Pennsylvania Adult / Older Adult Protective Services Report

PENNSYLVANIA ADULT / OLDER ADULT PROTECTIVE SERVICES — REPORT OF SUSPECTED ABUSE, NEGLECT, EXPLOITATION, OR ABANDONMENT

TABLE OF CONTENTS

1. Statutory Track Selection
2. Reporter Information
3. Subject (Alleged Victim) Information
4. