Adult Protective Services Functions and Grant Programs

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monitors; propane bottles; or glass

containers is prohibited.

7. You must not possess, discharge, or

use flammable devices, including but

not limited to gasoline bombs

commonly referred to as ‘‘Sobe Bombs’’

or flammable projectiles discharged

from a launching tube or other device.

8. You must not drink an alcoholic

beverage or possess an open alcoholic

beverage container while in the

passenger area of a motor vehicle,

including off-highway vehicles.

9. You must not violate any State laws

relating to the purchase, possession,

use, or consumption of alcohol.

10. You must not possess any drug

paraphernalia in violation of State law.

11. You must not tow or be in

possession of a trailer requiring

registration under Wyoming Revised

Statues that is either unregistered or has

an expired registration.

12. You must not violate any

Wyoming Revised Statute regarding

hunting, fishing, boating, or outfitters.

13. You must not violate any Federal

or State laws or regulations concerning

conservation or protection of natural

resources or the environment, including

but not limited to those relating to air

and water quality, protection of fish and

wildlife, plants, and the use of a

chemical toxicant.

14. You must not burn wood pallets

containing nails or staples.

15. You must not intentionally engage

in any activity within any distance that

disturbs, displaces, or otherwise

interferes with the free unimpeded

movement of wild horses.

16. You must not feed, water, or touch

any wild horse.

Exceptions

The following persons are exempt

from the supplementary rule: any

Federal, State, local, or military

employees or contractors acting within

the scope of their official duties;

members of any organized rescue or fire-

fighting force performing an official

duty; and persons who are expressly

authorized or approved by the BLM.

Enforcement

Any person who violates this

supplementary rule may be tried before

a United States Magistrate and fined in

accordance with 18 U.S.C. 3571,

imprisoned no more than 12 months

under 43 U.S.C. 1733(a) and 43 CFR

8560.0–7, or both. In accordance with

43 CFR 8365.1–7, State or local officials

may also impose penalties for violations

of Wyoming law.

Andrew Archuleta,

BLM Wyoming State Director.

[FR Doc. 2023–19634 Filed 9–11–23; 8:45 am]

BILLING CODE 4331–26–P

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Administration for Community Living

45 CFR Part 1324

RIN 0985–AA18

Adult Protective Services Functions

and Grant Programs

AGENCY

: Administration for Community

Living (ACL), Department of Health and

Human Services (HHS).

ACTION

: Notice of proposed rulemaking.

SUMMARY

: The Administration for

Community Living (ACL) within the

Department of Health and Human

Services (‘‘the Department’’ or HHS) is

issuing this Notice of Proposed

Rulemaking (NPRM) to modify the

implementing regulations of the Older

Americans Act of 1965 (‘‘the Act’’ or

OAA) to add a new subpart (Subpart D)

related to Adult Protective Services

(APS).

DATES

: To be assured consideration,

comments must be received no later

than November 13, 2023.

ADDRESSES

: You may submit comments,

including mass comment submissions,

to this proposed rule, identified by RIN

Number 0985–AA18, by any of the

following methods:

•Electronically. You may submit

electronic comments on this regulation

to http://www.regulations.gov. Follow

the ‘‘Submit a comment’’ instructions.

•Regular, Express, or Overnight Mail:

You may mail written comments to the

following address: Administration on

Aging, Administration for Community

Living, Department of Health and

Human Services, Attention: Stephanie

Whittier Eliason, 330 C Street SW,

Washington, DC 20201.

Do not include any personally

identifiable information (such as name,

address, or other contact information) or

confidential business information that

you do not want publicly disclosed. All

comments may be posted without

change to content to https://

www.regulations.gov and can be

retrieved by most internet search

engines. No deletions, modifications, or

redactions will be made to comments

received.

We will consider all comments

received or officially postmarked by the

methods and due date specified above.

Because of the large number of public

comments we normally receive on

Federal Register documents, we are not

able to provide individual

acknowledgements of receipt. Please

allow sufficient time for mailed

comments to be timely received in the

event of delivery or security delays.

Electronic comments with attachments

should be in Microsoft Word or Portable

Document Format (PDF).

Please note that comments submitted

by fax or email, and those submitted or

postmarked after the comment period,

will not be accepted.

Inspection of Public Comments: All

comments received before the close of

the comment period will be available for

viewing by the public, including

personally identifiable or confidential

business information that is included in

a comment. You may wish to consider

limiting the amount of personal

information that you provide in any

voluntary public comment submission

you make. HHS may withhold

information provided in comments from

public viewing that it determines may

impact the privacy of an individual or

is offensive. For additional information,

please read the Privacy Act notice that

is available via the link in the footer of

https://www.regulations.gov. Follow the

search instructions on that website to

view the public comments.

FOR FURTHER INFORMATION CONTACT

:

Stephanie Whittier Eliason, Team Lead,

Office of Elder Justice and Adult

Protective Services, Administration on

Aging, Administration for Community

Living, Department of Health and

Human Services, 330 C Street SW,

Washington, DC 20201. Email:

Stephanie.WhittierEliason@acl.hhs.gov,

Telephone: (202) 795–7467 or (TDD).

Assistance to Individuals With

Disabilities in Reviewing the

Rulemaking Record: Upon request, the

Department will provide an

accommodation or auxiliary aid to an

individual with a disability who needs

assistance to review the comments or

other documents in the public

rulemaking record for the proposed

regulations. To schedule an

appointment for this type of

accommodation or auxiliary aid, please

call (202) 795–7467 or email

Stephanie.WhittierEliason@acl.hhs.gov.

SUPPLEMENTARY INFORMATION

:

Table of Contents

I. Background

II. Statutory and Regulatory History and

Reasons for the Proposed Rulemaking

III. Adult Protective Services

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1

Mengting Li & XinQi Dong, Association Between

Different Forms of Elder Mistreatment and

Cognitive Change, 33 J. of Aging and Health, 249

(2020), https://pubmed.ncbi.nlm.nih.gov/33249977/

; Russ Neuhart, Elder Abuse: Forensic, Legal and

Medical Aspects, 163 (Amy Carney ed., 2019);

Rosemary B. Hughes et al, The Relation of Abuse

to Physical and Psychological Health in Adults with

Developmental Disabilities, 12 Disability and

Health J., 227 (2019), https://doi.org/10.1016/j.dhjo.

2018.09.007; Joy S. Ernst & Tina Maschi, Trauma-

Informed Care and Elder Abuse: A Synergistic

Alliance. 30 J. of Elder Abuse & Neglect, 354 (2018),

https://pubmed.ncbi.nlm.nih.gov/30132733/.

2

Ron Acierno et al., Prevalence and Correlates of

Emotional, Physical, Sexual, and Financial Abuse

and Potential Neglect in the United States: The

National Elder Mistreatment Study, 100 A

MER

. J.

OF

P

UB

. H

EALTH

292 (2010), https://www.ncbi.nlm.

nih.gov/pmc/articles/PMC2804623/; Andre Rosay &

Carrie Mulford, Prevalence Estimates & Correlates

of Elder Abuse in the United States: The National

Intimate Partner and Sexual Violence Survey, 29(1)

J. of Elder Abuse and Neglect, 1 (2017); E-Shien

Chang & Becca R Levy, High Prevalence of Elder

Abuse During the COVID–19 Pandemic: Risk and

Resilience Factors, 29(11) A

MER

. J.

OF

G

ERIATRIC

P

SYCHIATRY

(2021), doi.org/10.1016/

j.jagp.2021.01.007.https://pubmed.ncbi.

nlm.nih.gov/27782784/#:∼:text=More%20than%201

%20in%2010,both%20intimate%20and

%20nonintimate%20partners; Yongjie Yon et al.,

Elder Abuse Prevalence in Community Settings: A

Systematic Review and Meta-analysis, 5(2) Lancet

Global Health 147 (2017); Furthermore, it is

estimated that for every incident of abuse reported

to authorities, nearly 24 additional cases remain

undetected. See Jennifer Storey, Risk Factors for

Abuse and Neglect: A Review of the Literature, 50

A

GGRESSION AND

V

IOLENT

B

EHAVIOR

101339 (2020),

https://www.sciencedirect.com/science/article/abs/

pii/S1359178918303471.

3

Prevalence estimates for abuse subtypes

reported by institutionalized older residents were

highest for psychological abuse (33.4%), followed

by physical (14.1%), financial (13.8%), neglect

(11.6%), and sexual abuse (1.9%); Yongjie Yon et.

al., The Prevalence of Elder Abuse in Institutional

Settings: A Systematic Review and Meta-Analysis,

29 Eur. J. of Pub. Health 58 (2019).

4

Adult Protective Services Technical Assistance

Resource Center (2023). National Process

Evaluation of the Adult Protective Services System.

Submitted to the Administration for Community

Living, U.S. Department of Health and Human

Services. The U.S. Territories are not included in

the analysis. Extant policy information was not

available from the Territories, thus were not

included in the APS Policy Review or APS Systems

Outcomes Analysis. They were able to participate

A. Section 1324.400 Eligibility for

Funding

B. Section 1324.401 Definitions

C. Section 1324.402 Program

Administration

D. Section 1324.403 Investigation and

Post-Investigation Services

E. Section 1324.404 Conflict of Interest

F. Section 1324.405 Accepting Reports

G. Section 1324.406 Coordination with

Other Entities

H. Section 1324.407 APS program

Performance

I. Section 1324.408 State Plans

J. Regulatory Approach

K. Effective Date

L. Request for Comment

IV. Required Regulatory Analyses

A. Regulatory Impact Analysis (Executive

Orders 12866 and 13563)

B. Regulatory Flexibility Act

C. Executive Order 13132 (Federalism)

D. Executive Order 13175 (Consultation

and Coordination with Indian Tribal

Governments)

E. Unfunded Mandates Reform Act of 1995

F. Plain Language in Government Writing

G. Paperwork Reduction Act (PRA)

I. Background

The Administration for Community

Living (ACL) within the Department of

Health and Human Services (HHS) is

issuing this Notice of Proposed

Rulemaking to modify 45 CFR part 1324

of the implementing regulations of the

Older Americans Act of 1965 (OAA or

‘‘the Act’’) to add a new subpart

(Subpart D). The proposed rules

exercise ACL’s authority to regulate

Adult Protective Service (APS) systems

under section 201 of the Act, 42 U.S.C.

3011(e)(3) and section 2042(a) of the

Elder Justice Act (EJA), 42 U.S.C.

1397m–1(a). Currently, there are no

Federal standards for APS systems,

leading to wide variation in policies and

procedures, thus resulting in

inconsistent service delivery across

States and confusion for APS systems

and the general public, including

victims of adult maltreatment.

Historically, APS programs and

administrators have lacked reliable

information and guidance on best

practices and standards for conducting

case investigations and for staffing and

managing APS programs. These

challenges have impaired States’ ability

to respond in an effective and timely

way to reports of adult maltreatment

and to assess client outcomes and the

effectiveness of the services they are

providing. Nationally, this results in a

fragmented and unequal system that can

hinder coordination and lead to the

absence of critical support for some

people experiencing maltreatment. The

proposed regulation will create a

national standard to elevate evidence-

informed practices, bring clarity and

uniformity to programs, and improve

the quality of service delivery for adult

maltreatment victims and potential

victims.

Adult maltreatment is associated with

significant physical and mental health

consequences as well as financial losses.

Older adults and people with

disabilities may also experience

deteriorated family relationships,

diminished autonomy, and

institutionalization, all of which can

impact quality of life.

1

Studies have

found that at least one in ten

community-dwelling older adults

experienced some form of abuse in the

prior year.

2

In addition, a recent

systematic review that collected self-

reports of abuse by residents found high

levels of institutional abuse.

3

APS programs often link adults

subject to maltreatment to community

social, physical health, behavioral

health, and legal services which help

them maintain independence in the

settings they prefer to live. APS

programs are also often the avenue

through which adult maltreatment is

reported to police or other agencies of

the criminal justice system. As such,

APS plays a critical role in the lives of

adults more likely to be subjected to

maltreatment, particularly older adults

and adults with disabilities. APS

programs receive and respond to reports

of adult maltreatment, and work closely

with clients and a wide variety of allied

professionals to maximize safety and

independence and provide a range of

services to the people they serve,

including:

•receiving and investigating reports

of adult maltreatment;

•case planning, monitoring,

evaluation, and other case work and

services; and

•providing, arranging for, or

facilitating the provision of medical,

social service, economic, legal, housing,

law enforcement, or other protective,

emergency, or support services.

APS is a social and human services

program. Working collaboratively and

with the consent of the victim, APS

caseworkers develop service plans and

connect the victim to social, health, and

human services. The focus of APS is

entirely on assisting the victim to

recover from the experience of

maltreatment. As a social services

program, the ‘‘findings’’ in an APS case

are not legal determinations, either civil

or criminal. Rather, if APS suspects that

an act of maltreatment falls under a

State’s criminal statutes, APS will refer

the case to law enforcement.

As discussed in greater detail in the

Statutory and Regulatory History and

Reasons for the Proposed Rulemaking,

until 2021 APS systems were funded

primarily through a variety of local and

State resources. All States now accept

Federal funding, including ACL

funding, for their APS systems in

addition to their State and local

funding. However, there are currently

no mandatory Federal standards

governing APS policies, procedures, and

practices, which results in a significant

program variation across and within

States and, in some cases, sub-standard

quality according to APS staff and other

community members.

In 2021, ACL fielded a survey (OMB

Control No. 0985–0071) of 51 APS

systems (the 50 States and the District

of Columbia).

4

Results from that survey,

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in the APS Practice Survey, and their data are

included in internal survey results report to ACL.

5

NAMRS is a data reporting system established

and operated by ACL for the purpose of better

understanding of adult maltreatment in the United

States. The data collected is submitted by all APS

programs in all states, the District of Columbia, and

the Territories. NAMRS annually collects data on

APS investigations of abuse, neglect and

exploitation of older adults and adults with

disabilities, as well as information on the

administration of APS programs. The data provide

an understanding of key program policies,

characteristics of those experiencing and

perpetrating maltreatment, information on the types

of maltreatment investigated, and information on

services to address the maltreatment. For more

information, visit: T

HE

A

DMIN

. F

OR

C

MTY

. L

IVING

,

National Adult Maltreatment Reporting System,

www.namrs.acl.gov (last visited April 18, 2023).

6

We refer to ‘‘States’’ in this proposed rule to

encompass all fifty States, the District of Columbia,

and the five Territories (American Samoa,

Commonwealth of the Northern Mariana Islands,

Guam, Puerto Rico, and U.S. Virgin Islands).

7

See infra note 24. In addition to ACL formula

grants, States may receive Title XX Social Services

Block Grant (SSBG) funding. However, States have

discretion whether and how much of their SSBG

funding they choose to allocate to APS. Not all

States use SSBG funding for their APS systems.

8

See supra note 4; Numbers sum to 54 because

five Territories did not report data on their APS

administrative structure. All fifty States and the

District of Columbia reported data. Three States

(Massachusetts, Louisiana, and Pennsylvania) have

two separate APS systems, one program with

eligibility based on age and a separate and distinct

program with eligibility based on disability status.

The two separate systems were counted in these

States.

9

See supra note 4 at 21.

10

See supra note 4 at 20; Pennsylvania has used

a for-profit entity due to a unique circumstance in

the State related to the State’s aging services

structure. There are currently no for-profit APS

entities.

11

For example, 76 percent of APS programs

indicate that their State exerts ‘‘significant’’ control

over local APS operations. See supra note 4 at 20.

12

See supra note 4 at 21.

13

Id.

14

We note eligibility is set in State statute.

Discretion is exercised, however, on which eligible

cases to accept—often based on resource

constraints.

