Performance audit, Department of Economic Security, Division of Aging and Community Services

              PERFORMANCE AUDIT
DEPARTMENT OF ECONOMIC SECURITY
Division of Aging and Community Services
Report to the Arizona Legislature
By the Auditor General
October 1995
Report # 95- 5
DOUGLAS R. NORTON, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
October 4, 1995
DEBRA K. DAVENPORT, CPA
DEPUTVAUDIT0IGENEI) AL
Members of the Arizona Legislature
The Honorable Fife Symington, Governor
Dr. Linda J. Blessing, Director
Department of Economic Security
Transmitted herewith is a report of the Auditor General, A Performance Audit of the
Department of Economic Security, Division of Aging and Community Services. This
report is in response to a May 5, 1993, resolution of the Joint Legislative Audit
Committee. The performance audit was conducted as part of the sunset review set
forth in A. R. S. § § 41- 2951 through 41- 2957.
This audit addresses Adult Protective Services' ( APS) ability to adequately protect
Arizona's adults. Our review of case files revealed that APS generally appears to
investigate all reports that warrant investigation, and does so in a timely manner.
However, APS' decentralized intake process, with intake performed at 30 separate sites
located throughout Arizona, fosters noncompliance with standards and inconsistent
case handling throughout Arizona. We recommend centralizing the intake function,
as other states have done, to eliminate these problems and improve APS' intake
function. We also found APS staff lack sufficient training. We recommend the Division
of Aging and Community Services adequately fund the development of a formal
training curriculum designed to help staff master APS- specific skills.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on October 5, 1995.
Sincerely,
DOUR. NSort on
Auditor General
Enclosure
2910 NORTH 44Tn STREET m SUITE 410 . PHOENIX, ARIZONA 85018 l( 602) 553- 0333 m FAX ( 602) 553- 0051
SUMMARY
The Office of the Auditor General has conducted a performance audit of the Arizona
Department of Economic Security ( DES), Division of Aging and Community Services in
response to a May 5,1993, resolution of the Joint Legislative Audit Committee. This audit,
the fifth in a series of six audits of DES, was conducted as part of the sunset review as set
forth in Arizona Revised Statutes ( A. R. S.) 5541- 2951 through 41- 2957.
The Aging and Adult Administration, within the Department of Economic Security's Di-vision
of Aging and Community Services, administers statewide programs of advocacy,
information and referral, and long- term care for the elderly. Adult Protective Services
( APS), within the Aging and Adult Administration, provides investigative and protective
services to Arizona's vulnerable and incapacitated adults. APS' statistics suggest that it is
adequately protecting Arizona's adults. Although only 73 percent of reports received al-leging
abuse, neglect, and exploitation are investigated, our review of case files revealed
that the 27 percent of reports not investigated probably do not warrant an investigation.
Further, APS staff initiated over 80 percent of investigations within 48 hours. In most of
the remaining cases, the client could not be located within this time frame and subsequent
attempts were made to locate the client. Finally, despite admirable efforts, APS staff often
have difficulty removing clients from risk because of clients' resistance or because needed
services are unavailable.
Adult Protective Services Should
Centralize Its Intake Function
( See pages 7 through 14)
APS currently performs intake at 30 separate sites located throughout Arizona. As a re-sult
of this fragmented intake process, workers do not always follow standard proce-dures
in performing intake and handle cases with similar characteristics inconsistently.
Case files lack necessary information regarding the extent of abuse, neglect, or exploita-tion,
and/ or lack sufficient documentation to support the decision to investigate a case.
Additionally, supervisory reviews are untimely, sometimes coming 8 to almost 12 months
after a case has been handled. As a result, not only is the potential for case mishandling
high, there is little chance mistakes will be identified and corrected. While only a few
cases appeared to be improperly handled, the potential exists for others.
Other states have implemented a centralized intake function after experiencing similar
problems and report that one intake location creates a more efficient, consistent intake
process.
APS Lacks Formal Training
for Its Workers
( See pages 15 through 18)
New APS staff are required to handle cases without first receiving specific, job- related
training. Further, APS' ongoing training efforts do not provide sufficient training in the
skills necessary to conduct investigations, assess client needs, and find available services.
As a result, APS workers may not be adequately prepared to handle their challenging
caseload, placing workers and clients at risk.
In contrast, other states have developed or are currently developing training curricula,
generally including both initial and ongoing components. These states, recognizing the
benefits of adequate training, have formalized their processes by implementing training
requirements for their workers. Further, several states contract with firms or universities
to provide training, while also locating other effective training resources.
Arizona's Rapidly Growing Elderly Population
Could Overwhelm Already Burdened
Long- Term Care System
( See pages 19 through 22)
During the audit we also collected other pertinent information on the State's ability to
meet the long- term care needs of its rapidly growing elderly population. Unmet client
needs and growing budgets already burden Arizona's long- term care system. In fact,
over 1,000 clients were waiting for DES long- term care services in February 1995. Ex-pected
dramatic increases in Arizona's elderly population, almost 75 percent in the 85-
and- older population in just ten years, foreshadow increasing problems in meeting this
population's needs. Arizona may be able to identify more cost- effective ways to provide
long- term care services from other states. Washington, Oregon, and Wisconsin are able to
serve more clients with available service dollars by maximizing the use of less expensive
home- and community- based services.
Table of Contents
Page
Introduction and Background ....................................................... 1
in din^ I: Adult Protective Services
Should Centralize Its Intake Function .................................... 7
The Intake Function ........................................................................................ 7
Intake Process Varies
Throughout State ............................................................................................
