Hawaii Adult Protective Services Report — Vulnerable Adult Abuse / Neglect / Exploitation

HAWAII ADULT PROTECTIVE SERVICES REPORT — VULNERABLE ADULT ABUSE, NEGLECT, OR EXPLOITATION

TABLE OF CONTENTS

1. Header and Reporter Information
2. Statutory Basis for Report
3. Vulnerable Adult Information
4. Type of Abuse Reported
5. Narrative of Concern
6. Alleged Perpetrator(s)
7. Witnesses, Collaterals, and Other Reporters
8. Risk Assessment and Immediate Safety
9. Mandatory Reporter Certification
10. Hawaii APS Practice Notes
11. Sources and References

1. HEADER AND REPORTER INFORMATION

TO: State of Hawaii Department of Human Services
Social Services Division — Adult Protective and Community Services Branch (APCSB)
Adult Protective Services Section — [Oahu / Hawaii / Maui / Kauai] Unit

Statewide APS Intake (Oahu): (808) 832-5115
Toll-free (out-of-state): 1-888-380-3088
Online portal: https://apsreport.hawaii.gov
Mailing address (Oahu intake): 810 Richards Street, Suite 400, Honolulu, HI 96813

Date of this written report: [__/__/____]

Date and time of initial oral report: [__/__/____] at [______] ☐ AM ☐ PM

Method of oral report: ☐ Phone (number called: [__________]) ☐ In person ☐ Online portal ☐ Police department: [__________]

APS intake staff who took oral report (if known): [________________________________]

Intake/case reference number (if assigned): [________________________________]

Reporter

• Name: [________________________________]
• Title / profession: [________________________________]
• Employer / agency: [________________________________]
• License or registration number (if applicable): [________________________________]
• Business address: [________________________________]
• Phone: [________________________________]
• Email: [________________________________]
• Reporter's relationship to vulnerable adult: [________________________________]
• Reporting status:
• ☐ Mandatory reporter under HRS § 346-224 (specify category in §2)
• ☐ Permissive reporter (any person) under HRS § 346-224(b)
• ☐ Anonymous (reporter declines to be identified to alleged perpetrator)

2. STATUTORY BASIS FOR REPORT

2.1. Mandatory reporter category (check all that apply):

• ☐ Licensed/registered professional of the healing arts or health-related occupation (physician, physician-in-training, psychologist, dentist, nurse, osteopathic physician/surgeon, optometrist, chiropractor, podiatrist, pharmacist)
• ☐ Other licensed health-related professional (specify): [________________________________]
• ☐ Employee or officer of a public or private agency or institution providing social, medical, hospital, or mental-health services (including financial assistance)
• ☐ Employee or officer of any law-enforcement agency, including courts, police, and correctional institutions
• ☐ Employee of an adult day-care facility, adult residential care home, expanded ARCH, community care foster family home, assisted-living facility, or skilled-nursing facility
• ☐ Medical examiner, coroner, or member of clergy (subject to Rule 506 privilege)
• ☐ Other (specify): [________________________________]

2.2. Knowledge basis. I know or have reason to believe that a vulnerable adult has been abused or is in danger of abuse if immediate action is not taken, based on:

• ☐ Direct observation
• ☐ Statement(s) of the vulnerable adult
• ☐ Statement(s) of a third party (identified in §7)
• ☐ Records reviewed in the performance of my professional duties
• ☐ Other (describe): [____________________]

3. VULNERABLE ADULT INFORMATION

3.1. Full legal name: [________________________________]

3.2. Other names / aliases: [________________________________]

3.3. Date of birth / age: [__/__/____] / Age [____]

3.4. Sex / gender: [________________________________]

3.5. Current address / facility: [________________________________]

3.6. County: ☐ Honolulu ☐ Hawaii ☐ Maui ☐ Kauai ☐ Kalawao

3.7. Phone (if any): [________________________________]

3.8. Living arrangement: ☐ Own home ☐ With family ☐ Adult residential care home ☐ Community care foster family home ☐ Assisted living ☐ Skilled-nursing facility ☐ Hospital ☐ Homeless ☐ Other: [____________________]

3.9. Vulnerability factors (HRS § 346-222 — "vulnerable adult" means a person 18 or older who, because of mental, developmental, or physical impairment, is unable to: communicate or make responsible decisions to manage the person's own care or resources; carry out or arrange for essential activities of daily living; or protect oneself from abuse):

• ☐ Cognitive impairment (dementia, Alzheimer's, traumatic brain injury, intellectual disability)
• ☐ Mental illness (specify): [____________________]
• ☐ Physical impairment limiting self-care (specify): [____________________]
• ☐ Sensory impairment (vision, hearing)
• ☐ Mobility impairment / confined to bed or wheelchair
• ☐ Communication impairment (aphasia, non-verbal)
• ☐ Other (specify): [____________________]

3.10. Diagnosis / medical conditions known to reporter: [________________________________]

3.11. Primary care provider / care team: [________________________________]

3.12. Existing legal representatives:

• ☐ Agent under DPOA: [____________________]
• ☐ Court-appointed guardian (HRS Ch. 560 Article V): [____________________]
• ☐ Court-appointed conservator: [____________________]
• ☐ Healthcare surrogate / agent under AHCD: [____________________]
• ☐ Representative payee (Social Security): [____________________]
• ☐ None known

4. TYPE OF ABUSE REPORTED

5. NARRATIVE OF CONCERN

5.1. Date(s) and place(s) of incident(s): [________________________________]

5.2. Detailed factual narrative (use additional pages as needed; describe what was observed, when, where, by whom, and any quoted statements; identify physical findings, financial irregularities, or other corroborating evidence; avoid speculation and label inferences as such):

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

5.3. Physical findings (if applicable): Bruises, lacerations, pressure injuries, malnutrition/dehydration, untreated medical conditions, soiled clothing, hazardous environment, etc. — describe location, size, color, and apparent age:

[____________________________________________________________]

5.4. Financial indicators (if applicable): Unexplained withdrawals, missing checks, new joint accounts, sudden change of beneficiary, unusual gifts, isolation from advisors, signed documents during periods of confusion, etc.:

[____________________________________________________________]

5.5. Statements made by vulnerable adult (verbatim if possible; note demeanor, capacity to communicate):

[____________________________________________________________]

5.6. Documents attached / available:

• ☐ Photographs (date-stamped)
• ☐ Medical records
• ☐ Bank/brokerage statements
• ☐ Police report number: [____________________]
• ☐ Photographs of environment
• ☐ Email/text/voicemail records
• ☐ Other: [____________________]

6. ALLEGED PERPETRATOR(S)

6.1. Is the alleged perpetrator likely to retaliate? ☐ Yes ☐ No ☐ Unknown — basis: [____________________]

6.2. Is the alleged perpetrator likely to flee, alienate assets, or take the vulnerable adult from the jurisdiction? ☐ Yes ☐ No ☐ Unknown

7. WITNESSES, COLLATERALS, AND OTHER REPORTERS

7.1. Other agencies notified:

• ☐ Police department (case #: [____________________])
• ☐ Long-Term Care Ombudsman (1-888-229-2231) — if facility resident
• ☐ Office of Health Care Assurance (DOH) — if licensed facility
• ☐ Department of Commerce and Consumer Affairs (Securities Enforcement / Regulated Industries) — if financial professional involved
• ☐ Medicare/Medicaid Fraud Control Unit (Hawaii AG) — if billing fraud
• ☐ Other: [____________________]

8. RISK ASSESSMENT AND IMMEDIATE SAFETY

8.1. Is the vulnerable adult currently in immediate danger of serious harm? ☐ Yes — describe: [____________________] ☐ No

8.2. Has 911 been called? ☐ Yes — date/time/agency: [____________________] ☐ No

8.3. Is hospitalization in progress or required? ☐ Yes ☐ No

8.4. Does the vulnerable adult have capacity to consent to / refuse services? ☐ Apparent capacity ☐ Diminished capacity ☐ Unknown — basis: [____________________]

8.5. Recommended emergency intervention:

• ☐ Welfare check
• ☐ Emergency protective placement (HRS § 346-231)
• ☐ Petition for emergency guardianship/conservatorship
• ☐ Petition for emergency injunctive relief / TRO under HRS Chapter 586
• ☐ Freeze of suspicious accounts (DCCA / financial institution)
• ☐ Other: [____________________]

9. MANDATORY REPORTER CERTIFICATION

I certify that the information provided in this report is true and correct to the best of my knowledge, that I am making this report in good faith pursuant to HRS § 346-224, and that I understand the immunity protections of HRS § 346-227 apply to good-faith reports. I further understand that knowing failure to report, or willful prevention of another person from reporting, is a petty misdemeanor.

