Adult Protective Services Policy Manual
Investigation Section
Investigation Documentation and Conclusion
1703.70
At the conclusion of each investigation, the Adult Protective Community Worker (APCW) shall have:
· documented the findings;
· assessed the allegations;
· summarized the evidence and investigative results, including any need for intervention; and,
· completed the data entry into Case Compass, the electronic system used to capture all report information.
Documentation will be considered complete when all of the documentation recordings are entered electronically into the appropriate tab in Case Compass. The conclusion of the investigation will not always coincide with the completion of a case for prosecution (see Policy 1703.72, Referral Process).
I. Documentation of Findings
Documentation is an on-going process, which consists of the written communication of the actual detailed events and facts gathered during the investigation. All written findings must be entered in Case Compass including all contacts and references to all pertinent documents obtained. Repeated unsuccessful attempts to contact the Reported Adult (RA), Alleged Perpetrator (AP) or other witnesses shall be noted in the Recordings tab. All contacts made and actions taken shall be recorded as soon as possible but no later than thirty (30) calendar days from the date of contact (see Policy 1706.20).
It is imperative that all relevant information gathered during the investigation be recorded as part of the electronic case record in Case Compass, as information acquired but not documented does not accurately reflect the RA’s circumstances. All hand-written notes shall be entered in the Recordings tab in Case Compass. The hand-written notes shall then be disposed of and do not remain with the permanent record. The information entered in the Recording tab should be proofread to ensure accuracy and completion of all details. Any required assessments shall be completed and all necessary documents attached to Case Compass prior to closing the investigation.
II. Assessment of the Allegations
Based on the information gathered during the investigation process, the APCW shall:
A. Ascertain whether the allegation(s) contained in the initial report is (are) valid and provide data that clarifies what information was used to make this decision.
1. Reason to believe
When information is obtained which leads the APCW to believe there is a likelihood that the RA suffered injury or harm as a result of abuse or neglect, this shall give sufficient cause to find a determination of ‘reason to believe’ the allegations.
2. Suspected
Information obtained suggests the likelihood that the RA suffered injury or harm as a result of abuse or neglect, giving cause to suspect allegations are valid. This conclusion indicates that information gathered was insufficient to establish the facts necessary to determine the validity of the allegation.
3. Unsubstantiated
Information which indicates allegations of the report were inaccurate, misinterpreted, or did not present any risk of danger/harm to the RA shall be sufficient to unsubstantiate allegations.
B. Determine the degree of injury or harm to the RA.
Facts obtained during the investigation which suggests a chance that injury, harm, loss or damage may have or was likely to have occurred. (see Policy 1703.62 and 1703.66).
C. Determine the ability of the RA to protect their own interest and act on their own behalf.
Information gathered which establishes the RA’s ability to understand, consider and communicate decisions regarding his/her health and well-being shall determine the RA’s decisional capacity (see Policy 1703.60). The APCW shall conduct a Decisional Capacity Assessment when the RA’s ability to act on his/her own behalf is questionable.
D. Complete the Risk Assessment and make a determination as to the level of risk found during the course of the investigation. This assessment usually will be based on the risk established at the initial contact. Occasionally, a situation may escalate that would place the RA at a greater risk than initially determined.
The ANE score, which is generated from the assessments used to determine risk to the RA, is displayed on the Disposition tab in Case Compass. The ANE score shall be indicative of the level of risk assessed at the onset of the investigation or an elevated risk due to changes in the situation; whichever is highest (see Policy 1703.70, Appendix A).
III. Summary of Evidence and Investigative Results
1. At the conclusion of an investigation, a summary of evidence shall be documented in the Allegations tab of Case Compass for each of the allegations investigated. The evidentiary summary shall include a statement summarizing information obtained from pertinent witnesses, the RA, the AP and any documentation that leads to a determination regarding whether the allegation has been found reason to believe, suspected or unsubstantiated. This statement shall clearly indicate how the APCW reached this conclusion. The APCW shall “link” the RA or AP to each of the allegations, respectively, while also providing the facts that support the assigned status. For example:
- Self-Neglect, Physical. (Reason to believe). On initial home visit, RA was dirty and smelled of urine. RA reported to APCW that RA was unable to bathe without assistance and was incontinent.
