areas of the state.

APS needs to develop better communication and cooperation with other state health and human services agencies. In many areas APS is unable to successfully engage other health and human services agencies and programs, such as mental health and family services, in appropriate interventions. APS should engage other state health and human services agencies in collaborative working relationships to meet the needs of Texans.

APS can benefit from working collaboratively with community groups that currently provide health and human services. A number of successful partnership programs have identified best practices and APS could profit by engaging with them to provide services to clients of APS. In particular, the faith-based community has several well-regarded service delivery programs, most notably with Child Protective Services, from which APS may benefit.

Corrective actions include formalizing the process for building and maintaining community relations, engaging other state and local entities in collaborative service delivery, and developing local resource lists.

Judicial Relations

Judicial relations are important to the successful operation of the APS program. Deficiencies in current policies and procedures have resulted in a reduction of the number of referrals to probate courts, leaving APS clients at risk. These deficiencies reflect the need to develop policies, procedures, and training that will provide staff with the guidance and direction needed to effectively work with local judicial systems.

The varied quality of APS investigations, case documentation, and understaffing has impaired the relationships with local prosecutors and judges not only in El Paso, but also in other areas of the state. APS must act decisively to reestablish these relationships. Supervisors must engage the judicial community to build an effective working relationship based on mutual trust.

In building this trust, APS must ensure caseworkers are trained in the legal avenues available to protect clients, including emergency removals and guardianship. APS must also ensure caseworkers are trained in the appropriate documentation requirements to support legal action.

Guardianship should be used more effectively as a tool for ensuring client safety. Referrals should be made in a timely manner consistent with court requirements. Reform efforts related to guardianship are described in a previous section of this report.

Corrective actions include plans to mitigate strained relations with the judiciary, establishing uniform guidelines for relating with local law enforcement and the judicial system, and uniform criteria for emergency removals.

<<back to top>>

Timelines

The general timeline for implementation is in three phases.

First, policy must be developed, clarified, or altered to align with the desired outcomes for the APS program. Of particular concern are the policy issues related to the:

• Balance between self-determination and the agency's mandate for the protection of individuals at risk of abuse, neglect, and exploitation;
• Distinction between investigation and service delivery;
• Boundaries of protective services and non-protective services; and
• Responsibilities of the Guardianship program.

It is anticipated that these policy issues will be resolved by the fall of 2004.

Second, procedures must be developed to ensure established policy is effectively carried out. This will be accomplished by the following methods:

• Performance standards must be defined and adopted;
• Organizational structure must be uniformly defined;
• Mobile technology to streamline procedures must be defined;
• Current APS in-home investigations handbook must be modified;
• New and effective training curriculum and processes must be implemented; and
• Community and judicial relationships reestablished and maintained.

These procedures will be fully developed by the spring of 2005.

Finally, the administrative structure and supporting technology must be implemented until:

• Staffing positions are filled;
• IMPACT is modified to align with established policies and procedures; and
• Staff are retrained on new policies and procedures and IMPACT.

The administrative structure and supporting technology will be fully implemented by the summer of 2005.

Priority Corrective Actions

HHSC is committed to implementing the corrective actions in this plan as quickly as possible within the timeframes indicated. Three critical areas are receiving the highest priority. One area is ensuring sufficient staff in critical areas of the state. HHSC is working with APS to identify needs and deploy necessary staff as quickly as possible. Another critical area is the development and deployment of a new risk assessment tool to replace the current capacity tool. Field-testing of this tool should begin this fall. Lastly, HHSC will work closely with state leaders to secure funding to expand the capacity of local Guardianship programs.

A full accounting of progress will be provided in the final report required by Executive Order RP 33 due November 1, 2004.

<<back to top>>

Appendix A Combined Action Tables

<<back to top>>

Appendix B Glossary of Terms

Adult Protective Services (APS): The program under the purview of DFPS which is mandated to protect older adults and persons with disabilities from abuse, neglect, and exploitation by investigating and providing or arranging for services as necessary to alleviate or prevent further maltreatment.

Basic Skills Development (BSD): The term used by the DFPS Professional Development Division (PDD) that describes classroom training provided to employees.

Case Documentation: The information collected by APS investigative staff or caseworker staff that is included in the case record. This information lists client contacts, collateral contacts, perpetrator contacts, and other information obtained during the course of an investigation or in providing services to clients.

Caseworker: The APS staff that provides direct delivery or contracted services to clients after an investigation has been completed.

