IA: Abuse of Dependent Adults

Instructions
  1. To print everything you need, including the test, evaluation, and registration, click Print This Page at the top right. Study the course, pass the test, and fill out the forms.
  2. Make out your check or money order to ATrain Education, Inc. Or enter your credit card information on the form provided.
  3. Mail the completed forms with your payment to:
    ATrain Education, Inc
    5171 Ridgewood Rd
    Willits, CA 95490

When we receive your order, we will grade your test, process your payment, and email a copy of your certificate. For a paper copy of your certificate (suitable for framing), please add $7.50 to your payment.

Questions? Call 707 459-1315 (Pacific Time) or email (info@ATrainCeu.com).

This course has been approved by the Iowa Department of Public Health, approval #2908.

Course Summary

A thorough review of adult dependent abuse, including definitions, characteristics of victims and perpetrators, and reasons for abuse. The course identifies indicators of adult abuse and summarizes reportable criteria for mandated reporting. It further outlines the process for evaluating reported abuse, lists interventions available to abused adults, suggests ways to communicate with victims, and proposes measures for preventing adult abuse.

ATrain Education, Inc. is an approved provider by the American Occupational Therapy Association. The following course information applies to occupational therapy professionals:

  • Target Audience: Occupational Therapists, OTAs
  • Instructional Level: Intermediate
  • Content Focus: Category 1—Domain of OT, Client Factors; Category 2—Occupational Therapy Process, Outcomes

COI Support
Accredited status does not imply endorsement by ATrain Education Inc. or by the American Nurses Credentialing Center or any other accrediting agency of any products discussed or displayed in this course. The planners and authors of this course have declared no conflict of interest and all information is provided fairly and without bias.

Commercial Support
No commercial support was received for this activity.

This course will be reviewed every two years. It will be updated or discontinued on December 1, 2020.

Criteria for Successful Completions
80% or higher on the post test, a completed evaluation form, and payment where required. No partial credit will be awarded.

Accreditations

Course Objectives

When you finish this course you will be able to:

Dependent Adult Abuse

Dependent adults are anyone over age 18 whose physical and/or mental condition makes them dependent on others for care or protection. Dependent adults are at risk for abuse and federal and state laws and regulations have been promulgated to help protect against dependent adult abuse.

Federal law (Older Americans Act of 1965) defines elder abuse as the abuse, neglect, or exploitation of an individual age 60 or older. Until recently Iowa did not have a specific elder abuse law, but after the state’s Elder Abuse Task Force recommended in 2012 and 2013 that Iowa pass specific elder abuse legislation a bill was passed by the Iowa Legislature and went into effect on July 1, 2014.

The law expands protections in Iowa against abuse to a “vulnerable elder”—“a person sixty years of age or older who is unable to protect himself or herself from elder abuse as a result of age or a mental or physical condition.” The law adds to protections already in place for dependent adults against caretakers. Other protections are available under the domestic abuse law and criminal law (Iowa Legal Aid, 2014).

Illness, age, and disability render people vulnerable to abuse by those on whom they depend for care and protection. Abuse is an age-old crime that takes many forms: physical, psychological, sexual, and financial. It is a hidden form of mistreatment, occurring in private homes, adult daycare, and long-term care institutions. Adult abuse is far less likely to be reported than child abuse because of lack of public awareness. Abuse is “an intergenerational concern, as well as a health, justice, and human rights issue” (Lowenstein, 2009).

In Iowa, dependent adult abuse that occurs in the community is reported to the Department of Human Services (DHS). Dependent adult abuse that occurs in facilities and programs is reported to the Department of Inspections and Appeals (DIA). Each reporting process will be discussed later in the course. In addition, the Department on Aging provides advocacy, information, and training.

Note: The DHS also investigates reports of abuse in facilities and programs when the perpetrator is not an employee or staff member.

Our Aging Population and Elder Abuse

In the United States the population age 65 and over has increased from 36.6 million in 2005 to 47.8 million in 2015 (a 30% increase) and is projected to more than double to 98 million in 2060. By 2040 there will be about 82.3 million older people, over twice their number in 2000 (U.S. Administration on Aging, 2016).

People 65 and older represented 14.9% of the population in the year 2015 but are expected to grow to be 21.7% of the population by 2040. The population over 85 is projected to more than double from 6.3 million in 2015 to 14.6 million in 2040 (USAOA, 2016).

Racial and ethnic minority populations have increased from 6.7 million in 2005 (18% of the older adult population) to 10.6 million in 2015 (22% of older adults) and are projected to increase to 21.1 million in 2030 (28% of older adults) (USAOA, 2016).

Between 2015 and 2030, the white (not Hispanic) population 65+ is projected to increase by 43% compared with 99% for older racial and ethnic minority populations, including Hispanics (123%), African-Americans (81%), American Indian and Native Alaskans (82%), and Asians (90%) (USAOA, 2016).

 

Number of Persons 65+, 1900 to 2060 (numbers in millions)

chart: number of persons 65+ 1900 to 2060

Note: Increments in years are uneven. Source: U.S. Census Bureau, Population Estimates and Projections (USAOA, 2016, p. 3).

 

It is estimated that in 2014 there were 491,349 people age 65 and older living in Iowa, which represented 15.8% of the total population. Women accounted for 275,624 or 56.1% of this age group, and 52,632 of them were age 85 or older (66.9%).

Iowa ranked thirteenth in the United States in the percentage of population age 65 and older. Projections indicate that in 2050 Iowa’s population age 65 and older will be 696,450, constituting 20% of the state’s total population (IowaSDC, 2016).

Elder Abuse

In a review study done in 2003, the National Research Council (NRC) noted that between 1 and 2 million Americans age 65 or older had been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection (NRC, 2003). Despite the increase in the aging population and a broad concern that abuse is a serious problem, only a few national studies of the incidence of elder abuse have been published since 1998. However, Iowa’s Attorney General and others have asserted that local and regional studies can also provide information that is generally useful and pertinent (NIJ, 2015; IDJ/OAG, 2017).

In general, elder abuse refers to “any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult.” Although all fifty states have passed some form of elder abuse prevention laws, these laws and definitions of terms can vary considerably. However, broadly defined, abuse may be:

  • Physical abuse—inflicting physical pain or injury on a senior, eg, slapping, bruising, or restraining by physical or chemical means
  • Sexual abuse—non-consensual sexual contact of any kind
  • Neglect—the failure by those responsible to provide food, shelter, health care, or protection for a vulnerable elder
  • Exploitation—the illegal taking, misuse, or concealment of funds, property, or assets of a senior for someone else’s benefit
  • Emotional abuse—inflicting mental pain, anguish, or distress on an elder through verbal or nonverbal acts, eg, humiliating, intimidating, or threatening
  • Abandonment—desertion of a vulnerable elder by anyone who has assumed the responsibility for care or custody of that person
  • Self-neglect—characterized as the failure of a person to perform essential, self-care tasks and that such failure threatens his/her own health or safety (USAOA, 2016)

Iowa defines the following categories of abuse when the action is a result of the willful or negligent acts or omissions of a caretaker:

  • Physical Abuse
  • Sexual Abuse
  • Sexual Exploitation
  • Exploitation
  • Denial of Critical Care
  • Self Denial of Critical Care (Iowa Code Chapter 235B; IDA, 2016)

Prevalence

In 2009 a National Institute of Justice (NIJ) study of 5,777 adults over 60 years of age found that 11% reported some form of mistreatment other than financial exploitation in the previous year. Among them, the reporting of the mistreatment to authorities ranged from a low of 8% for emotional abuse, to 16% for sexual abuse, to 31% for physical abuse. Thus, 69% of the adults over 60 who are experiencing physical abuse are not reporting that abuse (Acierno et al., 2009). The problem of under-reporting remains a critical concern.

The same NIJ study found that previous-year financial exploitation by a family member had affected 5.2% of respondents and lifetime incidents of financial exploitation by a stranger had affected 6.2% (Acierno et al., 2009). Financial exploitation can directly affect quality of care, depriving victims of the financial means to access medical treatment or obtain medications, sometimes with dire consequences.

Financial exploitation is a fast-growing form of abuse of dependent adults and, like other forms of abuse, is seriously under-reported. In recent research, 1 in 20 elders reported recent incidents of perceived financial mistreatment, and 90% of abusers are family members or trusted others, such as caretakers, neighbors, friends, and professionals (attorneys, doctors and nurses, pastors, bank employees) (NAPSA, 2017; Acierno et al., 2009).

Victims

Many factors—race, gender, age, income and employment, physical and mental health, prior traumatic events, social support—can play a role in the likelihood of becoming a victim. These factors operate differently for the various types of mistreatment; some are indicative of potential for all types of abuse while others are significant only for certain forms of abuse. For example, those reporting very low social support face a three-fold greater risk of emotional mistreatment, while those needing assistance with daily life activities face double the risk. In fact, low social support affects the potential for all types of mistreatment, which may provide clues to important potential avenues of prevention (Acierno et al., 2009).

The NIJ study found that those in the 60–70 age group—the younger old—have an increased risk of physical, emotional, and stranger-perpetrated financial mistreatment, while age was not related to increased or decreased risk of sexual abuse, financial mistreatment by family members, or neglect. Variation in these findings among studies may be related to whether the experience of institutionalized people is considered.

The NIJ study also found that gender (being female) only increased the risk for sexual abuse, while belonging to a non-white racial group was associated with increased risk of physical mistreatment, financial mistreatment, and potential neglect. It is important to note that the role of risk factors can be affected by many things and combinations of factors increase that complexity.

Perpetrators

In the landmark National Elder Abuse Incidence Study done in 1998 it was found that nearly half of the perpetrators of elder abuse were adult children of the victims. Spouses accounted for 20% of the perpetrators, while other relatives, grandchildren, and siblings were also noted as perpetrators (NCEA, 1998).

The 2009 NIJ study breaks down similar findings with more detail. It found that in emotional, physical, sexual, and neglect incidents the majority were perpetrated by a family member. Partners or spouses accounted for 57% of physical mistreatment, 40% of sexual mistreatment, 28% of neglect, and 25% of emotional mistreatment. Children, grandchildren, and other relatives also play a significant role in these events (Acierno et al., 2009).

 

Perpetrators of Most Recent Emotional Mistreatment Event

chart: perpetrators of emotional event (percentages)

Source: Acierno, 2009.

 

Perpetrators of Most Recent Physical Mistreatment Event

chart: perpetrators of physical event (percentages)

Source: Acierno, 2009.

 

Perpetrators of Most Recent Sexual Mistreatment Event

chart: perpetrators of sexual event (percentages)

 

Source: Acierno, 2009.

 

While the NCEA study in 1998 showed that more than half (53%) of abusers were male, 75% were white, and nearly 40% were middle-aged, the NIJ study helps demonstrate that many factors may play a role in who becomes a perpetrator. The better these factors are understood, the better intervention strategies may be developed. For example, “relative to the general population, it appears that perpetrators of emotional, physical, and sexual mistreatment had high unemployment, increased substance abuse, and increased likelihood of mental health problems. Particularly striking was the older adult report that perpetrators of mistreatment were socially isolated….[This] may present targets for intervention. Reducing substance abuse and increasing social connections in isolated family members of older adults may have the secondary benefit of reducing elder mistreatment” (Acierno, et al., 2009; NCEA, 1998).

Adults with Disabilities and Abuse

Older adults are not the only population vulnerable to abuse from caretakers. Anyone over age 18 whose physical and/or mental condition makes them dependent on others for care or protection is at risk for abuse. Americans with Disabilities 2010, a report published in 2012 by the U.S. Census Bureau (most recent available data), notes that approximately 56.7 million non-institutionalized Americans of all ages live with disabilities in the communicative, mental, and/or physical domains. Of that total, 51.5 million are adults (Brault, 2012). Representative conditions in each domain are shown below:

Communicative

  • blindness or difficulty seeing
  • deafness or difficulty hearing
  • difficulty having speech understood

Mental

  • learning, intellectual, or developmental disability
  • Alzheimer’s disease, senility, or dementia
  • other mental or emotional condition that seriously interferes with everyday activities

Physical

  • use a wheelchair, can, crutches, or walker
  • difficulty walking a quarter mile, climbing a flight of stairs, lifting an object weighing 10 pounds, grasping objects, getting in or out of bed
  • disease or medical condition (eg, arthritis, cancer, cerebral palsy, heart trouble, missing or deformed limbs, back or head injuries, stroke, etc.) that contributes to a limitation of activity (Brault, 2012)

The prevalence of disability increases with age, from 11% of people ages 25 to 44, to 35% of those 65 to 69, and 70.5% of those 80 and over (Brault, 2012). According to the State Data Center of Iowa, in 2014, 353,430 Iowans had some kind of disability, and 112,390 of them were age 65 and older. That represents 31.8% of people 65 and older, the highest percentage of any age group in the state (IowaSDC, 2016).

