340:5-5-5. Documentation of Adult Protective Services (APS) cases
The APS specialist documents the referral, interviews, record reviews, other evidence, and investigation findings, or conclusions in the APS case. • 1
(1) Upon completion of the investigation, the vulnerable adult's identified caretaker, legal guardian, and next of kin receive a letter from the Oklahoma Department of Human Services, per Section 10-105.1(C)(6) of Title 43A of the Oklahoma Statutes (43A O.S. § 10-105.1(C)(6)).
(2) When the vulnerable adult has a court-appointed guardian, the APS specialist files a notice of the findings in the guardianship case and sends a copy of the findings to the court of jurisdiction, per 43A O.S. § 10-105.1(C)(6).
INSTRUCTIONS TO STAFF 340:5-5-5
1. (a) Documentation required to complete an investigation. The Adult Protective Services (APS) specialist documents investigations within 60-calendar days after the receipt of referral. The APS specialist downloads APS Report of Investigation in the APS Computer System and routes copies to the local district attorney's office..
(b) The APS Report of Investigation is a summary of the investigation and is not used as a tool to complete the investigation. The full case documentation on the APS Computer System provides a detailed chronological account of the entire investigation process including:
(1) specific circumstances of the report;
(2) date and time of the home visit;
(3) persons present during the home visit;
(4) condition of the vulnerable adult and the vulnerable adult's environment;
(5) information from collateral contacts, including dates and times;
(6) APS specialist's evaluation of the vulnerable adult's capacity to consent to services;
(7) assessment of risk;
(8) APS specialist's determination of the report as substantiated, unsubstantiated, or inconclusive;
(9) results of follow-up visits including dates and times;
(10) assessment of the vulnerable adult's needs;
(11) proposed service plan for substantiated investigations;
(12) circumstances of the vulnerable adult's acceptance or refusal of services offered;
(13) information concerning the actual delivery of services; and
(14) detailed descriptions of all legal actions and follow-up activities for the vulnerable adult receiving involuntary services.
(c) The APS specialist must document each new APS referral in the APS Computer System Intake Section. When there is no existing APS case number for the vulnerable adult, a new case is opened. For all APS referrals the APS specialist enters the relevant information including receipt of referral, substantiated, unsubstantiated, or inconclusive case findings, case conclusion when a Service Case, and services actually provided, including legal actions initiated into the APS Computer System.
(d) APS cases require documentation of a review by an APS specialist IV or designee or staffing in the APS Computer System Notes Section at:
(2) risk, needs, and capacity assessment;
(3) the determination of findings or conclusion;
(4) legal action determinations;
(5) service planning;
(6) follow-up; and
(7) case closure.
(e) At the conclusion of the investigation, the APS specialist routes the APS Report of Investigation to the local district attorney. Findings of self-neglect are not forwarded to the office of the district attorney unless similar findings were reported within six months prior. A summarized report is sent to any appropriate licensing agency. In substantiated investigations, the APS specialist works closely with the provider to develop a plan that addresses substantiated elements of the investigation.
(f) The APS specialist submits a summary of the investigation omitting the reporter's identity to the Nurse Aide Registry at the Oklahoma State Department of Health for all substantiated referrals against certified nurse aides. For substantiated referrals against licensed nurses, information is submitted to the Oklahoma State Board of Nursing at 405-962-1800 or faxed to 405-962-1821.
(g) The APS specialist sends a summary notification of findings to the caretaker, legal guardian, and next of kin. The summary notification includes:
(1) whether Oklahoma Human Services (OKDHS) determined the findings to be substantiated, unsubstantiated, or inconclusive; and
(2) a summary of OKDHS recommendations concerning the vulnerable adult.
2. Documentation required to conclude a Service Case.
(1) From the date an APS referral is received, the APS specialist completes the documentation for Service Case referrals within 60-calendar days.
(2) The APS specialist IV or designee reviews tasks, task completion, service plan, and case summary conclusion for completion and accuracy.
(3) Conclusions are not required to be sent to the district attorney.