Members Present
Sergeant Margaret Bahnson Joyce DeMonnin (on behalf of Jerry Cohen) Repesentative Vic Gilliam Ruth Gulyas Regine Goerke Representative Val Hoyle Mary Jaeger	Bob Joondeph Erinn Kelley-Siel Debra Buck (On behalf of Holly Mercer) Lucy Morgan Meghan Moyer Bill Olson Dr. Laurie E. Powers	Lauren Rhoades Rodney Schroeder Tina Treasure (on behalf of Sherry Stock) Matthew Smith John Thompson Kathryn Weit John D. Wentworth

 

Members Excused	Guests	Staff Present
Sen. Jackie Winters Sen. Floyd Prozanski	Nelsa Brodie James Toews Diana Norton Marie Cervantes Eva Kutas Karen Mainzer Julie Strauss Karen Mainzer Jeremy Emerson Marylee Fay Petronella Donovan Grover Simmons	Bill Lynch, Facilitator Carolyn Wilson Dawn Rustrum Kelsi Eisele

 

 
 

 

Erinn Kelley-Siel, Director, Department of Human Services, introduced herself and asked members to introduce themselves. Members introduced themselves.

 

Bill Lynch, Facilitator, briefly discussed the agenda for the meeting, highlighting a few revisions in regards to time allotments for presenters . Members reviewed the draft minutes, ground rules and charge of the group. Members were given an opportunity to suggest revisions to the minutes. No revisions were requested.

 

Bill Lynch encouraged members to review the redacted reports that were sent out electronically and shared that the group will have an opportunity to discuss them at the next meeting. He briefly touched on the focus of this meeting, the previous meeting, and upcoming meetings as identified on the handout that includes the groups' charge. Bill also reminded members that there's a feedback loop in place so they can submit comments in between meetings via the following email address: aps.safety@state.or.us

 

Eva Kutas, Director, Office of Investigations and Training, Department of Human Services, introduced Holly Ramsey-Klawsnik, Ph.D. and pointed members to an article in the packet that includes biographical information about her.

 

Holly presented on the following:

• Topics to be discussed:
  • Problems in facility sexual abuse investigations revealed through research
  • National and Oregon selected results
  • Press article findings
  • Feedback re: OR facility investigations based upon limited case review (3)
• The Sexual Abuse of Vulnerable Adults in Facilities: Research Findings in
  Oregon and Nationally - Pamela B. Teaster, Ph.D. & Holly Ramsey-Klawsnik, Ph.D.
• Participants of study:
  • Oregon APS
  • New Hampshire APS
  • Tennessee APS
  • Texas APS
  • Texas DADS
  • Wisconsin APS/Elder Abuse
  • Wisconsin BQA
• Methods:
  • Three-year National Institute on Aging study
  • Sexual Abuse Survey
  • Data collected and analyzed on all cases reported May 1, 2005 - October 31, 2005
  • Interviews with 15% of investigators
• Total investigations: Oregon – 43, All States - 429
• Major problems revealed:
  • Delays in reports to APS
  • Delays in APS commencing investigations
  • Failing to obtain independent, timely, forensic exams
  • Contamination of AV interviews
  • Failing to interview alleged perpetrators
  • Applying incorrect standard of evidence = under-substantiation
  • Differentiate handling: staff & residents APs
  • Failure to offer intervention to AVs
  • Insufficient response of law enforcement
• Terminology
  • AP vs RP
  • AV vs RV
• Comparison:
  • Oregon to All States Findings (Note: All states stats include OR)
  • Investigated sexual abuse cases
  • Time frames means
  • Results:
    • Time delays between incident and commencement of investigation caused tremendous loss of evidence
    • Handicapped the investigators (both APS and LE) from the onset
    • Contributed to low sub and arrest rates
  • Finding:
    • OR did significantly better than other states
    • However, time delays still too long (mean of 5 days)
    • Any steps that can lessen delays will result in better investigation and victim protection
  • Time frames
    • Report to investigation, substantiated and un-substantiated
  • Contamination: AV interviews
    • Communication remedies used
    • In 22 of 312 ALL AV interviews
    • In 2 of 32 OR AV interviews
    • Despite many AVs with communication barriers
    • In some cases, others allowed to be present during AV interview
    • Facility staff
    • Facility administration
    • Facility interns
    • Suggestive questioning of alleged victim by facility staff prior to APS interview cited as problem by investigators interviewed
  • AP interviews
  • Physical exams
  • Top interventions offered
  • Staff vs. resident APs
  • Arrests resulting
  • Lack of arrests
  • Interview data revealed:
    • Difficulties faced by investigators
    • Lack of understanding re: correct standard of evidence
    • Need for more training regarding both sexual assault and forensic investigation
  • Looking for proof:
    • "I just couldn't prove it"
    • "The medical exam showed no sign of SA therefore I unsub'ed"
    • "I base a lot on the medical exam"
    • "I'm pretty certain SA occurred – without proof had to unsub"
    • "To confirm sexual abuse I have to be really really confident that there is a witness and that there is physical evidence"
  • Need for training:
    • "If it had been a rape a rape exam could prove things one way or another"
    • "Hard to substantiate without semen"
    • "Male staff used the toilet while female client was in the bathtub in room - it was not sexual abuse."
    • "The AV was not harmed or traumatized so I unsub'ed"
    • "The AV did not seem upset" (unsub'ed)
  • Need for training revealed:
    • "The AP (staff) fit the profile - he used pornography at work" (unsub'ed)
    • AP not interviewed because he had left facility employment - attending nursing school
  • Press article:
    • 73 of 350 alleged sexual abuse cases substantiated = 21% (18.2% nationally)
    • 14 arrests = 4% (7% nationally)
  • Feedback Based Upon Selected Case Review
  • Global Suggestions
    • Confidentiality
    • Who is the RP?
      • "RP" is facility in sexual abuse cases rather than the actual alleged sexual offender
      • Resident accused perpetrator is called an "RV"
      • Rec: Name the alleged sexual offender as the RP and the facility as RP for neglect if accused of negligence
    • Amount of info:
      • Dearth of info in the investigation report
      • A reviewer is unable to evaluate the quality of the investigation - both forensic and clinical quality
      • No description of the AV and his/her special needs, vulnerability, or ability to self-protect or provide information
      • No description provided of interview circumstances - timing, location, who present, etc.
      • No description of investigative techniques or questions asked
  • Provided feedback on three Oregon cases reviewed and pointed out areas of concern are where Oregon has room for improvement

Questions and Answers

• Detective Matt Smith asked if there were cases where forensic evaluations and/or rape kits were done on victims with dementia or on individuals who were non communicative and if so, how did they facilitate the exams to take place. Holly responded that yes, many alleged victims had dementia and then explained that the people who do the forensic evaluations have ethics that they are required to follow and that they are not allowed to force someone who lacks capacity to undergo any procedure. She then explained the process they go through to make a determination of when and how to proceed.
• Bill Lynch asked if Holly's recommendations for Oregon are summarized in one location or just located throughout the power point presentation. Holly responded that they are summarized.
• Meghan Moyer asked for clarification regarding the population of individuals represented in the presentation. Holly responded that the population consists of vulnerable adults with any type of disability.
• Rep. Vic Gilliam asked for Holly's observations about the study and how other states stacked up against Oregon in terms of the issues she pointed out that appear to exist in Oregon's system. Holly responded that in the study, they didn't actually review any investigation reports so the information she presented was based solely on her observations from reviewing three investigation reports provided by APS in Oregon but that in her work as a consultant she has reviewed investigation reports from other states and they typically provide more detailed information than what she saw in the reports from Oregon.
• Bob Joondeph commented that he was interested in her comments about resident to resident abuse and who the perpetrator is and shared that it brought up questions in his mind regarding the appropriate way to view the investigation in terms of determining culpability as well as getting the facts out. He asked Holly if when the investigator is weighing in, whether or not they are also making a determination of culpability. Holly responded that they typically are since they are charged with the responsibility of substantiating cases and naming perpetrators.
• Detective Matt Smith asked if Holly knows of other states that have formal training for APS workers on how to conduct an interview or interrogation and then how to properly document it in a report. Holly responded that she is familiar with training programs in other states and described the training program that exists in Massachusetts. She clarified that even in states that have training programs, the training is often not sufficient.
• Tina Treasure asked if Holly has any investigation report content samples or a checklist of pertinent information that should be included in a report. Holly recommended posting on the elder abuse listserv to ask for forms and template samples from other states.
• Meghan Moyer asked for clarification regarding which facility types where included in the investigation reports that were provided to Holly. Marie Cervantes explained that the ten cases were mixed facility types and included seniors over 65 or adults with physical disabilities.
• Bob Joondeph offered an observation that in the course of his work, he reviews un-redacted investigation reports and that questions are often raised because of the lack of information included in the reports. He pointed out that there isn't a process in place to provide feedback on the reports.
• Erinn Kelley-Siel asked if there are any national best practice models that are evolving around investigation and documenting of investigations and investigative practice that she could recommend to Oregon. Holly responded that she is not aware of such a resource but that one place to look would be the power point presentation she used in Oregon last June. She recommended getting a copy of the presentation from Eva Kutas.
• Erinn Kelley-Siel asked Holly for her recommendations regarding what kinds of changes would have the greatest impact. Holly replied with four suggestions 1) shorten time frames, 2) offer forensic exams, 3) training of investigators, and 4) collaboration with law enforcement from the very beginning.

After the presentation, members discussed whether or not to have Holly review the other seven cases sent by Oregon. There was consensus not to have her review the remaining cases.

Additional comments and observations:

• Meghan Moyer shared that she thought Holly's perspective was incredibly helpful and pointed out that the lack of detail in the reports would make it difficult for someone who had not done the investigation to make determinations about the cases.
• Joyce DeMonnin reflected back to 10 years ago when she and others participated in a sexual assault training for adult protective services, advocates, and law enforcement and pointed out that it has been a long time since there was a statewide training on the topic. She also shared she was taken back by the amount of time it takes between a report of abuse and when the investigation commences.
• Kathryn Weit expressed interest in hearing a critique from those involved in the APS system to learn about issues they see from their perspective.
• Regine Goerke shared from her perspective as someone on the frontlines who is doing the APS investigation work that Holly's presentation resonated with her in many ways. Regine said that many of the problems Holly pointed out are the result of some sort of dilemma investigators are faced with in the field. She offered that interviewing training from the law enforcement angle would be very valuable. Regine also mentioned that often times, the focus of the investigation is to determine whether or not the facility has done something wrong and said that Holly raised an interesting point regarding whether or not that is the primary focus or if the focus should be on protection of the victim.
• Lauren Rhoades mentioned SB 557 which creates sexual abuse response taskforces in a variety of settings and encouraged the group to take a closer look at the bill. Bill Lynch asked for the bill to be added to the list of bills presented during the first meeting. Fred Steele agreed to do so.

John Wentworth, Deputy District Attorney, Clackamas County District Attorney's office, introduced himself and talked about the Clackamas County Multi-Disciplinary Team Vulnerable Adult Abuse Protocol that he's been involved with developing. He touched on the following:

• SYSTEMIC GAPS
• COMMUNICATION
  • Change mindset
  • • Social services need to report more to law enforcement.
    • Law enforcement needs to report more to social services.
    • Yes, we want to know about allpotential crimes.
  • Work together in investigations.
  • Use child welfare as a template?
  • Social service reports vs. law enforcement reports
    • Speak the same language
    • "RP" for DHS vs. "RP" for law enforcement, for example.
    • If you need a key, the report isn't easy to read.
  • Encourage getting the DA involved early in the investigation.
• PROTOCOL (HB 2442)
  • Generally
    • Follow HB 2442
    • Wanted to be more inclusive than statutorily mandated.
  • Identity Crisis (refer to p.4 of protocol)
    • What is the name of my agency?
    • Why types of cases do my agency handle?
      • Working cases not specific to that agency.
      • Not working cases specific to that agency.
    • Who handles the other types of cases?
    • Training among agencies is required.
  • Who to Call? (refer to p. 12 of protocol)
    • Three (actually, four) different phone numbers.
    • Prefer one phone number.
  • Reporting Allegations of Abuse: Six different standards!
    • Elders
    • Physically disabled
    • Developmentally disabled
    • Mental illness
    • Nursing homes
    • Child abuse
  • Not confident mandatory reporters are aware they are mandatory reporters. Notice.
  • Report Received (refer to p. 13 of protocol)
    • Social Service Report to Law Enforcement
      • When a report of a [possible crime] crime of abuse
      • is received by [the department] the social service agency
      • [under ORS 124.060] vs. [from a mandatory reporter]
      • [the department] the agency
      • [shall notify] shall notify by fax
      • The law enforcement agency having jurisdiction within the county where the report is made.
    • But, what if you knowit happened in another county?
    • Phone call vs. fax vs. email?
      • What form?
      • To whom?
• TRAINING
  • Only one statewide training in last 7 years?
  • Within own agencies
    • Mandatory reporting
    • What info is needed to substantiate/prove the case?
  • About other agencies
    • Who investigates?
    • Under what circumstances?
    • What are the investigative limitations?
    • How do we collaborate with law enforcement? The DA's Office?
  • About the criminal justice system
    • What is a crime?
  • Law enforcement and prosecutors need to learn about vulnerable adults.
    • Agencies/ resources
    • Financial exploitation
      • Guardianships
      • Conservatorships
      • Powers of attorney
    • Particular vulnerabilities of victim
    • Common defenses
    • How to present complicated cases
• RESOURCE ISSUES
  • Greater expectation with less.
  • Aging population + budget cuts = Perfect Storm
• POSITIVES
  • Eagerness to collaborate
• MY GOAL AS A PROSECUTOR
  • Conviction represents the actual act committed.
  • Crime cannot be expunged so there is always a record for those in healthcare.
    • Legislative fix: Make crimes against vulnerable victims non-expungable just like child abuse.

Questions and Answers

• Jeremy Emerson asked John if they had considered partnering with 211 info to screen calls and make referrals. John responded that he was not aware of 211 info so it had not been considered.
• Bill Olson asked when the protocol was adopted and how long it took to develop. John responded that it is in the process of being adopted by the chiefs currently and that the other agencies have bought off on it. He shared that the protocol has taken quite a while to develop but now that there is a template in place, it would likely take other counties less time to implement it for their areas if they want to use it as a model.
• Erinn Kelley-Siel asked if John has a sense of how many of his peers are having success or difficulty in implementing a similar tool for their areas and if perhaps others are struggling because of a resource issue. John shared that he has heard that Multnomah, Washington, and Clackamas counties seem to be way further ahead than other counties around the state in getting a protocol in place.
• Erinn asked John for written documentation for areas of HB 2442 where clarification was necessary when creating the protocol. John responded that he'd get her the information.
• Regine asked if there is a way to help other counties move forward with implementing a protocol more quickly. John responded that he'd be willing to start sharing the progress he's made with his peers, encourage them to take a look at what has been implemented, and try to get them to move forward with implementing something as well.
• Eva Kutas mentioned that some folks, especially in more rural areas, are trying to leverage their child abuse teams to do some of this work.
• Bill Lynch suggested that maybe a recommendation of this group could be to develop some strategies to prompt counties who are not onboard yet.
• Erinn Kelley-Siel pointed out that the DAs raised concerns about resource issues when HB 2442 was moving through the legislative process and the legislature wasn't able to offer a resource for them at the time of passage of HB 2442. Erinn suggested one of the things the group should consider is raising this as a legislative issue to be addressed.
• Bob Joondeph thanked John for his presentation and shared from a lawyer's perspective, a common understanding of the issues John raised.
• Erinn Kelley-Siel suggested to the group that staff can use the taskforce recommendations tracker as a tool to keep track of ideas being raised by the group and that an updated tracker could be provided to the group at each meeting with the new ideas highlighted. There was consensus amongst the group to do so.
• Joyce DeMonnin raised the question of how to incorporate a sustainability model into the work the group is doing.

William Buckley, Manager, Criminal Records Unit, Department of Human Services, introduced himself and referred to his handout on mandating fingerprints for long-term care. He briefly discussed options to consider on page three of the document and some of the opposing points of view including that of the American Civil Liberties Union.

Bill Lynch asked members to review the list of options and be prepared to discuss them and potentially take some action on them at the next meeting.

Bill Lynch asked members to review the taskforce recommendations handout and the brainstorming recommendations from the first meeting of the group and said that they will have time to discuss them and take action on them as necessary during the next meeting.

No public comment.

Meeting adjourned at 4:30 pm