A Cornell University study for Iowa in 2015 looked at the topic using slightly different categories, but reflected similar numbers and percentages. It identified the percentage of males and females with disabilities as nearly the same at 11.8% of females and 12% of males. The study found that 22.6% of people ages 65 to 74 and 46.4% of people 75 and older had some type of disability (Erickson, 2016).

People with disabilities are 4 to 10 times more likely to become victims of violence, abuse, or neglect than people without disabilities. Women with disabilities report greater numbers of perpetrators and longer time periods of individual episodes than women without disabilities (IDA, 2016).

Those who abuse people with disabilities may justify the abuse by considering the victim as somehow less than human, sometimes referring to them as “damaged merchandise,” “feeling no pain,” “a disabled menace,” or “helpless.” These attitudes may be shared by others who are aware of the abuse but do not report it (IDA, 2016).

Dehumanizing or demeaning attitudes about people with disabilities persist in society as well as among healthcare workers. Such attitudes may be especially problematic when dealing with sexual abuse because the victims may be seen as only seeking attention, as asexual or hypersexual, and/or as not credible witnesses.

There is a common misperception that having a disability protects a person from victimization, when in fact the opposite is true. People with disabilities are more vulnerable to abuse than non-disabled people. Certain difficulties or behaviors further increase the vulnerability of those with disabilities, including:

  • Difficulty with learning, communication, social adjustment
  • Difficulty with anger management, which prompts others to respond negatively
  • Cognitive problems such as perception, remembering or understanding risky situations
  • Spastic body movements, slow physical responses, speech impairments
  • Alcohol and drug abuse, in an effort to “fit in” (IDA, 2016)

Forms of Abuse and Where They Occur

Dependent adult abuse of people with disabilities usually occurs in isolated locations where victims have little or no control of their environment. As with elder abuse, private homes and institutional settings also provide opportunities for abuse.

Iowa acknowledges the following as categories of dependent adult abuse when they are a result of the willful, negligent acts or omission of a caretaker:

  • Physical abuse
  • Sexual abuse
  • Sexual exploitation
  • Financial exploitation
  • Denial of critical care
  • Self denial of critical care (IDA, 2016)

Victims and Perpetrators

Depending on the type and extent of their dependency, victims of abuse may be unable to work or may be underemployed, which limits their choice of caregivers and housing. Limited income may force them to live in high-crime areas.

Men, as intimate partners or as healthcare workers, are more likely to abuse disabled dependent adults than women are. Family members may victimize relatives, and staff members and other residents of a facility, or community-based personal care attendants may also be abusers (IDA, 2016).

Although dependent adults of both sexes are vulnerable to abuse, the most likely victim is a woman of advanced age (75 or older) who is isolated and dependent on someone else for care or protection. Alcohol abuse may also be an issue for some individuals, particularly in cases of self-neglect, and the effects of heavy alcohol use on memory and other cognitive functions are more evident in women than in men (Lopes et al., 2010). Alcohol also interacts with many prescription drugs used by older adults.

Dependent adults may also suffer abuse because of intergenerational conflict that intensifies with the increased dependency of the parent. Victims often blame themselves for making the abuser angry, rather than acknowledging that the abuser is at fault.

The presence of one or more of these characteristics does not indicate that abuse is occurring. Instead, they help explain why abuse may occur.

Attitudes Toward Reporting Abuse

Why Victims of Abuse Do Not Report

There are many reasons why victims do not report the abuse, including lack of confidence, a history of abuse, fear of retaliation by the abuser, cultural beliefs, embarrassment, and shame. For example, people who have never been self-confident are not likely to ask for help when they become dependent. Those who have been abused or neglected their entire lives expect maltreatment will continue, would never think someone would want to help, and often reject help when it is offered.

Abused dependent adults may have sought help from law enforcement or other agencies in the past, only to experience worse abuse, neglect, or exploitation when representatives of those agencies were not present.

Some cultures believe that whatever happens within a family is no one else’s business. The dependent adult may be ashamed or embarrassed to be neglected, abused, or financially exploited by a trusted family member. The victim may promise to keep the abuse secret so the abuser will not further abuse them or other loved ones, including pets. Abusers may threaten to withhold care or food or other necessities, or to send the dependent adult to a nursing home if the victim tells anyone about the abuse.

Why Mandatory Reporters Do Not Want to Report

Those who are required by law to report suspected abuse of elders or dependent adults share some of the same fears as the abused individuals: that reporting will hurt the relationship with the victim or the abuser or will cause retaliation by the perpetrator. Other stated reasons for reluctance to report include:

  • Damage relationship with victim and/or suspected abuser
  • Fear of losing a job
  • Court time—with loss of work time
  • Nothing will change, and everyone involved will get upset
  • Cannot get DHS or DIA to accept a report
  • Do not want to get involved (“none of my business”)

Why Abuse Occurs

There may be no single or simple answer as to why abuse occurs. The literature on family and behavior offers several theories about possible factors that contribute to abuse. These include the following:

  • Retaliation. Someone who was abused as a child may harbor anger and resentment toward the abusive parent. When roles are reversed, the once-abused child sees an opportunity for retaliation and this may be exacerbated if the elderly parent continues to bait the adult child.
  • Violence as a way of life. We live in a violent society. The media are filled with violence, both real and imagined. Violence saturates TV, movies, and video games. Domestic violence is increasingly common, particularly in tough economic times. Family violence often creates generational patterns.
  • Unresolved conflict. Conflict from childhood, from marital or other relationships, creates patterns of abuse that continue without resolution.
  • Lack of close family ties. Lack of closeness in the relationship between adult children and their parents can create stress and frustration when the parent suddenly or gradually becomes dependent. This can lead to abuse.
  • Lack of financial resources. Families who must juggle work and caregiving responsibilities may resent the addition of a dependent adult to the household. Increasing costs for medical care and other services can add to financial stress. Public assistance programs such as SSI and Medicaid may also decrease the dependent person’s stipend if he or she is living with family members.
  • Resentment of dependency. Caring for a frail older person who requires attention and assistance can be physically and emotionally exhausting. Stress and frustration can occur even when there is a close family tie.
  • Increased life expectancy. The dependency period of old age has expanded, leaving caretakers to provide extensive home care for a longer period of time. Smaller families mean fewer children to care for elderly parents and grandparents.
  • History of mental or emotional problems. Someone who is mentally or emotionally unstable may be unable to cope with the demands of caregiving. This can threaten the well-being of both caretaker and dependent adult.
  • Unemployment. Financial and emotional stress raises the level of frustration and weakens self-control.
  • History of alcohol and drug abuse. Substance abuse is often a factor in family violence. Alcohol suppresses inhibitions, making aggressive behavior more likely. This can be a factor for the caretaker as well as for the dependent adult.
  • Long distance caregiver. Today’s mobile population increases the likelihood that adult children may be living far from their parents, increasing the risk of neglect and additional stress.

Iowa Laws on Dependent Adult Abuse

[Much of the following is quoted or adapted from two documents: Dependent Adult Abuse Trainers’ Guide for Mandatory Reporters, Iowa Department on Aging, July 2015/Reapproved July 2016 (IDA, 2016); and Dependent Adult Abuse: A Guide for Mandatory Reporters, Iowa Department of Human Services (IDHS, 2009/2010). Citations to Iowa Code (IC) and Iowa Administrative Code (IAC) (the means by which laws are further interpreted) are noted in many places; see Resources for online links to these materials and to handouts and other information.]

Elder Abuse is defined by the Federal Older Americans’ Act as the abuse, neglect, or exploitation of an individual age 60 or older. Beginning July 1, 2014, newly established Iowa Code Chapter 235F, Elder Abuse Relief, became effective and created an elder abuse definition and law for civil elder abuse relief. Currently, the law does not mandate reporting of elder abuse; however, if mandatory reporters encounter such situations or circumstances that do not meet the criteria for dependent adult abuse, contact LifeLong Links at 866 468 7887 for available services and supports.

The Dependent Adult Abuse Law is in Iowa Code Chapter 235B and 235E. The law is specifically aimed at protecting dependent adults from abuse by their caretakers.

Three elements are needed for dependent adult abuse:

  • Dependent adult (age 18 or older)
  • Caretaker
  • Allegation of abuse recognized by 235B or 235E

Under the Dependent Adult Abuse Law, mandatory reporters who suspect a dependent adult is suffering from abuse by a caretaker shall report their reasonable belief to the Department of Human Services (DHS) or the Department of Inspections and Appeals (DIA).

Dependent Adult Abuse Agency Roles

DHS is responsible for the evaluation/assessment of dependent adult abuse in the community. DIA is responsible for the investigation of dependent adult abuse in facilities and programs. Each department must then investigate the report and make an evaluation of the situation.

In laying the groundwork for dependent adult services the law stresses the need for the state to provide protection of Iowa’s dependent adults. In the Dependent Adult Abuse Information Registry (Central Abuse Registry), the Code also focuses on the right to individual privacy, as well as the need for a centralized system of collecting, maintaining, and disseminating adult abuse information.

The Iowa Code is referred to throughout this course. Chapter 235B deals directly with dependent adult abuse in the community and Chapter 235E deals directly with dependent adult abuse in facilities and programs.

Central Abuse Registry

Iowa Code (235B.4) creates a central registry in the Department of Human Services (DHS) to provide a single source for the statewide collection, maintenance, and dissemination of dependent adult abuse information. The Central Abuse Registry includes report data, investigative data, and disposition data relating to reports of dependent adult abuse. The purpose of the Registry is to:

  • Facilitate the identification of victims or potential victims of dependent adult abuse by making available a single, statewide source of dependent adult abuse data
  • Facilitate research on dependent adult abuse by making available a single statewide source of dependent adult abuse data
  • Provide maximum safeguards against the unwarranted invasions of privacy that such a registry might otherwise entail

Immediately upon receipt of a report of dependent adult abuse, DHS is required to:

  • Make an oral report to the Central Abuse Registry
  • Forward a copy of the written report to the Registry
  • Notify the local county attorney of the receipt of the report
  • Begin an appropriate evaluation or assessment

Upon receipt of a report of dependent adult abuse, the Central Abuse Registry searches its records. If registry records reveal any previous report of dependent adult abuse involving the same adult or any other pertinent information with respect to the same adult, the Registry immediately notifies the appropriate DHS office or law enforcement agency of that fact.

Abuse Reports in the Community

Abuse reports are made under the following legislation:

  • Iowa Code (IC) Chapter 235B: Department of Human Services
  • Iowa Administrative Code 441—Chapter 176

Reports of dependent adult abuse alleged to have occurred in the following settings should be reported to the Department of Human Services (DHS):

  • Residential house, apartment, mobile home
  • Independent living
  • In facilities or programs when alleged perpetrator is not staff or employee

Definitions Used by DHS

Dependent adult: a person 18 years of age or older who is unable to protect that person’s own interests OR is unable to adequately perform OR obtain services necessary to meet essential human needs, as a result of a physical OR mental condition that requires assistance from another, or as defined by departmental rule.

Caretaker: a related or nonrelated person who has the responsibility for the protection, care, or custody of a dependent adult as a result of assuming the responsibility voluntarily, by contract, through employment, or by order of the court.

Examples of voluntary caretakers include an attorney-in-fact (power of attorney), a relative or friend who provides a daily meal, or a person who provides a service while visiting the dependent adult in a care facility. A caretaker by contract would include an individual personal care assistant who has a contract with a dependent adult to provide care. Healthcare workers employed by a facility or agency are considered caretakers by virtue of their employment. If a dependent adult has no family to provide care, the court may order that a caretaker be provided.

Dependent adult abuse: any of the following as a result of the willful or negligent acts or omissions of a caretaker:

  • Physical abuse, including assault
  • Sexual abuse
  • Sexual Exploitation
  • Exploitation
  • Denial of critical care
  • Self-denial of critical care

Types of Abuse

Abuse under Iowa law include physical and sexual abuse, sexual exploitation, other exploitation, denial and denial of critical care through neglect or denial of the means of survival (eg, food, shelter).

Physical Abuse

Physical injury to, or injury which is at a variance with the history given of the injury, or unreasonable confinement or unreasonable punishment, or assault of a dependent adult, as a result of the willful or negligent acts or omissions of a caretaker.

Assault

Assault is the act or process of taking unfair advantage of a dependent adult or a dependent adult’s physical or financial resources for one’s own personal or pecuniary profit, without the informed consent of the dependent adult including theft, by the use of undue influence, harassment, duress, deception, false representation, or false pretenses as a result of the willful or negligent acts or omissions of a caretaker.

As defined in IC 708.1, a person commits an assault when, without justification, the person does any of the following:

  • Commits any act intended to cause pain or injury to a dependent adult, or which is intended to result in physical contact that will be insulting or offensive to a dependent adult, coupled with the apparent ability to execute the act
  • Commits any act intended to place a dependent adult in fear of immediate physical contact that will be painful, injurious, insulting or offensive, coupled with the apparent ability to execute the act
  • Intentionally points any firearm toward a dependent adult or displays in a threatening manner any dangerous weapon toward a dependent adult

The act is not an assault when the caretaker and the dependent adult are voluntary participants in a sport, social activity, or other activity not in itself criminal, and the act is a reasonably foreseeable incident of such sport or activity, and does not create an unreasonable risk of serious injury or breach of the peace.

Note: An assault does not have to involve physical injury. A person can be assaulted and not have any injuries.

Indicators of Physical Abuse
  • Injury that has not been properly cared for
  • Any injury incompatible with history
  • Pain on touching
  • Cuts, lacerations, or puncture wounds
  • Dehydration and/or malnourishment without illness related cause; weight loss
  • Pallor
  • Sunken eyes, cheeks
  • Evidence of inadequate care
  • Eye problems, retinal detachment
  • Poor skin hygiene
  • Absence of hair or hemorrhaging below scalp
  • Soiled clothing or bed
  • Burns
  • Locked in a room
  • Lack of bandages on injuries or stitches when indicated, or evidence of unset bones
  • Heavy or excessive medication
Examples of Physical Abuse
  • Unauthorized use of physical or chemical restraints
  • Administration of medications or enforced isolation as punishment or simply for convenience
  • Use of substitute treatment in conflict with a physician’s order
Dating of Bruises

Physicians and law enforcement disagree about the validity of dating of bruises. However, they do agree that bruises change color as the injury ages and the simultaneous presence of bruises of various colors on the same person indicates separate injuries.

Sexual Abuse

The commission of a sexual offense under Iowa Code (709, 726.2, or 235B.2) with or against a dependent adult as a result of the willful or negligent acts or omissions of a caretaker.

Sexual abuse includes the following categories:

  • First-degree sexual abuse (IC 709.2)
  • Second-degree sexual abuse (IC 709.3)
  • Third-degree sexual abuse (IC 709.4)
  • Indecent exposure (IC 709.9)
  • Assault with intent to commit sexual abuse (IC 709.11)
  • Sexual exploitation by a counselor or therapist (IC 709.15)
  • Invasion of privacy, nudity (IC 709.21)
  • Incest (IC 726.2)
Indicators of Sexual Abuse
  • Person’s behavior changes drastically, eg, acting out, angry, lashing out, inappropriate affect
  • Person is depressed or shows symptoms of other mental health issues
  • Person acts afraid in the presence of the caretaker
  • Person does not want to be left alone with the caretaker
  • Genital or anal bruises
  • Vaginal or anal bleeding
  • Swelling or redness of genital area
  • Venereal disease
Special Sexual Vulnerabilities of Dependent Adults

Elders and people with disabilities may be targeted by sexual predators due to their vulnerability. Most people (99%) with developmental disabilities have had no sex education. More than 83% of women and 32% of men with developmental disabilities have experienced sexual assault. Nearly three-quarters of women with disabilities have been violently sexually victimized at some point in their lives.

Sexual assault is not spontaneous or accidental, but communities tend to blame the survivors. It is often treated as a scandal, an internal personnel matter, or a public relations problem. Although most of the victims are female, there are also male victims.

Sexual Abuse Differs with Age or Frailty

Frail elders too often lack a strong support system, which makes them more vulnerable to abuse. Their beliefs about sexual abuse increase feelings of shame and guilt. In addition, the abuse:

  • May complicate an existing illness
  • Involves a longer recovery time to deal with abuse
  • Increases the chance of sustaining serious injury
  • May cause genital tearing and bruising
  • May fracture pelvis or hip bones
  • Increases the risk of infections
Sexual Exploitation

Sexual exploitation is “any consensual or nonconsensual sexual conduct with a dependent adult. This includes but is not limited to kissing; touching of the clothed or unclothed inner thigh, breast, groin, buttock, anus, pubes, or genitals; or a sex act” (Iowa Code 702.17).

Sexual exploitation also includes the transmission, display, or taking of electronic images of the unclothed breast, groin, buttock, anus, pubes, or genitals of a dependent adult by a caretaker for a purpose not related to treatment or diagnosis or as part of an ongoing assessment, evaluation, or investigation.

Sexual exploitation does not include touching that is part of a necessary examination, treatment, or care by a caretaker acting within the scope of practice or employment of the caretaker; a brief touch or hug for the purpose of reassurance, comfort, or casual friendship; or touching between spouses or domestic partners in an intimate relationship.

Exploitation

Physical injury to, or injury which is at a variance with the history given of the injury, or unreasonable confinement or unreasonable punishment, or assault of a dependent adult, as a result of the willful or negligent acts or omissions of a caretaker.

Indicators of Exploitation
  • Dependent adult is inaccurate, confused, or has no knowledge of finances
  • Disparity between income/assets and lifestyle or living arrangement
  • Caretaker expresses unusual interest in the amount of money spent for care of the dependent adult
  • Unpaid bills when resources should be adequate
  • Caretaker is evasive about financial arrangements
  • Signatures on checks don’t match dependent adult’s
  • Unusual activity in bank accounts
  • Dependent adult turns over financial affairs to someone in exchange for lifelong care, but does not appear to have basic necessities such as food and shelter
  • Caretaker begins to handle the dependent adult’s financial affairs without his or her presence or without consultation
Examples of Exploitation
  • Misuse of power of attorney or conservatorship
  • Identity theft
  • Scams
  • Coercion into signing or changing legal documents
  • Taking or misusing a dependent adult’s property, money, social security or pension check, food stamps, medication, etc.

Exploitation can directly impact quality of care, depriving victims of the financial means to access medical treatment or obtain medications.

Denial of Critical Care (Neglect)

Denial of critical care (neglect) is defined as the deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, and other care necessary to maintain a dependent adult’s life or health as a result of the willful acts or negligent acts or omissions of a caretaker.

Iowa Administrative Code 176.1 adds:

Denial of critical care exists when the dependent adult’s basic needs are denied or ignored to such an extent that there is immediate or potential danger of the dependent adult suffering injury or death, or the failure to provide the mental health care necessary to adequately treat the dependent adult’s serious social maladjustment, or is a gross failure of the caretaker to meet the emotional needs of the dependent adult necessary for normal development, or a failure of the caretaker to provide for the proper supervision of the dependent adult.

Indicators of Denial of Critical Care
  • Pattern of failure to provide adequate food; malnourishment; or contaminated or spoiled food in home
  • Lack of adequate clothing to provide protection from the weather
  • Lack of heat in winter or lack of air conditioning or fans in summer; unsanitary or hazardous conditions
  • Refusal to provide medical evaluation for condition detected by medical personnel
  • Failure to follow through with medical treatment plan recommended by health professional
  • Unable to manage affairs because of confusion and deterioration
  • Leaving dependent adult who is incapable of self-supervision without a responsible caretaker
  • Knowingly selecting an inappropriate caretaker
  • Abandonment
Examples of Denial of Critical Care
  • Withholding of care, medication, food, liquids, assistance with hygiene, etc.
  • Failure to provide physical aids such as eyeglasses, hearing aids, false teeth
  • Failure to provide safety precautions and access to care
Denial of Critical Care (Self)

Denial of Critical Care (Self) is the deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, or other care necessary to maintain a dependent adult’s life or health, as a result of the acts or omissions of the dependent adult.

Indicators of Denial of Critical Care (Self)
  • Failure to provide adequate food, shelter or clothing
  • Intentional physical self-abuse
  • Suicidal statements
  • Refusal of medical treatment or medication (refusal not based on religious grounds)
  • Refusal of services that might alleviate the situation, when once would have accepted
  • Refusal of visitors
  • Denial of obvious problems
  • Apathy
  • Hopelessness
Examples of Denial of Critical Care (Self)
  • Unable to prepare food or obtain groceries
  • Unable to care for self
  • Confused and unable to understand living conditions
  • Holes in the floors and walls of home
  • Home is cluttered with garbage (health hazard)
  • Person subjects self to unsanitary living conditions
  • Person subjects self to a deplorable living environment
Personal Degradation

Being shamed, degraded, or humiliated is a deep, intensely personal experience that is often vividly remembered, no matter how much time has passed. When experienced frequently, these emotions have been associated with psychological, relational, and societal problems, as well as with clinical disorders such as low self-esteem, depression, anxiety, suicidal ideation, homicide, and domestic violence (Mann et al., 2017).

Personal degradation is a willful act or statement by a caretaker intended to shame, degrade, humiliate, or otherwise harm the personal dignity of a dependent adult. It is a situation in which the caretaker knows or reasonably should know that an act or statement will cause shame, degradation, humiliation, or harm to the personal dignity of the person under their care.

Personal degradation includes taking, transmitting, or displaying an electronic image of a dependent adult by a caretaker, where the caretaker's actions constitute a willful act or statement intended to shame, degrade, or humiliate, or otherwise harm the personal dignity of the dependent adult or when the caregiver knows or reasonably should know that act will shame, degrade, humiliate, or harm the personal dignity of the person under their care.

Personal degradation does not include taking, transmitting, or displaying an electronic image in accordance with a facility's confidentiality, consent, or release of information policies.

Indicators of Degradation, Humiliation, or Shame
  • Hiding from others, withdrawal
  • Anger, rage, fear
  • A desire for revenge
  • Depression
  • Lowered self-esteem
  • Social anxiety
  • Suicidal ideation
Examples of Degradation, Humiliation, or Shame
  • Being teased, harassed, ridiculed, or put down
  • Being neglected, excluded, or ostracized
  • Experiencing public insults, especially related to personal, cultural, or religious values
  • Being bullied, including cyberbullying
  • Having a caregiver laugh at your personal difficulties
  • Being the victim of humiliating texts, images, or videos
  • Having your identity devalued or demeaned

(Mann et al., 2017)

What Dependent Adult Abuse Is Not

There are some situations that may appear to be dependent adult abuse but, according to the Iowa Code and Administrative Rules, are not.

  1. Refusal or deprivation of medical treatment based on religious beliefs. The practices and beliefs of some religions call for reliance on spiritual means for healing rather than medical treatment. A patient may refuse treatment based on religious grounds.
  2. Withholding, withdrawing or refusing medical treatment based on terminal illness. If based upon the request of the dependent adult, their next-of-kin, attorney-in-fact (power of attorney), or guardian.
  3. Domestic abuse. In domestic abuse situations where the victim is not dependent as defined in law.
  4. People incarcerated in a penal setting. While one could make a case that an incarcerated person is a dependent adult, the Code excludes these people from the Dependent Adult Abuse Law.
  5. Lack of means or access to means for providing care. Where there is a lack of means to care for a dependent adult, the caretaker would not be guilty of perpetrating denial of critical care. Likewise, cases where a dependent adult lacks the means to care for her or himself would not be considered self-denial of critical care. [Iowa Administrative Rules 441, Ch 176.3(2) & Iowa Code 235B.2(5)(b)]

Abuse Reports in Facilities and Programs

These abuse reports are covered under the following legislation:

  • Iowa Code Chapter 235E: Department of Inspections & Appeals
  • Iowa Administrative Code 48—Chapter 52

The Department of Inspections and Appeals (DIA) shall receive and evaluate reports of dependent adult abuse in facilities and programs and shall inform the Department of Human Services (DHS) of such evaluations and dispositions for inclusion in the central.

Facility means a health care facility (135C.1) or hospital (135B.1) and includes:

  • Long term care facilities
  • Residential care Facilities
  • Intermediate care facilities for people with mental illness
  • Intermediate care facilities for people with mental retardation
  • Hospitals

Program means:

  • Elder group home (231B.1)
  • Assisted living program (231C.3)
  • Adult day services (231D.1)

Definitions Used by DIA

Dependent adult: A person eighteen years of age or older whose ability to perform the normal activities of daily living or to provide for the person’s own care or protection is impaired, either temporarily or permanently.

Caretaker: a staff member of a facility or program who provides care, protection, or services to a dependent adult voluntarily, by contract, through employment, or by order of the court. For the purposes of an allegation of exploitation, if the caretaker-dependent adult relationship started when a staff member was employed in the facility, the staff member may be considered a caretaker after employment is terminated.

Dependent adult abuse: Any of the following as a result of the willful misconduct or gross negligence or reckless acts or omissions of a caretaker, taking into account the totality of the circumstances:

  1. Physical injury, unreasonable confinement, unreasonable punishment, and assault
    1. Physical Injury. A physical injury or injury which is at a variance with the history given of the injury which involves a breach of skill, care, and learning ordinarily exercised by a caretaker in similar circumstances.
    2. Unreasonable Confinement. Confinement that includes but is not limited to, the use of restraints, either physical or chemical, for the convenience of staff. “Unreasonable confinement” does not include the use of confinement and restraints if the methods are employed in conformance with state and federal standards governing confinement and restraints or as authorized by a physician or physician extender.
    3. Unreasonable Punishment. A willful act or statement intended by the caretaker to punish, agitate, confuse, frighten, or cause emotional distress to the dependent adult. Such willful act or statement includes but is not limited to intimidating behavior, threats, harassment, deceptive acts, or false or misleading statements.
    4. Assault. “Assault of a dependent adult” means the commission of any act which is generally intended to cause pain or injury to a dependent adult, or which is generally intended to result in physical contact which would be considered by a reasonable person to be insulting or offensive or any act which is intended to place another in fear of immediate physical contact which will be painful, injurious, insulting, or offensive, coupled with the apparent ability to execute the act.
  2. Sexual Offense: the commission of a sexual offense as defined under Iowa Code, section 709 or 726.2, with or against a dependent adult.
  3. Exploitation a caretaker who knowingly obtains, uses, endeavors to obtain to use, or who misappropriates, a dependent adult’s funds, assets, medications, or property with the intent to temporarily or permanently deprive a dependent adult of the use, benefit, or possession of the funds, assets, medication, or property for the benefit of someone other than the dependent adult.
  4. Neglect of a dependent adult the deprivation of the minimum food, shelter, clothing, supervision, physical or mental healthcare and other care necessary to maintain the life or physical and mental health of a dependent adult.
  5. Sexual exploitation of a dependent adult by a caretaker whether within a facility or program or at a location outside of a facility or program. Any consensual or nonconsensual sexual conduct with a dependent adult, which includes but is not limited to kissing; touching of the clothed or unclothed breast, groin, buttock, anus, pubes, or genitals; or a sex act as defined in 702.17. Sexual exploitation includes the transmission, display, or taking of electronic images of the unclothed breast, groin, buttock, anus, pubes, or genitals of a dependent adult by a caretaker for a purpose not related to treatment or diagnosis or part of an ongoing investigation.

Sexual exploitation does not include touching which is part of a necessary examination, treatment, or care by a caretaker acting within the scope of practice or employment of the caretaker; the exchange of a brief touch or hug for the purpose of reassurance, comfort, or casual friendship; or touching between spouses or domestic partners in an intimate relationship.

Dependent adult abuse does not include:

  • Circumstances in which the dependent adult or the dependent adult’s caretaker acts in accordance with the dependent adult’s stated or implied consent, declines medical treatment or care due to a belief or is an adherent of a religion whose tenets and practices call for reliance on spiritual means in place of reliance on medical treatment.
  • The withholding or withdrawing of health care from a dependent adult who is terminally ill in the opinion of a licensed physician, when the withholding or withdrawing of health care is done at the request of the dependent adult’s next of kin, attorney in fact, or guardian.

Behavioral Indicators of Abuse

Mandatory reporters should be alert to behaviors of both the victim and the abuser that signal possible abuse or other serious problems. These behaviors may occur in the absence of abuse but their presence warrants consideration of the possibility of abuse.

Victim Behaviors

  • Fear or reluctance to openly talk with others
  • Withdrawal, self isolates, quiet/subdued, depressed mood
  • Depression, either acute or situational, that is uncharacteristic of the person’s past behavior
  • Helplessness or resignation, an “I don’t care” attitude, too accepting of their perceived fate/future
  • Hesitation to talk openly, reluctant to discuss their well-being, changes the subject to non-threatening issues
  • Implausible stories (not related to dementia),explanations that don’t match up with facts or visible circumstances
  • Confusion or disorientation (not related to dementia),difficulty in expressing thoughts, appears distracted
  • Ambivalence/contradictory statements, fails to show concern about personal events, unable to repeat the same explanation of events or circumstances
  • Anger, displayed toward you, family/friends, or toward everyone and everything
  • Non-responsiveness, refuses to answer questions appropriately
  • Agitation/anxiety, becomes increasingly agitated or anxious when you are there

Abuser Behaviors

  • Victim not allowed to speak for himself or herself
  • Obvious absence of assistance
  • Indifference or anger toward victim
  • Blames the victim
  • Aggressive behavior
  • Previous history of abuse to others
  • Problems with alcohol or drugs
  • Flirtations, coyness, etc.
  • Conflicting accounts of incidents by the family, supporters, victim
  • Noncompliance with service providers in planning for care and implementation
  • Withholding of security and affection

Perpetrators frequently groom their targets before assault, gaining trust, testing the waters to see how the person will react. Indicators of grooming include showing special interest in the person, gifts, touching, massage, setting up time to be alone (bathing in the late evening, providing transportation).

The presence of a single indicator may not raise suspicion of abuse, but a combination of indicators may reveal a serious situation. The potential reporter may want to question further, document the situation for future use, or make a report.

Types of Perpetrators

Abusers can be categorized across a spectrum of types from well-intentioned to sadistic. The categories include:

  • Well-intentioned: overwhelmed, stressed, lashing out (means well but tries to do too much)
  • Well-intentioned: ignorant, incompetent (doesn’t really understand how to take care of someone, for example leaves an Alzheimer’s patient tied to a chair and goes grocery shopping)
  • Lacks interest and concern (a lazy person who needs a job, takes no pride in work, just wants an “easy” paycheck)
  • Abusive: motivated by self-interest, power, and control (gains trust of dependent person, manipulates into signing over money or property)
  • Sadistic: enjoys hurting, extreme power and control (looks for jobs with position and authority to gain control for the purpose of hurting others)
Expected Responses from Perpetrators

Depending on the type of perpetrator involved, responses vary among the following:

  • Admission of guilt, embarrassment, desire to do better
  • Admission but believes abusive action was justified
  • Varies with intelligence and social sophistication
  • Denial, outrage, rationalizations, attempts to “turn the tables” on the victim, reporter and/or investigator

Reporting Suspected Abuse

Any person who believes that a dependent adult has suffered abuse may make a report of the suspected abuse to DHS. For example, an employee of a financial institution may report suspected financial exploitation of a dependent adult. Greater public awareness of the prevalence of abuse of elders and people with disabilities would bring this crime out of the shadows. People who report suspected abuse even though they are not legally required to are called permissive reporters.

Mandatory Reporters

Iowa law requires certain professionals to report suspected abuse [IC 235B.3(2)]. They are called mandatory reporters. Mandatory reporters are required to complete a minimum of two hours of training on dependent adult abuse within six months of employment and every five years thereafter.

Note: Mandatory reporters may also report suspected abuse outside the scope of their professional practice, as permissive reporters.

Iowa Code sections 235B.3(2) and 235E.2 require all of the following people to report suspected dependent adult abuse to the Department of Human Services or the Department of Inspections and Appeals if the person in the course of employment examines, attends, counsels, or treats a dependent adult and reasonably believes the dependent adult has suffered abuse:

  • A member of the staff of a community mental health center
  • A peace officer
  • An in-home homemaker-home health aide
  • A person employed as an outreach person
  • A health practitioner, as defined in Iowa Code section 232.68
  • A member of the staff or an employee of a supported community living service, sheltered workshop, or work activity center
  • A social worker
  • A certified psychologist

Reportable Criteria

For DHS or DIA to conduct an evaluation/investigation of an abusive situation, the following three criteria must be met:

  • Victim is a dependent adult
  • Allegation of abuse is under the Dependent Adult Abuse Law
  • The alleged perpetrator is the caretaker (or self)

Under the Dependent Adult Abuse Laws, people who suspect a dependent adult is suffering from abuse by a caretaker shall report their belief to the Department of Human Services (DHS) or the Department of Inspections and Appeals (DIA). It is the role of the mandatory reporter to report suspected abuse and it is the role of DHS or DIA to determine if abuse has occurred.

When in doubt, REPORT!

DHS is responsible for the evaluation/assessment of dependent adult abuse in the community. DIA is responsible for the investigation of dependent adult abuse caused by staff or an employee of a facility (health care facility, hospital) or program (Assisted Living, Adult Day Services, Elder Group Homes). Each department must then investigate the report and make an evaluation of the situation.

This is not to say that other forms of abuse which do not fall under the Dependent Adult Abuse Law should be ignored. Avenues are available to pursue abuse that does not involve a dependent adult or caretaker. To locate the appropriate resource, contact the Iowa Department on Aging (IDA), DHS, or DIA.

When, Where, and How to Make a Report

Mandatory reporters shall:

  • Report suspected abuse of a dependent adult within 24 hours of becoming aware of an abusive incident.
  • Make a written report within 48 hours after an oral report.
  • If a staff member or employee, you must immediately notify the department and also immediately notify the person in charge or the person’s designated agent.
  • If the person making the report has reason to believe that immediate protection for the dependent adult is advisable, that person shall also make an oral report to an appropriate law enforcement agency.

Iowa Code Section 235B.3 requires that mandatory reporters of dependent adult abuse who suspect that a dependent adult in the community has been abused must report it to DHS. Iowa Code 235E.2 requires that if the suspected abuse occurred in a healthcare facility, hospital, elder group home, assisted living or adult day services program, it must be reported to DIA. The report should be made by telephone or by other means.

The DHS Central Abuse Registry accepts reports from any person who believes dependent adult abuse has occurred. DHS maintains a toll-free telephone line 800 362 2178, which is available 24/7. Any person may use this number to report cases of suspected dependent adult abuse. All authorized people may also use this number for obtaining dependent adult abuse information. DIA can be contacted at 877 686 0027.

If you believe that immediate protection for the dependent adult is advisable, also make an oral report to the appropriate law enforcement agency. A county attorney or law enforcement agency that receives a report of dependent adult abuse must refer it to DHS.

You must also make a report in writing within 48 hours after your oral report. You may use DHS form 470-2441, Suspected Dependent Adult Abuse Report, or a format you develop that meets the requirements listed below, based on 441 Iowa Administrative Code 176.5(235B).

If you are a staff member or employee, you must also immediately notify the person in charge or the person’s designated agent. “Immediately” means within 24 hours from the time the mandatory reporter suspects abuse of a dependent adult. The employer or supervisor of a mandatory abuse reporter shall not apply any policy, work rule, or other requirement that interferes with the person making a report of dependent adult abuse or that results in the failure of another person to make the report.

If you are a staff member or employee of a facility or program licensed or certified by the DIA, you must immediately notify the person in charge or the person’s designated agent, who then makes the report to the DIA, within 24 hours, unless the person you are to report directly to is the person you suspect of abusing the dependent adult.

Reporting to DHS

When you suspect dependent adult abuse occurring in the community, you must report it within 24 hours to DHS, followed by a written report within 48 hours. The time period begins when you first suspect abuse, not necessarily when the abuse may have occurred.

DHS Intake Form 470-0657 (Oral Report) can be used as a guide for the information the intake worker will be asking during the oral report. Complete the form as much as possible and refer to abuse indicators as described above. Take care to include:

  • Name and address of dependent adult
  • Names of all parties involved
  • Reasons dependency is suspected
  • Name of alleged perpetrator/caretaker
  • What type of abuse is suspected
  • Why you suspect abuse

A Dependent Adult Abuse Notice of Intake Decision form (470-3944) will be sent to the mandatory reporter indicating whether the report was accepted for referral or rejected. Typically, the form is received within 10 days.

Within 48 hours of the oral report a written report (Suspected Dependent Adult Abuse Report 470-2441) shall be submitted. The written report presents, in detail, reasons for concern. It can reinforce the oral report and ensure all the information shared was recorded accurately. It is wise to maintain copies of these forms in a secured confidential file. You can access this form at https://dhs.iowa.gov/sites/default/files/470-2441.pdf.

Suggestion: Within the 24-hour requirement, complete the written report and then make the oral report. On the written report, note the date and time the report is made as well as the name of the individual receiving the report. Ask the intake worker for the fax number and indicate the written report will be faxed as soon as the oral report is complete. This will assist DHS in getting a clearer picture of the situation.

When completing the report be sure to note special communication issues, verify address and phone number, and note if the dependent adult does not have a phone or has a hard-to-locate home. Describe the person’s dependency in accordance with the definitions and carefully note the suspected abuse and information regarding the caretaker(s) involved. Provide all your contact information and note any collateral reporters for the incident. Make a copy and submit the report, preferably by fax, to the local DHS office after making the oral report. Keep the copy in a secured confidential file.

Did You Know . . .

Being listed as a collateral reporter in another person’s report does not fulfill your responsibilities as a mandatory reporter of the incident.

Because you are a mandatory reporter, DHS is required to notify you in writing as to what action was taken regarding your report (Adult Protective Notification 470-2444). If you should disagree with the report, the notice provides information on how to appeal. If you wish to receive a copy of the unfounded or founded report, which is highly recommended, complete the form on the back of the notification and return it to DHS.

Reporting to DIA

When dependent adult abuse is suspected an oral report must be made within 24 hours or the next business day. In addition, federal law requires that a written report must be made within 5 days. Remember the time frame begins when you first suspect abuse.

Per IAC 481—52.2(2)(f) a report of suspected dependent adult abuse shall contain as much of the following information as the person making the report is able to furnish:

  • The date and time of the incident
  • The name, date of birth and diagnoses of the dependent adult
  • Whether the dependent adult sustained an injury and, if yes, whether photographs of the injury were taken
  • The nature and extent of the dependent adult abuse, including evidence of previous dependent adult abuse allegations
  • A list of the staff members working at the time of the incident, including each staff member’s full name, title, date of birth, address and telephone number
  • The alleged perpetrator’s full name, title, date of birth, social security number, address and telephone number
  • Other information which the person making the report believes might be helpful in establishing the cause of the abuse or the identity of the person or people responsible for the abuse or helpful in providing assistance to the dependent adult
  • The name, address and telephone number of the person making the report

A report shall be accepted whether or not it contains all of the information requested. When the report is made to any agency other than the department, that agency shall promptly refer the report to the department [IAC 481-52.2(3)].

Reports are made to DIA at the toll-free complaint intake line (877 686 0027), or faxed to 515 281 7106, or sent via the Internet using the online form at https://dia-hfd.iowa.gov/DIA_HFD/Process.do.

Reports can also be submitted by regular mail to:

Iowa Department of Inspections and Appeals
Health Facilities Division/Complaint Unit
Lucas State Office Building, 3rd Floor
321 East 12th Street
Des Moines IA 50219-0083

Note: If you suspect Medicaid Fraud, call 515 281 5717 or 515 281 7086. If you suspect Medicare Fraud, call 800 447 8477 or email HHSTips@oig.hhs.gov.

The facility or program shall separate the victim and the alleged abuser immediately and shall maintain that separation until the department’s abuse investigation is completed and the abuse determination is made [IC 235E.2(10) & IAC 52.6].

Immunity and Legal Behavior

This section spells out immunity from liability and also covers legal responsibilities and rights as well as sanctions.

Immunity from Liability

Iowa Code 235B.3(10) and 235E.2(7) state that:

A person participating in good faith in reporting or cooperating with or assisting the department in evaluating a case of dependent adult abuse has immunity from liability, civil or criminal, which might otherwise be incurred or imposed based upon the act of making the report or giving the assistance. The person has the same immunity with respect to participating in good faith in a judicial proceeding resulting from the report or cooperation or assistance or relating to the subject matter of the report, cooperation, or assistance.

Legal Responsibilities and Rights

Mandatory reporters:

  • Shall report suspected dependent adult abuse orally and in writing
  • Shall complete two hours of training within six months of initial employment and 2 hours every 5 years thereafter [IC 235B.16(5)(b)]
  • Must report to law enforcement if immediate protection of dependent adult is advisable
  • Must cooperate with DHS and/or DIA

Mandatory reporters have a right to:

  • Receive a copy of the notice of finding of the report
  • Request and receive a copy of the report for founded and unfounded incidents. (IC 235B.6(2)(b)(6) and 235B.6(3) respectively)
  • Immunity from liability civil or criminal [(IC 235B.3(10)]
  • Remain anonymous when the disclosure of the reporter’s identity would be detrimental to the person’s interest [441 IAC 176.10(3)]

Sanctions

  • Any mandatory reporter who knowing and willfully fails to report suspected dependent adult abuse (within 24 hours) is guilty of a simple misdemeanor.
  • Any mandatory reporter who knowingly fails to make a report or knowingly interferes with the making of such a report or applies a requirement that results in such a failure is civilly liable for the dames proximately caused by the failure.

 

Did You Know . . .

HIPAA prevents the release of information about patients to anyone other than the legal representative of the patient. In cases of suspected abuse, HIPAA waives this rule and state law mandates such reports are made (45 CFR 164.512).

Evaluation Process and Records Management

This section covers jurisdiction over evaluation, management of information, and the role of law enforcement.

Jurisdiction over Evaluation

There are four types of jurisdiction over the formal evaluation/investigation of alleged dependent adult abuse cases. They include:

  • Department of Human Services (DHS). For abuse that occurs in the community, DHS is responsible to respond with an evaluation/assessment of the situation.
  • Department of Inspections and Appeals (DIA). For abuse that occurs in a facility or program (hospital, long-term care, assisted living, elder group home, adult day services, etc.), DIA is responsible for conducting an investigation.
  • Law Enforcement. When the abuse constitutes a crime, law enforcement must be notified and must conduct its own investigation.
  • Joint Investigations. Sometimes a situation may involve dependent adult abuse and a criminal offense. In those cases, parallel investigations are conducted by DHS or DIA, as appropriate, and the local law enforcement agency.

Evaluation Components

When DHS personnel undertake an evaluation they consider many factors. They must first determine that the alleged victim is at least 18 years of age and is dependent as a result of a physical or mental condition requiring the assistance of another. To determine dependence they will consider:

  • Is the person able to protect the person’s own interests?
  • Is the person at substantial risk of injury, harm, or being taken advantage of financially?
  • Is the person unable to perform adequately to meet minimal essential human needs?
  • Does the person require assistance with activities of daily living, such as eating, grooming, taking medication, walking, toileting, dressing, food preparation, grocery shopping, or money management?
  • Is the person able to obtain services necessary to meet essential human needs?

Physical factors

  • What health problems does the person have? (Include medical diagnosis if available)
  • Is the person able to complete activities of daily living (food preparation, bathing, toileting, eating, dressing) without assistance? If the person needs assistance, is it being provided?
  • Is the person able to communicate needs to others?
  • Can the person call for “help”? Is such “help” available if needed?
  • Is the person able to walk with or without the assistance of a walker, wheelchair, a care provider?
  • Does the existence of the person’s physical problems prevent the person from obtaining the services necessary to meet essential human needs?

Mental factors

  • Does the person have any mental problems? (Include diagnosis, if available.)
  • Is the person oriented to time, place, and person?
  • Is the person mentally capable of caring for the person’s own interests?
  • Is the person able to reason and make a conscious choice understanding the possible consequences?
  • Does the existence of mental health problems prevent the person from obtaining the services necessary to meet needs?

Social factors

  • Does the person have a support system?
  • Do any members of the support system help the person meet needs?
  • How frequently does the person come into contact with others?
  • Does the person live in an isolated environment, either self-imposed or due to physical or mental challenges?

Environmental factors

  • Is the person able to maintain the current environment? Cleaning, cooking, grocery shopping?
  • Is the person able to adequately care for self in the current environment?
  • Does the person need supervision to continue living in current environment?
  • Is the person living in a safe environment?
  • If the environment is hazardous, is the person able to move from that environment?

Financial factors

  • Is the person able to handle his/her own finances?
  • Is someone assisting the person in taking care of finances? (Guardian, conservator, payee, friend, family, etc.)
  • Is the person able to manage personal, home, and financial affairs in own best interest?

DHS will also determine if the alleged abuser is in fact a “caretaker”—a related or unrelated person who has the responsibility for the protection, care, or custody of the dependent adult as a result of:

  • Assuming the responsibility voluntarily
  • A contract
  • Employment
  • An order of the court

If the alleged abuser is the dependent adult, as in a case of self denial of care, then DHS will consider:

  • If the dependent adult is at substantial risk of injury or harm by failing to adequately meet minimal essential human needs in the following areas: food, shelter, medical care, money management, or mental health care
  • If a significant incident occurred that brought inadequacies to the attention of the reporter, or if there is a pattern of the dependent adult being responsible for self-denial of care

 

Did You Know . . .

A dependent adult has the right to make unhealthy choices, as long as they are not health- or life-threatening.

 

Report Outcomes

There are three possible outcomes from evaluation of a report alleging dependent adult abuse:

  • Founded: Requires a preponderance of evidence (51% or greater) that abuse has occurred. Founded reports remain on the Central Abuse Registry for 10 years from the date of the last founded report.
  • Unfounded: Requires a preponderance of evidence (51% or greater) that abuse has not occurred.
  • Confirmed, not registered:
    • Under 235B (DHS) When physical abuse or denial of critical care by a caretaker is determined to be minor, isolated and unlikely to recur, the report is maintained as an assessment only for five years and then destroyed, unless a subsequent report is founded in the interim. If the subsequent report involves physical abuse or denial of critical care by the same caretaker in the original report, then the abuse shall not be considered minor, isolated, and unlikely to reoccur.
    • Under 235E (DIA) and IAC 481-52.3(3)(a) & (b) Reports of Abuse that is minor, isolated, and unlikely to reoccur.
      1. Minor, isolated, and unlikely to reoccur—first instance. A report of dependent adult abuse that meets the definition of physical abuse assault, unreasonable confinement, unreasonable punishment, or neglect of a dependent adult which the department determines is minor, isolated, and unlikely to reoccur shall be collected and maintained by the department of human services for a five-year period, shall not be included in the central registry and shall not be considered to be founded dependent adult abuse.
      2. Minor, isolated, and unlikely to reoccur—subsequent instance(s). A subsequent report of dependent adult abuse that meets the definition of physical abuse, assault, unreasonable confinement, unreasonable punishment, or neglect of a dependent adult that occurs within the five year period, and that is committed by the same caretaker may also be considered minor, isolated, and unlikely to reoccur depending on the totality of circumstances.

In 2016, 7167 reports of suspected dependent adult abuse were reported to DHS for evaluation/assessment. Of those, 2266 (32%) were accepted for evaluation by a social worker and about 81% of those were determined to be unfounded. The most common types of abuse reported were denial of critical care (neglect), denial of critical care (self), and exploitation (financial) (IDHS, 2017, 2016).

Reports of suspected abuse are rejected by DHS for evaluation or assessment for the following reasons:

  • The person named in the report is not a dependent adult.
  • The alleged perpetrator is not a caretaker.
  • The allegations do not constitute abuse.
  • The information provided is insufficient to suspect abuse.
  • The information duplicates or adds to a previous report.
  • The report was referred to the Department of Inspections and Appeals.

Appeals of Abuse Reports

Under 235B (DHS)

Any subject of a dependent adult abuse report, except a nurse aide, who believes there is incorrect information in the evaluation or assessment report, or who disagrees with the conclusions of the report, may request correction of the report. Subjects of a report are the:

  • Dependent adult
  • Dependent adult’s guardian or attorney
  • Individual responsible for the abuse
  • Attorney for the individual responsible for the abuse

A nurse aide who is the subject of a report may request a hearing within 30 days from the date of the notice of the finding (IAC441–81.16(6)).

Under 235E (DIA)

If a request for an appeal is filed by a caretaker within fifteen (15) days of the issuance of the notice of a founded determination of dependent adult abuse, DIA shall not place the caretaker on the central abuse registry until final agency action is taken.

If a caretaker fails to request an appeal of a founded determination within fifteen (15) days, the caretaker shall have sixty (60) days from the issuance of the written notification of the abuse findings to file an appeal pursuant to chapter 17A.

Under 235E, appeals of determinations other than founded, 235B.10 applies.

An appeal is made by filing a written statement to the effect that the information referring to the person is in whole or in part erroneous. This must be done within six months of the date of the notice of the results of the evaluation, and must be submitted to the DHS Appeals Section, 1305 E Walnut Street, 5th Floor, Des Moines IA 50319-0114.

Management of Information

Iowa Code 235B.6 provides for the maintenance of confidentiality of information on dependent adult abuse, except as specifically authorized. DHS must withhold the name of the reporter of suspected dependent adult abuse. Only the court or the Central Abuse Registry may allow release of the reporter’s name.

Retention of Records

Information on all founded reports (whether evaluated by DHS or DIA) is maintained on the Central Abuse Registry for 10 years and then sealed. Exception: When the dependent adult is responsible for self-denial of critical care, DHS keeps the report in the local office, not on the Central Registry. These are called “assessments” rather than “evaluations.”

Information on DHS-evaluated reports that are confirmed, not registered is maintained in the local office for 5 years and then destroyed, unless a subsequent report is founded. If there is a subsequent report committed by the same caretaker within 5 years, the original report will be kept in the local office and sealed 10 years after the subsequent report.

Information on unfounded reports is destroyed 5 years from the date they were unfounded.

Reports that are rejected for evaluation or assessment are kept in the local office for 3 years and then expunged.

Access to Information

Access to “founded” or “unfounded” dependent adult abuse information is authorized to:

  • “Subjects” of a report (the adult victim, the guardian or legal custodian of the adult victim, and the alleged perpetrator) or the attorney for any subject
  • An employee or agent of DHS responsible for investigating an abuse report
  • DHS personnel as necessary for the performance of their official duties
  • The mandatory reporter who reported the abuse
  • The long-term care resident’s advocate
  • Multidisciplinary teams

In addition, founded reports may be authorized to additional personnel, such as people involved in an investigation, people providing care to the dependent adult, judicial and administrative proceedings, bona fide researchers, DHS personnel, and others.

To request dependent adult abuse information, complete a Request for Dependent Adult Abuse Registry Information (Form 470-0612). Send form to the local DHS office or to the Central Abuse Registry at: DHS Central Abuse Registry, 1305 E. Walnut Street, 5th Floor, Des Moines, IA 50319-0114.

Background Checks on Employees

All facilities and agencies that provide care to dependent adults must complete criminal and abuse background checks on prospective employees (IC 135C.33). If the applicant has either a criminal or abuse background, the employer may request a Record Check Evaluation be completed by the Department of Human Services, to determine if the person may be employed even though there is the criminal or abuse background.

When evaluating criminal or abuse backgrounds to determine employability, DHS considers the following:

  • The nature and seriousness of the crime or founded abuse in relation to the position sought or held
  • The time elapsed since the commission of the crime or founded abuse
  • The circumstances under which the crime or founded abuse was committed
  • The degree of rehabilitation
  • The likelihood the person will commit the crime or founded abuse again
  • The number of crimes or founded abuses committed by the person involved

Role of Law Enforcement

In addition to the oral report a mandatory reporter must make to DHS or DIA, if they have “reason to believe that immediate protection for the dependent adult is advisable, that person shall also make an oral report to an appropriate law enforcement agency” [IAC 441–176.5(2) and 481–52.2(2)(e)].

For law enforcement, jurisdiction is determined by the location of the alleged act(s) of abuse and dictates which agency is responsible for the primary investigation, and will also determine where a case will be prosecuted. When an investigation is initiated, the county attorney’s office is also notified. Law enforcement will be responsible for taking any actions necessary to protect the dependent adult from further immediate harm and provide notification of rights as appropriate.

Dependent adult abuse is a crime. The potential charges for the forms of abuse previously discussed cover various degrees of misdemeanors and felonies and reflect a range of prison terms from 2 to 50 years and fines as specified in law up to $10,000. In addition, Chapter 726 of the Iowa Code, which addresses Protection of the Family and Dependent People, defines “wanton neglect of a resident of a health care facility” (726.7) and “wanton neglect or nonsupport of a dependent adult” (726.8) due to knowing acts likely to be injurious; both are serious misdemeanors.

Even if the crime does not fit the three criteria required for dependent adult abuse, the perpetrator may be charged with a different crime. For example, if perpetrators are not a caretaker, they cannot be charge with financial exploitation, but their actions may fall under theft or extortion as defined in Iowa criminal code. Other charges that may be relevant include manslaughter, assault, sexual abuse, indecent exposure, robbery, forgery, and others.

Prevention of Additional Abuse—Notification of Rights

If a peace officer has reason to believe that dependent adult abuse, which is criminal in nature, has occurred, the officer shall use all reasonable means to prevent further abuse, including but not limited to any of the following (IC 235B.3A):

  1. If requested, remaining on the scene as long as there is a danger to the dependent adult’s physical safety without the presence of a peace officer.
  2. Assisting the dependent adult in obtaining medical treatment necessitated by the dependent adult abuse.
  3. Providing a dependent adult with immediate and adequate notice of the dependent adult’s rights…[to] ask the court for…help on a temporary basis…[for] keeping the alleged perpetrator away from you…[to] stay at your home without interference from the alleged perpetrator…[to] professional counseling…[for assistance getting to] medical treatment…[and] that the peace officer present remain at the scene until you and other affected parties can leave or safety is otherwise ensured.

The notice of rights must include telephone numbers for local emergency shelter services, support services, and crisis lines operating in the area.

Note: A perpetrator’s action or inaction may still be considered a crime if all elements of dependent adult abuse cannot met or proven. For example financial exploitation may not met the definition of dependent adult abuse if the perpetrator was not a caretaker; however, it may fall under theft or extortion in the criminal code. Other recourse may be available.

Interventions with Survivors of Abuse

After an assessment and evaluation, services may be recommended for the victim of abuse, that person’s family, or a caretaker. Professionals, relatives, and others seeking to help the dependent adult need to consider whether or not the person will accept these services, and whether the person is of sound mind to give consent.

It is useful to remember that the intervener’s role is to help stop the abuse, not to change anyone’s lifestyle or personality. Solutions may be imperfect but if everyone does the best they can, the results will certainly be better than the alternative. If your agency has established protocols for responding to dependent adult abuse be sure to follow them when developing a response to dependent adult abuse.

Determining Possible Interventions

In regard to interventions, there are three possible scenarios: the dependent adult accepts services, the person lacks the decision-making capacity to give consent, or the person refuses services. Each of these requires different actions to protect the welfare of the dependent adult.

Dependent Adult Accepts Services

  1. Implement a safety plan such as relocation, a protective order, or admission to a hospital.
  2. Alleviate causes of mistreatment through “voluntary services.”
  3. Provide written information on emergency numbers and make appropriate referrals.
  4. Get assistance in legal/financial matters.
  5. If the report is founded, the county attorney may bring criminal charges against the perpetrator.

Dependent Adult Lacks Capacity to Give Consent

  1. Power of attorney, which must be pre-existing because once a person lacks capacity they cannot sign such an agreement
  2. Conservatorship
  3. Guardianship
  4. Involuntary commitment of abuser or victim
  5. Special court order—injunctions, restraining orders
  6. Family member/guardian/case worker may want to consider social services, legal, or financial management assistance for the dependent adult
  7. If the report is founded, the perpetrator may be prosecuted.

Dependent Adult Refuses Services

  1. Provide written information on emergency numbers and make appropriate referrals.
  2. Develop contingency safety plan.
  3. If there is immediate danger, consider involuntary relocation of the victim or perpetrator, or protective order, or commitment.
  4. Do not enforce your decision without first taking the proper legal steps.
  5. If the report is founded, the perpetrator may be prosecuted.

Effective Post Trauma Responses

The following responses are designed to aid the victim in coping with abuse or neglect:

  • Assess the victim’s psychological response to the abuse/neglect and his or her ability to cope with the situation.
  • Tell the victim about services immediately available, such as hotlines, protective services, police, and legal actions.
  • The victim should be encouraged to make his or her own decisions. Maintain a nonjudgmental attitude throughout the discussion.
  • Depending on the type of abuse, counseling may be available through a geriatric program, a rape counseling program, a domestic violence center, or an adult abuse program.
  • Inform the person about appropriate advocacy groups such as legal services programs, protection and advocacy programs, the local area agencies on aging, or other relevant programs.

Legal Interventions Available to Dependent Adults

Conservatorship

Under a conservatorship (IC 633.551, 633566) a person (the conservator) assumes responsibility for custody and control of the property of another (the ward). The determination that an adult needs a conservator is made if the proposed ward’s decision-making process is so impaired that the person is unable to make, communicate, or carry out important decisions concerning the ward’s financial affairs. It does not mean that the ward is of unsound mind. No person has the right to manage the property of an adult without their consent, unless they are a conservator.

A conservator has these general powers on behalf of the ward: payment/receipt of property or income; sale or transfer of personal property; with a court order, invest funds and sell, lease, or mortgage real estate.

Guardianship

Under a guardianship (IC 633.552–633.565) an individual is appointed by the court to make personal and healthcare decisions for a person (ward) who is incapacitated. The appointment of a guardian does not constitute a decision that the ward is of unsound mind. Guardianship may be limited, temporary, standby, or general (plenary).

To file a petition, the proposed ward’s decision-making capacity must be so impaired that the person is unable to care for personal safety or to attend to or provide for necessities such as food, shelter, clothing, or medical care, without which physical injury or illness may occur.

A guardian has a variety of powers and duties, some of which may be exercised only with prior court approval (eg, changing the ward’s residence, arranging for major medical procedures, or giving consent to withhold or withdraw life-sustaining procedures).

Powers of Attorney

Power of attorney is a legal document by which one person (the principal) gives to another person (the attorney in fact) the authority to act on the principal’s behalf in one or more matters. There are several types, including:

  • General powers—financial
  • Limited powers or temporary
  • Durable
  • Health care

The principal, who is giving the power to the attorney in fact, must be able to understand the agreement into which they are entering.

Various Legal Orders

Under Iowa Code 235 B.18 and B.19, protective, restraining, and injunctive orders are intended to protect the abuse victim from physical harm and to prevent further abuse. These orders may evict the perpetrator from the victim’s home, bar the perpetrator from any contact with the victim, require the perpetrator to provide an accounting of the victim’s assets, prevent the perpetrator from transferring the victim’s property, or prohibit any violation under the dependent adult abuse statute. When victims lack decision-making capacity or are in an emergency situation, they may also receive help from an adult protective services program.

Substance Abuse/Mental Health Commitment

Both perpetrators of dependent adult abuse and victims of self-neglect may be involuntarily committed to a facility or hospital. The county attorney and/or any interested person may file an application with the court to commit a chronic substance abuser or seriously mentally impaired person (IC125, 222, 229).

Iowa Services

Long-Term Care Ombudsman’s Office

The Long-Term Care Ombudsman serves as an advocate for the residents of long-term care facilities or assisted living programs. The Ombudsman is charged with the duty of investigation and resolving complaints in long-term care facilities that may adversely affect the health, safety, welfare, or rights of residents.

LifeLong Links Elder Rights Specialists (866 236 1430)

Focus on the prevention, intervention, detection and reporting of elder abuse, neglect and exploitation by presenting elders with options to enhance their lifestyle choices. Objectives include increasing public awareness; Responding to concerns of elders at risk of, or experiencing, abuse, neglect or exploitation; Collaborate and be a resource for case managers, physicians, law enforcement, county attorneys, DHS, domestic violence agencies and long term care facilities.

Office of Substitute Decision Maker (800 532 3213)

Assists individuals in finding alternatives to substitute decision-making services and less intrusive means of assistance before an individual’s independence or rights are limited. It also provides assistance to both public and private substitute decision makers throughout the state in securing necessary services for their wards, principals, clients, and decedents.

Voluntary Services

These services may be offered regardless of whether a report to DHS or DIA is determined to be founded. Voluntary services are social services needed to protect the dependent adult or assist the adult toward independence. People with the capacity to consent have the right to refuse such services. Examples include homemaker service, personal care assistance, adult day care, transportation, legal assistance (restraining orders, restitution), financial management assistance (bill paying, insurance counseling, representative payee), admission to hospital, and assistance with applying for Medicare or Medicaid.

Other Remedies

Other remedies might include direct deposit of Social Security and pension checks directly into the person’s bank account to help prevent theft of a dependent adult’s income; use of the Representative Payee Program, which is available in several Iowa counties, to provide a financial protective service to assist older or disabled low-income people unable to manage their bills and other financial obligations.

Further investigation and action may be indicated by the Medicaid Fraud Control Unit; Crime Victim Assistance Program; Iowa Domestic Abuse Hotline; Medicare Fraud Hotline; Licensing Board of Professionals; Social Security Administration; or Veterans’ Benefits. See the Resources section at the end of this course for details.

Civil actions may be appropriate to address charges that may include conversion, replevin (Iowa Code 643), or breach of contract, to recover property or damages. Under Iowa Code 714.16A, a fund is established to give additional civil penalties to an individual who commits consumer fraud against the elderly.

Communication with Victims and Families

Effective communication is based first of all on the principle of respect. Both the sender and the receiver of the message have unique physical, emotional, mental, social, and spiritual characteristics. Effective communication shows acceptance of a person’s individual worth and involves good listening skills.

Overcoming Communication Barriers

When talking with a dependent adult, the following principles will facilitate communication:

  • Use clear, simple language.
  • Ask open-ended, one-part questions.
  • Be an attentive listener and allow for periods of silence.
  • Allow sufficient time so there is no pressure to hurry.
  • Use explanations that progress from simple to complex.
  • Allow eye contact, but do not force it.
  • Allow plenty of space to move around; medications may cause restlessness.
  • Keep background noise to a minimum.
  • Sit facing the person to help them identify visual cues.

Ways to Ask About Abuse

First, be direct. Ask non-threatening questions and respond empathetically. Second, universalize the question rather than personalizing it. For example, “Many people are hurt physically or in other ways by someone they know. Is this happening to you?”

Make your questions gradual and exploratory, such as:

  • How are things going for you?
  • What kinds of stresses do you have in your everyday life?
  • Is there anyone in your life who is pretty strict, or hard to please?
  • Do you get blamed a lot?
  • Can you disagree? What happens when you don’t agree?
  • Have there been situations in which you felt afraid?
  • How often are you called names? How often are your feelings hurt?
  • Are you ever threatened with forced sex, been pushed or shoved, had your hair pulled or been slapped?
  • Have you had things thrown at you?
  • Have any of your precious possessions been deliberately broken?
  • Have your pets, children, grandchildren, or other people close to you been intentionally hurt?
  • Are you ever prevented from leave the house, or from seeing friends or family?
  • Do you feel safe in your home?
  • Should I be concerned for your safety?