15

See supra note 4. Specifically, 34 States serve

adults (age 18 and older) with disabilities regardless

of age. This is the largest eligibility category.

Twelve States serve older adults (either age 60 and

older or age 65 and older) regardless of disability

status, and younger adults with a disability. Four

States serve only older adults regardless of

disability status. Two States serve only older adults

with a disability. Two States have programs that

only serve young adults with disabilities, and older

adults are served by a different APS program within

the State.

16

See supra note 4.

17

See supra note 4.

18

See supra note 4.

19

See supra note 4.

20

See supra note 4.

21

For detailed information on the development

process for the 2016 and subsequent 2020

Consensus Guidelines, see T

HE

A

DMIN

. F

OR

C

MTY

.

L

IVING

, F

INAL

N

ATIONAL

V

OLUNTARY

G

UIDELINES FOR

S

TATE

A

DULT

P

ROTECTIVE

S

ERVICES

S

YSTEMS

(2016),

https://acl.gov/sites/default/files/programs/2017-

03/APS-Guidelines-Document-2017.pdf (last visited

May, 16 2023); T

HE

A

DMIN

. F

OR

C

MTY

. L

IVING

,

V

OLUNTARY

C

ONSENSUS

G

UIDELINES FOR

S

TATE

APS

S

YSTEMS

(2020), https://acl.gov/programs/elder-

justice/final-voluntary-consensus-guidelines-state-

aps-systems (last visited Apr. 18, 2023).

22

Off. Of Mgmt. & Budget, Exec. Off. Of the

President, OMB Circular A–119, Federal

Participation in the Development and Use of

Voluntary Consensus Standards and in Conformity

Assessment Activities, https://www.nist.gov/

system/files/revised_circular_a-119_as_of_01-22-

2016.pdf); National Technology Transfer and

Advancement Act of 1995, Public Law No. 104–113,

including amendment Utilization of consensus

technical standards by Federal agencies, Public Law

No. 107–107, §1115 (2001), https://www.nist.gov/

standardsgov/national-technology-transfer-and-

advancement-act-1995; The Admin. For Cmty.

Living, Report on the Updates to the Voluntary

Consensus Guidelines for APS Systems (2020)

https://acl.gov/sites/default/files/programs/2020-

05/ACL-Appendix_3.fin_508.pdf (last visited May 9,

2023).

along with an analysis of the 2020

National Adult Maltreatment Reporting

System (NAMRS)

5

data, and collected

policy profiles of APS in all States, the

District of Columbia, and the Territories

illustrate the wide variability across

APS programs.

6

As discussed in the Definitions

section, an APS system is made up of

both the State entity (e.g., the

department of health and human

services) that receives State and Federal

funding for APS, including ACL

funding, and the local APS programs

that provide adult protective services.

7

All APS systems are organized under a

State government entity, with 20

systems located within a State Unit on

Aging, 14 within a State division or

department of social services (mostly

responsible for child welfare), and 20

within some other State department or

agency of health and human services.

8

Despite all States having a designated

State office for APS, the degree to which

the State entity controls and administers

the APS systems varies across States. In

78 percent of APS systems, the State

office sets program policy for, and

conducts oversight of, the APS

programs, and in 22 percent of States,

the authority to set policy and conduct

oversight rests in the local APS program

in each county or service area.

9

In 70

percent of APS programs, State

employees implement the APS program

and conduct investigations; county and

non-profit employees conduct

investigations in the remaining 30

percent of programs.

10

While the State entity establishes APS

policy, conducts training, administers

funding, and provides information

technology infrastructure support to

local APS programs in almost all APS

systems,

11

27 States have indicated the

need for greater consistency in

practice.

12

Specific obstacles identified

included: lack of resources for oversight

in general or quality assurance

processes specifically, differing policy

interpretations across local programs,

and not enough supervisors.

13

Eligibility for APS services varies

dramatically across the States, Tribal

Nations, and Territories. States use age

and terms such as ‘‘disability,’’

‘‘dependency,’’ or ‘‘vulnerability’’ to

define the populations they serve.

14

In

some States, being an older adult (some

States set the age at 60 and older, others

at 65 and older) is the only criterion for

determining whom they serve; in others,

eligibility is defined by a combination of

age and ‘‘disability,’’ ‘‘dependency,’’ or

‘‘vulnerability.’’ States with programs

that serve younger adults (age 18–59 or

18–64) always require ‘‘disability,’’

‘‘dependency,’’ or ‘‘vulnerability’’ as a

criterion.

15

However, despite eligibility

being established at the State level, APS

programs often triage which eligible

cases they have the capacity to

investigate based on numerous factors,

including resources.

Responsibility for investigations

involving residents in congregate

residential facilities such as nursing

facilities, assisted living facilities, and

group homes varies across APS systems.

Most APS systems investigate

allegations of maltreatment that do not

involve the facility or its staff, and a few

APS programs investigate allegations

involving the staff of the facility.

16

Eleven APS systems report they do not

have authority to conduct investigations

in congregate residential facilities.

17

Forty-two APS systems report they have

authority to investigate allegations of

abuse, neglect, or exploitation when

they occur in congregate residential

facilities.

18

Of those 42, 19 report the

APS system has authority to conduct

investigations in congregate residential

facilities in all situations regardless of

whether the alleged perpetrator is

facility staff, visitor, or resident.

19

Twenty-three States report the APS

system has authority to conduct

investigations in some congregate

residential settings depending on

whether a staff person is the alleged

perpetrator or not.

20

In an effort to elevate uniform

evidence-informed practices across APS

programs, ACL issued Voluntary

Consensus Guidelines for State APS

Systems (Consensus Guidelines) in

2016, which were subsequently updated

in 2020.

21

In developing the Consensus

Guidelines, ACL applied Office of

Management and Budget (OMB) and

National Institutes of Standards and

Technology (NIST) standards and

processes for creating field-developed,

consensus-driven guidelines.

22

The

development of the 2016 Consensus

Guidelines and its 2020 update

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23

Individual input was received from the APS

community, thus exempting the process from

Federal Advisory Council Act requirements; 5

U.S.C. 1001 et. seq.

24

See supra note 4.

25

For example, South Carolina had the highest

SSBG expenditure for Vulnerable and Elderly

Adults in FY 2020 at $14,311,707 representing 58

percent of their entire block grant. The Dep’t. of

Health and Hum. Servs., Social Services Block

Grant: Fiscal Year 2020. Ann. Rep. (2020). https://

www.acf.hhs.gov/sites/default/files/documents/ocs/

RPT_SSBG_Annual%20Report_FY2020.pdf (last

visited May 11, 2023).

26

42 U.S.C. 1397k.

27

The Admin. for Cmty. Living, Federal Elder

Justice Coordinating Council, https://ejcc.acl.gov/

(last visited Apr. 18, 2023).

28

42 U.S.C. 1397m–1.

29

Coronavirus Response and Relief Supplemental

Appropriations Act of 2021, Public Law 116–260,

134 Stat. 1182; American Rescue Plan Act of 2021,

Public Law 117–2, 135 Stat. 4.

consisted of multiple steps. ACL

performed a review of research available

on promising practices in APS systems

and in other analogous systems

throughout the United States; convened

a review group consisting of experts

selected from the APS, the Long-Term

Care Ombudsman, and disability rights

communities; and engaged in an

extensive and wide-reaching

community engagement and outreach

process. Through our community

engagement process, we received input

on an individual basis from a variety of

sources, including the general public,

the aging network, APS systems, the

disability community, law enforcement,

and others. We drafted our guidance

based on the individual input we

received.

23

The Consensus Guidelines represent

recommendations from the field based

on experience and expertise serving

adults and communities. These

guidelines provide a core set of

principles and common expectations to

encourage consistency in practice,

ensure adults are afforded similar

protections and APS services regardless

of locale, and support interdisciplinary

and interagency coordination. These

recommendations enhance effective,

efficient, and culturally competent APS

service delivery. While the Consensus

Guidelines have been commended by

APS systems and the APS community,

they have yet to produce measurable

change in APS systems or practice, and

consistency and uniformity are still

lacking across and within APS systems.

Our recently published National Process

Evaluation Report using 2021 data and

ongoing NAMRS data collection bear

out gaps between current State policy

and practice and the recommendations

contained in the Consensus Guidelines.

We have received feedback from the

APS community that because the

Consensus Guidelines are voluntary

recommendations and not regulatory

requirements, their efficacy is limited.

These proposed rules are informed by

the extensive research, analysis,

community input, and

recommendations of our Consensus

Guidelines, as well as experience and

information from our NAMRS data, and

the 2021 51 State National Process

Evaluation Report.

24

II. Statutory and Regulatory History

and Reasons for the Proposed

Rulemaking

APS programs have historically been

administered and primarily funded by

States. They have been recognized in

Federal law since 1974 when the Social

Security Act was amended by the Social

Services Amendments of 1974 (Pub. L.

93–647), 42 U.S.C. 1397a(a)(2)(A) to

permit States to use Social Services

Block Grant (SSBG) funding under Title

XX for APS programming. However,

while most States currently use SSBG

funding for their APS programs, the

amount of SSBG funding allocated to

APS varies and the allocations can be

very small.

25

Through a series of legislative actions,

Congress designated ACL as the Federal

entity with primary responsibility for

providing Federal policy leadership and

program oversight for APS. This

includes authority granted by the OAA

to promulgate regulations, to oversee

formula grants to State and Tribal APS

programs, to enhance APS programs, to

collect data to increase APS

effectiveness, and to directly link the

authorities of the EJA with those

contained in the OAA.

Title VII of the OAA (Vulnerable

Elder Rights Protection Activities),

enacted in 1992, authorizes funding to

States to address protections for

vulnerable adults. Some activities are

specifically identified to be conducted

with Title VII funding. Section 201(e) of

the OAA, 42 U.S.C. 3011(e) added in

2006, vests responsibility for a

coordinated Federal and national

response to elder justice issues broadly

with the Assistant Secretary for Aging.

ACL has rulemaking authority for elder

justice activities by virtue of section

201(e)(3), 42 U.S.C. 3011(e)(3), which

states, ‘‘the Secretary, acting through the

Assistant Secretary, may issue such

regulations as may be necessary to carry

out this subsection . . .’’ and

specifically references the responsibility

of the Assistant Secretary for elder

abuse prevention and services,

detection, treatment and response in

coordination with heads of State APS

programs. Section 2042(b) of the EJA, 42

U.S.C. 1397m–1, establishes an APS

grant program under which the

Secretary annually awards grants to

States. The Secretary of HHS has

designated ACL as the grant-making

agency for APS. Coupled together, the

EJA and OAA provide the Assistant

Secretary with broad authority to

coordinate, regulate, and fund State APS

systems.

Through the enactment of the EJA in

2010, Congress again recognized the

need for a more coordinated national

elder justice and APS system. The EJA

creates a national structure to promote

research and technical assistance to

support Federal, State, and local elder

justice efforts, as well as authorization

for dedicated APS funding. A

component of the EJA is specifically

designed to address the need for better

Federal leadership. The Federal Elder

Justice Coordinating Council (EJCC) is

established by the EJA

26

to coordinate

activities across the Federal Government

that are related to elder abuse, neglect,

and exploitation. The EJA designates the

Secretary of HHS to chair the EJCC, and

continually since the establishment of

the EJCC in 2012, the HHS Secretary has

designated that responsibility to the

Assistant Secretary for Aging and

Administrator of ACL. Under the

chairmanship of the Assistant Secretary

for Aging, and since its establishment,

the EJCC has met regularly, soliciting

input from the APS community—

ranging from individual citizens to

expert practitioners and industry

associations—on identifying and

proposing solutions to the problems

surrounding elder abuse, neglect, and

financial exploitation, including for

strengthening national support for

APS.

27

Since Fiscal Year (FY) 2015, Congress

has appropriated funds to ACL in

support of APS through section 2042(a)

and 2401(c) of the Elder Justice Act.

This funding is used to collect data,

disseminate best practices, and provide

discretionary elder justice

demonstration grants.

28

In FY 2021,

Congress provided the first dedicated

appropriation to implement the Elder

Justice Act section 2042(b), 42 U.S.C.

1397m–1(b), formula grants to all States,

the District of Columbia, and the

Territories to enhance APS, totaling

$188 million, and another $188 million

in FY 2022.

29

The recent Consolidated

Appropriations Act of 2023 included an

annual appropriation of $15 million to

ACL to continue providing formula

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Consolidated Appropriations Act, 2023, Pub. L.

117–328. FY 21 and 22 funding was one-time

funding to help with start-up costs and

infrastructure and the surge of needs during the

COVID–19 Public Health Emergency. FY 23 funding

was the first ongoing formula grant funding to State

grantees.

31

Public and Outside Witness, Hearing Before the

Subcomm. on Lab., Health and Hum. Servs. Educ.

& Related Agencies of the House Appropriations

Comm., 113th Cong. (2014) (statement of Kathleen

M. Quinn, Exec. Dir. of the Nat’l. Adult Protective

Servs. Ass’n.) https://www.napsa-now.org/wp-

content/uploads/2014/03/Appropriations-

Testimony-NAPSA.pdf.

32

Enhancing Response to Elder Abuse, Neglect,

and Exploitation: Elder Justice Coordinating

Council, Testimony of William Benson (Oct. 10,

2012), http://www.aoa.acl.gov/AoA_Programs/

Elder_Rights//Meetings/2012_10_11.aspx.

33

Kathleen Quinn & William Benson, The States’

Elder Abuse Victim Services: A System in Search

of Support, 36 G

ENERATIONS

66 (2012).

34

U.S. Gen. Acct. Off., GAO–11–208, Elder

Justice: Stronger Federal Leadership Could Enhance

National Response to Elder Abuse (2011) https://

www.gao.gov/products/gao-11-208; U.S. Gen. Acct.

Off., GAO–13–110, Elder Justice: National Strategy

Needed to Effectively Combat Elder Financial

Exploitation (2012) https://www.gao.gov/products/

gao-13-110; U.S. Gen. Acct. Off., GAO–13–498,

Elder Justice: More Federal Coordination and Public

Awareness Needed (2013) https://www.gao.gov/

products/gao-13-498.

35

Since 2011, ACL has received questions and

comments from Congress, OMB, and others

regarding comparisons between CPS and APS. For

example, GAO made comparisons between APS and

CPS in their 2011 report ‘‘ELDER JUSTICE—

Stronger Federal Leadership Could Help Improve

Response to Elder Abuse,’’ (https://www.gao.gov/

assets/gao-11-384t.pdf) and the Congressional

Research Service did a report on this subject as

recently as 2020: (https://crsreports.congress.gov/

product/pdf/R/R43707).

36

Admin. for Child. and Fams., Dep’t. of Health

and Hum. Servs., About CAPTA: A Legislative

History (2019) https://www.childwelfare.gov/

pubpdfs/about.pdf.

37

Emilie Stoltzfus, U.S. Cong. Rsch. Serv. Child

Welfare: Purposes, Federal Programs, and Funding

(2023) https://crsreports.congress.gov/product/pdf/

IF/IF10590.

grants to APS programs under the Elder

Justice Act section 2042(b), 42 U.S.C.

1397m–1(b).

30

On numerous occasions, the APS

community has stressed the need for

more Federal guidance, leadership,

stewardship, resources, and support for

State and local APS programs and for

victims of adult maltreatment.

Advocates have requested greater

funding and Federal regulatory

guidance for APS systems in their

testimony before Congress,

31

in their

statements to the EJCC,

32

and in peer-

reviewed journals.

33

The GAO conducted three studies on

the topic of abuse, neglect, and

exploitation between 2010 and 2013 to

shed light on the need for Federal

leadership. The studies’ findings

repeatedly recommend a coordinated,

Federal response to address the gaps in

public awareness, prevention,

intervention, coordination, and research

of elder maltreatment, as well as a

Federal ‘‘home’’ for APS.

34

This proposed rule represents the first

exercise of ACL’s regulatory authority

over APS under the OAA and the EJA.

While we have issued sub-regulatory

guidance, including comprehensive

Consensus Guidelines in 2016 and 2020

that include APS evidence-informed

practices, we believe it is necessary to

codify and clarify a set of mandatory

minimum national standards to ensure

uniformity across APS programs and to

promote high quality service delivery

that thus far has not been achieved

under the current Consensus

Guidelines.

In determining the scope of the APS

regulations, we considered modeling

our regulations after the child protective

services (CPS) regulations administered

by the Department’s Administration for

Children and Families.

35

We ultimately

rejected this approach. The Child Abuse

Prevention and Treatment Act of 1974

(Pub. L. 93–247), 42 U.S.C 5116,

provides Federal funding to States for

prevention, assessment, investigation,

prosecution, and treatment of child

abuse and neglect, and awards grants for

demonstration projects.

36

In FY 2023,

approximately $12 billion was provided

for child welfare programs, and of that

$852 million was appropriated

specifically for child protection.

37

In

contrast, the appropriation for activities

under section 2042(b) of the EJA was

funded for the first time in FY 2021

with one-time funding at $188 million

a year for FYs 2021 and 2022 for State

program start-up costs and to address

urgent needs related to COVID–19, and

$15 million in ACL’s FY 2023 annual

appropriation for ongoing operations.

Further, the EJA is much smaller in

scope both in terms of requirements and

discretionary activities. Given the

differences in size and scope of

Federally authorized and supported

activities, ACL believes it would not be

appropriate to model the proposed APS

regulations after CPS regulations.

Moreover, our approach takes into

consideration the differences between

minor children and adults legally,

developmentally, and specifically with

regards to rights to make decisions

about their lives. ACL invites comment

on both the scope and depth of topics

proposed for regulatory action and the

rationale presented.

Instead of providing detailed and

broad requirements like those that apply

to CPS, our proposals require the State

entity to establish written policies and

procedures in areas of significant APS

practice. In the interests of

transparency, we considered mandating

that State entities disclose such policies

and procedures (for example, through

publication on a State website) except

where such disclosure might adversely

affect law enforcement efforts, but we

ultimately decided to leave such

disclosure to State discretion. We

welcome comment on the costs and

benefits of mandating such disclosure.

Our proposed standards are a

minimum floor. States may impose

additional requirements on their APS

systems above and beyond these

proposed minimum Federal standards.

ACL invites comment on both the scope

and depth of topics proposed for

regulatory action and the rationale

presented.

III. Adult Protective Services Programs

A. Section 1324.400 Eligibility for

Funding

Proposed § 1324.400 clarifies that

eligibility for funding is conditioned on

compliance with all proposed regulatory

provisions. Under the proposed rules,

State entities eligible for annual funding

from ACL through section 2042 of the

EJA, 42 U.S.C. 1397m–1(b) are required

to submit a State plan in accordance

with § 1324.408 detailing their

activities, which ACL proposes to

review and approve as a means of

verifying compliance with the proposed

rule. A State that failed to submit an

approvable State plan would no longer

be eligible for funding under section

2042(b) of the EJA.

ACL will provide States support and

technical assistance in developing an

approvable State plan. All States are

afforded an opportunity to appeal the

Assistant Secretary’s disapproval of a

State plan submission under proposed

§ 1324.408(e). If a State declines or fails

to qualify for section 2042(b) funding,

ACL will redistribute the funds in

accordance with the EJA section 2042

formula. Further information on State

plan development will be provided in

sub-regulatory guidance.

B. Section 1324.401 Definitions

We propose to define the following

terms in § 1324.401 to provide clarity on

the terms used and referenced in this

proposed rule: ‘‘Abuse,’’ ‘‘Adult,’’

‘‘Adult maltreatment,’’ ‘‘Adult

Protective Services (APS), ’’ ‘‘Adult

Protective Services (APS) program,’’

‘‘Adult Protective Services (APS)

system,’’ ‘‘Allegation,’’ ‘‘Assistant

Secretary for Aging,’’ ‘‘At risk,’’ ‘‘Case,’’

‘‘Client,’’ ‘‘Conflict of Interest,’’ ‘‘Dual

Relationship,’’ ‘‘Emergency Protective

Action,’’ ‘‘Exploitation,’’

‘‘Inconclusive,’’ ‘‘Intake or pre-

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See supra note 4.

39

The Cntrs. for Disease Control and Prevention,

Elder Abuse Surveillance: Uniform Definitions and

Recommended Core Data Elements (2016) https://

www.cdc.gov/violenceprevention/pdf/EA_Book_

Revised_2016.pdf.

40

See 45 CFR 75.321(c)(1).

screening,’’ ‘‘Investigation,’’ ‘‘Mandated

Reporter,’’ ‘‘Neglect,’’ ‘‘Perpetrator,’’

‘‘Post-investigation services,’’ ‘‘Quality

assurance,’’ ‘‘Screening,’’ ‘‘Self-neglect,’’

‘‘Sexual abuse,’’ ‘‘State entity,’’

‘‘Substantiated,’’ ‘‘Trust Relationship,’’

‘‘Unsubstantiated,’’ and ‘‘Victim.’’

Definitions of note are discussed

below.

‘‘Abuse’’ Consistent with definitions

in section 102(1) of the OAA, 42 U.S.C.

3002(1), and section 2011 of the EJA, 42

U.S.C. 1397j(1), we propose to define

abuse as a component of adult

maltreatment to encompass the

knowing psychological, emotional, and/

or physical harm or the knowing

deprivation of goods or services

necessary to meet essential needs or

avoid such harm.

‘‘Adult’’ For purposes of this

regulation, we propose to define adult to

mean the eligible APS population in any

given State. The term ‘‘adult’’ will be

used in place of ‘‘older adults and

adults with disabilities who are eligible

for adult protective services.’’ We have

chosen to defer to States’ definitions of

‘‘adult’’ for the purposes of determining

eligibility for APS services in

recognition of the complex and

intersecting nature of social services,

public benefits, and behavioral health

care services in States. In many States,

eligibility for APS services is consistent

with eligibility for social services,

behavioral health, and other public

benefits. A change to eligibility for APS

in a State to conform with the proposed

rule’s definition of ‘‘adult’’ may

potentially disrupt important

relationships among programs and

services outside APS. We request

comments on this approach.

‘‘Adult maltreatment’’ We propose to

define adult maltreatment to bring

uniformity and specificity to a

foundational term used throughout APS

systems and this proposed regulation.

Although there is increasing consensus

on the core components of adult

maltreatment, the field has not adopted

a universally accepted definition. The

definition of adult maltreatment and its

component parts has a direct impact on

the reports accepted for investigation,

discussed in greater detail below at

§ 1324.402. Our proposed definition and

the requirements set out in § 1324.402(a)

that States investigate, at a minimum,

the five elements of adult maltreatment

will establish a comprehensive and

uniform approach to investigations of

adult maltreatment while still allowing

for State flexibility and discretion. Our

definition represents a consistent

baseline upon which States may build.

In developing our definition and the

requirements contained in proposed

§ 1324.402(a), we adopted categories

generally recognized by the field, used

by the research community, and in

common use by the vast majority of

States.

38

We propose that adult maltreatment

encompass five categories further

defined in this Section: abuse, neglect,

exploitation, sexual abuse, and self-

neglect. Adult maltreatment occurs

when there is self-neglect or when a

perpetrator commits abuse, neglect,

exploitation, or sexual abuse of an adult.

The adult must have a relationship of

trust with the perpetrator of abuse,

neglect, exploitation, or sexual abuse

and be at risk of harm from the

perpetrator.

This proposed rule, in alignment with

most States’ policies, limits the

definition of abuse or maltreatment to

relationships of trust where the alleged

victim is at risk of harm from the

perpetrator. A relationship of trust

includes a caregiving relationship or

other familial, social, or professional

relationship where a person assumes

responsibility for protecting the

interests of the adult or where

expectations of care or protection arise

by law or social convention.

39

APS

systems refer cases outside trust

relationships to partner organizations

and services, such as other social

service programs or law enforcement.

This distinction acknowledges the

elevated harm engendered when injury

occurs within the context of a

relationship of trust and an adult is

vulnerable to harm generally and in

relation to the perpetrator. It prioritizes

finite APS resources to focus on this

heightened injury. We further define

‘‘trust relationship’’ and ‘‘at risk’’ later

in this proposed rule. We recognize that

our current proposal narrows the

universe of required APS investigations

under proposed § 1324.402(a) and in

developing our proposal, we considered

a more expansive definition of adult

maltreatment. We invite comment on

our definition and whether it reflects

current practice in APS programs and

whether it will resolve confusion. We

describe some of this confusion

throughout this discussion.

‘‘At risk’’ We propose to define ‘‘at

risk’’ in accordance with Centers for

Disease Control and Prevention (CDC)

Elder Abuse Surveillance: Uniform

Definitions and Recommended Core

Data Elements (CDC Uniform

Definitions) as ‘‘the possibility that an

individual will experience an event,

illness, condition, disease, disorder,

injury or other outcome that is adverse

or detrimental and undesirable.’’ We

recognize the considerable variation

among States in determining whether

maltreatment must include

‘‘vulnerability’’ or other qualifier, and

we seek comment on this definition.

The CDC definition on which ours is

based was developed through a

collaborative process among a panel of

scientists and practitioners representing

multiple disciplines (e.g., medicine,

psychology, epidemiology, sociology,

gerontology), as well as Federal staff.

‘‘Conflict of Interest’’ means a

situation that interferes with a program

or program employee or representative’s

ability to provide objective information

or act in the best interests of the adult.

Such a conflict of interest would arise,

for example, when an employee, officer,

or agent, any member of their immediate

family, their partner, or an organization

which employs or is about to employ

any of the parties indicated herein, has

a financial or other interest in or a

tangible personal benefit from their

affiliation with an APS system.

40

‘‘Dual Relationship’’ means

relationships in which an APS worker

assumes one or more professional,

personal, or volunteer roles in addition

to their role as an APS worker at the

same time, or sequentially, with a client.

‘‘Exploitation’’ Consistent with

definitions in section 102 of the OAA,

42 U.S.C. 3002(18)(A), and section 2011

of the EJA, 42 U.S.C. 1397j(8), we

propose to define exploitation as a type

of adult maltreatment. Financial

exploitation and exploitation are used

interchangeably in the OAA, and

exploitation for the purposes of adult

maltreatment in this proposed rule is

likewise confined to illegal,

unauthorized, or improper acts related

to the personal finances of an adult (as

defined above) (for example,

exploitation does not encompass labor

rights violations).

‘‘Neglect’’ Consistent with the

definitions in section 102 of the OAA,

42 U.S.C. 3002(38) and section 2011 of

the EJA, 42 U.S.C. 1397j(16), we propose

to define neglect as the failure of a

caregiver or fiduciary to provide the

goods or services that are necessary to

maintain the health or safety of an adult

(as defined above).

‘‘Self-neglect’’ Consistent with the

definitions in section 102(48) of the

OAA, 42 U.SC. 3002(48), and section

2011 of the EJA 42 U.S.C. 1397j(18) we

propose to define self-neglect as an

adult’s (as defined above) inability to

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See supra note 4, at 17. Other maltreatment

type categories exist in State statutes, including

non-specific exploitation, abandonment, abduction,

isolation, other maltreatment, and suspicious death.

42

Id.

43

The total potential universe for any analysis is

56, however American Samoa and the

Commonwealth of the Northern Mariana Islands do

not currently have staffed programs. The unit of

analysis for this data is 54. This includes APS

programs in all States and the District of Columbia.

In three States—Louisiana, Massachusetts, and

Pennsylvania—APS is provided in two different

programs for older adults and younger adults.

44

See supra note 4.

perform essential self-care tasks due to

physical or mental impairment or

diminished capacity.

‘‘Sexual abuse’’ The OAA defines

‘‘sexual assault’’ at section 102(50), 42

U.S.C. 3002(50), to have the meaning

given in section 2003 of the Omnibus

Crime Control and Safe Streets Act of

1968, 42 U.S.C. 3796gg–2. Our proposed

definition encompasses, but is broader

than, sexual assault as defined in the

OAA. Consistent with the definition

outlined in the CDC Uniform

Definitions, we propose to define sexual

abuse as the forced and/or unwanted

sexual interaction (touching and non-

touching acts) of any kind with an adult

(as defined above).

‘‘Trust relationship’’ Consistent with

the CDC Uniform Definitions, ACL

proposes to define ‘‘trust relationship’’

as ‘‘the rational expectation or belief

that a relative, friend, caregiver, or other

person with whom a [. . .] relationship

exists can or should be relied upon to

protect the interests of an adult (as

defined above) and/or provide for an

adult’s care. This expectation is based

on either the willful assumption of

responsibility or expectations of care or

protection arising from legal or social

conventions.’’ Including the

requirement of a trust relationship for

purposes of determining when APS

becomes involved furthers consistency

of APS interventions in adult

maltreatment. Furthermore, most APS

systems apply a standard of ‘‘trust

relationship’’ in their definition of

maltreatment. We seek comments on

this approach.

C. Section 1324.402 Program

Administration

Proposed § 1324.402(a) requires APS

systems to respond to reports of adult

maltreatment, which include allegations

of abuse, neglect, exploitation, sexual

abuse, and self-neglect. Currently, all

APS systems are required by State

statute to investigate allegations of

neglect and physical abuse, and nearly

all states investigate allegations of self-

neglect, sexual abuse, financial

exploitation, and emotional or

psychological abuse.

41

Forty-two States

investigate six or more types of

maltreatment.

42

T

ABLE

C.1—T

YPES OF

M

ALTREATMENT

I

NVESTIGATED BY

S

TATES

43

Maltreatment type Physical

abuse Neglect Exploitation Sexual abuse Self-neglect

Emotional

abuse

No. of States ............................................ 54 54 46 52 51 45

However, definitions of these terms

vary across States. In certain States, APS

programs are not required to respond to

certain forms of adult maltreatment.

This means that adults are not

adequately protected by APS throughout

the United States.

In addition to our request for

comment on the definition of adult

maltreatment, we seek comment as to

whether a mandatory requirement for

investigation based on the definitions of

abuse, neglect, exploitation, sexual

abuse, and self-neglect is appropriate,

adequately reflects the needs and

experiences of APS systems, as well as

any potential State and local burden

associated with such a requirement.

Proposed § 1324.402(a) also requires

the State entity to adopt certain policies

and procedures for receiving and

responding to reports of adult

maltreatment. These policies and

procedures must be person-directed and

rely on concepts of least restrictive

alternatives. Principles of person-

directedness respect the integrity and

authority of adults to make their own

life choices. They promote APS clients’

concepts of what safety and quality of

life mean, and success and positive

outcomes are defined by the client, not

the APS worker. This provision sets

minimum requirements for States as

they establish or revise policies and

procedures while still leaving flexibility

to best meet their unique needs.

The State entity must create precise,

standardized criteria for determining or

assessing eligibility for APS services.

States must also create clear and

specific parameters of the settings,

locations, and types of alleged

perpetrators for which allegations of

maltreatment will be investigated by

their APS system. For example, States

vary on whether they conduct

investigations in congregate residential

settings. In addition, States must

establish processes to ensure the

parameters are implemented

consistently across APS programs in

their State.

We propose that States define

processes for receiving, screening,

prioritizing, and referring cases based

on risk and the nature of the adult

maltreatment in a uniform and

consistent manner across their State.

Under this proposal, the State entity

would be required to establish policies

and procedures to manage a tiered risk-

based assessment system, differentiating

response requirements for cases that

represent immediate and non-

immediate risks. As proposed,

immediate risk would be assessed via

the likelihood of death, irreparable

harm, or significant loss of income,

assets, or resources. Responses should

occur no later than 24 calendar hours

(one calendar day) after receiving the

report for cases representing an

immediate risk, and no later than seven

calendar days for cases of non-

immediate risk.

Currently, there is data on all but one

APS systems’ tiered report response

procedures. Two State APS systems

have no priority levels, and one has two

priority levels. The rest have three or

more. States vary widely in their

response time and not all States address

high priority cases within 24 hours,

although most do.

44

We seek to bring all

States into alignment with the

Consensus Guideline in this area of

practice; timely response to immediate

need cases is essential to the health and

safety of potential maltreatment victims.

For allegations of adult maltreatment

outside APS jurisdiction, we propose

the State entity establish appropriate

referral mechanisms and information

and data sharing agreements with the

state and/or local entity with

jurisdiction to investigate.

In proposed § 1324.402(b), we require

State entities to establish policies and

procedures to inform potential APS

clients of their rights at first contact

with client. With this provision, we seek

to address concerns that APS programs

do not regularly inform potential clients

of their rights under existing State laws,

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Jane E. Ball et. al., Post-operative Mortality,

Missed Care and Nurse Staffing in Nine Countries:

A Cross-Sectional Study,78, Int. J. Nursing Studies,

10 (Feb. 2018) https://pubmed.ncbi.nlm.nih.gov/

28844649/; Charlene Harrington et. al. Appropriate

Nurse Staffing Levels for U.S. Nursing Homes, 13

Health Serv. Insights (2020) https://www.ncbi.nlm.

nih.gov/pmc/articles/PMC7328494/.

46

Pi-Ju Liua & Leslie Ross, Adult Protective

Services Training: A Brief Report on the State of the

Nation, 33 J. of Elder Abuse and Neglect, 82 (2021).

https://www.tandfonline.com/doi/epdf/10.1080/

08946566.2020.1845271?needAccess=true&role

=button.

47

Kelli Connell-Carrick & Maria Scannapieco,

Adult Protective Services: State of the Workforce

and Worker Development, 29(2) Gerontology &

Geriatrics Education, 189–206 (2008) https://

pubmed.ncbi.nlm.nih.gov/19042235/.

48

See supra note 22.

including confidentiality and privacy

requirements, the right to refuse

services, and the right to refrain from

speaking with APS. This is directly

responsive to problems that have been

reported by the APS and disability and

aging community advocates to ACL in

listening sessions and other community

engagement activities. Failure to inform

potential clients of their rights

undermines trust between individuals

and APS and may alienate communities.

Under this proposal, APS programs

must inform potential APS clients of

their rights in the format and language

preferred by the individual, including

those with limited English proficiency

and individuals with disabilities. APS

programs should take appropriate steps

to ensure communication with

individuals with disabilities are as

effective as communications with others

More generally, standard plain language

practice is to write informational

materials at or near a fourth grade

reading level and not to exceed an

eighth grade reading level. We expect

State entities to meet these standards in

complying with language proposed at

§ 1324.402(b).

Proposed § 1324.402(d) requires the

State entity to establish policies and

procedures for the staffing of APS

systems. We propose to require States to

establish a minimum staff to client ratio

appropriate to the circumstances in the

State. We believe, consistent with the

literature, that fixed staff to client ratios

in APS systems will improve health and

safety outcomes for adult victims of

maltreatment.

45

We also believe that

establishing fixed staff to client ratios

will improve the long-term continuity of

APS programs. We request comment on

whether staff to client ratios are feasible

for APS programs and whether required

workload studies would assist in

development of appropriate ratios.

We also propose to require mandatory

APS training as a part of implementing

the proposed policies and procedures.

Findings from a 2015–2018 survey

completed by 49 APS offices found that

half of programs were not training on

core competencies while two had no

training whatsoever.

46

Training and

ongoing education increases staff

knowledge, leading to increased rates of

investigation and substantiation.

47

Supervisors provide both clinical and

administrative oversight, approve key

casework decisions, and guide the

caseworkers in overall case

management. Sufficient training is

critical to ensuring they can perform

these functions.

D. Section 1324.403 Investigation and

Post-Investigation Services

Proposed § 1324.403 requires the

State entity to develop and implement

a standardized set of policies and

procedures for essential APS functions

throughout the lifecycle of a case. The

purpose of an APS investigation is to

collect information about the allegations

of maltreatment, determine if the

alleged victim is eligible for APS

services, assess the immediate risk of

the situation, conduct an investigation,

and ultimately make a finding as to the

presence or absence of adult

maltreatment. If adult maltreatment is

present, APS then identifies the service

needs of the client and develops a plan,

including recommendations or referrals

to other entities, such as social services.

Many, but not all, APS systems also

follow cases post-investigation. If it is

found the individual seeking APS

services is ineligible, the APS program

may develop referrals to appropriate

services.

Proposed § 1324.403 sets forth

requirements for the development of

standardized, specific policies and

procedures governing an APS

investigation from initiation to post-

investigation services. Initiation of the

investigation encompasses screening

and triaging reports as well as decision-

making processes for determining

immediate safety and risk factors

affecting the adult. The investigation

itself includes the collection of relevant

information and evidence. Policies and

procedures must also detail methods to

make determinations on allegations and

record case findings, including

consultation with outside experts when

appropriate. Professional fields for such

experts include: medicine, social work,

behavioral health, finance/accounting,

and long-term care. We likewise

propose the APS worker provide

referrals to other agencies and programs,

as appropriate under State law, such as

referrals to Area Agencies on Aging

(AAAs), State Medicaid programs, or

Centers for Independent Living for

services. For example, the APS program

may make a referral to the State

Medicaid agency for home and

community-based services to mitigate

harm and assist the victim in recovery

from the abuse. During the course of an

investigation, APS may in limited

circumstances take emergency

protective action, which we propose to

define in § 1324.401. Such action

should be person-directed and taken as

a last resort after exploring all other

viable options, prioritizing community

integration, autonomy, and individual

choice. This proposed section also

requires the APS investigator or

supervisor to communicate results of

the investigation to the client.

Post-investigation services are

provided through a variety of

mechanisms and funding sources. APS

staff may provide services directly (e.g.,

assistance with housing relocation),

purchase them (e.g., pay for medications

or utility bills), or make referrals to

community-based services (e.g., home-

delivered meals). Our proposals provide

a framework for the provision of post-

investigation services that promote the

dignity and autonomy of the client,

leverage community resources, and aim

to prevent future adult maltreatment.

Proposed § 1324.403 draws heavily

from the Consensus Guidelines.

48

We

seek comment on whether this approach

includes all necessary activities for

investigation and post-investigation

services as well as examples of

investigation and post-investigation

services we have not proposed for

inclusion.

E. Section 1324.404 Conflict of Interest

Proposed § 1324.404 requires the

State entity to establish policies and

procedures to prevent, recognize, and

promptly addresses both real and

perceived conflicts of interest at the

organizational and individual level.

Trust in APS by individuals receiving

services and the broader community is

essential to the ability of APS programs

to effectively perform their functions.

APS programs form partnerships and

referral relationships with allied

organizations and professionals to

provide necessary services and supports

to victims of adult maltreatment before,

during, and after intake and

investigation. Conflicts of interest may

arise when a State employee, APS

worker, or APS system’s financial or

personal interests influence, or are at

odds with, the interests of a client or

cohort of clients.

Many APS programs that provide

services for victims of adult

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See supra note 4, at 4. State Units on Aging

house APS in 20 States. Other State health and

human services agencies (not SUAs or Child

Welfare) house APS in 20 States.

50

See supra note 4, at 30.

51

See supra note 4.

52

Kristin Elizabeth Lees, (2018) Elder

Mistreatment: An examination of formal and

informal responses to a growing public health

concern (Mar. 23, 2018) (Ph.D. dissertation,

Northeastern University) https://repository.

library.northeastern.edu/files/neu:cj82r9210/

fulltext.pdf.

53

Olanike Ojelabi et al., Closing the Loop: An

Environmental Scan of APS-Reporter Feedback

Policies and Practices, 5(1) Innovation in Aging 931

(2021) https://doi.org/10.1093/geroni/igab046.3370;

S. Jackson, Adult Protective services and victim

services: A review of the literature to increase

understanding between these two fields, 34

Aggression & Violent Behavior 214 (2017) https://

www.semanticscholar.org/paper/Adult-protective-

services-and-victim-services%3A-A-of-Jackson/

15e2bbf7e180170443f67e90ae1acfc50ffbdb8a;

Marguerite DeLiema et al., Voices from the

Frontlines: Examining Elder Abuse from Multiple

Professional Perspectives, 40 Health & Social Work

e15 (2015) https://doi.org/10.1093/hsw/hlv012.

54

Health and Human Serv. Off. of the Insp. Gen.

Incidents of Potential Abuse and Neglect at Skilled

Nursing Facilities Were Not Always Reported and

Investigated (2008) https://oig.hhs.gov/oas/reports/

region1/11600509.pdf.

maltreatment have close relationships

and shared locations and data systems

with AAAs, State Units on Aging

(SUAs), and other health and human

services agencies.

49

Without appropriate

conflict of interest safeguards,

familiarity and ease of referral arising

from proximity and shared data systems

may create incentives for APS to refer

clients to the AAA or SUA over another

more appropriate service provider.

Individual APS workers may face

conflicts of interest if they are in a ‘‘dual

relationship’’ serving multiple roles for

a single client. For example, an

individual who serves as both an APS

worker and a long-term services and

supports options counselor for the same

client may be unable to make objective

findings of adult maltreatment in a case

where a caregiver is an alleged

perpetrator of adult maltreatment

against the client. The individual

serving as APS worker and options

counselor may, in their role as APS

worker, choose not to substantiate

findings of adult maltreatment against

the caregiver because, as an options

counselor, they know the client chooses

the alleged perpetrator as their

caregiver. We propose these dual

relationships be permitted only when

unavoidable and that conflicts of

interest be appropriately mitigated.

We further propose that APS

programs have policies and procedures

that ensure conflicts of interests are

avoided and, if found, remedied. These

procedures could include firewalls and

disclosure requirements. We seek

comment on whether our proposal

reflects the universe of actual and

potential conflicts of interest, those who

may be a party to a conflict, and ways

in which we may strengthen these

requirements while not placing undue

programmatic or administrative burden

on APS systems.

F. Section 1324.405 Accepting Reports

Proposed § 1324.405 requires the

State entity to have policies and

procedures for accepting reports of adult

maltreatment. We propose such policies

and procedures require prompt receipt

of reports of alleged maltreatment,

including multiple methods for

receiving reports 24 hours a day, 7

calendar days a week in manners that

are fully accessible (e.g., using

augmentative communication devices or

translation services). Currently 29

programs meet the Consensus

Guidelines recommendation to be

available 24/7 for intake of new

reports.

50

Receiving reports 24 hours a

day 7 calendar days a week is

paramount to the safety of victims and

potential maltreatment victims. For this

reason, we propose a specific timeframe

for receiving reports consistent with our

recommendations in the Consensus

Guidelines. In the interests of

accessibility, we considered mandating

that APS systems establish an online

reporting mechanism (for example,

accepting reports of adult maltreatment

through a website), but we ultimately

decided to leave such operational

details to State discretion. We welcome

comment on the costs and benefits of

mandating such an online reporting

mechanism.

APS receives reports from both the

general public and individuals

mandated by the State to report

suspected adult maltreatment.

Mandatory reporting is an essential tool

in combating adult maltreatment; 49

States currently have mandatory

reporting statues.

51

In one study,

researchers found that reports made by

mandatory reporters to APS were more

likely to be substantiated and less likely

to result in service refusal than reports

made by non-mandated reporters.

52

However, most APS programs are not

required to contact mandatory reporters

with information about the case after a

report is made. Mandatory reporters

have stated that the absence of a

reporting feedback loop creates a

disincentive for reporting.

53

The most

common complaint ACL receives from

community providers that work with

APS is that while they may be required

under State law to report, they do not

receive information back on the status of

their report. We propose mandatory

reporters be provided information on

the status of a report consistent with

State confidentiality laws. In the

interests of accountability, we

considered mandating that States

provide such status information to such

mandatory reporters within a certain

timeframe (for example, within 30

calendar days of the report), but we

ultimately decided to leave such

operational details to State discretion.

We welcome comment on the costs and

benefits of mandating such a mandatory

response timeframe. Additionally, we

invite comment on the type of

information that might be returned to

mandatory reporters after a report of

maltreatment is submitted to an APS

program, including potential

administrative burdens to APS programs

and client confidentiality and privacy

conflicts that may arise from such

requirements.

G. Section 1324.406 Coordination

With Other Entities

Proposed § 1324.406(a) requires the

State APS system to coordinate with

other State and local governmental

agencies, community-based

organizations, and other entities

engaged in activities to promote the

health and wellbeing of older people

and adults with disabilities for the

purposes of addressing the needs of the

adult experiencing the maltreatment.

These entities include, but are not

limited to, the Long-Term Care

Ombudsman, State offices that handle

scams and frauds, State and local law

enforcement, State Medicaid agencies

and other State agencies responsible for

home and community-based services

(HCBS) programs, and financial services

providers. Such coordination maximizes

the resources of APS systems, improves

investigation capacity, and ensures post-

investigation services are effective. We

have chosen to require States coordinate

with these specific entities to ensure

coordination with critical partners in

the investigation of abuse, neglect, and

exploitation. Various non-APS entities

have authority to investigate

maltreatment based on who the victim

and perpetrator of the maltreatment are,

and where the maltreatment took place.

An effective, holistic response to adult

maltreatment must include all

enumerated entities working in

coordination with APS. Currently, the

research suggests this is not taking

place.

54

We seek comment as to whether

we have accurately captured the scope

of appropriate entities with which APS

should collaborate, and whether our

proposal would create unintended

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Elder Justice Act sections 2042, 2042(b)(4), 42

U.S.C. 1397m–1(a)(1)(B), 1397m–1(b)(4); Older

Americans Act of 1965 section 201(e)(2)(A)(ii)(I), 42

U.S.C. 3011.

56

45 CFR 75.206(d) allows for State plans vs.

applications for funding, thereby reducing burden.

The Older Americans Act of 1965 section

201(1)(e)(A)(ii), 201(1)(e)(A)(iv)–(B), 42 U.S.C.

3011(e)(1)(A)(ii), 3011(e)(1)(A)(iv) and 42 U.S.C.

3011(e)(1)(B) directs the Assistant Secretary for

Aging to collect data and information, and strategic

plans from States. The Elder Justice Act section

2042(b)(4), 42 U.S.C. 1397m–1(b)(4) authorizes

State reports from each entity receiving funding.

consequences for APS programs. We

also seek examples of where

coordination is working and where

barriers to coordination exist.

Proposed § 1324.406(b) requires the

State APS system to develop policies

and procedures to address coordination

and information sharing with several

governmental and private entities both

within a State and across State lines for

the purpose of carrying out

investigations. Coordination could

include development of memoranda of

understanding (e.g., for referrals and

information sharing), establishment of

multi-disciplinary teams across and

among governmental and non-

governmental entities (with appropriate

safeguards for confidentiality to protect

client privacy and the integrity of APS

investigations), and collaboration

regarding training and best practices.

We recognize that State laws may

preclude sharing of certain information

related to individual investigations, but

we believe that all APS systems at a

minimum can work with other entities

around prevention and best practices to

address adult maltreatment.

State authority to investigate alleged

maltreatment of adults resides in

different entities. Therefore, it is

imperative to have a clear

understanding of which entities are

responsible for which types of

investigations. Which entity is

responsible for an investigation will

depend upon various factors including:

the location or setting of the

maltreatment; the category of adult

maltreatment; the relationship between

an alleged perpetrator and an alleged

victim; and the characteristics of the

alleged victim. To help resolve

confusion within States, we propose in

§ 1324.406(b) that the APS programs

develop and implement information and

data sharing agreements to ensure

coordination of investigations and that

appropriate referrals are made when

APS receives a report that is outside

their jurisdiction to investigate,

including with law enforcement, the

State Medicaid office, and State

licensing and certification agencies.

Coordination between entities reduces

the imposition of multiple

investigations on adults who have been

harmed and helps prevent future

maltreatment. Such agreements will

allow one program to share with the

other information about alleged

maltreatment by someone who works

with, or who has a relationship of trust

with, individuals being served by both

organizations. Additionally, such

agreements will allow the sharing of

information between these entities on

the outcome of individual

investigations, as permissible under

State law. For example, this could

include communication of the results to

State Medicaid agencies in instances in

which a Medicaid provider or direct

care worker is determined by APS to be

a perpetrator of the maltreatment. We

seek comment on our proposals.

We also believe it is critical to address

coordination across States given that

perpetrators may move a victim to

another jurisdiction or may move to

another jurisdiction themselves where

they engage in the same practices

investigated in the first State. We

request comments and examples of best

practices on how coordination and

collaboration with other States and local

jurisdictions may be effectively

achieved, minimizing administrative

burden.

H. Section 1324.407 APS Program

Performance

Proposed § 1324.407 requires the APS

State entity to collect and report

aggregated data annually to ACL.

55

We

anticipate data elements to be similar to

those already reported voluntarily by

most States through the NAMRS system.

However, because NAMRS data

submission is voluntary, the

completeness of the data varies widely

and therefore limits our ability to

understand incidence of adult

maltreatment within and across States.

We will provide future guidance on data

elements to be collected and seek

comment on what these data elements

should be.

We also propose that the State entity

develop policies and procedures

regarding the maintenance of individual

APS case data. We propose that APS

systems keep the individual data set for

at least five years. We believe five years

is an appropriate timeframe to allow

APS programs to assess clients across

time to determine whether repeated

abuse or recidivism is occurring,

providing APS knowledge critical to

prevent future instances of

maltreatment. In developing our

proposal, we considered a requirement

of ten years; while a longer timeframe

would improve data accuracy, it would

increase burden for States. We seek

comment on whether five years is an

appropriate timeframe or whether a

greater or lesser duration is optimal.

I. Section 1324.408 State Plans

Proposed § 1324.407 requires each

APS State entity to develop a State plan

consistent with 45 CFR 75.206(d) and

requirements set forth in the EJA and by

the Assistant Secretary for Aging.

56

State plans will allow States to

document the tangible outcomes

planned and achieved as a result of the

funding they receive from ACL. Funding

provided to State APS entities through

the Elder Justice Act is contingent on

compliance with our proposed

regulations. The State plan is the

mechanism through which States

demonstrate, and ACL evaluates, this

compliance.

State plans also can be used to

translate activities, data, and outcomes

into proven best practices, which can be

used to leverage additional resources.

State plans promote coordination and

collaboration to better serve the people

of a State by providing a blueprint that

describes what the State will undertake

to meet the needs of the population it

serves. The State plan should be

developed in conjunction with the APS

programs and with input from

interested parties and updated at least

every five years or as frequently as every

three years at State option..

ACL has administrative oversight

responsibility with respect to the

expenditures of Federal funds pursuant

to the EJA. As a condition of approval

and receipt of Federal funding, APS

systems must include assurances in

their State plans that they will develop

and adhere to policies and procedures

as defined by these regulations. ACL

will provide technical assistance to

States regarding the preparation of State

plans and are responsible for reviewing

those that are submitted for compliance.

Annual State program performance data

collected and submitted to ACL

pursuant to § 1324.407 will be used to

measure performance and assess the

extent to which State systems are

meeting State plan objectives.

State plans will be reviewed and

approved by the Director of the Office

for Elder Justice and Adult Protective

Services (OEJAPS), the position

designated by Sec. 201(e)(1) of the OAA,

42 U.S.C. 3011(e)(1). A State entity

dissatisfied with the Director of

OEJAPS’ final determination may

appeal to the Deputy Assistant Secretary

for review not later than 30 calendar

days after the date of the determination.

The State entity will then be afforded an

opportunity for a hearing before the

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Deputy Assistant Secretary. If State

disagrees with the determination of the

Deputy Assistant Secretary, it may

appeal to the Assistant Secretary not

later than 30 calendar days after the date

of the Deputy Assistant Secretary’s

decision.

We seek comment on our proposals

for the development of State plans as

well as ACL oversight and monitoring of

State plan objectives.

J. Regulatory Approach

The proposed regulations seek to

bring States into alignment with

evidence-informed practices while

recognizing that States should have the

flexibility and discretion to tailor

policies and procedures to their

circumstances. In general, we have

provided broad guidelines for the

required policies and procedures but

leave States to fill in the details and set

their own standards as they develop

new, or amend current, policies and

procedures. In several areas, we have

taken a more proscriptive approach to

establish a uniform national baseline.

Where we have been more directive, we

have done so because we believe it is

critical to the safety of maltreatment

victims or potential victims, is

foundational to the functioning of an

APS system, or because the APS

community has requested granular

policy direction. These proscriptive

requirements have been drawn from the

evidence-informed Consensus

Guidelines and represent promising

practices for APS service delivery. We

invite comment as to whether we have

struck the appropriate balance between

setting a proscriptive minimum floor for

essential policies and procedures and

leaving general implementation of the

policies and procedures to State

discretion.

K. Effective Date

We propose an effective date for these

provisions of three years from date of

issuance of the final rule.

L. Request for Comment

ACL seeks comment on all issues

raised by this proposed regulation as

detailed above.

IV. Required Regulatory Analyses

A. Preliminary Regulatory Impact

Analysis (Executive Orders 12866 and

13563)

1. Introduction

We have examined the impacts of the

proposed rule under Executive Order

12866, Executive Order 13563, the

Regulatory Flexibility Act (5 U.S.C.

601–612), and the Unfunded Mandates

Reform Act of 1995 (Pub. L. 104–4).

Executive Orders 12866 and 13563

direct agencies to assess all costs and

benefits of available regulatory

alternatives and, if regulation is

necessary, select regulatory approaches

that maximize net benefits (including

potential economic, environmental,

public health and safety effects;

distributive impacts; and equity).

Executive Order 13563 emphasizes the

importance of quantifying costs and

benefits, reducing costs, harmonizing

rules, and promoting flexibility.

Under Executive Order 12866,

‘‘significant’’ regulatory actions are

subject to review by the Office of

Management and Budget (OMB). As

amended by Executive Order 14094

entitled ‘‘Modernizing Regulatory

Review’’ section 3(f) of the Executive

order defines a ‘‘significant regulatory

action’’ as any regulatory action that is

likely to result in a rule that may:

(1) have an annual effect on the

economy of $200 million or more

(adjusted every 3 years by the

Administrator of the Office of

Information and Regulatory Affairs

(OIRA) for changes in gross domestic

product); or adversely affect in a

material way the economy, a sector of

the economy, productivity, competition,

jobs, the environment, public health or

safety, or State, local, Territorial, or

Tribal governments or communities;

(2) create a serious inconsistency or

otherwise interfere with an action taken

or planned by another agency;

(3) materially alter the budgetary

impacts of entitlement grants, user fees,

or loan programs or the rights and

obligations of recipients thereof; or

(4) raise legal or policy issues for

which centralized review would

meaningfully further the President’s

priorities or the principles set forth in

this Executive order, as specifically

authorized in a timely manner by the

Administrator of OIRA in each case.

It has been determined that this

proposed rule is significant. Therefore,

OMB has reviewed this proposed rule.

The Unfunded Mandates Reform Act

of 1995 (section 202(a)) requires us to

prepare a written statement, which

includes an assessment of anticipated

costs and benefits, before proposing

‘‘any rule that includes any Federal

mandate that may result in the

expenditure by State, local, and tribal

governments, in the aggregate, or by the

private sector, of $100,000,000 or more

(adjusted annually for inflation) in any

one year.’’ The current threshold after

adjustment for inflation is $177 million,

using the most current (2022) Implicit

Price Deflator for the Gross Domestic

Product. This proposed rule would not

result in impacts that exceed this

threshold.

Summary of Costs and Benefits

Compared to the baseline scenario

wherein APS systems continue to

operate under State law with no Federal

regulation, we identify several impacts

of this proposed rule. We anticipate that

the proposed rule will: require the

revision of State policies and

procedures, require training on new

rules for APS staff, require the

submission of new State plans, require

data sharing agreements between APS

systems and other State entities, require

APS systems create a feedback loop to

provide information to mandatory

reporters, require data reporting to ACL,

inform potential APS clients of their

rights under State law, and require new

or updated record retention systems for

certain States. We anticipate that the

final rule will result in improved

consistency in implementation of APS

systems within and across States, clarity

of obligations associated with Federal

funding for administrators of APS

systems, and will result in better and

more effective service delivery within

and across States with better quality

investigations in turn leading to more

person-directed outcomes.

This analysis describes costs

associated with issuing APS regulations

and quantifies several categories of costs

to grantees (State entities) and sub-

grantees (APS programs), collectively

referred to as APS systems, and to ACL

under the proposed rule. Specifically,

we quantify costs associated with APS

systems (1) revising policies and

procedures, (2) conducting trainings, (3)

implementing policies and procedures

(3) reporting data to ACL (4)

maintaining records retention system (5)

developing State plans. The proposed

effective date of this rulemaking is three

years from the date of final publication.

This is to allow for variation in the

timing of State legislative sessions. We

anticipate that all States will have fully

implemented the rule by its effective

date and impacts will be measurable by

that time. We conclude the proposed

rule would result in a cost of

$3,532,916.99 to fully implement. This

cost will be offset by improved

investigations and better outcomes for

the victims of adult maltreatment. This

represents significant value, particularly

given the widespread and egregious

nature of adult maltreatment in the

United States.

The analysis also includes a

discussion of the potential benefits

under the rule that we do not quantify.

We request comments on our estimates

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The structure and administration of APS in the

United States is variable and we lack data on the

number of local APS programs. Some States have

a single entity that controls and administers the

program, others have a State entity and local

programs. There is a staffed APS office in every

State government, the District of Columbia and

three Territories which receives ACL grant funding.

Fifteen States have local level APS programs, the

others are State-administered and have a single APS

entity for the entire State. We have used counties

as a proxy for the 15 with local programs.

58

Wages are multiplied by a factor of 2 for non-

wage benefits and indirect costs.

59

Represents adjusted Federal salary in DC–VA–

MD area, https://www.opm.gov/policy-data-

oversight/pay-leave/salaries-wages/salary-tables/

pdf/2023/DCB.pdf.

of the cost and benefits of this proposed

rule, including the impacts that are may

not be quantified in this analysis.

A detailed discussion of costs and

benefits associated with the rulemaking

follows.

a. Costs of the Proposed Rule

1. Revising Policies and Procedures

This analysis anticipates that the

proposed rule would result in one-time

costs to State entities and APS programs

to revise policies and procedures. The

majority of APS systems currently

maintain policies and procedures, often

based on State statute. Data from our

National Process Evaluation Report of

Adult Protective Services (OMB Control

Number 0985–0054) and State

experiences incorporating concepts

from the Consensus Guidelines suggest

our proposed rules will establish a

minimum standard that may reflect

current practice in many States. For

example, while all States currently

require a screening process for intake,

there is no uniformity or

standardization in this process across or

within States and detail contained in

policies and procedures (if present)

varies. Therefore, in requiring standard

policies and procedures for APS

systems, ACL anticipates that all APS

programs may create new or revise their

current policies and procedures under

the proposed rule; however, the level of

revision will vary by State. There is

currently no data on the total number of

APS programs. Our estimates reflect our

understanding of the structure of State

APS systems and the assumption that

there is one program per county in

local-level systems, totaling 928 APS

programs nationwide.

57

We estimate that roughly half of these

entities will require more extensive

revisions, with the rest requiring limited

revisions to their current policies and

procedures. We estimate that programs

with more extensive revisions will

spend twenty (20) total hours on

revisions per entity. Of these, fifteen

(15) would be spent by a mid-level

manager equivalent to a first-line

supervisor (Occupation code 43–1011),

at a cost of $30.47 unadjusted hourly

wage, $60.94 per hour adjusted for non-

wage benefits and indirect costs (15 ×

$60.94), while an average of five (5)

hours would be spent by executive staff

equivalent to a general and operations

manager (Occupation code 11–1021), at

a cost of $55.41 per hour unadjusted

hourly wage, $110.82 per hour adjusted

for non-wage benefits and indirect costs

(5 × $110.82).

58

For programs with less

extensive revisions, we assume fifteen

(15) total hours spent on revisions per

entity. Of these, ten (10) hours would be

spent by a mid-level manager equivalent

to a first-line supervisor (Occupation

code 43–1011), at a cost of $30.47 per

hour unadjusted hourly wage, $60.94

per hour adjusted for non-wage benefits

and indirect costs (10 × $60.94), while

an average of five (5) hours would be

spent by executive staff equivalent to a

general and operations manager

(Occupation code 11–1021), at a cost of

$55.41 unadjusted hourly wage, $110.82

adjusted for non-wage benefits and

indirect costs (5 × $110.82).

We monetize the time that would be

spent by APS programs on revising

policies and procedures by estimating a

total cost per entity of $1,468.02 or

$1,163.50, depending on the extent of

the revisions. For the approximately 464

programs with less extensive revisions,

we estimate a cost of approximately

$539,864. For the 464 programs with

more extensive revisions, we estimate a

cost of approximately $681,244.80.28.

We estimate the total cost associated

with revisions with respect to the

proposed rule for APS systems of

$1,221,108.80.

The above estimates of time and

number of State entities or APS

programs that would revise their

policies under the regulation are

approximate estimates based on ACL’s

extensive experience working with APS

systems, including providing technical

assistance, and feedback and inquiries

that we have received from State entities

and APS programs. Due to variation in

the types and sizes of State entities and

incomplete data on local programs, the

above estimates of time and number of

entities that would revise their policies

under the regulation is difficult to

calculate precisely.

2. Trainings on New Requirements

Cost to conduct trainings (ACL staff

and contractors): ACL estimates that the

Federal Government will incur a one-

time expense with respect to training or

re-training State entities under the

proposed rule.

Senior ACL staff will train State

entities by the ten (10) HHS regions

assisted by its technical assistance

provider the APS Technical Assistance

Resource Center (TARC). We assume for

each of the ten (10) regions that

trainings will take three (3) hours of

staff time for one Federal GS–14

equivalent

59

at a cost of $63.64

unadjusted hourly wage, $127.28

adjusted for non-wage benefits and

indirect costs (3 × $127.28), three (3)

hours of staff time for one GS–13

equivalent at a cost of $53.85 per

unadjusted hourly wage, $107.70 per

hour adjusted for non-wage benefits and

indirect costs (3 × $107.70), and (3) and

three hours of staff time for five (5)

contractors equivalent to training and

development managers (U.S.

Department of Labor (DOL) Bureau of

Labor Statistics (BLS) Occupation code

11–3131) at a cost of $61.92 per hour

unadjusted for non-wage benefits,

$123.84 per hour adjusted for non-wage

benefits and indirect costs (3 × 5 ×

$123.84). This is inclusive of time to

prepare and conduct the trainings.

We monetize the time spent by

Federal employees and contractors to

prepare and conduct trainings for State

entities by estimating a total cost per

regional training of $2,562.54. For ten

trainings a total of $25,625.40.

Cost to conduct training (State entity

to local APS program): We further

anticipate in each of the 15 local-level

systems the State entity would incur a

one-time expense to conduct a training

on the new policies and procedures for

the State’s local APS programs. For each

State entity to prepare and conduct a

training (15 trainings total) we

anticipate two (2) employees per State

entity each equivalent to a first-line

supervisor (BLS Occupation code 43–

1011), would spend two (2) total hours

(one (1) hour per employee) at a cost of

$30.47 per hour unadjusted hourly

wage, $60.94 per hour adjusting for non-

wage benefits and indirect costs (2 ×

$60.94).

We monetize the time spent by State

entities to prepare and conduct trainings

for local APS programs at $121.88 per

training. For 15 State entities we

anticipate a total of $1,828.20.

Cost to conduct training (APS

programs to APS workers): We

anticipate each of the 928 local APS

programs will incur a one-time expense

to conduct a training for APS workers

on new policies and procedures. For

each program to prepare and conduct a

training we anticipate three (3) hours to

prepare and conduct a training of one

mid-level manager equivalent to a first-

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See supra note 53.

line supervisor (BLS Occupation code

43–1011), at a cost of $30.47 per hour

unadjusted hourly wage, $60.94 after

adjusting for non-wage benefits and

indirect costs (3 × $60.94). We monetize

the time spent by APS programs to

prepare and conduct trainings at

$182.82 (928 × $182.82). We monetize

the time spent by APS programs to train

their workers at $169,656.96.

Cost to receive training: There is no

data on individual local APS program

staffing. However, NAMRS does track

an aggregate number of APS staff at the

State and local level, from State

supervisors to local APS workers: 8,287.

We assume 5 percent of these workers

are executive staff equivalent to a

general and operations manager (BLS

Occupation code 11–1021), at a cost of

$55.41 unadjusted hourly wage, $110.82

per hour adjusted for non-wage benefits

and indirect costs (414 × $110.82), 15

precent are first-line supervisor

(Occupation code 43–1011), at a cost of

$60.94 per hour adjusting for non-wage

benefits and indirect costs (1,243 ×

$60.94) and 80 percent are Social and

Human Service Assistants (Occupation

code 21–1093) at a cost of $19.45 per

hour unadjusted hourly wage, and

$38.90 adjusted for non-wage benefits

and indirect costs. (6,629 × $38.90).

We monetize the time spent by APS

staff to receive a one-hour training at

$379,496.

We monetize the total amount of time

spent to give and receive trainings at

$576,606.56. Of this, $550,981.16 is

State expense and $25,625.40 is Federal

expense.

3. Implementing New Policies and

Procedures

The proposed rule requires several

changes in APS practice which may

represent a cost to States.

Cost to implement a two-tiered,

immediate vs. non immediate risk,

response system: Forty-nine States

currently have a two-tiered (or higher)

system. Forty-nine States currently

respond to immediate need intakes

within 24 hours. After consulting former

APS administrators, we have

determined that we cannot fully

quantify how much it would cost a State

to develop and implement a new two-

tiered system. However, given that most

States currently already maintain such a

system, we anticipate it would be a very

minor on-going cost in total.

Cost to implement mandatory staff to

client ratios: The provision requiring

States to establish a minimum staffing

ratio is intended to better enable States

to ensure long-term continuity of

programs. We anticipate that this will be

an on-going, cost neutral provision;

States have the discretion to set

minimum staffing ratios consistent with

current practice, and therefore currently

available resources. We do not

anticipate that States would commit to

increasing staffing ratios without a

commensurate increase in Federal or

other funding. Consequently, we

anticipate that this provision will not

result in increased cost to APS

programs. We invite comment as to

whether our analysis of the potential

financial burden of this proposal is

accurate.

Cost to implement a mandatory

reporter feedback loop: According to

2021 ACL Evaluation survey and

NAMRS data, of all reports nationally

which resulted in an investigation,

255,395 (59 percent) were made by

professionals. However, not all

professionals are mandated reporters

and who is a mandated reporter varies

by State. For example, a home and

community-based service provider or

other social service provider would be

considered a professional but may not

be a mandated reporter. For this reason,

we assume 75 percent of reports

resulting in an investigation made by

professionals were made by mandated

reporters (191,546). One such response

an APS program could make to a

mandated reporter is to send an email.

If for each report leading to an

investigation received by a mandatory

reporter, an APS program sends an

email in response, we anticipate a

Social and Human Service Assistants

(Occupation code 21–1093) at a cost of

$19.45 per hour unadjusted hourly

wage, and $38.90 adjusted for non-wage

benefits and indirect costs would spend

ten (10) minutes sending the email. We

monetize the on-going cost for all 56

systems to send an email for each report

of maltreatment from a mandatory

reporter to be $1,241,856.57 annually.

81 percent APS programs do not

currently require a feedback loop for

mandatory reporters.

60

To bring all

States into compliance (.81 ×

$1,241,856.57) with the proposed rules

would amount to $1,005,903.82

annually.

Cost to implement data sharing

agreements: Anecdotally we know very

few States currently have data sharing

agreements with other maltreatment

investigatory entities in place. We have

estimated 50 APS systems currently

have no data use agreements in place

while six may have one or more. For

illustrative purposes we assume each

State without a data sharing agreement

will establish three (3) MOUs (with, for

example, the Medicaid agency, the

Long-term care ombudsman, and the

Protection and Advocacy System). Each

MOU will take one mid-level manager

equivalent to a first-line supervisor

(Occupation code 43–1011), at a cost of

$30.47 per hour unadjusted hourly

wage, $60.94 after adjusting for non-

wage benefits and indirect costs three

(3) hours to draft (3 × $60.94). It will

take a privacy officer equivalent to a

lawyer (Occupation code 23–1011) at a

cost of $78.74 unadjusted hourly wage,

$156.80 per hour adjusted for non-wage

benefits and indirect costs one (1) hour

to review and approve (1 × $156.80). It

will take an executive staff equivalent to

a general and operations manager

(Occupation code 11–1021), at a cost of

$55.41 unadjusted hourly wage, $110.82

per hour adjusted for non-wage benefits

and indirect costs two (2) hours (2 ×

$110.82) to review and approve. We

monetize the cost for one (1) State APS

system to develop one (1) MOU to be

$561.26. For a State APS system to

establish three (3) MOUs, we monetize

the cost to be $1,683.78. For fifty (50)

State APS systems to develop one

MOUs we monetize the cost to be

$84,189. We likewise assume that each

of the three (3) entities the APS entity

is entering into an MOU with will incur

substantially similar costs. We monetize

the expense of three (3) entities in fifty

(50) states to enter into MOUs with the

APS system in their State at $84,189.

We monetize the one-time total cost of

establishing data sharing agreements to

be $168,378.

Cost to inform individuals of their

rights under State law: We do not

currently have data on the number of

States informing individuals of their

rights under State law. We know

anecdotally some States offer potential

clients a paper brochure informing them

of their rights. We anticipate costs of

producing and distributing such

brochures to be one new pamphlet per

State system or 56 pamphlets total. It

will require three (3) hours of staff time

by a Social and Human Service

Assistants (Occupation code 21–1093) at

a cost of $19.45 per hour unadjusted

hourly wage, and $38.90 adjusted for

non-wage benefits and indirect costs (3

× $38.90) and one (1) hour for a first-line

supervisor (Occupation code 43–1011),

at a cost of $30.47 per hour unadjusted

hourly wage, $60.94 to review and

approve (1 × $60.94) for a total of

$177.64 per State in staff time to

develop each pamphlet. We monetize

the one-time staff cost for 56 State

systems to develop a pamphlet (56 ×

$177.64) at $9,947.84. According to our

NAMRS data, 806,219 client

investigations were performed in FFY

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The Admin. for Cmty. Living, Adult

Maltreatment Report 2020 (2021) https://acl.gov/ sites/default/files/programs/2021-10/2020_

NAMRS_Report_ADA-Final_Update2.pdf.

2022. Each pamphlet will cost 23 cents

to print and produce. Assuming a

pamphlet is provided for every new

client at the initiation of an

investigation (806,219 × .23) it would

cost $185,430.37 annually to produce

and distribute pamphlets nationwide. In

total, to develop a new pamphlet in all

56 States and distribute them at the

beginning of all investigations would

cost $195,378.21 in staff time and

materials the first year the policy is in

place. Subsequently, States would incur

$185, 430.37 annually to implement this

provision.

3. Data Reporting to ACL

In our proposed regulations, we

require States to collect and report

specific data to ACL. As in our NAMRS

data collection system, this data

collection uses existing State

administrative information systems.

Therefore, States will not incur new

data collection costs as the result of this

rulemaking. Most of the data collected

are standard data used by the agency.

Operating costs of the information

systems are part of State agency

operations and would not maintained

solely for the purpose of submitting data

in compliance with the proposed rules.

For data reporting from the State to

ACL under the proposed regulations, we

anticipate a similar system as NAMRS

case component data currently reported

voluntarily by States. We performed a

burden estimate prior to launching this

reporting system. We estimated for 35

States staff cost would be a total annual

burden of 675 hours at $46.00 per hour

(675 × $46.00) for a total of $31,050. IT

staff total annual burden was estimated

at 3,075 hours at $69.00 (3,075 × $69.00)

per hour for a total of $212,175. Using

this measure as a proxy, we estimate the

proposed rule’s data reporting

requirements will cost a total of

$339,480 annually for all 56 State

entities.

4. Record Retention

The proposed rule imposes a new

requirement that APS programs retain

case data for five years. Many, but not

all, programs currently retain case data

for a number of years, but

comprehensive information does not

exist on State retention policies. We can

extrapolate from data reporting in the

NAMRS that most States retain case

data for an average of two years.

61

NAMRS is a comprehensive, voluntary,

national reporting system for APS

programs. It collects quantitative and

qualitative data on APS practices and

policies, and the outcomes of

investigations into the maltreatment of

older adults and adults with disabilities

from every State and Territory. All but

one State currently maintains an IT

infrastructure that supports the

retention of electronic APS data and

maintains it for one year. For this

reason, the cost to further store it for

five years will create a de minimis cost

for APS.

5. State plans and NAMRS

This will be the first times State

entities are required to develop and

submit State plans under section 2042

of the Elder Justice Act, 42 U.S.C.

1397m–1(b). However, States develop

spending plans under 45 CFR 75.206(d)

every three to five years and, based on

our extensive experience working with

APS systems and OAA grantees on their

State plans, we do not anticipate a

significantly greater level of detail for

the development of State plans. We

anticipate for each State the equivalent

of two (2) hour of executive staff

equivalent to a general and operations

manager (Occupation code 11–1021), at

a cost of $55.41 per hour unadjusted

adjusted hourly wage, $110.82 adjusted

for non-wage benefits and indirect costs

(2 × $110.82), and four (4) hours of a

first-line supervisor (Occupation code

43–1011), at a cost of $30.47 per hour

unadjusted hourly wage, $60.94

adjusting for non-wage benefits and

indirect costs (4 × $60.94). State plans

will be updated every three to five

years. We monetize the cost of drafting

one State plan at $465.40. We monetize

56 State plans at $26,062.40.

1. Total Quantified Costs

a. One-Time Costs

Item of cost:

Policies and Procedures Update ....................................................................................................................... $1,221,108.80

Policies and Procedures Implementation .......................................................................................................... State ................. Federal

Training ....................................................................................................................................................... $550,981.16 ..... $25,625.40

Policies and Procedures Implementation:

Data Sharing Agreements .......................................................................................................................... $168,378.00

Policies and Procedures:

Informing Individuals of Their Rights Under State Law ............................................................................. $9,947.84

Total ..................................................................................................................................................... $1,976,041.20

b. Ongoing Costs (Annual)

Item of Cost:

Policies and Procedures Implementation:

Two-Tiered Response System ........................................................................................................................................................ $0

Policies and Procedures Implementation:

Staff to Client Ratios ....................................................................................................................................................................... 0

Policies and Procedures Implementation:

Mandatory Reporter Feedback Loop .............................................................................................................................................. 1,005,903.82

Policies and Procedures Implementation:

Informing Individuals of Their Rights Under State Law .................................................................................................................. 185,430.37

Data reporting to ACL ............................................................................................................................................................................. 339,480.00

Record Retention .................................................................................................................................................................................... 0

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M.S. Lachs et al. The Mortality of Elder

Mistreatment, 280(5) JAMA 428–432 (Aug. 1998)

https://pubmed.ncbi.nlm.nih.gov/9701077/.

63

U.S. Consumer. Fin. Protection. Bur.,

Suspicious Activity Reports on Elder Financial

Exploitation: Issues and Trends (2019); https://

www.gao.gov/assets/gao-21-90.pdf.

64

U.S. Gen. Acct. Off., GAO–21–90, HHS Could

Do More to Encourage State Reporting on the Costs

of Financial Exploitation (2020) https://

www.gao.gov/assets/gao-21-90.pdf.

65

The Northern Mariana Islands and American

Samoa currently have no staffed program; they are

in the process of developing one.

66

See supra note 4, at 20.

67

We have made our calculations based on 2022

Census Bureau Data.

State plan ................................................................................................................................................................................................ 26,062.40

(renewed

every

three to

five years)

Total ................................................................................................................................................................................................. 1,556,876.59

d. Discussion of Benefits

Older adults who experience

maltreatment are three times more likely

to experience adverse consequences to

health, living arrangements, or financial

arrangements than their counterparts

who do not experience maltreatment.

62

According to 2022 NAMRS data, four

percent or approximately 36,000 APS

clients died during the course of an APS

investigation. According to the

Consumer Financial Protection Bureau,

financial institutions reported $1.7

billion in elder financial abuse in

2017.

63

However, in 2016 three States

projected the cost could be over $1

billion in their State alone.

64

While this proposed rule does not

directly affect the underlying causes of

maltreatment, which are complex and

multifactorial, it does establish a

national baseline of quality in APS

practice to intervene in maltreatment

and mitigate harm as it is occurring. We

anticipate this could reduce the number

of deaths that may occur during the

course of an APS investigation.

Generally speaking, the benefits of the

rule are difficult to quantify. The

minimum standards proposed by the

NPRM are in direct response to requests

from APS systems for more guidance

and uniformity in policy within and

among States. We anticipate that if

implemented, the rule would elevate

evidence-informed practices, bring

clarity and consistency to programs, and

improve the quality of service delivery

for adult maltreatment victims and

potential victims. For example, if all

States implemented 24 hour per day, 7

days per week reporting acceptance

protocols, an individual experiencing

maltreatment may be identified earlier,

and an investigation could commence

and intervene sooner. Staffing ratios can

promote adequate staffing, allowing a

worker to devote more time to a case.

Training requirements allow

caseworkers to better handle and resolve

cases. It may also decrease repeat abuse

through post-investigation services.

Similarly, proposals on APS

coordination with other entities

maximize the resources of APS systems,

improve investigation capacity, ensure

post-investigation services are effective,

reduce the imposition of multiple

investigations on adults who have been

harmed, and help prevent future

maltreatment.

Another example of a difficult to

quantify benefit is a standardized

timeframe for case record retention.

There are currently no minimum

requirements for States to retain their

records. The proposed rule’s five-year

minimum retention period facilitates

States’ ability to track victims and

perpetrators across time to deter abuse

and identify recidivism while

minimizing administrative burden.

The proposed rules were informed by

expert-developed evidence-informed

practices as articulated in our

Consensus Guidelines. These evidence-

informed practices, when implemented,

will result in higher quality

investigations allowing APS to

apprehend perpetrators of adult

maltreatment with greater frequency

and accuracy, in turn protecting the

health and wellbeing of older adults and

adults with disabilities.