[________________________________]

[REPORTER NAME]

Title: [________________________________]

Date: [__/__/____]

10. HAWAII APS PRACTICE NOTES

• Statutory framework. HRS Chapter 346, Part X (sections 346-221 through 346-235) creates Hawaii's protective-services system for vulnerable adults. The Department of Human Services Social Services Division administers Adult Protective Services.
• Who must report. HRS § 346-224 requires reporting by professionals listed in §2 above when, "in the performance of their professional or official duties," they "know or have reason to believe that a vulnerable adult has incurred abuse or is in danger of abuse if immediate action is not taken." The standard is reasonable cause to suspect — not proof.
• Oral plus written. The statute requires an immediate ORAL report followed "as soon as possible" by a written report. Use this form for the written report. The DHS-1640 (Report Form for Vulnerable Adult Abuse) is the official form; the online portal is DHS-1640 WEB at apsreport.hawaii.gov. Submission of the form fulfills the statutory written-report obligation.
• Police shortcut. If a police department is the initiating agency, a written report is not required unless the police decline to take further action and DHS notifies the police that DHS intends to investigate the oral report.
• Immunity. HRS § 346-227 provides civil and criminal immunity for any person who in good faith makes a report, testifies, or assists in any investigation or judicial proceeding under Part X. Immunity extends to the disclosure of otherwise confidential information.
• Confidentiality. Reports and APS records are confidential under HRS § 346-229; DHS may disclose only as authorized by statute. Reporters may request anonymity.
• Clergy privilege. HRS § 346-224 expressly preserves the clergy-penitent privilege under Hawaii Rules of Evidence Rule 506. Communications protected by Rule 506 need not be reported.
• Penalties. Knowing failure to report, or willful prevention of a report, is a petty misdemeanor (up to 30 days, fine up to $1,000).
• APS investigation. Upon receipt, DHS opens an investigation, which may include unannounced visits, interviews, medical and financial record review, and coordination with police, the Long-Term Care Ombudsman (for facility residents), the Office of Health Care Assurance (for licensed facilities), and the Office of the Attorney General.
• Emergency intervention. HRS § 346-231 authorizes DHS, with court order where required, to provide emergency protective services to a vulnerable adult who lacks capacity to consent and is in immediate danger.
• Time limits. "Immediate" reporting is required; the statute does not impose a fixed-hour clock, but mandatory reporters should report as soon as the basis for belief is formed. Investigations are typically initiated within 24 hours for emergencies and within several business days for non-emergencies under DHS internal protocol.
• Coordination with facility complaints. If the alleged abuse occurs in a licensed long-term care facility, also notify the Hawaii Long-Term Care Ombudsman (1-888-229-2231) and the DOH Office of Health Care Assurance.

11. SOURCES AND REFERENCES

• Hawaii DHS Adult Protective and Community Services Branch — https://humanservices.hawaii.gov/ssd/home/adult-services/
• Online vulnerable-adult abuse report (DHS-1640 WEB) — https://apsreport.hawaii.gov
• DHS-1640 PDF report form — https://humanservices.hawaii.gov/ssd/files/2015/04/DHS-1640-Rev.-3-15-Form-Fill.pdf
• DHS Mandated Reporter Guidelines — https://humanservices.hawaii.gov/ssd/files/2015/10/Guidelines-for-Mandated-Reporters.pdf
• HRS § 346-222 (definitions) — https://www.capitol.hawaii.gov/hrscurrent/Vol07_Ch0346-0398/HRS0346/
• HRS § 346-224 (reports; mandatory and permissive reporters) — https://law.justia.com/codes/hawaii/title-20/chapter-346/section-346-224/
• HRS § 346-227 (immunity) — https://www.capitol.hawaii.gov/
• HRS § 346-229 (confidentiality) — https://www.capitol.hawaii.gov/
• Hawaii Long-Term Care Ombudsman — https://www.hi-ltc-ombudsman.org (1-888-229-2231)
• Hawaii Department of Health, Office of Health Care Assurance — https://health.hawaii.gov/ohca/
• Statewide APS Intake (Oahu): (808) 832-5115; out-of-state toll-free: 1-888-380-3088
• Honolulu Police Department vulnerable-adult abuse policy — https://www.honolulupd.org/policy/policy-vulnerable-adult-abuse/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Reporters must call the APS Intake Line at (808) 832-5115 (Oahu) or contact their county APS unit to satisfy the oral-report requirement of HRS § 346-224; this form is the written follow-up. In an emergency, call 911. Confirm current intake numbers and form versions with the Hawaii Department of Human Services before submitting.