Supportive Ways to Respond

When talking with victims of abuse:

  • Allow time for the person to speak.
  • Listen.
  • Believe what the person says.
  • Empathize: validate the person’s feelings.
  • Make it clear that the abuse was wrong and it was not the victim’s fault.
  • Speak directly about the violence.
  • Ask in what ways you can be helpful.
  • Respect the person’s right to self-determination.
  • Assure the person there are resources to help and that he or she is not alone.
  • Discuss a safety plan and offer followup contacts.

Communication Don’ts

When talking with victims of abuse:

  • DON’T talk to the victim while others are present. Confidentiality and privacy are essential and the presence of others may interfere with information the victim wants to provide, particularly if the perpetrator is present.
  • DON’T blame the victim. Societal attitudes often blame the victim for the abusive situation. This is extremely harmful to the victim and may result in an inability to trust.
  • DON’T tell the victim it is not that bad or minimize the pain. The shame and fear he or she feels is natural.
  • DON’T check out the story with the abuser. Talking with abusers may tip them off to a possible evaluation. This not only hinders the evaluation but may also endanger the victim.
  • DON’T demand that the victim take a certain course of action. You may offer suggestions, but it is necessary for him or her to be comfortable with the plan of recourse.
  • DON’T think you have failed if you did not fix the situation. Many abusive situations indicate long-entrenched patterns of behavior. To assume that you can always alleviate the situation by reporting the abuse or other action is unrealistic.

Try to establish whether the victim is competent and does or does not want help, or whether he or she is incompetent to make decisions. If he or she is not competent, someone else is needed to make decisions for that person. In some cases the victim is competent to make decisions but there are barriers to that person’s being able to ask for or accept help.

Prevention of Abuse

All health and human service professionals have a role in preventing abuse, but particularly those who provide care to dependent adults in facilities, agencies, and programs. Criminal background checks are an important first step in hiring new employees.

The general public also needs greater awareness of the prevalence of dependent adult abuse, how to recognize the signs of abuse, and what to do when they suspect abuse. Professionals can help increase public awareness of this hidden crime.

As noted earlier, employers must complete all legally mandated criminal and abuse background checks including checks of child abuse and sex offender registries when applicable [Iowa Code 235B.6(2)(c); 235B.6(2)(3); 135C.33].

Public Awareness

Anyone can help raise public awareness about dependent adult abuse. Resources include:

  • Work with local area agency on aging or the Department on Aging (IDA) public awareness campaign. Put up flyers or notices around your workplace, talk to friends and colleagues, or encourage local radio and TV stations to broadcast public service announcements.
  • Publicize the dependent adult abuse hotlines.
    • Abuse in the community—DHS: 800 362 2178
    • Abuse in facilities or programs—DIA: 877 686 0027
    • Medicaid fraud—DIA: 515 281 5717 or 515 281 7086
    • Information on elder abuse: LifeLong Links: 866 468 7887
  • Encourage people to volunteer in healthcare facilities, at domestic violence shelters, and as respite caretakers.
  • Invite a speaker with professional experience with dependent adults to speak to an organization to which you belong.
  • Encourage people to identify dependent or older adults in the community who may be at risk.

Ten Tips for Preventing Abuse

The following list suggests actions that are designed to prevent abuse and to help the family and caretaker develop effective coping mechanisms and support systems:

  1. Assess the person for signs of abuse/neglect. Early identification is essential to break a pattern of abuse or neglect.
  2. Assess the family at risk for abuse or neglect, and intervene as necessary before abuse occurs. Identifying high-risk families can stop abuse before it starts.
  3. Develop a trusting relationship with the dependent adult and their relatives. This promotes open discussion of difficulties.
  4. Offer guidance in caregiving. The caretaker may lack information on how to properly care for the person.
  5. Provide information about community resources and alternative living arrangements before an older person moves in with an adult child. Knowledge of options and services can help avoid situations that may lead to abuse.
  6. Encourage the caretaker to join a self-help group and/or to use respite services. Discussion groups provide education and support. They also help relieve frustration.
  7. Emphasize the importance of social involvement. Using multiple support sources lessens the caretaker’s responsibilities and increases the older adult’s sense of independence.
  8. Report suspected abuse accurately. Use direct quotes and give specific descriptions of physical findings. Sketches and photographs of injuries may be extremely helpful. Accurate and comprehensive documentation is essential for diagnosis and intervention by legal or social services.
  9. Consult a social worker about referring the person to community agencies or providing alternative living arrangements. This encourages her/him to choose formal support services that maximize independence and enhance well-being.
  10. Discuss the possibility of alternative living arrangements to prevent abuse or neglect. If appropriate, the dependent adult may need to relocate to live with relatives, friends, or in a boarding home, retirement community, or healthcare facility.

Resources and References

State Resources

Abuse Reporting–Dependent Adults, Department of Human Services

The Dependent Adult Abuse program provides evaluations and assessments of alleged abused dependent adults. The program attempts to provide services and makes referrals to assist abused dependent adults acquire safe living arrangements. Reports of suspected abuse of dependent adults (or of children) can be made to your local DHS office or to the toll-free hot line:

800 362 2178 (24/7)
Catherine Stack, Program Manager
Hoover Bldg., 1305 E Walnut St
Des Moines, IA 50319-0114
515 281 5392

cstack@dhs.state.ia.us
http://dhs.iowa.gov/dependent_adult_abuse
List of county DHS offices: http://dhs.iowa.gov/dhs_office_locator

Children & Families of Iowa

Children & Families of Iowa operates the Iowa Domestic Violence Hotline, a toll-free service for victims, loved ones and community members. Certified Domestic Violence Advocates are here 24 hours a day to provide crisis support, help victims find safe solutions across the state, answer questions, and provide resource referrals.

515 288 1981
email: contactus@cfiowa.org
web: http://www.cfiowa.org/Iowa
Domestic Violence Hotline: 800 942 0333

Iowa Department on Aging

The mission of the Iowa Department on Aging is to develop a comprehensive, coordinated and cost-effective system of long term living and community support services that help individuals maintain health and independence in their homes and communities. The Department’s vision is to work closely with Iowa’s six Area Agencies on Aging and other partners to design a system of information, education and long-term services and supports that results in Iowa being considered the best state for older adults to live in and retire.

510 E 12th Street, Suite 2
Des Moines, IA 50319-9025

515 725 3333
Toll-free: 800 532 3213
TTY: 515 725 3333
contactida@iowa.gov

https://www.iowaaging.gov/

Area Agencies on Aging

Under the Older Americans Act, the Iowa Department on Aging has designated six Area Agencies on Aging (AAAs) to provide information and referrals to older adults, adults with disabilities, veterans and their caregivers, and coordinate a wide range of long-term living and community support services, such as case management, congregate and home-delivered meals, employment services, family caregiver services, options counseling, respite care and transportation services. Maps, information, and online and printable lists of all the individual agencies are available from the website.

https://www.iowaaging.gov/about/area-agencies-aging

Office of the State Long-Term Care Ombudsman

In Iowa, the Office of the State Long-Term Care Ombudsman (OSLTCO) is authorized by the federal Older Americans Act and the state Older Iowans Act. Operating as an independent entity within the Iowa Department on Aging, its mission is to protect the health, safety, welfare and rights of individuals residing in long-term care facilities by investigating complaints, seeking resolutions to problems and providing advocacy with the goal of enhancing quality of life and care.

Toll-free: 866 236 1430
https://www.iowaaging.gov/state-long-term-care-ombudsman

Iowa Senior Medicare Patrol (SMP)

Iowa Senior Medicare Patrol (SMP) is part of a nationwide, grassroots education and assistance program working to empower seniors and caregivers to protect personal information and Medicare benefits by learning to detect mistakes or potential fraud in Medicare payments. You can report suspected problems to SMP. Our staff and trained volunteers work to correct errors and report abuse of the Medicare system to government authorities.

Northeast Iowa Area Agency on Aging
2101 Kimball Ave., Suite 320
Waterloo, IA 50702
800 423 2449

IowaSMP@nei3a.og
http://www.nei3a.org/our-services/senior-medical-patrol.aspx

Older Iowans Legislature (OIL)

The Older Iowans Legislature is a statewide non-partisan, non-profit volunteer organization. Its members advocate for state legislators and the Governor to sign legislation that will result in an improved “Quality of Life for Older Iowans”. The Older Iowans Legislature places special emphasis on the frail elderly; those citizens who have contributed much to our society, but have exhausted their resources and in need of assistance to lead meaningful lives.

5835 Grand Avenue, Suite 106
Des Moines, IA 50312-1437
info@olderiowans.org
http://www.olderiowans.org/

University of Iowa Center on Aging

The University of Iowa Center on Aging is an interdisciplinary resource for aging-related interests and activities throughout the University community and the state.

University of Iowa
2159 Westlawn
Iowa City, IA 52242
319 335 6576
center-on-aging@uiowa.edu
https://aging.uiowa.edu/

Iowa Legislature

Main search site for Iowa Code and legislative documents.

https://www.legis.iowa.gov/

Crime Victim Assistance Division (Office of the Attorney General)

515 281 5044
800 373 5044

Medicaid Fraud Control Unit

The unit conducts investigations of alleged abuse and neglect of residents in long-term care facilities that receive Medicaid reimbursements from the federal government. Investigators also look into allegations that residents have been defrauded of personal funds or possessions.

Department of Inspections and Appeals
Medicaid Fraud Control Unit
Lucas State Office Building – Third Floor
321 E 12th Street
Des Moines, IA 50319
Phone: 800 831 1394

Bureau of Professional Licensure

515 281 0254

Nursing Home Complaint Hotline (DIA)

877 686 0027

National Resources

National Center on Elder Abuse

The NCEA provides the latest information regarding research, training, best practices, news and resources on elder abuse, neglect and exploitation to professionals and the public. First established by the U.S. Administration on Aging (AoA) in 1988 as a national elder abuse resource center, the NCEA was granted a permanent home at AoA in the 1992 amendments made to Title II of the Older Americans Act.

National Center on Elder Abuse
c/o University of Southern California Keck School of Medicine
Department of Family Medicine and Geriatrics
1000 South Fremont Avenue, Unit 22, Building A-6
Alhambra, CA 91803
855 500 3537 (855 500 ELDR)
626 457 4090 (fax)

ncea-info@aoa.hhs.gov
https://ncea.acl.gov/

U.S. Department of Veterans Affairs

VA benefits: 800 827 1000

Social Security Administration

To report suspected fraud, waste, or abuse related to Social Security or Supplemental Security Income (SSI) payments.

Social Security Fraud Hotline
PO Box 17785
Baltimore, Maryland 21235
https://oig.ssa.gov/report-fraud-waste-or-abuse/fraud-waste-and-abuse
800 269 0271 (10 am–4 pm EST)
866 501 2101 (TTY)

Note: If unable to reach a representative on the Fraud Hotline during open hours, you can report Social Security program fraud directly to any Social Security office, including representatives at the SSA’s toll-free number, 800 772 1213, 7 am to 7 pm. SSA employees will take your information and send it directly to our office.

Medicare Fraud Hotline

https://www.medicare.gov/forms-help-and-resources/report-fraud-and-abuse/fraud-and-abuse.html

To report suspected errors, fraud, or abuse, you can contact either:

HHS Office of Inspector General

Toll-free: 800 447 8477
TTY: 800 377 4950
https://forms.oig.hhs.gov/hotlineoperations/report-fraud-form.aspx

or

Centers for Medicare & Medicaid Services

800 633 4227
877 486 2048 (TTY)
Medicare Beneficiary Contact Center, P.O. Box 39, Lawrence, KS 66044

 

References

Acierno R; Hernandez-Tejada M; Muzzy W, Steve K. (2009). National Elder Mistreatment Study (National Institute of Justice). Retrieved March 5, 2017 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804623/ or https://www.ncjrs.gov/pdffiles1/nij/grants/226456.pdf.

Brault M. (2012). Americans with Disabilities, 2010: Household Economic Studies, Current Population Reports, US Census Bureau. Retrieved April 4, 2017 from https://www.census.gov/newsroom/cspan/disability/20120726_cspan_disability_slides.pdf or http://www.census.gov/prod/2012pubs/p70-131.pdf.

Erickson W, Lee C, von Schrader S. (2016). 2015 Disability Status Report: Iowa. Ithaca, NY: Cornell University Yang Tan Institute on Employment and Disability (YTI). Retrieved April 6, 2017 from http://www.disabilitystatistics.org/StatusReports/2015-PDF/2015-StatusReport_IA.pdf.

Iowa Department of Human Services (IDHS). (2017). Dependent Adult Abuse Statistical Report, For Division DHS, Through Periods 7/1/2016–12/31/2016. Report Series D-3. Retrieved April 6, 2017 from http://dhs.iowa.gov/sites/default/files/5.DARpt_July2016-Dec%202016.pdf.