Centralization Could Improve
the Intake Process ........................................................................................... 10
Recommendations .......................................................................................... 14
Finding II: APS Lacks Formal
Training for Its Workers ......................................................... 15
Background ..................................................................................................... 15
APS Workers Lack
Task- Related Training .................................................................................... 15
DES Efforts Lag
Behind Other States ........................................................................................ 17
Recommendations .......................................................................................... 18
Other Pertinent Information .......................................................... 19
Arizona's Rapidly Growing Elderly
Population Could Overwhelm Already
Burdened Long- Term Care System ............................................................... 19
Area For Further Audit Work ......................................................... 24
Agency Response
Tables
Page
Table 1 APS Reports Received
and Investigation Rates,
Fiscal Years 1991- 92 through 1994- 95 .................................. 2
Table 2 Percent Increase in Arizona's
Population from Current Year 1995. ................................ .... 21
INTRODUCTION AND BACKGROUND
The Office of the Auditor General has conducted a performance audit of the Arizona
Department of Economic Security ( DES), Division of Aging and Community Services in
response to a May 5,1993, resolution of the Joint Legislative Audit Committee. This audit,
the fifth in a series of six audits of DES, was conducted as part of the sunset review as set
forth in A. R. S. 5541- 2951 through 41- 2957.
The Division of Aging and Community Services ( Division) administers two types of pro-grams.
First, the Division, through its Community Services Administration, coordinates
several social service programs designed to meet the short- term emergency needs of Ari-zona
citizens such as homelessness and hunger. Second, the Division's Aging and Adult
Administration administers the Adult Protective Service ( APS) program and provides
services to the elderly including advocacy, information and referral, and home- and com-munity-
based care.
Adult Protective Services
Adult Protective Services ( APS) is responsible for protecting Arizona's vulnerable and
incapacitated adult population. APS staff receive reports alleging abuse, neglect, and ex-ploitation
of adults at 30 offices located in 6 districts throughout the State. After an inves-tigation,
workers attempt to remove people from risk by offering services, seeking guard-ians
or conservators, or, if necessary, involving law enforcement. However, unlike Child
Protective Services ( CPS), APS serves adults who, if they are mentally competent, have
the right to live as they choose, even if personal harm may result.
Despite statistics suggesting otherwise, APS staff are able to investigate virtually all cases
warranting an investigation. While APS staff also conduct timely investigations, they must
often overcome significant barriers to removing their clients from the risk they find.
APS statistics do not tell the whole sto y - APS' investigation rate is actually better than
its statistics suggest. As Table 1 ( see page 2) illustrates, APS received 10,219 reports in
fiscal year 1995 and investigated approximately 73 percent of them. However, during
intake, workers evaluate all reports to determine if they require a field investigation.
Reports that identify alternative sources of help, lack sufficient information to identify a
client, or involve clients already known to APS may not be investigated. In these cases,
APS staff may be able to provide sufficient assistance at the time the report is taken. Our
review of APS cases confirms the 27 percent of cases not investigated probably did not
warrant a field investigation.
Table 1
APS Reports Received and Investigation Rates,
Fiscal Years 1991 - 92 through 1994- 95
Total Reports 8,979 9,205 8,974 10,219
Reports Investigated 6,660 6,531 6,331 7,417
Reports Not Investigated 2,319 2,674 2,643 2,802
Investigation Rate 74.17% 70.95% 70.55% 72.58%
Source: Statistical reports from APS' automated data system.
APS initiates the majority of its investigations within the required 48- hour time frame. In
fact, APS staff initiated investigations within 48 hours in 80 percent of the cases we re-viewed.
In most of the remaining cases, the client could not be located within this time
and subsequent attempts to locate the client were made. This time frame is quicker than
that used in several other states, which allow up to ten days to contact certain clients.
APS stag often unable to help clients - After an investigation, workers often face barri-ers
in removing clients from risk. In many cases, clients themselves present the greatest
barrier to workersf efforts, as many are unwilling to accept APS' assistance. The majority
of APS cases are neglect cases, involving clients who fail to take care of themselves. Many
of these clients refuse to make the lifestyle changes necessary to alleviate their situation,
despite the consequences. Even clients who have been abused or financially exploited by
relatives and friends are sometimes reluctant to take action against the perpetrator. How-ever,
APS cannot coerce mentally competent clients into accepting assistance. An adult's
right to live as he or she chooses is foremost, and is to be considered before safety and
lifestyle.
Through our case review, we identified many cases involving uncooperative clients who
were unresponsive to APS assistance. cl) In over half of the cases reviewed clients refused
any APS assistance. Some of these clients insisted they had no problems for APS to re-
(') We randomly selected 150 APS cases open between ~ u19l94 t~ hro ugh February 1995. In each case the
client was a female, 60 years of age or older, which is the typical APS client. Ninety cases involved
allegations of neglect, with 30 each from Districts 1 and 2, covering Maricopa and Pima Counties
respectively, and 30 additional cases from Districts 3 through 6, which cover the remainder of the
State. We also reviewed 30 cases with allegations of abuse, and 30 with allegations of exploitation,
from all 6 districts.
solve, even though the reporting source stated otherwise. Others flatly refused to con-sider
the worker's suggestions, allowing themselves to physically deteriorate. For ex-ample:
One client allegedly lived in her car and slept in her backyard, without water or elec-tricity
in her home. A worker twice attempted to visit the client, but was unable to
contact her. To obtain additional information, the worker called the reporting source
who stated that although the client was competent, she was a poor housekeeper. Later
the client herself called APS and declined any APS assistance, explaining she was too
busy for APS' help as she volunteered at five different agencies.
APS investigated a reportedly bedbound client receiving home health services and
improperly taking her medications. The referral source also alleged that although the
client needed long- term care, her son refused to help her apply for i t When the worker
determined that the client would benefit from more care and supervision, possibly
from a nursing home, the client adamantly disagreed. After the worker made a sec-ond
visit and again tried to convince the client to move, the client reiterated her oppo-sition.
The worker closed the case, since the client was competent and refused APS'
recommendation.
Workers' dependence on other programs to provide services also hinders their ability to
impact clients. Although APS is responsible, by statute, for offering services to its clients,
APS is not funded to directly provide them. Workers have access to the APS emergency
budget to meet immediate client needs such as emergency lodging or nursing services;
however, funds are limited. On average, each of the 6 districts is allocated only $ 28,000
per year. In addition, workers must prove the funding needed is a " last resort." As a
result, workers must rely on other programs to provide clients with services such as per-sonal
care and housekeeping. However, extensive waiting lists exist for these services, or
they are simply unavailable. This is especially true in the rural areas of the State, where
workers shared their frustrations with the lack of mental health, transportation, and other
services for the elderly.
Budget and Personnel
The Department of Economic Security's Division of Aging and Community Services was
appropriated $ 16.4 million in state dollars for fiscal year 1996. Over half of this, $ 9.0 mil-lion
in state funds, along with $ 37.4 million in federal and local funds, will be used to
provide services for the elderly and physically disabled adults, $ 3.6 million will be used
for Division operating costs, and another $ 3.6 million is designated for the Community
Services Administration's programs. Additionally, $ 176,100 in state funds are allocated
to APS to provide emergency services.
Aging and Adult Administration is authorized 156 full- time equivalent positions in fiscal
year 1996,75.4 of which are state funded. The majority of staff, 104, are APS workers and
administrators that are located in 6 districts throughout the State. The remaining 52 Ag-ing
and Adult Administration staff are located in the central office and perform a variety
of functions. Staff oversee provider contracts, coordinate the State's Older Worker pro-grams,
develop and maintain policies and procedures, and handle the Division's busi-ness
and information functions.
Scope and Methodology
Our audit focused on Adult Protective Services. We interviewed Aging and Adult Ad-ministration
and APS management and elder advocates, spent time with numerous APS
workers observing the intake and investigative process, conducted extensive case file
reviews, and contacted nine states to draw comparisons with their adult protective ser-vice
systems.( l)
During the preliminary phase of the audit, we interviewed several service providers,
planning agencies, and people familiar with the Division's Community Services
Administration's ( CSA) practices, and determined that they were generally satisfied with
CSA's performance. In addition, the majority of CSA's programs are federally funded.
Further, this money is passed through CSA to local agencies for the actual provision of
services. For these reasons, we chose not to concentrate on CSA's responsibilities during
the audit, and instead focused our efforts on Adult Protective Services.
This audit contains findings and recommendations in two areas:
H the potential for case mishandling during the APS intake process due to workers not
following standard procedures consistently, and
H the unmet training needs of APS workers.
Concerned about the growth in Arizona's elderly population, we also studied the State's
elder service system and its ability to meet current and future client needs. We inter-viewed
officials at agencies providing services to the elderly, reviewed literature, and
studied long- term care systems in several other states, including Washington, Wisconsin,
We contacted Texas, I h o i s , Virginia, Nebraska, Maine, Utah, Kansas, Missouri, and New Mexico.
These states were mentioned during the audit as being innovative in at least one aspect of providing
adult protective services.
and Oregon, recognized leaders in long- term care policy and service delivery. This audit
also presents other pertinent information on Arizona's ability to meet the long- term needs
of its rapidly growing elderly population.
This audit was conducted in accordance with government auditing standards.
The Auditor General and staff express appreciation to the Director of the Department of
Economic Security, the Assistant Director of the Division of Aging and Community Ser-vices,
and their staff for their cooperation and assistance throughout the audit.
FINDING I
ADULT PROTECTIVE SERVICES SHOULD
CENTRALIZE ITS INTAKE FUNCTION
Adult Protective Services' ( APS) decentralized intake system fosters noncompliance with
standards and inconsistent case handling throughout the State. Furthermore, supervisory
review of the intake process is not possible at all APS offices, and when possible, often is
untimely. As a result, the potential for case mishandling is high and errors may go unde-tected,
thereby exposing the State to liability. Centralizing the intake function, as other
states have done, could eliminate these problems and improve APS' intake function. Ad-ditionally,
APS could further improve its intake process by prioritizing reports for inves-tigation.
The Intake Function
During intake, APS workers at 30 offices statewide receive reports of abuse, neglect, or
exploitation of adults and provide information and referral services. APS classifies intake
calls into two categories: 1) Reports and 2) Information and Referral ( I& R). Of the 18,668
calls APS offices received in fiscal year 1995,54.7 percent were Reports involving allega-tions
of abuse, neglect, or exploitation of an adult and the remaining 45.3 percent were
I& Rs. I& Rs represent calls from people needing only information or assistance in gaining
access to various social services, such as the programs offered at the nearest senior center,
or how to apply for social security.
APS Reports are further classified into reports accepted for investigation and reports not
accepted for investigation, termed Assess and Review cases ( A& Rs). Almost three- quar-ters
of all Reports ( 72.6 percent) are investigated. Cases are not investigated when there is
insufficient identifying information, other people or agencies are available to help the
individual, or APS has already investigated the case and no new information is presented.
The intake function serves two purposes. First, intake permits the APS worker to screen
out calls that do not meet the established criteria for abuse, neglect, or exploitation. Sec-ond,
for those cases meeting the criteria, intake represents the first opportunity to obtain
valuable information that can help determine how a particular case should be handled.
Intake Process Varies
Throughout State
In performing intake, APS workers do not always follow standard procedures and may
handle similar cases differently. This can lead to case mishandling, potentially placing
clients at risk, and exposing the State to liability.
Standard procedures not followed - A review of A& R and Report case files revealed that
the documentation within the case files is inadequate and not in compliance with the APS
Policies and Procedures Manual ( Manual). l According to APS management, the Manual
provides workers direction in screening calls and verifying that APS clients meet statu-tory
eligibility criteria. It contains specific guidelines for performing intake, including a
list of questions intake workers should address, such as how long a problem has existed,
the degree of urgency, the client's functional level, and if assistance is being provided by
other agencies or individuals. Also, the worker is to elicit specific information regarding
the allegation of abuse, neglect, or exploitation. Once obtained, the worker can use this
information to determine if a report should be investigated.
Unfortunately, APS workers often disregard many of these requirements. Overall, 60 per-cent
of the cases reviewed were not handled in accordance with the APS Manual during
intake. For example:
Approximately 40 percent of the cases lacked documentation explaining the extent of
abuse, neglect, or exploitation, or the situation's urgency. One case involving a men-tally
retarded woman who was allegedly being exploited by her payee ( person desig-nated
by the Social Security Administration to receive an individual's social security
checks and pay his or her bills), lacked information on what led the caller to suspect
exploitation. The file did not even include the alleged perpetrator's name. In another
case, a caller feared for the safety of a client who was leaving a care center. The center
would not provide follow- up services at the client's home because it was unsafe. How-ever,
the file did not include information on why the situation was deemed unsafe,
possibly exposing the assigned investigator to unknown danger.
Additionally, 47 percent of the cases lacked documentation detailing the worker's
efforts in determining what, if any, services the client may be receiving from other
agencies, groups, or individuals. This information is specifically needed to determine
if a case should be investigated.
Sixty randomly selected cases, 30 A& Rs and 30 Reports, were selected for review. Cases selected were
active between July 1994 and February 1995.
Timely supervisory review of cases could increase the likelihood that Manual policies are
followed. According to the Manual, Reports are to be reviewed by a supervisor within
one month of completion; however, there is no policy on supervisory review of A& R's.
Yet supervisory review of A& R's, completed directly following intake, is critical to en-sure
a case warranting an investigation is not overlooked. One month, the policy for Re-ports,
may be too late if a case should have been investigated. ( APS recently changed its
policies and now requires A& Rs be reviewed within 48 hours.) However, we noted that
approximately 17 percent of A& Rs we examined were not reviewed by a supervisor even
within 1 month. We found one A& R case that was still open over a year after it was
resolved, waiting for supervisory review. Other cases were waiting for reviews from one
and a- half months up to eight months. Also troublesome, nowhere in the case files were
there supervisory review comments, notations, or questions regarding the cases, raising
questions about the quality of the supervisory reviews.
Cases handled diflerently throughout State - Several inconsistencies also result from
performing intake at many offices throughout the State. First, staff performing intake at
each site have varying levels of experience. While Human Service Specialists I11 ( investi-gators),
the most experienced staff, usually perform intake, they are not always available.
Many rural offices have only one investigator and when they visit a client or are in Phoe-nix
for training, a less experienced staff member, a secretary, a DES employee from an-other
division, or even an answering machine takes calls.
Second, similar intake calls, even when received by investigators, can be handled differ-ently.
This problem, raised by Aging and Adult Administration management and APS
staff during the audit, was confirmed while monitoring the intake function at several APS
offices. For example, the following case example was noted at one site:
A client called APS two times with the same information, requesting assistance each
time. The first call was handled by an APS worker who was new to the office, and was
classified as an A& R. The second call was received by an APS worker with 13 years of
related protective services experience, who classified the call as a Report and plans to
conduct an investigation and offer services. She stated that she assessed the situation
differently than her colleague because she has more experience and training.
Additional inconsistencies identified include:
APS workers obtain and document information differently. For example, some work-ers
take notes manually and enter the information onto the APS computer system at a
later point in time, sometimes days or weeks after receiving the call. Such delays may
prevent the worker from remembering key facts pertaining to a case that are not writ-ten
down. On the other hand, some workers simultaneously receive calls and enter
the information received into the APS computer system.
APS offices operate with different levels of supervisory review. For example, urban
offices have supervisors available to review all cases immediately after intake and
assign those requiring an investigation to the appropriate staff. However, rural offices
allow APS workers to assign cases for investigation ( usually to themselves) without
supervision, as a supervisor may have to cover APS offices in several counties and
visit offices only once a month.
Weaknesses may result in case mishandling - For the most part APS staff accurately
determine which cases require an investigation; however, weaknesses in the intake sys-tem
have led to a few instances of apparent case mishandling. First, APS may have inves-tigated
cases not warranting one. In 37 percent of cases reviewed, there was insufficient
documentation in the case files to determine whether an investigation was warranted.
More importantly, there were several cases that appeared serious enough to warrant an
investigation, but none was conducted. These cases involved the physical abuse of an
elderly woman by her son, a drug user; and exploitation of a mentally retarded woman
by her payee ( mentioned earlier). Further, one case involved a referral from a social ser-vice
provider who called numerous times stating that a client's medical condition was
getting increasingly worse. The APS worker decided during intake that the case should
not be investigated, yet the individual was hospitalized a week later. After reviewing
these specific cases, an APS official believed in one case, involving the woman abused by
her son, that the worker appropriately referred the reporting source to community legal
services, as the woman was deemed competent. However, he had difficulty determining
if the remaining two cases should have been investigated due to the lack of documenta-tion
in the case files.
APS caseloads will probably increase due to Arizona's growing elderly population ( see
pages 19 through 21), thus it may only be a matter of time until serious tragedy such as
permanent injury or even death results from case mishandling. Should this occur, the
State may be held responsible. The State is usually liable for its negligence, defined as
breaching a duty which proximately causes any injury or damage. Because APS holds a
duty to provide adult protective services to eligible adults within a reasonable amount of
time after notification, breaching that duty would place the State in a vulnerable position.
Centralization Could Improve
the Intake Process
Centralizing the intake function could reduce noncompliance with standards and incon-sistent
case handling. States with a centralized APS intake system have been able to over-come
these problems. Additionally, in Arizona, the new Centralized Intake Unit in DES'
Child Protective Services Division provides significant benefits to the intake process.
hprovements result through centralization - A centralized system, by its nature, ad-dresses
the current problems in several ways:
First, one location offers increased monitoring capabilities. Monitoring and supervi-sory
review activities can be facilitated at one location, creating better opportunities to
enforce compliance with the APS Manual.
Second, centralization encourages specialization. As the staff in the centralized intake
unit perform only one function, they ultimately become " resident experts" on intake.
Finally, centralization limits the intake function's drain on resources, allowing APS
workers to better meet clients' needs. One APS worker stated she spent more than 60
percent of her time handling phone calls unrelated to legitimate APS cases. The staff
located throughout the State will no longer be burdened with the task of performing
intake, significantly increasing the time available to address client needs.
In agreement, one APS supervisor stated the ideal intake function would have all intake
personnel in one room, in one location where they could ask each other questions while
receiving calls to ensure cases are classified and handled correctly. He believes the cur-rent
system with many different people performing intake in separate offices limits staff's
ability to solicit advice or information from fellow intake staff.
Other states realized benefits subsequent to centralizing intake - Several states, includ-ing
Florida, Missouri, Texas, and Utah, have centralized or are in the process of centraliz-ing
their intake function.(') For example, Missouri's APS operation, which received over
19,000 reports in fiscal year 1994, implemented its central intake unit in 1980. One Mis-souri
official stated that centralization improved consistency and efficiency as staff per-forming
intake become experts in this area and local staff can spend more time investigat-ing
cases and offering protective services.
Operationally, Missouri's central intake unit receives all calls, statewide, regarding alle-gations
of abuse, neglect, and exploitation. A toll- free hotline is manned 24 hours a day
by 16 staff. Intake forms are faxed to the local office where the client resides for investiga-tion.
However, the central intake does not prevent people from calling the local offices.
Approximately 20 percent of their total calls still come into the local offices.
Utah's APS operation, considerably smaller than Arizona's ( 2,425 reports received in fis-cal
year 1994), consolidated intake into three intake sites in May of 1995 and recently
proposed further centralizing their intake function into one state intake unit. In the old
decentralized operation, where intake occurred in numerous cities throughout the State,
Maine has a centralized intake unit which operates during non- business hours. Local offices perform
intake Monday through Friday from 8: 00 am to 5: 00 pm.
11
workers were not available 24 hours a day, or even during business hours while conduct-ing
investigations, leaving callers talking to answering machines. Utah officials argued
that having one location would be more efficient, bring consistency to the intake process,
and allow increased intake coverage.
CPS is experiencing benefits through centralization - Within DES, Child Protective Ser-vices
( CPS) implemented its Centralized Intake Unit to improve consistency in report
screening and prioritization. CPS determined its fragmented intake system led to a high
number of callbacks, too many people performing duplicate functions, and misinterpre-tation
of policies, procedures, statutes, and regulations. Calls that should have been in-vestigated
were not and others were needlessly assigned for investigation. Therefore,
CPS centralized its intake function, and has reaped the following benefits:
consistency in performing intake functions,
limited and focused training requirements,
simplified monitoring of compliance with policies, procedures, statutes, and regula-tions,
more time for investigators to conduct investigations and meet client needs, and
timely entry of data onto the system.
APS management recognize benefits of centralization - The Division of Aging and Com-munity
Services ( Division) and APS management at the time of this audit agree that cen-tralization
could improve APS' intake function. These management officials echoed the
sentiments registered by other states, citing consistency, more time for investigators in
the field to handle their caseload, and increased intake coverage as benefits from such a
system.
The primary concern with centralization registered by Division and APS officials cen-tered
on the information and referral function. Should intake become centralized, the
rural offices will no longer provide information and referral services, leaving residents
without a convenient source of information on local services. However, the information
and referral responsibility may not appropriately belong with APS. Instead, the State's
eight Area Agencies on Aging ( Area Agencies) should provide these services.(') Despite
having fewer offices than APS, the Area Agencies are designated as regional elder plan-ning
and service centers and should be able to provide the same assistance currently
DES contracts with eight Area Agencies on Aging to coordinate providing the majority of services for
the elderly.
provided by APS staff. In fact, when asked if they could assume this responsibility, sev-eral
Area Agency representatives stated that, given additional resources, they would pre-fer
to handle information and referral calls, maintaining that APS should be an emer-gency
responder specifically addressing crisis situations. One Aging and Adult Adminis-tration
official agreed with the transfer of APS' information and referral role; stating,
however, that it will take additional resources for the Area Agencies to handle these calls
and time before people get used to calling another agency for assistance.
Other states prioritize cases to further improve APS seruices - During the audit, we also
collected information on report priority systems used in other states to identify cases
needing immediate attention. Although APS is currently able to initiate most investiga-tions
within the established 48- hour time frame, given the probable future increase in its
reports, APS may need to prioritize cases during intake in the future. Additionally, a
priority system could allow complicated cases to receive more investigative resources.
Several states have systems in place to ensure that cases presenting the most risk are
investigated first.@ M) oreover, workers can take more time to start investigations involv-ing
less risk. For example:
Nebraska assigns each case during intake to one of three categories: Priority 1 are the
highest risk cases and require the worker to contact the client within eight hours.
Priority 2 cases involve less risk and require contact within five days. Priority 3 cases,
involving the least risk, require contact within ten days.
Missouri, similar to Nebraska, assigns reports to one of three classes. However,
Missouri's Class 3 reports, which require no immediate protective services, may not
involve the worker contacting the client.
Kansas' APS also assigns priority levels to cases. In cases where clients are in immi-nent
danger, workers must make the initial contact within 24 hours. However, if the
client is allegedly abused and not in danger, the worker has three days to contact the
client. Finally, the worker has five days to contact the client if neglect or exploitation is
alleged and the client is not in danger.
Of the nine states we contacted, seven have priority systems: Nebraska, Maine, Kansas, Missouri,
Illinois, New Mexico, and Texas prioritize cases.
13
RECOMMENDATIONS
1. The Division should consider centralizing the intake function to better enforce com-pliance
with APS policies and to ultimately ensure appropriate decisions are made for
each case.
2. APS should strengthen its supervisory review process, including enforcing more timely
supervisory reviews.
3. APS should consider implementing a case prioritization system for investigated cases
to ensure those needing immediate attention are investigated first.
FINDING II
APS LACKS FORMAL TRAINING
FOR ITS WORKERS
Currently, Adult Protective Services ( APS) staff are required to handle cases without first
receiving specific, job- related training. As a result, APS workers may not be adequately
prepared to handle their challenging caseload. To improve the preparedness of APS work-ers,
the Division should follow other states' lead and adequately fund development and
implementation of a formal training curriculum.
Background
Although many APS workers come to the Division with extensive social service experi-ence,
either through education and/ or work with other organizations, the nature of some
APS work requires specific training. In fact, several APS staff we interviewed commented
that their formal education in social work proves deficient in certain situations, magnify-ing
the importance of formal training specifically directed toward APS work. For ex-ample,
they may not have the necessary knowledge of 1) accounting, bookkeeping, or
legal practices to prepare them for exploitation cases, or 2) photography or physical indi-cators
to assist in the substantiation of abuse and neglect cases. Additionally, workers
may not be sufficiently trained in the unique needs and problems of the elderly, APS
primary client. Finally, certain rural offices have difficulty finding people with college
degrees to hire.
APS Workers Lack
Tas k- Related Training
Despite needing additional training once they are hired by APS, workers receive no for-mal,
specific, job- related training prior to taking on a caseload. In addition, APS ongoing
training efforts do not sufficiently provide task- related information to its workers. In the
absence of adequate training, learning these skills occurs on the job. As a result, inconsis-tencies
have developed and APS clients are potentially at risk.
No formal initial staff training - Interviews with several workers revealed that the
districts do not sufficiently train staff prior to assigning them cases and some do not
provide any training at all. For example, on the first day of employment, a worker in one
office went through an orientation covering basic office tasks such as preparing time sheets
and answering the phone. After the orientation, the worker was required to handle an
actual case, because no other APS staff were available. The worker described her experi-ence
as " baptism by fire.'"
Staff also receive an APS Manual when starting, but the Manual alone does not adequately
prepare workers to perform their jobs. Several APS worker commented that reading the
Manual provides little help in dealing with the unique real- life situations APS workers
encounter. For example, the Manual states the staff should evaluate the physical and mental
condition of potential victims to substantiate abuse or neglect. However, the Manual lacks
specific details regarding what types of injuries indicate abuse or neglect or what mental
conditions lead to substantiated cases.
In- service training - In- service training is also inadequate. Currently, the Division limits
ongoing training efforts to quarterly training conferences. These conferences, which gen-erally
last one or two days, are not mandatory, and do not occur prior to APS workers
handling cases. Moreover, the training conferences often lack specific job- related or task-oriented
instruction.
While attending one of these training conferences, we noted that the entire first day of the
two- day conference was spent discussing the activities of the APS workers' committee,
employee evaluations, and other administrative topics. In addition, a review of training
agendas for several other conferences revealed that the topics did not often relate to daily
APS activities. Examples of topics covered at these conferences include: Managing Life at
Work, Advocacy for the Disabled, and Humor in the Workplace.
The APS Training Coordinator stated that skill- based training aimed at teaching APS
workers how to properly perform their jobs is often neglected. APS workers agreed that
specific training in APS related skill areas is needed most. For example, one APS worker
commented:
" I hate exploitation cases because I have no experience, expertise, or power. Instead, the
banks, attorneys, ... and perpetrators have all the knowledge, power, and control. Being at
such a disadvantage puts me in a no- win situation because I lack the knowledge and confi-dence
to deal with these parties and therefore cannot help my client. Only training specifi-cally
on accounting, banking, the law, and similar topics would improve how I handled
these cases. Unfortunately, such training does not currently exist."
Poor training potentially causes problems - The current method of placing employees
in the field without training prevents consistency in following APS policies. One APS
official stated that a training program teaching workers how to handle APS cases in ac-cordance
with APS policies could eliminate much of the inconsistency in classification
and case handling as noted in Finding I. Further, on- the- job training also potentially re-sults
in workers not learning how to handle certain situations, such as dealing with alco-holic
clients or those with serious mental illness, until they involve actual cases. Unpre-pared
workers place both themselves and clients at risk. One worker related her experi-
ence conducting an investigation in a nursing facility, which involved reviewing client
records. Not trained in interpreting medical records, nor the record- keeping requirements
of licensed nursing facilities, the worker was unable to quickly understand the client's
condition and help remove the client from risk.
DES Efforts Lag
Behind Other States
While several other states utilize a formal training curriculum to train their adult protec-tive
service workers, Arizona's APS unit only recently acknowledged the importance of
more formal training by hiring a training coordinator. However, inadequate funding still
hampers progress in this area.
Other states - Unlike Arizona, six of the nine states we surveyed, including Texas, New
Mexico, Virginia, Illinois, Nebraska, and Utah, have training curricula and the other three
are currently developing them. The training curricula vary but most include both manda-tory
initial and in- service training components. Some training curriculum characteristics
included:
training topics such as how to conduct intake and investigations, develop case plans,
and identify mental disorders and client exploitation,
mandatory hourly training requirements for all APS workers,
initial training components lasting from 1 week ( 40 hours) to 2 weeks ( 80 hours), and
W requirements for APS workers to pass an exam upon completion of the initial staff
training.
These states effectively utilize a myriad of resources to provide sufficient training to their
workers, including their own training units with specialized APS trainers, consulting
firms, and local universities. Some states effectively use a training coordinator and com-mittee
to organize, arrange, and evaluate the training being offered and make changes
when necessary. Others use " experts" such as lawyers, police officers, doctors, psycholo-gists,
nurses, university professors, and professional trainers to provide information and
training.
Recent, limited improvements in APS training - APS has not emphasized or devoted
resources to training in the past. In fact, APS has not designated training funds in many
years, and still no funds have been set aside for fiscal year 1996. Instead, money needed
for the training conferences, such as renting meeting space and hiring speakers, must
come out of other areas of APS' operating budget.
Additionally, prior to fiscal year 1995, APS did not have a training coordinator to develop
initial staff training and improve in- service training. While a new training coordinator
was hired in the fall of 1994, her responsibilities have been expanded to include coordi-nating
training for the entire Aging and Adult Administration. Despite having limited
time for APS, the new training coordinator has taken several steps to improve its training.
For example, she has
worked with DOA to provide additional training to APS workers,
corresponded with several other states regarding their training curricula,
contacted the National Institute for Human Services in Ohio regarding its services to
assist states in developing training curricula,( l) and
requested APS conduct a training needs assessment to define workers' needs.
RECOMMENDATIONS
1. APS should develop and implement a formal training curriculum designed to help
staff master APS specific skills such as conducting investigations and assessing client
needs. The curriculum should include both a mandatory initial training component
for all new APS staff and ongoing training sessions.
2. The Division of Aging and Community Services should adequately fund the develop-ment
and implementation of a formal training curriculum.
The National Institute for Human Services developed DES' Administration for Children, Youth, and
Families training curriculum.
Other Pertinent Information
During the audit, we developed other pertinent information on the State's ability to meet
the long- term care needs of its rapidly growing elderly population.
Arizona's Rapidly Growing Elderly
Population Could Overwhelm Already
Burdened Long- Term Care System
Unmet client needs and growing budgets burden Arizona's long- term care system for the
elderly and physically disabled. Expected dramatic increases in Arizona's number of eld-erly
persons foreshadow increasing problems meeting this population's long- term care
needs. Arizona can learn from three states leading the development of more cost- effective
ways to serve this population.
Ovemhelmed long- tenn care system - While both the Department of Economic Security
( DES) and Arizona Health Care Cost Containment System ( AHCCCS) provide long- term
care services, AHCCCS' long- term care budget has grown dramatically in recent years,
and DES cannot provide long- term care services to all eligible clients. AHCCCS provides
nursing home and home- and community- based services such as adult day care, and
homemaker and personal care services, to approximately 12,000 low- income elderly and
physically disabled adults through the Arizona Long- Term Care System ( ALTCS). ALTCS
has experienced significant growth since its inception in 1988. In fact, its budget has more
than doubled in the last seven years, and now totals over $ 370 million for fiscal year
1996.( l)
DES, through the Aging and Adult Administration's Non- medical Home and Commu-nity-
Based Care System, serves individuals with fewer functional impairments and more
resources than those eligible for ALTCS. DES long- term care services include housekeep-ing,
nurse, and home health aid visits, home- delivered meals, and adult day care. How-ever,
DES' program, spending over $ 20 million on services for approximately 18,000 cli-ents
in fiscal year 1995, has extensive waiting lists.( 2) I n February 1995, approximately
1,100 individuals were waiting for DES long- term care services. Although DES received
additional funding for its home- and community- based program for fiscal year 1996, Aging
and Adult Administration officials believe it will provide services for approximately one-fourth
of the waiting list clients.
ALTCS will receive $ 246.3 million in federal Medicaid in fiscal year 1996. T11e counties provide the
entire state match of $ 126.2 million.
( 2) The $ 20.4 million in service dollars used in fiscal year 1995 was comprised of $ 8.6 million in state
appropriations and $ 11.8 million in Older American's Act funds.
Growing elderly population - Increases in Arizona's elderly population will further
burden the long- term care system. Arizona currently ranks second in the nation, behind
Hawaii, in the increase of the 65- and- older population between 1990 and 2000. This group
currently represents 14 percent of Arizona's total population. Additionally, the 85- and-older
segment of Arizona's elderly population is expected to grow by almost 38 percent
in the next 5 years. This segment is significant as individuals over 85 are most likely to
need long- term care. As Table 2 shows, the rapid growth in both groups continues 10,15,
and 20 years into the future. In fact, the 65- and- older segment is expected to represent
over one- sixth of Arizona's total population by 2020.
Percent Increase in Arizona's Population
from Current Year 1995
Year 2000 2005 201 0 201 5
Total Pop. I + 12.5% + 24.5% + 36.6% + 49.3%
Age 65+ El + 14.8% + 28.0% + 45.9% + 74.0%
Age 85+ + 37.7% + 74.5% + I 15.4% + 141.6%
Source: Auchtor General analysis of DES' Arizona population projections 1995 to 2045.
Other states finding solutions - Florida also faces a rapidly growing elderly population.
One former Florida senator sees long- term care for this population as the " black hole" of
state government. A Department of Elder Affairs official stated:
" The challenge to states is to build a system that targets scarce state resources to the right
mix of institutional, residential, and community long- term care. In an age of high de-mands,
it is critical that we provide long- term care in the least expensive setting, which, at
the same time, provides the level and quality of services that people need."
Three states, Oregon, Washington, and Wisconsin, have already developed ways to serve
more clients with the federal ( Medicaid) and state dollars available by consolidating pro-grams
and maximizing the use of less expensive home- and community- based services.
