GSSSI Did Not Always Properly Prepare, Obtain, and Maintain Case Documentation Related to Abuse of Elderly Persons.

Without proper documentation, GSSSI cannot ensure steps have been taken to address allegations of elder abuse.

Overview

We reviewed 60 cases of substantiated allegations of abuse of elderly persons, and 40 cases of unsubstantiated ones, investigated by GSSSI during the audit period to determine whether GSSSI prepared, obtained, and maintained case record documentation. We identified the following issues:

• Six (10%) of 60 investigations where allegations were substantiated lacked documentation describing activity conducted during the investigation, 1 (1.7%) lacked documentation of facts supporting decisions made on cases, and 6 (10%) lacked documentation describing actions taken on the client’s behalf during the investigation.
• In 25 (41.7%) of 60 investigations of substantiated allegations, and 15 (37.5%) of 40 investigations of unsubstantiated ones, we found instances where more than five business days lapsed before the caseworker documented his/her actions in the investigation or contact with the elderly person or other case participant.
• One (4.3%) of 23 applicable⁷ investigations of substantiated allegations, and 1 (16.7%) of 6 applicable investigations of unsubstantiated ones, lacked supporting documentation obtained from an outside source. In one instance, a police report had not been requested when it should have been, and in the other, a housing court agreement was said to be included in the case record but was not.
• Twenty (33.3%) of 60 investigation summaries for investigations of substantiated allegations, and 2 (5%) of 40 investigation summaries for investigations of unsubstantiated ones, were not properly completed. The identified issues comprised 4 cases where the caseworker’s disposition, or determination, of the allegation did not match the supervisor’s; 8 cases where the investigation summary did not address some or all of the allegations; and 10 cases where the investigation summary was not completed at all.
• Three (5.7%) of 53 applicable⁸ investigations of substantiated allegations, and 16 (40%) of 40 investigations of unsubstantiated ones, were not approved by the supervisor within five business days after they ended.
• Three (7%) of 43 applicable⁹ case records for substantiated allegations lacked documentation of the elderly person’s consent to, or refusal of, services described in the service plan, and in 6 (10.7%) of 56 applicable¹⁰ case records for substantiated allegations, the service plan was not approved by a supervisor within five business days after a caseworker submitted it.

If GSSSI does not obtain and keep required records, and document and properly complete casework and case supervision in a timely manner, there is a risk that it will not address alleged abuse, which may be serious and threatening, in an appropriate and timely manner.

Authoritative Guidance

During our audit period, 651 CMR 5 was updated (as of January 13, 2017). The updates included slight changes to the requirements for documentation of case records related to abuse of elderly persons. According to the version of 651 CMR 5.18(2) that was in place before the update,

Written documentation . . . shall be maintained in the Protective Services case record. . . . These forms shall be kept current to within five business days of contact or actions.

Case record documentation shall include, but not be limited to . . .

(b)  Investigation information . . . in accordance with 651 CMR 5.10 . . .

(d)  Progress notes [that] shall include, but not be limited to:

1.   All activity conducted during the Investigation. . . .

4.   Documentation of facts to support casework decisions including options weighed, supervisory input, and rationales for decisions made.

5.   Actions taken on the client’s behalf and projected time lines for proposed actions. . . .

(e)  Supporting documentation such as reports, evaluations, and Investigations obtained from case managers, nurses, doctors, lawyers, psychotherapists, police officers, coroners, and other professionals . . .

(g)  Consent for services describing services provided or arranged. . . . The way in which consent was provided or refused . . . shall be documented in the progress notes.

The version of 651 CMR 5.18(2) effective January 13, 2017 states,

Case record documentation shall be kept current to within five business days of contacts or actions. Case record documentation shall include, but not be limited to . . .

(b)  Investigation information . . . in accordance with 651 CMR 5.10 . . .

(d)  Progress notes [that] shall include, but not be limited to:

1.   All activity conducted during the Investigation. . . .

4.   Documentation of facts to support casework decisions including options weighed, supervisory input, and rationales for decisions made.

5.   Actions taken on the client’s behalf and projected time lines for proposed actions. . . .

(e)  Supporting documentation such as reports, evaluations, and Investigations obtained from case managers, nurses, doctors, lawyers, psychotherapists, police officers, coroners, and other professionals . . .

(g)  Consent for services describing services provided or arranged. . . . The way in which consent was provided or refused . . . shall be documented in the progress notes . . .

(h)  Supervisory Review. Designated Protective Services Agencies shall monitor the overall provision and documentation of Protective Services through supervisory review of case records.

1.   When a Protective Services Caseworker submits a completed investigation for approval, a Protective Services Supervisor shall complete the approval process within five business days.

2.   When a Protective Services Caseworker submits a completed Service Plan or Service Plan reassessment for approval, a Protective Services Supervisor shall complete the approval process within five days.

3.   The Protective Services Supervisor shall document his or her review of the case record and approval of case actions in the progress notes.

In addition, both before and after the update, 651 CMR 5.10(1)(f) required investigation summaries to include the following:

The Investigation summary shall address all allegations reported and all additional types of Abuse identified during the Investigation whether or not the completed Investigation resulted in Reasonable Cause to Believe that Abuse exists.

Reasons for Noncompliance

GSSSI had not established monitoring controls to ensure that its staff properly prepared, obtained, and maintained case record documentation. Additionally, GSSSI stated that turnover of Protective Services Unit personnel during fiscal year 2017, and increased caseloads due to changes in the intake and screening process in June 2017, led to delays in documenting and supervising cases. Finally, GSSSI had not updated its policies and procedures for documentation of case records to reflect the changes in this area in the January 13, 2017 update of 651 CMR 5.

Recommendations

1. GSSSI should establish monitoring controls to ensure that case record documentation is properly prepared, obtained, and maintained in a timely manner, even in the event of increased caseloads and employee turnover.
2. GSSSI should update its policies and procedures for documentation of case records.

Auditee’s Response

During the audit period, GSSSI acknowledges the issue with meeting regulatory timeframes. In January of 2017, GSSSI, as an organization, underwent leadership changes which led to a more collaborative approach with the Executive Office of Elder Affairs relating to its Protective Services Department, as well as an analysis of existing systems and staffing models.

In March of 2018, a new Protective Services Program Director (PSPD) was hired with direct reporting responsibilities to the Executive Director (a change from the previous reporting structure). Since March of 2018, the department has undergone tremendous transformation from an operational perspective, as well as a staff perspective. As of July 2019, the supervisory staff has increased 29% and additional PSWs by 37%, as well as the addition of PSOC and a Housing Specialist.

In April 2019, GSSSI increased its pay range for PSWs by 10% and increased its bi-lingual rate from 4% to 6% in order to help with staff retention.

Also noteworthy is the turnover in staff from every level within the department. While turnover is generally not desired, turnover needed to occur, in order to transition the culture of the department to a culture of accountability. As of May 2019, a designated PSW was taken off of new intakes, in order to focus on pending investigations from staff transitioning out of the department/agency. This change was implemented in order to ensure a smooth transition of the case and to avoid any gaps in coverage. Simultaneously occurring within the same time period, EOEA instituted mandatory basic Protective Services training for all Protective Service Staff across the Commonwealth. The ability to train new staff or retrain seasoned staff improves the unit’s understanding of the regulations and how they should be applied in the field.

In order to further address issues in terms of the preparation and retention of case documentation, the Protective Services Program Director will include as part of her monthly quality assurance report, a section which ensures the rationale and allegation match, as well as a review of supporting documentation. The PSPD will also check the closure queue on a weekly basis to ensure investigations are approved in a timely manner. Any issues identified will be reviewed with the respective supervisor.

Auditor’s Reply

Based on its response, GSSSI is taking measures to address our concerns in this area.

7.   This requirement did not apply to the remaining investigations because no outside documentation had to be obtained in those cases.

8.    This requirement was introduced in the January 13, 2017 update of 651 CMR 5; the criterion did not apply to the other seven investigations because they were conducted before this date.

9.    This requirement did not apply to the other 17 investigations because the elderly persons in those cases lacked the capacity to consent.

10. This requirement did not apply to the other four investigations because a service plan either was not needed or was refused by the elderly person in those cases.

Date published:	September 4, 2019