Iowa Department of Human Services (IDHS). (2016). Dependent Adult Abuse Statistical Report, For Division DHS, Through Periods 1/1/2016–6/30/2016. Report Series D-3. Retrieved April 6, 2017 http://dhs.iowa.gov/sites/default/files/4.DARpt_Jan2016-June%202016.pdf.

Iowa Department of Human Services (IDHS). (2009/2010). Dependent Adult Abuse: A Guide for Mandatory Reporters. Retrieved March 5, 2017 from https://dhs.iowa.gov/sites/default/files/comm118.pdf. [Document contains changes made through July 2010.]

Iowa Department of Justice/Office of the Attorney General (IDJ/OAG). (2017). For Older Iowans. Retrieved April 6, 2017 from https://www.iowaattorneygeneral.gov/for-consumers/for-older-iowans/.

Iowa Department of Justice/Office of the Attorney General (IDJ/OAG). (2016). Elder Abuse, Neglect, and Exploitation: Legal Resources & Remedies Booklet. ILAST. Retrieved April 6, 2017 from https://www.iowaattorneygeneral.gov/media/cms/
091916__Complete_LRM_552547A9BE517.pdf.

Iowa Department on Aging (IDA). (2016). State of Iowa’s Trainer’s Guide on Dependent Adult Abuse for Mandatory Reporters. Revised July 2015. Reapproved July 2016. Retrieved March 5, 2017 from https://www.iowaaging.gov/state-iowas-trainers-guide-approved-2016-0. [Curriculum includes 17 files that encompass background material and a Participants Handbook.]

Iowa Legal Aid. (2014). Protecting Elderly Iowans from Abuse. Retrieved April 1, 2017 from http://www.iowalegalaid.org/resource/elder-abuse-what-it-is-and-what-to-do-about-i.

Iowa Legislature. (2017). Iowa Code—2017. Retrieved March 2017 from https://www.legis.iowa.gov/law/statutory.

Chapter 235E, Dependent adult abuse in facilities and programs. https://www.legis.iowa.gov/docs/ico/code/235E.pdf.

Chapter 235B, Dependent Adult Abuse Services-Information Registry https://www.legis.iowa.gov/docs/ico/code/235B.pdf.

Iowa, State Data Center of (IowaSDC). (2016). Older Iowans: 2016 (May 2016). Retrieved April 5, 2017 from http://www.iowadatacenter.org/Publications/older2016.pdf.

Iowa, State Data Center of (IowaSDC). (2016a). Iowans with Disabilities: 2016. Retrieved April 6, 2017 from http://www.iowadatacenter.org/Publications/disabilities2016.pdf.

Lopes MA, Erikson F, Furtado EF, et al. (2010, January 26). Prevalence of alcohol-related problems in an elderly population and their association with cognitive impairment and dementia. Alcoholism: Clinical and Experimental Research. doi: 10.1111/j.1530-0277.2009.01142.x.

Lowenstein A. (2009). Elder abuse and neglect, “old phenomenon”: New directions for research, legislation, and service developments. Lecture, Rosalie S. Wolf Memorial Elder Abuse Prevention Award, International Category. Journal of Elder Abuse and Neglect 21(3):278–87.

Mann L, Feddes AR, Leiser A,Doosje B, and Fischer AH. (2017). When Is Humiliation More Intense? The Role of Audience Laughter and Threats to the Self. Front. Psychol. Retrieved August 8, 2018 from https://www.frontiersin.org/articles/10.3389/fpsyg.2017.00495/full.

National Adult Protective Services Association (NAPSA). (2017). Policy & Advocacy. Elder Financial Exploitation. Retrieved April 6, 2017 from http://www.napsa-now.org/policy-advocacy/exploitation/.

National Center on Elder Abuse (NCEA). (2012). Abuse of Adults with a Disability. Retrieved April 6, 2017 from https://ncea.acl.gov/resources/docs/Abuse-Adults-Disabilities-2012.pdf.

National Center on Elder Abuse (NCEA). (1998). National Elder Abuse Incidence Study. Administration on Aging, U. S. Department of Health and Human Services. Retrieved April 6, 2017 from https://aoa.acl.gov/aoa_programs/elder_rights/ELDER_ABUSE/Index.aspx.

National Institute of Justice (NIJ). (2015). Extent of Elder Abuse Victimization. Retrieved April 4, 2017 from https://www.nij.gov/topics/crime/elder-abuse/Pages/extent.aspx.

National Research Council. (2003). Elder Mistreatment: Abuse, Neglect and Exploitation in an Aging America. Panel to Review Risk and Prevalence of Elder Abuse and Neglect. Retrieved April 18, 2014 from http://www.nap.edu/openbook.php?record_id=10406&page=R1.

U.S. Administration on Aging (USAOA). (2016). Profile of Older Americans: 2016. Retrieved March 10, 2017 from https://aoa.acl.gov/Aging_Statistics/Profile/index.aspx.

U.S. Administration on Aging (USAOA). (2016a). Older Americans Act Reauthorization Act of 2016. Retrieved April 6, 2017 from https://aoa.acl.gov/AoA_Programs/OAA/Introduction.aspx.

Post Test

Use the answer sheet following the test to record your answers.


  • a. Only those over 85 whose physical and/or mental condition makes them dependent on others for care or protection.
  • b. Anyone under 18 whose physical and/or mental condition makes them dependent on others for care or protection.
  • c. Anyone over 18 whose physical and/or mental condition makes them dependent on others for care or protection.
  • d. Only those over 65 whose physical and/or mental condition makes them dependent on others for care or protection.


  • a. Income.
  • b. Gender.
  • c. Alcoholism.
  • d. Low levels of social support.


  • a. Partners, spouses, children, or other relatives.
  • b. Home intruders, muggers, or other criminals.
  • c. Caretakers and healthcare personnel.
  • d. Accountants, financial advisors, and bankers.


  • a. True
  • b. False


  • a. They fear retaliation by the abuser.
  • b. They have a history of complaining.
  • c. They have a history of abuse.
  • d. They lack confidence that someone will care.


  • a. Retaliation.
  • b. Unresolved conflict.
  • c. Close family ties.
  • d. History of alcohol and drug abuse.


  • a. Provide a single, statewide source of information.
  • b. Collect data for future legislation.
  • c. Provide law enforcement with background checks.
  • d. Encourage each locality to establish its own registry.


  • a. Suspend the caregiver until further notice.
  • b. Investigate the family for any previous infractions of the law.
  • c. Notify law enforcement immediately.
  • d. Begin an appropriate evaluation or assessment.


  • a. Over age 21 and living with parents.
  • b. Over age 18 and requires assistance with self-care.
  • c. Past their 16th birthday and truant from school.
  • d. Over age 18 with an unconventional lifestyle.


  • a. True
  • b. False


  • a. True
  • b. False


  • a. Reminiscing about earlier sexual exploits.
  • b. Sexual exploitation by a counselor or therapist.
  • c. Joking about sexual scenes on TV.
  • d. Teasing residents about their attraction for one another.


  • a. True
  • b. False


  • a. Person’s checkbook has not been balanced for more than 3 months.
  • b. Person claims to be the “black sheep” of the family.
  • c. Unexplained weight gain is noted.
  • d. Lifestyle is not reflective of income or assets.


  • a. Withholding food or medications.
  • b. Failure to provide physical aids such as hearing aids.
  • c. Withholding TV privileges.
  • d. Failure to provide safety precautions.


  • a. True
  • b. False


  • a. Show special interest through gifts, touching, or setting up time to be alone.
  • b. Gain trust by being meticulous about caretaker duties.
  • c. Take care of the person’s physical needs.
  • d. Pay attention to hairdressing.


  • a. Report it to law enforcement.
  • b. Inform management of the healthcare facility.
  • c. Report it orally or in writing to DHS or DIA within 24 hours.
  • d. Talk to the suspected abuser to try to persuade a change in behavior.


  • a. When the abuse occurred.
  • b. After you have reported it to your supervisor.
  • c. The first full day after you suspect abuse.
  • d. When you first suspect abuse.


  • a. Prevents the release of information except to a legal representative of the patient.
  • b. Insists that mandated reporters be identified publicly to ensure fairness.
  • c. Waives the rule preventing release of information about patients.
  • d. Ensures immunity from any liability for Iowa reporters.


  • a. Founded with cause; founded without cause; and unfounded.
  • b. True; not true; and undetermined.
  • c. Founded; unfounded; and confirmed, not registered.
  • d. Founded; not founded; and confirmed.


  • a. True
  • b. False


  • a. Tell the individual about appropriate advocacy groups.
  • b. Offer several suggestions that you think would be best for the person.
  • c. Take a firm hand in planning for the person, who is probably traumatized.
  • d. Think of the person as needy and vulnerable.


  • a. Take the lead in conversation about the abuse.
  • b. Make sure they understand that it was not their fault.
  • c. Try to lighten the mood with humor.
  • d. Urge them to share their experience with other residents.

Answer Sheet

IA: Abuse of Dependent Adults

Name (Please print your name):
 
Date:
 

Passing score is 80%


Course Evaluation

Please use this scale for your course evaluation. Items with asterisks * are required.

  • 5 = Strongly agree
  • 4 = Agree
  • 3 = Neutral
  • 2 = Disagree
  • 1 = Strongly disagree
  1. *
    Upon completion of the course, I was able to:
      • 5
      • 4
      • 3
      • 2
      • 1
      • 5
      • 4
      • 3
      • 2
      • 1
      • 5
      • 4
      • 3
      • 2
      • 1
      • 5
      • 4
      • 3
      • 2
      • 1
      • 5
      • 4
      • 3
      • 2
      • 1
      • 5
      • 4
      • 3
      • 2
      • 1
      • 5
      • 4
      • 3
      • 2
      • 1
      • 5
      • 4
      • 3
      • 2
      • 1
      • 5
      • 4
      • 3
      • 2
      • 1
      • 5
      • 4
      • 3
      • 2
      • 1
      • 5
      • 4
      • 3
      • 2
      • 1
      • 5
      • 4
      • 3
      • 2
      • 1
      • 5
      • 4
      • 3
      • 2
      • 1
      • 5
      • 4
      • 3
      • 2
      • 1
  2. *
    The author(s) are knowledgeable about the subject matter.
    • 5
    • 4
    • 3
    • 2
    • 1
  3. *
    The author(s) cited evidence that supported the material presented.
    • 5
    • 4
    • 3
    • 2
    • 1
  4. *
    This course contained no discriminatory or prejudicial language.
    • Yes
    • No
  5. *
    The course was free of commercial bias and product promotion.
    • Yes
    • No
  6. *
    As a result of what you have learned, do you intend to make any changes in your practice?
    • Yes
    • No
  7. If you answered Yes above, what changes do you intend to make? If you answered No, please explain why.
  8. *
    Do you intend to return to ATrain for your ongoing CE needs?
    • Yes, within the next 30 days.
    • Yes, during my next renewal cycle.
    • Maybe, not sure.
    • No, I only needed this one course.
  9. *
    Would you recommend ATrain Education to a friend, co-worker, or colleague?
    • Yes, definitely.
    • Possibly.
    • No, not at this time.
  10. *
    What is your overall satsfaction with this learning activity?
    • 5
    • 4
    • 3
    • 2
    • 1
  11. *
    Navigating the ATrain Education website was:
    • Easy.
    • Somewhat easy.
    • Not at all easy.
  12. *
    How long did it take you to complete this course, posttest, and course evaluation?
    • 60 minutes (or more) per contact hour
    • 50-59 minutes per contact hour
    • 40-49 minutes per contact hour
    • 30-39 minutes per contact hour
    • Less than 30 minutes per contact hour
  13. I heard about ATrain Education from:
    • Government or Department of Health website.
    • State board or professional association.
    • Searching the Internet.
    • A friend.
    • An advertisement.
    • I am a returning customer.
    • My employer.
    • Other
    • Social Media (FB, Twitter, LinkedIn, etc)
  14. Please let us know your age group to help us meet your professional needs.
    • 18 to 30
    • 31 to 45
    • 46+
  15. I completed this course on:
    • My own or a friend's computer.
    • A computer at work.
    • A library computer.
    • A tablet.
    • A cellphone.
    • A paper copy of the course.

Please enter your comments or suggestions here:
 
 
 
 
Registration Form

Please print and answer all of the following questions (* required).

*Name:
 
*Email:
 
*Address:
 
*City:
 
*State:
 
*Zip:
 
*Country:
 
*Phone:
 
*Professional Credentials/Designations:
 

Your name and credentials/designations will appear on your certificate.

*License Number and State:
 

*Please email my certificate:

(If you request an email certificate we will not send a copy of the certificate by US Mail.)

Payment Options

You may pay by credit card or by check.
Fill out this section only if you are paying by credit card.
2 contact hours: $19

Credit card information

*Name:
 
Address (if different from above):
 
*City:
 
*State:
 
*Zip:
 
*Card type:
*Card number:
 
*CVS#:
 
*Expiration date: