Massachusetts Elder Abuse Report to Adult Protective Services (EOEA)

MASSACHUSETTS ELDER ABUSE REPORT TO ADULT PROTECTIVE SERVICES

TABLE OF CONTENTS

1. Verbal-Report Confirmation
2. Reporter Information
3. Mandated-Reporter Status
4. Elder (Alleged Victim) Information
5. Alleged Abuser / Caretaker Information
6. Type of Abuse Alleged
7. Description of Incident(s)
8. Risk Assessment and Immediate Safety
9. Other Persons with Knowledge / Witnesses
10. Prior Reports and Other Authorities Contacted
11. Supporting Documentation
12. Reporter Certification and Immunity Statement
13. Submission Instructions
14. Massachusetts Practice Notes
15. Sources and References

1. VERBAL-REPORT CONFIRMATION

1.1. Verbal report made to EOEA Elder Abuse Hotline (1-800-922-2275): ☐ Yes ☐ No

1.2. Date of verbal report: [__/__/____]

1.3. Time of verbal report: [__:__] ☐ AM ☐ PM

1.4. Hotline intake worker name / ID (if obtained): [________________________________]

1.5. Hotline reference / intake number: [________________________________]

1.6. Designated Protective Services (PS) agency assigned: [________________________________]

2. REPORTER INFORMATION

3. MANDATED-REPORTER STATUS

3.1. Under M.G.L. c. 19A § 15(a), the following individuals are mandated reporters of elder abuse. Indicate the basis on which the reporter is required to report:

• ☐ Physician, physician assistant, medical intern
• ☐ Dentist
• ☐ Nurse
• ☐ Family counselor / social worker
• ☐ Probation officer / police officer / firefighter
• ☐ Emergency medical technician
• ☐ Animal control officer
• ☐ Licensed psychologist
• ☐ Coroner / medical examiner
• ☐ Registered physical or occupational therapist
• ☐ Osteopath / podiatrist
• ☐ Director of a council on aging or COA outreach worker
• ☐ Executive director of a licensed home-health agency
• ☐ Executive director of a homemaker service agency
• ☐ Manager of an assisted-living residence
• ☐ Other professional designated by 651 CMR 5.05: [________________________________]
• ☐ Not a mandated reporter — reporting permissively under M.G.L. c. 19A § 15(b)

3.2. Reporter understands that failure of a mandated reporter to make a required report is punishable by a fine of up to $1,000 (M.G.L. c. 19A § 15(d)).

4. ELDER (ALLEGED VICTIM) INFORMATION

5. ALLEGED ABUSER / CARETAKER INFORMATION

6. TYPE OF ABUSE ALLEGED

Mark all that apply (definitions per M.G.L. c. 19A § 14 and 651 CMR 5.02):

• ☐ Physical abuse — non-accidental act causing injury, pain, or impairment
• ☐ Emotional / psychological abuse — verbal or non-verbal conduct causing mental anguish
• ☐ Sexual abuse — non-consensual sexual contact of any kind
• ☐ Financial exploitation — misappropriation of money or property; undue influence; predatory transfers
• ☐ Caretaker neglect — failure of a caretaker to provide necessities (food, shelter, clothing, medical care, supervision)
• ☐ Self-neglect (where assessed by EOEA) — inability to perform essential self-care due to physical or mental impairment
• ☐ Abandonment — desertion by a caretaker
• ☐ Suspicious death of an elder potentially resulting from abuse (also notify medical examiner / law enforcement)

7. DESCRIPTION OF INCIDENT(S)

7.1. Date(s) of alleged abuse: [__/__/____] through [__/__/____]

7.2. Location(s): [________________________________]

7.3. Narrative — describe what happened, who was involved, the elder's statements (verbatim where possible), observed injuries or conditions, and the source of the reporter's information. Use additional pages as needed.

[________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________]

7.4. Pattern: ☐ Single incident ☐ Repeated / ongoing ☐ Escalating

7.5. For financial exploitation, identify:

• Approximate dollar value at issue: $[__________]
• Accounts, properties, or instruments involved: [________________________________]
• Suspicious transactions (dates, amounts, payees): [________________________________]
• Power-of-attorney / joint-account / beneficiary changes: [________________________________]

7.6. For physical abuse / neglect, describe observed injuries (location, color, size, pattern), aids/devices missing, hygiene, weight loss, pressure ulcers, medication mismanagement, environmental hazards.

[________________________________________________________________________________
________________________________________________________________________________]

8. RISK ASSESSMENT AND IMMEDIATE SAFETY

8.1. Is the elder in immediate danger of death or serious bodily harm? ☐ Yes ☐ No

8.2. Has 911 been called? ☐ Yes ☐ No — Date / time: [__/__/____] [__:__]

8.3. Has medical evaluation been obtained? ☐ Yes ☐ No — Provider: [________________________________]

8.4. Risk factors present (check all that apply):

• ☐ Alleged abuser has access to weapons
• ☐ Alleged abuser is intoxicated / impaired
• ☐ Threats of harm have been made
• ☐ Elder is isolated; access controlled by alleged abuser
• ☐ Elder lacks capacity to protect self
• ☐ History of prior abuse / domestic violence
• ☐ Elder's basic needs are not being met (food, medication, hygiene)
• ☐ Other: [________________________________]

8.5. Recommended emergency action under M.G.L. c. 19A § 18 (emergency intervention): [________________________________]

9. OTHER PERSONS WITH KNOWLEDGE / WITNESSES

10. PRIOR REPORTS AND OTHER AUTHORITIES CONTACTED

• ☐ Prior EOEA / APS report — Date: [__/__/____]; Reference: [____________]
• ☐ Local police department — Date: [__/__/____]; Report no.: [____________]
• ☐ District attorney's elder unit — Date: [__/__/____]
• ☐ Long-Term Care Ombudsman — Date: [__/__/____]
• ☐ Department of Public Health (facility complaint) — Date: [__/__/____]
• ☐ Disabled Persons Protection Commission (DPPC) — Date: [__/__/____]
• ☐ Office of the Attorney General (elder hotline / Medicaid Fraud Division) — Date: [__/__/____]
• ☐ Bank / financial institution (suspicious-activity contact) — Date: [__/__/____]
• ☐ Other: [________________________________]

11. SUPPORTING DOCUMENTATION

Attach copies (not originals) of:

• ☐ Photographs of injuries, environment, or financial documents
• ☐ Medical records or chart entries
• ☐ Bank / brokerage statements showing suspicious transactions
• ☐ Written communications (texts, emails, letters)
• ☐ Power of attorney, health-care proxy, will, deed
• ☐ Police report
• ☐ Incident reports from facility
• ☐ Witness statements
• ☐ Other: [________________________________]

12. REPORTER CERTIFICATION AND IMMUNITY STATEMENT

12.1. I certify that the foregoing information is true and accurate to the best of my knowledge, that I make this report based on a reasonable cause to believe an elderly person is suffering from or has died as a result of abuse, and that I did not perpetrate, inflict, or cause the abuse described.

12.2. I understand that under M.G.L. c. 19A § 15(g), no person required to report under subsection (a) shall be liable in any civil or criminal action by reason of such report; and that no other person making a report under subsection (b) or (c) in good faith shall be liable in any civil or criminal action by reason of such report — provided in each case that the reporter did not perpetrate, inflict, or cause the abuse.

12.3. I understand that EOEA records are confidential under M.G.L. c. 19A § 19 and 651 CMR 5.15, and that the identity of a reporter is not disclosed except as authorized by law.

Reporter signature: [________________________________]

Printed name: [________________________________]

Date: [__/__/____]

13. SUBMISSION INSTRUCTIONS

13.1. Verbal report (immediate): EOEA Elder Abuse Hotline — 1-800-922-2275 (24 hours, 7 days).

13.2. Written report (within 48 hours): Submit Form 19A and this supplement to the designated Protective Services agency for the elder's town of residence. Locate the assigned PS agency at https://www.mass.gov/orgs/executive-office-of-elder-affairs.

13.3. Facility-based abuse: In addition to EOEA, contact:

• Massachusetts Long-Term Care Ombudsman: (617) 222-7495
• Department of Public Health, Bureau of Health Care Safety and Quality, complaint intake: (800) 462-5540
• For criminal matters: local police and the District Attorney for the county

13.4. Alleged abuser is licensed (RN, LPN, MD, etc.): Notify the appropriate Board of Registration in addition to EOEA.

13.5. Persons under 60 with disabilities: Disabled Persons Protection Commission (DPPC) hotline — 1-800-426-9009.

14. MASSACHUSETTS PRACTICE NOTES

• Statutory framework. M.G.L. c. 19A §§ 14-20 establish the Massachusetts elder protective-services system. EOEA contracts with regional Aging Services Access Points (ASAPs) to receive and investigate reports.
• Definitions matter. "Abuse" under § 14 includes physical, emotional, and sexual abuse, financial exploitation, and caretaker neglect. The reporter need only have reasonable cause to believe abuse has occurred — investigation and proof are EOEA's role.
• Time frame. Verbal report is "immediate"; written report is due within 48 hours after the verbal report.
• Investigation. EOEA / its designated agency must commence an investigation within prescribed timeframes (typically same-day for emergencies, within 5 business days for non-emergencies under 651 CMR 5.09). The investigator decides whether the report is screened in, screened out, or referred elsewhere.
• Confidentiality. The report, the reporter's identity, and investigation records are confidential under § 19 and 651 CMR 5.15. Disclosure to law enforcement, district attorneys, the Medicaid Fraud Division, and licensing boards is authorized in defined circumstances.
• Immunity. Mandated reporters are immune from civil and criminal liability for the report itself if they did not perpetrate the abuse (§ 15(g)). Non-mandated reporters receive immunity if the report was made in good faith.
• Penalties for non-reporting. Up to $1,000 fine for a mandated reporter who knowingly fails to report (§ 15(d)).
• Retaliation prohibited. It is unlawful to retaliate against a reporter (§ 15(h)) — including any employer retaliation against a mandated reporter.
• Self-determination. Under § 20, EOEA cannot impose protective services over the objection of a competent elder, except via court order in narrow circumstances.
• Cross-reporting. Financial exploitation involving banks may require Suspicious Activity Reports under federal law (FinCEN Advisory FIN-2011-A003) in addition to EOEA reporting.
• Criminal referrals. Serious cases are referred to the local district attorney's elder-abuse unit and the Office of the Attorney General (Elder Justice / Medicaid Fraud Division).

15. SOURCES AND REFERENCES

• M.G.L. c. 19A § 14 (Definitions): https://malegislature.gov/Laws/GeneralLaws/PartI/TitleII/Chapter19a/Section14
• M.G.L. c. 19A § 15 (Reports of abuse; liability): https://malegislature.gov/Laws/GeneralLaws/PartI/TitleII/Chapter19a/Section15
• M.G.L. c. 19A § 16 (Designation of protective services agencies): https://malegislature.gov/Laws/GeneralLaws/PartI/TitleII/Chapter19a/Section16
• 651 CMR 5.00 — Elder Abuse Reporting and Protective Services Program: https://www.mass.gov/doc/651-cmr-5-elder-abuse-reporting-and-protective-services-program/download
• Mass.gov — Mandated Reporters of Abuse in Adults Aged 60+: https://www.mass.gov/info-details/mandated-reporters-of-abuse-in-adults-aged-60
• Mass.gov — Form 19A Elder Abuse Mandated Reporter Form: https://www.mass.gov/doc/form-19a-elder-abuse-mandated-reporter-form/download
• Mass.gov — Executive Office of Elder Affairs overview: https://www.mass.gov/info-details/overview-of-the-executive-office-of-elder-affairs
• EOEA Elder Abuse Hotline: 1-800-922-2275 (24/7)
• Massachusetts Long-Term Care Ombudsman Program: https://www.mass.gov/orgs/massachusetts-long-term-care-ombudsman-program ; (617) 222-7495
• Disabled Persons Protection Commission (DPPC): 1-800-426-9009
• Elder Justice Act, 42 U.S.C. § 1397j et seq.: https://www.ssa.gov/OP_Home/ssact/title20/2040.htm

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Mandated reporters must comply with the timing and content requirements of M.G.L. c. 19A § 15 and 651 CMR 5.00. If an elder is in immediate danger, call 911 first. Verify all hotline numbers, agency contacts, and statutory citations before use.