Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20441AI (01/2009)

STATE OF WISCONSIN

ADULT-AT-RISK ABUSE, NEGLECT, AND / OR EXPLOITATION VALID VALUES
SECTION A: INITIAL INFORMATION
Category: Caller's Initial Concern AND Primary Issue Identified Self-Neglect Financial Exploitation Neglect by Other(s) Emotional Abuse Physical Abuse Sexual Abuse Treatment without Consent Unreasonable Confinement or Restraint Other Details: Caller's Initial Concern AND Primary Issue Identified AND Other Issues Identified Self Neglect Medical needs Medication Mismanaging basic financial activities Physical needs Psychiatric needs Supervision Unsafe, unsanitary environment Hoarding (animal) Hoarding (non-animal) Other self-neglect (specify) Financial Exploitation Computer Crimes Deception Diverting income Embezzlement Financial transaction card crimes Forgery or fraudulent writings Misappropriation of personal identifying information or documents Mismanagement of property Security fraud Substantial failure or neglect of a fiscal agent to fulfill his or her responsibilities Theft by fraud Theft from a person Other financial exploitation (specify) Neglect by Other(s) Medical needs Medication Physical needs Psychiatric needs Supervision Unsafe, unsanitary environment Other neglect (specify) Emotional Abuse Demeaning statements Harassment Isolating person from family, friends Threats, intimidation, frightening Other emotional abuse (specify) Physical Abuse Abrasions, cuts, punctures, bites Beating Bone fracture Bruises, welts Burns, scalding Freezing Internal injuries Pain, no physical marks Skull fracture Sprains, dislocations Strangling Other physical abuse (specify) Sexual Abuse Digital penetration of vagina or anus Exhibitionism Exposure of victim's buttocks, breast, genitalia to humiliate/embarrass Harmful genital practices (not for the benefit of the adult at risk) Oral genital contact Prostitution of victim Rape (anal) Rape (vaginal) Rape (vaginal/anal rape with an object) Sadistic sexual activity Sexual jokes and comments Sexualized kissing Showing victim pornography Unwelcome description or discussion of sexual topics or threats Unwelcome sexual interest in victim's body Using alleged victim to produce pornography Voyeuristic activity Other sexual abuse (specify) Unknown Treatment without Consent Administration of medication to an individual who has not provided informed consent. Experimental research on an individual who has not provided informed consent. Performance of electroconvulsive therapy on an individual who has not provided informed consent Performance of psychosurgery on an individual who has not provided informed consent Other treatment without consent (specify) Unreasonable Confinement or Restraint Intentional and unreasonable confinement of an individual in a locked room. Involuntary separation of an individual from his/her living area Provision of unnecessary or excessive medication to an individual Use of physical restraining devices on an individual Other unreasonable confinement (specify) Other Information only (specify) Other Issues Identified Same as for Primary Reason for Call Incident Occurred At or Near Place of employment/day services Place of residence School Transportation Other (specify) Referral Source ADRC Agency (specify) Alleged abuser Anonymous Employer Friend/neighbor Housing Inspection/Zoning Law enforcement Medical professional Mental health service provider Regulatory authority (DHS/DQA) Relative Residential support provider Substance abuse service provider Victim Vocational/day support provider Other provider (specify) Other referral source (specify) Call Received By ADRC Aging unit Animal control / humane society Department of Community Programs (51.42/437) Developmental disability Board Disability Rights Wisconsin (WI Coalition for Advocacy) Housing Inspection/Zoning Human services department Law enforcement Ombudsman (BOALTC) Publicized helpline number Regulatory authority (DHS/DQA) Social services department Other (specify) Initial Response Agency Assigned ADRC Aging unit Animal control/humane society BOALTC/Ombudsman Department of Community Programs (51.42/437) Developmental Disability Board DQA/Licensing and Reg Housing inspection/zoning Human services dept Law enforcement Public health dept Social services dept WI DOJ Other (specify)

F-20441AI

Page 2

SECTION B: INFORMATION ABOUT ADULT-AT-RISK (AAR)
AAR Sex Male Female Unknown AAR Living Arrangement Own home/apt. alone Own home/apt. with others Relative's home Friend's home Adult family home Adult family home (licensed) Nursing home CBRF RCAC Homeless Institution Other (specify) AAR Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other AAR ­ Ethnicity Hispanic or Latino Hmong What county/state programs or services have served this individual? Community Support Program Comprehensive Community Services Family Care Home and Community Based Waivers Medicaid (Title 19, Card Services) Other Unknown None Current Waiver Participant No Unknown Alzheimer's or related dementia Blind/visually impaired Brian injury Challenging/dangerous behavior Chronic alcoholic Chronically mentally ill Communication disorder Deaf or hard of hearing Developmentally disabled Diabetic Disoriented/confused Drug abuse Frail elderly Functionally illiterate Homebound Incontinent Limited English Proficiency Medically fragile Mental illness Mobility impaired Morbidly obese Physically disabled Stroke-related impairments Unemployed Other medical condition (specify) Other physical disability (specify) Other (specify) None

Yes

If there is Substitute Decision Maker, identify type of decision maker Conservator Guardian of the Estate Guardian of the Person Power of Attorney ­ Finances (Activated) Power of Attorney ­ Health Care (Activated) Representative Payee Program Temporary guardian Power of Attorney Finances - Not Activated Power of Attorney Health Care - Not Activated Other (specify) AAR Characteristics Adult-at-Risk financially dependent on alleged abuser Alcohol abuse Alleged abuser financially dependent on Adult at Risk

SECTION C: INFORMATION ABOUT ALLEGED ABUSER
Abuser Sex Male Female Unknown Abuser Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Abuser - Ethnicity Hispanic or Latino Hmong Abuser Relationship to AAR Daughter Employer Friend/neighbor Grandchild Parent Roommate Service provider ­ facility staff Service provider ­ home agency staff Sibling Son Spouse Transportation provider Vocational/day service provider Other relative (specify) Other residential service provider (Specify) Other (specify) Unknown Abuser Legal Status to AAR Power of Attorney Finances - Activated Power of Attorney Health Care - Activated Conservator Guardian of the Estate Guardian of the Person Representative payee Temporary guardian Power of Attorney Finances - Not Activated Power of Attorney Health Care - Not Activated Other (specify) Unknown None Abuser Characteristics Same as AAR Characteristics

SECTION D: REPORT SUMMARY
Incident Result Substantiated Unsubstantiated Unable to Substantiate Action Taken Guardian referral Investigation not accepted Mental health commitment Outreach continues Protective services/placement Referral made to other agency (specify) Referral made to state agency Referral to Caregiver Misconduct Registry/DQA Referral to detoxification services Referral to law enforcement/Dept of Justice Referral to protection/advocacy agencies Referral to regulatory authority/DQA Response/investigation continues Services needed are not available (specify) Services not needed Services offered - all accepted Services offered - some accepted Services offered but not accepted Other legal action (specify) Other disposition (specify) Services Planned for AAR Person AND Alleged Abuser Advocacy/Legal Advocacy and defense resources Attorney (Agency) Attorney (Attorney General's office) Attorney (County corporation counsel) Attorney (District Attorney's office) Attorney (Private) Benefit specialist services Court intake and studies Law Enforcement Protective Services/Protective Placement Temporary Restraining Order/Restraining Order Other legal services (specify) Community Based Aids and Services Adaptive aids Adaptive aids - other Assistive technology Chore services - major (e.g., dumpster, exterminator)

F-20441AI
Chore services - routine (e.g., sweep, mop, vacuum) Communication aids Companion animal assistance/rehoming Congregate meals Durable medical equipment Energy Assistance Home delivered meals Home modifications Housing Assistance

Page 3

Cont'd on next page

SECTION D: REPORT SUMMARY (Cont'd)
Community Based Aids and Services (Cont'd) Housing startup Interpreter services Personal care Respite care (in adult day care) Respite care (other) Specialized medical supplies Supportive home care services Other services (specify) Day Care Services and Treatment Adult day care Alcohol and other drug abuse day treatment services (in all settings) Alcohol and other drug abuse outpatient services Community support program Consumer education and training Counseling/therapeutic resources Daily living skills training Day svcs/Adult (Sheltered workshop) Financial management Medical outpatient care Mental health day treatment Mental health outpatient services Peer counseling Prevocational services Recreation/alternative activities Support group Supported employment Other services (specify) Emergency Response Services Client supplies/misc. services (specify) Crisis Intervention Detoxification services Emergency funds for clothing Emergency funds for food Emergency funds for medical needs Emergency funds for transportation Personal emergency response system Shelter care Other services (specify) Facility Based Care Adult family home (certified) Adult family home (licensed) Community-Based Residential Facility (CBRF) Inpatient - Alcohol/Drug Inpatient - Medical Inpatient - Psychiatric Institution for Mental Disease (IMD) Intermediate Care Facility for people with Mental Retardation (ICF/MR) Nursing Home Residential Care Apartment Complex (RCAC) Other setting (specify) Medical Services Home health care agency Nursing services Occupational therapy (in all settings except for inpatient hospital) Physical therapy (in all settings except for inpatient hospital) Speech and language pathology services Other services (specify) Service Coordination Care/Case management (including assessment and case planning) Crisis intervention Housing counseling Information and referral Outreach Relocation services Vocational futures planning Other services (specify) Substitute Decision Making Conservatorship Guardian of the Estate Guardian of the Person Power of Attorney ­ Finances/Activated Power of Attorney ­ Finances/Not Activated Power of Attorney - Health Care/Activated Power of Attorney ­ Health Care/Not Activated Representative Payee Program Temporary guardianship Other (specify) Transportation Escort services Transportation Other transportation (specify) Victim Services Domestic violence victim services including shelter and advocacy Sexual assault/abuse victim services including counseling and support services Victim/Witness Program Other services (specify) Other Services Other direct services (specify) None Services Planned for Alleged Abuser Same as for Adult-at-Risk