- Self-neglect, Environmental. (Unsubstantiated). APCW made 3 home visits over a two-month period and found home well maintained with no signs of bugs or rodents.
- Financial Exploitation. (Reason to believe). Joe Green at Midwest Bank reports that on 4/4/12, a $5,000 CD belonging to RA was cashed by RA’s son, John Doe, who is also POA for RA. RA states money was kept by his son and used for down payment on a new car and this was done without the RA’s knowledge or approval. Son confirms the purchase of a new vehicle on 4/5/12, but claims his father gave permission. RA’s daughter, Jane Doe, states she was present on 4/4/12 when son asked RA for $5,000 and RA refused.
2. An Investigation Summary consisting of a brief statement portraying the overall findings, effect of the situation on the RA, interventions, and the closing status shall be documented on the Disposition tab. Each Investigation Summary shall include the conclusion of findings with a statement on the disposition of the case.
3. Facts that identify unmet needs and insufficient supports establish a necessity to continue to explore intervention on behalf of the RA to reduce or alleviate the risk of injury or harm. Once a need for continued protective services has been identified and a plan for intervention developed, the APCW shall document the need for continued protective services and the RA’s willingness to accept these services as directed in Policy 1704.20.
All investigative results shall be documented according to Policy 1706.20.
IV. Data Entry, Feedback, and Conclusion
APCW Responsibilities:
A. The APCW shall data enter the findings of an investigation into Case Compass. Forms completed as part of the investigation or intervention and any exhibits (i.e., Power of Attorneys, medical records, bank statements, etc.) collected shall be uploaded to Case Compass as an attachment. Any original hard copies of these documents that the APCW wishes to retain shall be numbered as directed in Policy 1706.10 and filed in a paper record.
B. The APCW shall conference with the APCS on the status of an investigation as often as needed but at least every thirty (30) days. The APCW shall conference with the APCS at least twice during the investigation and document the conference as “Feedback” type in the Recordings tab in Case Compass. The APCS shall offer feedback for additional actions or interventions as needed. The conference with the APCS allows for an exchange of information with the APCW and strives to create a collaborative approach to the investigation.
C. All data entry shall be completed and the APCW shall close the investigation on or before the 60th calendar day from the date the report was received by the Central Registry Unit (CRU), unless extenuating circumstances occur and are documented and a delay is approved by the APCS.
D. In rare situations in which the investigation cannot be closed on or before the 60th day, the APCW may conference with the APCS and request a delay to complete an investigation after the 60th day. The postponement of investigation closure will only be approved when absolutely necessary due to extenuating circumstances. The APCS may grant permission for the delay based on appropriate documentation and legitimacy of the reason for request. The use of the Delayed Conclusion Code shall be documented by the APCS in the Recording tab, “Feedback” type. After approving a request for a delay, the APCS shall select the appropriate Delayed Conclusion Code on the Disposition tab in Case Compass, which will leave the report open. For example, the investigation may need to remain open past sixty (60) days due to delays in obtaining documentation, joint investigations involving EDL referrals, law enforcement or SIU, obtaining evidence documentation on financial exploitation cases, or determining the need for guardianship. The Delayed Conclusion Codes may also be warranted in natural disaster situations. Delay Codes should only be utilized when necessary.
E. Occasionally an investigation may need to remain open more than ninety (90) calendar days from the date the report was received by CRU. An Extension Code will need to be selected and the reason documented by the APCS if this circumstance exists. An Extension is only warranted when the conclusion of the investigation continues to be delayed due to extenuating circumstances.
REMOVED SECTION “APCS Responsibilities”
Memorandum History: APS16-03
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Effective: 05/16