B. Regulatory Flexibility Act

Under the Regulatory Flexibility Act

(RFA), as amended by the Small

Business Regulatory Enforcement

Fairness Act (SBREFA) (5 U.S.C. 601 et

seq.), agencies must consider the impact

of regulations on small entities and

analyze regulatory options that would

minimize a rule’s impacts on these

entities. Alternatively, the agency head

may certify that the rule will not have

a significant economic impact on a

substantial number of small entities.

ACL does not anticipate that this

rulemaking will have a significant

economic impact on a substantial

number of small businesses.

APS is a State-based social services

program controlled centrally by a State

office. Thirty-nine APS systems are

State-administered, meaning State staff

operate programs out of locally placed

State offices.

65

Fifteen States are county-

administered and controlled or a hybrid

of State and county-administered and

controlled. In county-administered

systems, the State entity grants funding

to local entities, including counties and

non-profits, but does not perform

investigatory functions. In hybrid

systems, the State maintains a more

active oversight and investigatory role,

but delegates to local entities.

Nationally, State employees perform 70

percent of APS investigations. County

and non-profit employees perform the

remainder.

66

In State-administered systems, no

small entities are implicated. State

Government employees and offices are

not small entities as defined by 5 U.S.C.

601. In the 15 county and hybrid

administered systems, there are 459

counties of less than 50,000 people.

67

The administrative structure of APS is

complex and data is incomplete.

However, for illustrative purposes we

assume that in these 459 counties there

is one APS program that is a small

entity under 5 U.S.C. 601, either a small

government jurisdiction or non-profit.

Much of the cost of implementation

will be borne by State entities in both

State-administered and county and

hybrid-administered States. In both

such systems, the State entity exercises

significant control; the State entity

receives and distributes Federal funding

and is responsible for revising policies

and procedures, training local entities,

and reporting data to ACL. We monetize

the average cost per State APS system to

be $63,087.80. As an example, Colorado

has an estimated 48 counties under

50,000 people. Assuming the State

entity absorbs the 25 percent of the cost

of implementation, each entity would

incur $985.75 in implementation

expenses per year. Much of this would

be a one-time expense. North Carolina

has ten counties under 50,000 people.

On average, assuming the State entity

absorbs 25 percent of the cost burden of

the rule, each small entity would incur

$4,731.58 in expense per year, much of

this representing a one-time expense.

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Report on the Updates to the Voluntary

Consensus Guidelines for APS Systems, Appendix

3: 19, https://acl.gov/sites/default/files/programs/

2020-05/ACL-Appendix_3.fin_508.pdf.

Furthermore, many small entities may

already be in compliance with

significant portions of these proposed

regulations whether as written in

policies and procedures or as informal

practice.

Consequently, we have examined the

economic implications of the proposed

rule and find that if finalized, it will not

have a significant economic impact on

a substantial number of small entities.

C. Executive Order 13132 (Federalism)

Executive Order 13132 requires

Federal agencies to consider the impact

of their regulatory actions on State and

local governments. Where such actions

have federalism implications, agencies

are directed to provide a statement

describing the agency’s considerations.

Policies that have federalism

implications include regulations that

have ‘‘substantial direct effects on the

States, on the relationship between the

national government and the States, or

on the distribution of power and

responsibilities among the various

levels of government.’’

The proposed rule requires State APS

systems to implement policies and

procedures reflecting evidence-based

practices. Receipt of Federal funding for

APS systems under the EJA Sec. 2042,

42 U.S.C. 1397m–1(b) is contingent

upon compliance with these proposed

rules. Many States are already in

substantial compliance with this

proposal, however, some may need to

revise or update their current APS

policies, develop new policies or, in

some cases, pass new laws or amend

existing State statutes.

Consultations With State and Local

Officials

Executive Order 13132 requires

meaningful and timely input by State

and local officials in the development of

regulatory policies that have federalism

implications. As detailed in the

preamble, the proposed regulations

closely mirror the 2020 Voluntary

Consensus Guidelines for State Adult

Protective Services Systems (Consensus

Guidelines). All specific mandates (for

example, day and time requirements for

case response) contained in the

proposed regulation reflect the

Consensus Guidelines.

The Consensus Guidelines were

developed with extensive input from

the APS community, including State

and local officials. Interested parties

were invited to provide feedback for the

proposed updates to the Consensus

Guidelines through a public comment

period and five webinars. A Request for

Information was posted on ACL’s

website and the comment period ran

from March until May 2019. Five

webinars were held during April and

May 2019 hosting approximately 190

participants, representing 39 states and

the District of Columbia. Participants

represented ten fields, with most

participants representing the APS

network (66 percent). The vast majority

of these APS programs are administered

and staffed by State and local

government entities.

The goals of the outreach and

engagement process were to hear from

all interested entities, including State

and local officials, the public, and

professional fields about their

experiences with APS. The engagement

process ensured affected parties

understood why and how ACL was

leading the development of the

Consensus Guidelines and provided an

opportunity to give input into the

process and content of the Consensus

Guidelines. ACL will also review

comments on the proposed rule from

State and local officials and consider

any additional concerns in developing a

final rule.

Nature of Concerns and the Need To

Issue This Proposed Rule

Community members welcomed the

Consensus Guidelines and were

generally in support of the process by

which they were created and updated as

well as the substantive content, noting

that they ‘‘help set the standard and

support future planning and State

legislative advocacy.’’

68

We received comments that the

Consensus Guidelines were

‘‘aspirational’’ and would be

challenging to implement absent

additional funding. We seriously

considered these views in developing

this proposed rule. We also completed

a regulatory impact analysis to fully

assess costs and benefits of the new

requirements. We recognize that some of

the new proposed regulatory provisions

will create administrative and monetary

burden in updating policies and

procedures as well as potential changes

to State law. However, much of this

burden will be a one-time expense and

States will have significant discretion to

implement the proposed provisions in

the manner best suited to State needs.

Extent To Which We Meet Those

Concerns

In FY 2021, Congress provided the

first dedicated appropriation to

implement the Elder Justice Act section

2042(b), 42 U.S.C. 1397m–1(b), formula

grants to all States, the District of

Columbia, and the Territories to

enhance APS, totaling $188 million, and

another $188 million in FY 2022. The

recent Consolidated Appropriations Act

of 2023 included an annual

appropriation of $15 million to ACL to

continue providing formula grants to

APS programs under EJA section

2042(b), 42 U.S.C. 1397m–1(b). This

funding is available to States for the

implementation of the proposed

regulation and meet the concerns

commenters raised in 2019 around

dedicated funding for APS systems.

Additionally, the regulatory changes we

propose have already been implemented

by many States, and we believe the

benefit of the proposed requirements

will be significant.

D. Executive Order 13175 (Consultation

and Coordination With Indian Tribal

Governments)

ACL will fulfill its responsibilities

under Executive Order 13175,

‘‘Consultation and Coordination with

Indian Tribal Governments.’’ Executive

Order 13175 requires Federal agencies

to establish procedures for meaningful

consultation and coordination with

tribal officials in the development of

Federal policies that have Tribal

implications. ACL will solicit input

from affected Federally recognized

Tribes as we develop these updated

regulations and will conduct a Tribal

consultation meeting [exact date to be

specified in NPRM when NPRM

publication date is known].

E. Unfunded Mandates Reform Act of

1995

Section 202 of the Unfunded

Mandates Reform Act of 1995 requires

that a covered agency prepare a

budgetary impact Statement before

promulgating a rule that includes any

Federal mandate that may result in the

expenditure by State, local, and Tribal

governments, in the aggregate, or by the

private sector, of $100 million or more

in any one year. If a covered agency

must prepare a budgetary impact

Statement, section 205 further requires

that it select the most cost-effective and

least burdensome alternative that

achieves the objectives of the rule and

is consistent with the statutory

requirements. In addition, section 203

requires a plan for informing and

advising any small governments that

may be significantly or uniquely

impacted by the rule. We have

determined that this rulemaking would

not result in the expenditure by State,

local, and Tribal governments, in the

aggregate, or by the private sector, of

more than $100 million in any one year.

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Accordingly, we have not prepared a

budgetary impact Statement,

specifically addressed the regulatory

alternatives considered, or prepared a

plan for informing and advising any

significantly or uniquely impacted small

governments.

F. Plain Language in Government

Writing

Pursuant to Executive Order 13563 of

January 18, 2011, and Executive Order

12866 of September 30, 1993, Executive

Departments and Agencies are directed

to use plain language in all proposed

and final rules. ACL believes it has used

plain language in drafting the proposed

rule and would welcome any comment

from the public about how to make this

rulemaking easier to read and

understand.

G. Paperwork Reduction Act (PRA)

The proposed rule contains new

information collection requirements

under 5 CFR part 1320. These new

burdens include: new State plans, new

program performance data collection

and reporting, a requirement that States

generate, maintain, and retain written

policies and procedures, a requirement

that State APS systems disclose

information to clients regarding their

rights under State law, and a

requirement that States generate,

maintain, and retain information and

data sharing agreements (while also

disclosing data through such

agreements).

As detailed in the regulatory impact

analysis, we estimate the following total

burden across all States and Territories

for such requirements:

(1) State plans: $26,062.40 (renewed

every three to five years);

(2) Program performance data

collection: $339,480.00 (annually);

(3) Creation of written policies and

procedures: $1,221,108.00 (one-time

expense);

(4) Disclosure to potential clients their

rights under State law: $195,378.21

($9,947.84 in one-time expense and

$185,430.37 annually);

(5) Creation and maintenance of data

sharing agreements: $168,378.00 (one-

time expense).

ACL will submit information to the

OMB for review, as appropriate. The

State plans, program performance data,

written policies and procedures,

disclosure to potential clients of their

rights under State law, and the creation

and maintenance of data sharing

agreements will be submitted for

approval as part of a generic clearance

package for information collections

related to ACL Administration on Aging

programs. ACL intends to update

applicable guidance as needed.

List of Subjects in 45 CFR Part 1324

Adult Protective Services, Elder

Rights, Grant programs to States, Older

Adults.

For the reasons discussed in the

preamble, ACL proposes to amend 45

CFR part 1324 as follows:

■1. Add subpart D to read as follows:

PART 1324—ALLOTMENTS FOR

VULNERABLE ELDER RIGHTS

PROTECTION ACTIVITIES

Subpart D—Adult Protective Services

Programs

Sec.

1324.400 Eligibility for funding.

1324.401 Definitions.

1324.402 Program administration.

1324.403 Investigation and post-

investigation services.

1324.404 Conflict of interest.

1324.405 Accepting reports.

1324.406 Coordination with other entities.

1324.407 APS program performance.

1324.408 State plans.

Authority: 42 U.S.C. 3011(e)(3); 42 U.S.C.

1397m–1.

§ 1324.400 Eligibility for funding.

To be eligible for funding under 42

U.S.C. 1397m–1(b) State entities are

required to adhere to all provisions

contained herein.

§ 1324.401 Definitions.

As used in this part, the term—

Abuse means the knowing infliction

of physical or psychological harm or the

knowing deprivation of goods or

services that are necessary to meet

essential needs or to avoid physical or

psychological harm.

Adult means older adults and adults

with disabilities as defined by State APS

laws.

Adult maltreatment means self-

neglect or abuse, neglect, exploitation,

or sexual abuse of an adult at-risk of

harm from a perpetrator with whom

they have a trust relationship.

Adult Protective Services (APS) means

such services provided to adults as the

Assistant Secretary for Aging may

specify in guidance and includes such

services as:

(1) Receiving reports of adult abuse,

neglect, exploitation, sexual abuse, and

self-neglect;

(2) Investigating the reports described

in paragraph (1) of this definition;

(3) Case planning, monitoring,

evaluation, and other case work and

services, and;

(4) Providing, arranging for, or

facilitating the provision of medical,

social services, economic, legal,

housing, law enforcement, or other

protective, emergency, or supportive

services.

Adult Protective Services Program

means local Adult Protective Services

providers within an Adult Protective

Services system.

Adult Protective Services (APS)

System means the totality of both the

State entity and the local APS programs.

Allegation means an accusation of

adult maltreatment associated with each

adult in a report made to APS. There

may be multiple allegations in an

investigation.

At risk of harm means the possibility

that an individual will experience an

event, illness, condition, disease,

disorder, injury, or other outcome that

is adverse or detrimental and

undesirable.

Assistant Secretary for Aging means

the position identified in section 201(a)

of the Older Americans Act (OAA), 42

U.S.C. 3002(7).

Case means all activities related to an

APS investigation of, and response to,

an allegation of adult maltreatment.

Client means an adult who is the

subject of an investigation by APS

regarding a report of alleged adult

maltreatment.

Conflict of Interest means a situation

that interferes with a program or

program representative’s ability to

provide objective information or act in

the best interests of the adult. A conflict

of interest would arise when an

employee, officer, or agent of APS, any

member of their immediate family, their

partner, or an organization which

employs or is about to employ any of

the parties indicated herein, has a

financial or other interest in or a

tangible personal benefit from their

affiliation with APS systems.

Dual relationship means relationships

in which an APS worker assumes one or

more professional, personal, or

volunteer roles in addition to their role

as an APS worker at the same time, or

sequentially, with a client.

Emergency Protective Action means

emergency use of APS funds to

purchase goods or services, immediate

access to petitioning the court for

temporary or emergency orders, and

emergency out-of-home placement.

Exploitation means the fraudulent or

otherwise illegal, unauthorized, or

improper act or process of a person,

including a caregiver or fiduciary, that

uses the resources of an adult for

monetary or personal benefit, profit, or

gain, or that results in depriving an

adult of rightful access to, or use of,

their benefits, resources, belongings, or

assets.

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Inconclusive means a determination

that there was not sufficient evidence

obtained during an APS investigation

for APS to conclude whether adult

maltreatment occurred.

Intake or pre-screening means the

APS process of receiving allegations of

adult maltreatment and gathering

information on the reports, the alleged

victim, and the alleged perpetrator.

Investigation means the process by

which APS examines and gathers

information about an allegation of adult

maltreatment to determine if the

circumstances of the allegation meet the

States ’s standards of evidence for a

finding of a substantiated,

unsubstantiated, or inconclusive

allegation.

Mandated Reporter means someone

who is required by State law to report

suspected adult maltreatment to APS.

Neglect means the failure of a

caregiver or fiduciary to provide the

goods or services that are necessary to

maintain the health or safety of an adult.

Perpetrator means the person

determined by APS to be responsible for

one or more instances of adult

maltreatment for one or more victims.

Post-investigation Services means the

activities undertaken by APS in support

of a client after a finding on an

allegation of adult maltreatment has

been made.

Quality assurance means the process

by which APS programs ensure

investigations meet or exceed

established standards, and includes:

(1) Thorough documentation of all

investigation and case management

activities;

(2) Review and approval of case

closure; and

(3) Conducting a case review process.

Screening means a process whereby

APS carefully reviews the intake

information to determine if the report of

adult maltreatment meets the minimum

requirements to be opened for

investigation by APS, or if the report

should be referred to a service or

program other than APS.

Self-neglect means an adult’s

inability, due to physical or mental

impairment or diminished capacity, to

perform essential self-care tasks

including:

(1) Obtaining essential food, clothing,

shelter, and medical care;

(2) Obtaining goods and services

necessary to maintain physical health,

mental health, or general safety, or;

(3) Managing one’s own financial

affairs.

Sexual abuse means the forced and/or

unwanted sexual interaction (touching

and non-touching acts) of any kind with

an adult.

State entity means the unit of State,

District of Columbia, or U.S. Territorial

Government designated as responsible

for APS programs, including through

the establishment and enforcement of

policies and procedures, and that

receives Federal grant funding from

ACL under section 2042(b) of the EJA,

42 U.S.C. 1397m–1(b).

Substantiated means APS has made

an investigation disposition that the

allegation of maltreatment meets state

law or agency policy for concluding that

the adult was maltreated.

Trust relationship means the rational

expectation or belief that a relative,

friend, caregiver, or other person with

whom a relationship exists can or

should be relied upon to protect the

interests of an adult (as defined above)

and/or provide for an adult’s care. This

expectation is based on either the

willful assumption of responsibility or

expectations of care or protection

arising from legal or social conventions.

Unsubstantiated means that APS has

made an investigation disposition that

the allegation of maltreatment does not

meet State law or agency policy for

concluding that the adult was

maltreated.

Victim means an adult who has

experienced adult maltreatment.

§ 1324.402 Program administration.

(a) The State entity shall create and

implement policies and procedures for

APS systems to receive and respond to

reports of adult maltreatment in a

standardized fashion. Such policies and

procedures, at a minimum, shall:

(1) Incorporate principles of person-

directed services and planning and

reliance on least restrictive alternatives,

as well as other policies identified by

the Assistant Secretary for Aging;

(2) Define the populations eligible for

APS services;

(3) Define the settings, locations, and

types of alleged perpetrator for each

adult maltreatment type that are subject

to APS investigations in the State;

(4) Define processes for receiving,

screening, prioritizing, and referring

cases based on risk and type of adult

maltreatment consistent with

§ 1324.403, including:

(i) Creation of at least a two-tiered

response system for initial contact with

the alleged victim based on risk of

death, irreparable harm, or significant

loss of income, assets, or resources.

(A) For immediate risk, response

should occur in person no later than

twenty-four hours after receiving a

report of adult maltreatment.

(B) For non-immediate risk, response

should occur no more than seven

calendar days after report of adult

maltreatment is received.

(5) Define investigation and post-

investigation procedures, as identified

in § 1324.403.

(b) At first contact APS systems shall

provide to potential APS clients an

explanation of their rights, including:

(1) The right under State law to

confidentiality of personal information;

(2) The right under State law to refuse

to speak to APS;

(3) The right under State law to refuse

APS services, and;

(4) Such other explanations of rights

as determined by the Assistant Secretary

for Aging.

(c) Information shall be provided in a

format and language understandable by

the individual, and in alternative

formats as needed.

(d) The State entity shall establish

policies and procedures for the staffing

of APS systems that include:

(1) Staff training and on-going

education, including training on

conflicts of interest;

(2) Staff supervision, and;

(3) Staff to client ratios.

(e) The State entity shall establish

such other program administration

policies and procedures and provide

other information to APS clients as

established by the Assistant Secretary

for Aging.

§ 1324.403 Investigation and post-

investigation services.

The State entity shall adopt

standardized and systematic policies

and procedures for APS investigation

and post-investigation activities across

and within the State including, at a

minimum:

(a) Screening, triaging, and decision-

making criteria or protocols to review

and assign adult maltreatment reports

for APS investigation, and to report to

other authorities;

(b) Tools and/or decision-making

processes for APS to review reports of

adult maltreatment for any emergency

needs of the adult and for immediate

safety and risk factors affecting the adult

or APS worker when responding to the

report and;

(c) Practices during investigations to

collect information and evidence to

inform allegation disposition and

service planning that will:

(1) Recognize acceptance of APS

services is voluntary, except where

limited by State law;

(2) Ensure safety of APS client and

worker;

(3) Ensure the preservation of an

adult’s rights;

(4) Integrate principles of person-

directedness and trauma-informed

approaches;

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(5) Maximize engagement with the

APS client, and;

(6) Permit APS to seek emergency

protective action only as appropriate

and necessary as a measure of last resort

to protect the life and wellbeing of the

client from self-harm or harm from

others.

(d) Methods to make determinations

on allegations and record case findings,

including:

(1) Ability for APS programs to

consult with appropriate experts, other

team members, and supervisors;

(2) Protocols for the standards of

evidence APS should apply when

making a determination on allegations.

(e) Provision of APS post-

investigation services, as appropriate,

that:

(1) Respect the autonomy and

authority of clients to make their own

life choices;

(2) Respect the client’s views about

safety, quality of life, and success;

(3) Hold perpetrators accountable for

the adult maltreatment and for stopping

the abusive behavior;

(4) Develop any service plan or

referrals in consultation and agreement

with the client;

(5) Engage community partners

through referrals for services or

purchase of services where services are

not directly provided by APS, and;

(6) Monitor the status of client and

services, and the impact of services.

(f) Case handling criteria that:

(1) Establish timeframes for on-going

review of open cases;

(2) Establish length of time by which

investigations should be completed, and

determinations be made; and

(3) Documents, at a minimum:

(i) The APS interventions and services

delivered;

(ii) Significant changes in client

status;

(iii) Assessment of the outcome and

efficacy of intervention and services;

(iv) Assessment of safety and risk at

case closure; and

(v) The reason or decision to close the

case.

§ 1324.404 Conflict of interest.

The State entity shall establish

standardized policies and procedures to

avoid both actual and perceived

conflicts of interest for APS. Such

policies and procedures must include

mechanisms to identify, remove, and

remedy any existing conflicts of interest

at organizational and individual levels,

including to:

(a) Ensure that employees and agents

engaged in any part of an APS

investigation do not also provide direct

services to, or oversee the direct

provision of services, to the client;

(b) Ensure that employees and agents

administering APS programs do not

have a personal financial interest in an

entity to which an APS program they

refer clients to services recommended

by the APS program;

(c) Ensure that no APS employee or

agent, or member of an employee or

agent’s immediate family, is subject to

conflict of interest;

(d) Prohibit dual relationships unless

unavoidable and ensure appropriate

safeguards are established should such

relationships occur;

(e) Establish robust monitoring and

oversight, to identify conflict of interest,

and;

(f) Remove and remedy actual,

perceived, or potential conflicts that

arise.

§ 1324.405 Accepting reports.

(a) The State entity shall establish

standardized policies and procedures

for receiving reports of adult

maltreatment 24 hours per day, 7

calendar days per week, using multiple

methods of reporting to ensure

accessibility.

(b) The State entity shall establish

standardized policies and procedures

for APS to accept reports of alleged

adult maltreatment by mandatory

reporters that:

(1) Shares information regarding a

report to APS with the mandated

reporter which shall include, at a

minimum:

(i) Whether a case has been opened as

a result of the report, and;

(ii) The disposition or finding of the

allegation in the report.

(c) The State entity shall establish and

adhere to standardized policies and

procedures to maintain the

confidentiality of reporters and

information provided in a report.

§ 1324.406 Coordination with other

entities.

(a) State entities shall establish

policies and procedures, consistent with

State law, to ensure coordination and to

detect, prevent, address, and remedy

adult maltreatment with other

appropriate entities, including but not

limited to:

(1) Other APS programs in the state,

when authority over APS is divided

between different jurisdictions or

agencies;

(2) Other governmental agencies that

investigate allegations of adult

maltreatment, including, but not limited

to, the State Medicaid agency, State

nursing home licensing and

certification, State department of health

and licensing and certification, and

tribal governments;

(3) Law enforcement agencies with

jurisdiction to investigate suspected

crimes related to adult maltreatment;

State or local police agencies, tribal law

enforcement, State Medicaid Fraud

Control Units, and Federal law

enforcement agencies;

(4) Organizations with authority to

advocate on behalf of individuals who

experienced the alleged adult

maltreatment, such as the State Long-

Term Care Ombudsman Program and/or

investigate allegations of adult

maltreatment such as the Protection and

Advocacy Systems;

(5) Emergency management systems,

and;

(6) Banking and financial institutions.

(b) Policies and procedures must, at a

minimum:

(1) Address coordination and

collaboration to detect, prevent, address,

and remedy adult maltreatment during

all stages of an adult maltreatment

investigation conducted by APS or by

other agencies and organizations with

authority and jurisdiction to investigate

reports of adult maltreatment;

(2) Address information sharing on

the status and resolution of

investigations between the APS system

and other entities responsible in the

state or other jurisdiction for

investigation, to the extent permissible

under applicable State law, and;

(3) Allow for the establishment of

memoranda of understanding, where

appropriate, to facilitate information

exchanges, quality assurance activities,

cross-training, development of formal

multidisciplinary and cross agency

adult maltreatment teams, co-location of

staff within appropriate agencies, and

other activities as determined by the

State entity.

§ 1324.407 APS program performance.

The State entity shall develop policies

and procedures for APS for the

collection and maintenance of data on

investigations conducted by APS

systems. They shall:

(a) Collect and report annually to ACL

such APS system-wide data as required

by the Assistant Secretary for Aging.

(b) Develop policies and procedures

to ensure that the APS system retains

individual case data obtained from APS

investigations for a minimum of 5 years.

§ 1324.408 State plans.

(a) State entities must develop and

submit to the Director of the Office of

Elder Justice and Adult Protective

Services, the position designated by 42

U.S.C. 3011(e)(1), a State APS plan that

meets the requirements set forth by the

Deputy Assistant Secretary for Aging.

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(b) The State plan shall be developed

by the State entity in collaboration with

APS programs.

(c) The State plan shall be updated at

least every five years but as frequently

as every three years.

(d) The State plan shall contain an

assurance that all policies and

procedures described herein will be

developed and adhered to by the State

APS system;

(e) State plans will be reviewed and

approved by the Director of the Office

of Elder Justice and Adult Protective

Services. Any State dissatisfied with the

final decision of the Director of the

Office of Elder Justice and Adult

Protective Services may appeal to the

Deputy Assistant Secretary for Aging

within 30 calendar days of the date of

the Director of the Office of Elder Justice

and Adult Protective Services’ final

decision and will be afforded the

opportunity for a hearing. If the State is

dissatisfied with the final decision of

the Deputy Assistant Secretary for

Aging, it may appeal to the Assistant

Secretary for Aging within 30 calendar

days of the date of the Deputy Assistant

Secretary for Aging’s decision.

Dated: September 6, 2023.

Xavier Becerra,

Secretary, Department of Health and Human

Services.

[FR Doc. 2023–19516 Filed 9–11–23; 8:45 am]

BILLING CODE 4154–01–P

DEPARTMENT OF COMMERCE

National Oceanic and Atmospheric

Administration

50 CFR Parts 224 and 226

[Docket No. 230906–0211]

RIN 0648–BL86

Endangered and Threatened Wildlife

and Plants; Designation of Critical

Habitat for the Rice’s Whale, Public

Hearing and Extension of Public

Comment Period

AGENCY

: National Marine Fisheries

Service (NMFS), National Oceanic and

Atmospheric Administration (NOAA),

Commerce.

ACTION

: Notice of public hearing,

extension of comment period.

SUMMARY

: We, NMFS, have rescheduled

a public hearing related to the proposed

rule to designate critical habitat for the

Rice’s whale under the Endangered

Species Act (ESA). We are also

extending the public comment period

for this proposed rule to October 6,

2023.

DATES

: A virtual public hearing on the

proposed rule will be held online on

September 28, 2023, from 3 p.m. to 5

p.m. (Eastern Daylight Time).

The proposed rule to designate

critical habitat for the Rice’s whale

under the ESA was published on July

24, 2023 (88 FR 47453), and provided

for a public comment period to

September 22, 2023. The comment

period is now extended to October 6,

2023. Comments must be received by

October 6, 2023. Comments received

after this date may not be accepted.

ADDRESSES

: The public hearing will be

conducted as a virtual meeting, and any

member of the public can join by

internet or phone regardless of location.

You may join the virtual meeting using

a web browser, a mobile app on a phone

(app installation required), or—to listen

only—using just a phone call, as

specified at this link: https://

www.fisheries.noaa.gov/species/

riceswhale#conservationmanagement.

You may submit comments verbally at

the public hearing. You may also submit

comments in writing by any of the

following methods:

•Electronic Submissions: Submit all

electronic comments via the Federal

eRulemaking Portal. Go to https://

www.regulations.gov and enter NOAA–

NMFS–2023–0028. Click on the

‘‘Comment’’ icon, complete the required

fields, and enter or attach your

comments.

•Mail: Submit written comments to

Assistant Regional Administrator,

Protected Resources Division, NMFS,

Southeast Regional Office, 263 13th

Avenue South, St. Petersburg, FL 33701.

Instructions: Comments sent by any

other method, to any other address or

individual, or received after the end of

the comment period might not be

considered by NMFS. All comments

received are a part of the public record

and will generally be posted for public

viewing on https://www.regulations.gov

without change. All personal identifying

information (e.g., name, address, etc.),

confidential business information, or

otherwise sensitive information

submitted voluntarily by the sender will

be publicly accessible. NMFS will

accept anonymous comments (enter ‘‘N/

A’’ in the required fields if you wish to

remain anonymous). Attachments to

electronic comments will be accepted in

Microsoft Word, Excel, or Adobe

portable document format (PDF) formats

only.

Details on the virtual public hearing

will be made available on our website

at: https://www.fisheries.noaa.gov/

species/riceswhale#conservation

management. The Endangered Species

Act Critical Habitat Report, geographic

information system (GIS) data, and

maps that were prepared to support the

development of this proposed rule are

available on our website at: https://

www.fisheries.noaa.gov/species/

riceswhale#conservationmanagement.

Previous rulemaking documents related

to the listing of the species can also be

obtained electronically on our website

at: https://www.fisheries.noaa.gov/

species/rices-whale#conservation

management.

FOR FURTHER INFORMATION CONTACT

:

Grant Baysinger, NMFS Southeast

Region, (727) 551–5790; or Lisa

Manning, NMFS Office of Protected

Resources, (301) 427–8466.

SUPPLEMENTARY INFORMATION

: On July

24, 2023, NMFS published a proposed

rule to designate critical habitat for the

endangered Rice’s whale (Balaenoptera

ricei) under the ESA (88 FR 47453). In

that notice, we also announced a 60-day

public comment period, two virtual

public hearings to be held on August 24,

2023 and August 30, 2023, and an

option to request an additional public

hearing made in writing by September

7, 2023. On August 24, 2023, we held

a virtual public hearing. On August 28,

2023, we canceled the public hearing

scheduled for August 30, 2023, ahead of

Hurricane Idalia’s expected landfall. We

have now rescheduled that public

hearing to September 28, 2023, from 3

p.m. to 5 p.m. (Eastern Daylight Time),

as described in this notice. To

accommodate this second public

hearing and provide additional time

needed to submit public comments

following the disruptions stemming

from Hurricane Idalia, we are also

extending the public comment period to

October 6, 2023.

Public Hearing

The public hearing on September 28,

2023, will be conducted online as a

virtual meeting, as specified in

ADDRESSES

above. More detailed

instructions for joining the virtual

meeting are provided on our web page

(see https://www.fisheries.noaa.gov/

species/riceswhale#conservation

management). The hearing will begin

with a brief presentation by NMFS that

will give an overview of the proposed

critical habitat designation under the

ESA. After the presentation, there will

be a question and answer session during

which members of the public may ask

NMFS staff questions about the

proposed rule. Following the question

and answer session, members of the

public will have the opportunity to

provide oral comments on the record

regarding the proposed rule. In order to

VerDate Sep<11>2014 17:03 Sep 11, 2023 Jkt 259001 PO 00000 Frm 00048 Fmt 4702 Sfmt 4702 E:\FR\FM\12SEP1.SGM 12SEP1

lotter on DSK11XQN23PROD with PROPOSALS1

Citation	88 FR 62503
Published date	12 September 2023
Record Number	2023-19516
Court	Community Living Administration

Adult Protective Services Functions and Grant Programs

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