In Oregon, one agency administers both the Medicaid and state- funded programs. Offi-cials
believe consolidation has been instrumental in developing a comprehensive long-term
care system. Additionally, all three states attempt to place as many people as pos-sible
in less expensive home- and community- based settings, while at the same time lim-iting
the number of nursing home beds. Washington's overall priority is to aggressively
battle nursing home growth; as one official stated, " a built bed is a filled bed." Further,
Oregon actively promotes alternative living arrangements that are less expensive and
restrictive than nursing homes, but provide more care than can be given at a client's home.
AREA FOR FURTHER AUDIT WORK
During the course of our audit, we identified an issue we were unable to fully pursue at
this time.
Is duplication and overlap among agencies serving the elderly adversely impacting
access to services? The Department of Economic Security's Aging and Adult Administra-tion
and the Arizona Health Care Cost Containment System's Arizona Long- Term Care
Systems ( ALTCS) have separate entry points for their services for the elderly; however,
an individual may not know which program he or she qualifies for and therefore where
to go first. The Aging and Adult Administration utilizes local case management agencies
throughout the State to authorize services. ALTCS also has eligibility offices located in
several cities throughout the State. Adding to the confusion, individuals can also enter
the system through Adult Protective Services ( APS), and then be referred to ALTCS or a
case management agency.
Moreover, simply obtaining information may sometimes be difficult, requiring several
phone calls, as information and referral services are also dispersed among many agen-cies.
In fact, at least three separate places provide information and referral in Maricopa
County. The Area Agency on Aging ( Area Agency) sponsors a Senior Help Line, the local
case management agency provides information and referral at its central intake line, and
APS also currently provides this service. Despite so many sources of information, indi-viduals
may still not get the help they need. Several people interviewed during our audit
stated that any single referral source lacks information on all available services. Transfer-ring
information and referral services from APS to the Area Agency as suggested in Find-ing
I could allow the Area Agency to take the lead in providing information and referral
services.
Perhaps further inconveniencing clients, each agency uses a separate assessment instru-ment
to determine eligibility and client needs. Although Aging and Adult Administra-tion
and ALTCS' assessment instruments are similar, they are not used interchangeably.
For example, ALTCS requires an assessment for eligibility and possibly another to iden-tify
service needs. The Aging and Adult Administration also conducts its own assess-ment.
Unfortunately, both most likely reassess individuals referred from the other pro-gram.
Additionally, APS assesses its clients for risk and if ongoing needs are identified, it
refers them to ALTCS or an Aging and Adult Administration case management agency,
and the cycle continues. The following case example illustrates how confusing this can be
for the client:
A one- hundred- year- old man who has been falling down and is mentally incapaci-tated
was assessed by an APS worker who determined the client needed housekeep-ing
and bathing services and home- delivered meals. Yet, the Aging and Adult
Administration's locally contracted case manager had to reassess the client before au-
thorizing any of these services. The client also needed a guardian or conservator, so
meanwhle the public fiduciary's office conducted its own assessment. The client was
also assessed by ALTCS for financial eligibility. As a result of so many assessments,
the client is frustrated and confused, and even fired the people who finally came to
provide services.
Other states utilize a single entry point and uniform assessment instrument to improve
access to services. In Wisconsin, counties are responsible for providing all long- term care
services. County case managers assess client needs and authorize services from any fund-ing
source. Further, Washington utilizes a standard assessment instrument for its long-term
care program. Despite having two agencies providing services, like Arizona, these
agencies share assessment results and every effort is made to ensure a second assessment
is never conducted.
Further audit work is needed to determine the extent of the problem and the possibility of
developing a uniform assessment instrument.
Agency Response
I
B
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
1717 W. Jefferson - P. 0. Box 6123 - Phoenix, AZ 85005 ( Fife Syrnington Linda J. Blessing, DPA
Governor SEP 2 9 1995 Director
The Honorable Douglas R. Norton
Auditor General
Ofice cf the Aditor Generzl
2910 N. 44th Street, Suite 410
Phoenix, AZ 850 18
Dear Mr. Norton:
Thank you for providing the preliminary draft report of the performance audit of the Department of
Economic Security, Division of Aging and Community Services. My staff and I are pleased to see
that your findings are consistent with the direction we have taken to continually improve our ability
to protect older and disabled adults and to plan for the future influx of older persons requiring our
services.
DES concurs with your findings and recommendations and will work with the Division of Aging
and Community Services to establish and implement, to the extent that our resources will allow, the
knctions and procedures listed below:
1) Centralize the intake function in order to:
* Ensure consistent intake procedures are followed throughout the state,
* Simplify the interpretation and monitoring of compliance with policies, procedures,
rules and laws,
* Relieve field investigators of the intake function in order to increase time devoted to
investigating reports and offering needed protection to vulnerable and incapacitated
adults, and
* Ensure that consistently appropriate decisions are made regarding whether or not to
investigate an incident report involving a vulnerable adult.
2) Enhance the supervisory review process to ensure that report decisions and case reviews are
conducted in a thorough and timely manner.
3) Prioritize case investigations in order that APS can immediately respond to situations that
are life threatening, or affect the health or safcty of vulnerable adults.
Page 2 SEP 2 9 1995
4) Provide core and ongoing training for all APS workers. We consider training to be the
cornerstone of our improvement strategy. Toward that end, the Department has identified the
need for funding to develop competency- based, core and on- going training.
5) Continue to work closely with the Governor's Ofice, the Legislature and affected state
agencies to encourage needed coordination andlor integration of planning, programming and
administration of Long- Term- Care ( LTC) and other programs for the elderly. This
cooperation is essential given the fact that Arizona's rapidly growing elderly population will
continue to stress the already burdened LTC system.
This report is thorough and objective and will undoubtedly prove to be helpful in continuing to
improve protective and community services for older and vulnerable adults.
Sincerely,
%/ Linda J. Blessing