Overview of the Executive Office of Elder Affairs

This section describes the makeup and responsibilities of the Executive Office of Elder Affairs.

Overview

The Executive Office of Elder Affairs (EOEA), established by Section 1 of Chapter 19A of the Massachusetts General Laws, contracts with 20 protective-service agencies (PSAs) located in various regions throughout the Commonwealth that assist EOEA in receiving and investigating reports of alleged elder abuse. These 20 agencies, if necessary, also make referrals so that elderly people can seek other services, including, but not limited to, housing, nutrition, in-home support, caregiver support, and healthcare counseling. According to EOEA’s 2016 Annual Report, the office’s core mission is to “promote the independence, empowerment, and well-being of older adults, individuals with disabilities, and their caregivers.”

EOEA Protective Services

In addition to investigating instances of alleged abuse of elderly people, EOEA’s Protective Services Program makes referrals for other services such as adult day care, foster care, medical care through visiting nurse associations or personal care attendants, therapy, family support, and other in-home and out-of-home support to reduce risks to elderly people in the community.

EOEA administers its Protective Services Program from its central office in Boston and from the 20 designated PSAs across the Commonwealth. EOEA enters into contracts with PSAs to process reports of alleged abuse of elderly people. During our audit period, contracted PSAs working with EOEA to provide protective services were responsible for receiving and screening reports, investigating alleged abuse of elderly people, and educating mandated reporters¹ on their legal responsibilities in reporting alleged abuse of elderly people. Section 16(c) of Chapter 19A of the General Laws permits EOEA to designate PSAs to assist it in receiving and processing reports of alleged abuse of elderly people:

Subject to appropriation, the department shall designate at least one local agency to act on behalf of the department with a geographic area as defined by the department. The department may designate any public agency or private nonprofit organization which has the capacity to implement a service plan through direct access to social, health and mental health services.

While the aforementioned law allows EOEA to designate some protective-service responsibilities to PSAs, Section 16(c) of Chapter 19A of the General Laws requires EOEA to “monitor assessments, evaluations and the provision of protective services by designated local agencies.” To accomplish this, EOEA has established a Protective Services Program director position and four regional Protective Services Program manager positions.

EOEA had an annual appropriation of approximately $4 billion for fiscal year 2016 and approximately $4.2 billion for fiscal year 2017.² The Protective Services Program had an annual appropriation of approximately $23 million for fiscal year 2016 and $28 million for fiscal year 2017. EOEA’s database system of record contains 10,435 unique reports of abuse that were screened in for investigation for fiscal year 2016 and 14,598 unique reports that were screened in during fiscal year 2017.³

EOEA’s Adult Protective Services System

The Adult Protective Services (APS) system is a Web-based database system that EOEA uses as its system of record to document reports of alleged abuse of elderly people. EOEA also uses the system to maintain case notes, referrals, and inquiries, as well as to run a variety of general and administrative reports on incidents, abuse reports, and investigations of alleged abuse of elderly people. PSA caseworkers use APS to query pending notifications for action, cases, investigations, and other tasks. Additionally, PSA supervisors document their screening decisions in APS before initiating investigations. Abuse reports received by PSAs are transcribed into APS by PSA caseworkers.

Protective-Service Designation Reviews

According to our discussion with EOEA management, every three years, the Protective Services Program director, along with the four managers, conducts a general review of the PSAs contracted with EOEA. EOEA management stated that the Protective Services Program director and managers visit the sites of the designated PSAs to ensure that the agencies comply with Section 5 of Title 651 of the Code of Massachusetts Regulations (CMR) and the applicable General Laws based on standards used by EOEA in conjunction with that regulation. The designation review reports show that these standards comprise the areas of intake, screening, investigation, ongoing services, documentation, and supervision. According to our discussion with the Protective Services Program director, instances of significant noncompliance with the standards may lead EOEA to assess a PSA as “ineffective” in its abuse-report processing, and as a result, the agency may be subject to termination as a designated agency. EOEA then contracts with a different local agency.

According to the Protective Services Program director, during a designation review, EOEA reviews 50 abuse investigations and 25 abuse reports from APS for compliance and effectiveness of abuse-report processing. The director further stated that EOEA evaluates compliance and effectiveness of the entire abuse-reporting process, from the time a report of alleged abuse is received by a PSA to the time the risks of abuse are alleviated and the case is closed. Eight designated PSAs that were contracted with EOEA underwent designation reviews during the audit period.

Abuse-Report Referral

Abuse reports are received by PSAs in a variety of ways, such as telephone, email, Web intake reports, walk-ins at EOEA and the PSAs, fax, and mail. Section 15 of Chapter 19A of the General Laws requires certain professionals whose work directly involves elderly people to notify EOEA if they believe that an elderly person is suffering from abuse. This law designates such professionals as mandated reporters, who are required to make an immediate verbal report and a subsequent written report to EOEA or its designated PSAs within 48 hours when they have reasonable cause to believe that a person who is 60 or more years old is suffering from, or has died as a result of, abuse.

Elder Abuse Hotline

During the audit period, EOEA contracted with a third-party vendor to provide an Elder Abuse Hotline for verbal reports of alleged abuse of elderly people by telephone at 1-800-922-2275. The hotline worked in two different ways. During business hours (9:00 a.m. through 5:00 p.m. Monday through Friday), all calls made to the hotline were routed to the appropriate local PSAs based on callers’ area codes using an interactive voice response system. This “mirroring” function needed to be activated and deactivated by the hotline’s telephone service provider when it transitioned between business and non-business hours.

Outside business hours, when the 20 local PSAs were closed, the hotline was available, but the mirroring function was disabled and the hotline was staffed by PSA and hotline employees.

On June 30, 2017, EOEA implemented a new system, the Centralized Intake Unit, for receiving reports of alleged abuse of elderly people 24 hours per day, seven days per week. EOEA anticipates that the new system will provide a streamlined way of receiving reports of alleged abuse by telephone.

Screening of Abuse Reports

Upon receipt of a verbal or written report (whichever is received first), PSAs are required to ensure that all reports of alleged abuse of elderly people are evaluated immediately by a PSA supervisor or designated backup supervisor. For this task to be performed, the supervisor must screen the abuse report. According to 651 CMR 5.09, screening reports requires a PSA supervisor to “determine the immediacy and severity of the alleged harm or risk, and the appropriate initial response.” The purpose of screening reports is as follows:

(a)  To determine whether the allegation constitutes a Reportable Condition to the Protective Services Program/Agency, and

(b)  To determine whether or not an Emergency, Rapid Response, or Routine response is needed.

According to 651 CMR 5.02, a reportable condition is one or more of the following (see Authoritative Guidance under Finding 1 for detailed descriptions):

(a)  Abuse;

(b)  Physical Abuse;

(c)  Sexual Abuse;

(d)  Emotional Abuse;

(e)  Neglect;

(f)   Self-neglect; and

(g)  Financial Exploitation.

The chart below shows the four unique types of abuse allegations and the percentage of each that was reported during the audit period.

More than half the incidents of abuse reported to PSAs during the audit period were incidents of alleged self-neglect.

If the PSA supervisor determines that an emergency exists, the supervisor must immediately screen in the report and assign it to a PSA caseworker for investigation. The emergency needs of the allegedly abused elderly person must be assessed within 24 hours after EOEA or a PSA receives the abuse report. If the PSA supervisor determines that a report is related to a rapid-response situation, the supervisor must immediately assign the report to a PSA caseworker for investigation, and the needs of the allegedly abused elderly person must be assessed within 72 hours after EOEA or a PSA receives the report. Finally, a routine response with a reportable condition, or any other nonemergency report, must be immediately assigned to a PSA caseworker for investigation, and the investigation must be completed within 30 calendar days.⁴ If a PSA caseworker determines that there is no reasonable cause to believe⁵ that the allegations of abuse constitute a reportable condition, the report is screened out, and a PSA supervisor concludes that an investigation of the allegations is not necessary. All reports of alleged abuse must undergo screening. Reports that are screened out undergo expungement, which means that the report, along with any other supporting information, is removed from EOEA’s and its designated PSAs’ records in the APS database one year and one day after the report and its supporting records are entered in the system (see Other Matters for further discussion).

Investigation of Alleged Abuse

PSAs are required to investigate information from reports of alleged abuse of elderly people. Investigations include in-person visits to the residences of elderly people who are the alleged victims of abuse and may include meeting with appropriate service agencies and, according to Section 18(a) of Chapter 19A of the General Laws, “individuals who have knowledge of the elderly person’s situation including the person filing the report.” The law also states that if a PSA’s investigation determines that the elderly person is suffering abuse, the PSA must “evaluate the elderly person’s functional capacity, situation, and resources” before developing a service plan that addresses the provision of protective services and specific objectives to aid the elderly person and collaterals⁶ in preventing, eliminating, and/or alleviating the risks of abuse. The PSA can also hire medical professionals or social workers to visit an elderly person’s home to assess the person’s functional capacity. In some unique circumstances, such as domestic-violence disputes, PSA caseworkers can meet with an elderly person away from their home as long as the meeting is face to face.

At the conclusion of an investigation, if a PSA caseworker determines that there is no reasonable cause to believe that a reportable condition exists, they conclude, with approval from the PSA supervisor, that the allegations are unsubstantiated. This means that at the completion of an investigation, there is not sufficient evidence to conclude that the alleged abuse occurred. Unsubstantiated reports of abuse are subject to expungement. However, 651 CMR 5.12(1)(b) states that at the completion of an investigation, “where appropriate, the Protective Services Caseworker shall provide information and referral to the Elder regarding social, health, legal, or other services.”

Before January 13, 2017, when 651 CMR 5.00 was revised, elderly people could refuse investigations according to 651 CMR 5.11. However, because of changes to 651 CMR 5.00 as of January 13, 2017, elderly people can no longer refuse investigations by PSA caseworkers. Elderly people can refuse to participate in investigations, but the PSAs still perform them. After an investigation is conducted, in accordance with 651 CMR 5.11, elderly people have always had the choice to refuse services (e.g., home care or Meals on Wheels) if they possess the “decisional capacity”⁷ to do so.

Referrals to District Attorneys’ Offices

EOEA and its designated PSAs must report allegations of serious abuse to the district attorney’s (DA’s) office that covers the county where abuse occurred⁸ if EOEA or a PSA determines that an elderly person has suffered abuse. At the conclusion of an investigation, if a reportable condition other than death is substantiated and meets the conditions of 651 CMR 5.19(2) for reporting to a DA, then EOEA or the PSA must submit a referral to a DA’s office within 48 hours. Under 651 CMR 5.02 before January 13, 2017, reportable conditions other than death that required a DA referral included, but were not limited to, “brain damage,” “fracture of a bone,” “sexual assault,” “unreasonable” bedsores, “serious bodily injury as the result of a pattern of repetitive actions,” “financial exploitation” involving potential “criminal” behavior, and any other injury that was deemed “non-trivial.” If it was determined that the elderly person died because of the abuse, EOEA or the PSA was required to make an immediate referral to a DA’s office, and a written follow-up notice had to be made available to the DA’s office as soon as possible.

Eight PSAs underwent designation reviews by EOEA during the audit period. The scope of each designation review requires EOEA to evaluate compliance with the protective-service standards established in 651 CMR 5. Within these standards, there are particular areas of EOEA’s alleged-abuse report processing that include mandated DA referrals. One standard that EOEA uses as part of its designation review of its contracted PSAs is whether reports of substantiated claims of elder abuse were made to the DA in a timely manner.

Seven of the eight PSAs had submitted at least one referral to a DA’s office. The table below shows each of the seven agencies’ compliance scores, assessing timeliness in reporting to their local DAs’ offices. For example, Agency 1 was timely in referring reports to a DA’s office for half of the total reports reviewed by EOEA. Among the seven agencies evaluated, the average compliance score for timely referrals to DAs’ offices was 38%.

Timely DA Referral Designation Review Scores

Agency	Score*
1	50%
2	67%
3	0%
4	50%
5	25%
6	25%
7	50%

*    The results in this table were taken from the seven designation review reports completed by EOEA. The reports were provided to us by the director of EOEA’s Protective Services Program.

1. Section 15(a) of Chapter 19A of the General Laws lists the various professionals, including, but not limited to, “any physician, physician assistant, . . . dentist, . . . social worker, policeman, [or] firefighter,” who are required to “immediately make a verbal report” to EOEA or a PSA if they have “reasonable cause to believe that an elderly person is suffering from or has died as a result of abuse.”
2. The current EOEA appropriation/budget is approximately $583.5 million. Prior appropriations included funding for MassHealth programs that have since been formally apportioned to MassHealth in the Commonwealth’s budget.
3. These reports were not expunged from APS (see Other Matters for more information on expungement).
4. In spring 2016, EOEA piloted and implemented a change that required that extensions of investigation deadlines of elder-abuse allegations be approved by EOEA. Before the change, designated PSAs would approve their own extensions.
5. According to 651 CMR 5.02, “reasonable cause to believe” is “a basis for judgment that rests on specific facts, either directly observed or obtained from reliable sources, that supports a belief that it is more probable than not that a particular event took place or a particular condition exists.”
6. According to EOEA, collaterals are people who are involved in alleged-abuse investigations, including, but not limited to, family members, caregivers, witnesses, reporters of alleged abuse, alleged-abuse perpetrators, and other professionals.
7. According to 651 CMR 5.02, decisional capacity is the “Elder’s ability to: (a) understand and appreciate the nature and consequences of decisions, including the benefits and risks of and alternatives to any proposed Protective Services; and (b) reach an informed decision while free from any apparent duress, intimidation, coercion, use of force, or threat of force by another.”
8. According to Section 18 of Chapter 19A of the General Laws, EOEA and its designated PSAs must report their determination of serious abuse in the “county where the abuse occurred within forty-eight hours.” In addition, Section 16(b) of Chapter 19A of the General Laws states that if EOEA or one of its designated PSAs has “reasonable cause to believe that an elderly person has died as a result of abuse, the death shall be reported immediately to the district attorney of the county in which the abuse occurred.”

Date published:	October 9, 2018