Certification Process: A voluntary process designed to recognize professional development beyond the basic job skills required for DFPS specialists and supervisors.

Community Involvement: A process that ensures effective and deliberative methods of participation in local communities with the purpose of providing information on the APS program and being visible in the community as a partner in addressing needs of the community.

Community Organization: The process of organizing activities with various groups or organizations within a community for a specific purpose of meeting the needs of elderly or disabled clients served by APS.

Community Resources: Services or items provided by groups or organizations within a community that meet the immediate or long-term needs of a client.

Comprehensive Risk Assessment Tool: The process by which a caseworker or investigator completes a thorough analysis of the environment, financial circumstances, physical and medical condition, social interaction and support, and the mental and problem-solving abilities of the individual to assess risk factors associated with the client remaining in the home.

Community Relations: The effort to establish two-way communication with the public to create understanding of APS programs and related actions and to ensure public participation into decision-making processes related to the delivery of services in the community.

Corrective Action: The administrative remedy imposed on an agency or section of an agency that defines the scope of change that must occur.

Department of Family and Protective Services (DFPS): The APS and CPS oversight agency that is mandated to protect the unprotected children, elderly, and people with disabilities from abuse, neglect, and exploitation.

Emergency Removals: A process through which the court may authorize that an elderly or disabled person be moved to safer surroundings based on an assessment that the person suffers from abuse, neglect, or exploitation that presents a threat to life or physical safety and lacks the mental or physical ability to consent to services.

Environment Issues: Refers to client's current living situations including an assessment of working utilities, health hazards, adequate food in the home, appropriate seasonal dress, and other factors associated with the client remaining in a suitable living situation.

Equity of Service Statement (ESS): This is an allocation formula tool that is used by DFPS to allocate funds for the APS program.

Forcible Entry: The process through which law enforcement is contacted to gain entrance into a home for the purpose of gaining access to the individual to conduct the investigation.

Guardianship: The power and duty of taking care of another person and managing the property and rights of another person who, because of age, understanding or self-control, is considered incapable of administering his or her own affairs.

Health and Human Services Commission (HHSC): The oversight agency responsibilities for designated health and human services agencies, which includes DFPS, and administers certain health and human services programs including the Texas Medicaid Program, Children's Health Insurance Program (CHIP), and Medicaid waste, fraud, and abuse investigations.

Information Management Protecting Adults and Children in Texas (IMPACT):
IMPACT is a case tracking and reporting system that is used by APS staff to document case activities. It also supports the Child Protective Services and Child Care Licensing programs at DFPS.

Intake Specialist: APS staff responsible for obtaining information on potential abuse, neglect, or exploitation referrals.

Intake: The process of obtaining information from a complainant on the possible abuse, neglect, or exploitation of an elderly or disabled individual.

Investigative Stage: Part of the APS process in which the investigator initiates contact with the client, collateral contacts and contacts with the alleged perpetrator to determine if there is abuse, neglect, or exploitation of the elderly or disabled individual.

Investigator: The APS staff designated to conduct the investigation regarding allegations of abuse, neglect, or exploitation.

Multi-Disciplinary Team (MDT): A group of subject matter experts who work together in a coordinated and collaborative manner to review and suggest corrected actions to address areas of concerns. Members of the MDT are comprised of agency staff, stakeholders, and/or private practitioners who have an interest in the way services are provided to clients.

Performance Management: The systematic process of monitoring the results of activities; collecting and analyzing performance information to track progress toward planning results; using performance information to inform program decision-making and resource allocation; and communicating results achieved, or not attained.

Performance Standard: An established level of achievement, quality of performance, or degree of proficiency.

Refresher Training: Training provided to APS staff to update them on changes that are made to existing policies and procedures.

Service Delivery: The process of providing direct or contracted services to clients to address client's immediate or long-term needs.

Service Delivery Plan: The types of services that will be provided to the client and documented in the IMPACT system.

Service Delivery Stage: The part of the investigation that begins when the investigator has determined that abuse, neglect, or exploitation exists and services need to be provided to the client.

Skill Sets: The abilities needed by an individual in performing the duties of an Adult Protective Services caseworker or supervisor.

Subcommittee: A subgroup of the APS Reform Team that was established by HHSC to review and identify issues in specific areas of the APS program.

Volunteer Programs: Groups established using volunteers to provide services to individuals. Meals on Wheels is an example of a program that utilizes volunteers to deliver meals.

Workgroup: A subgroup of the APS Task Force established to work on a specific issue.

<<back to release>>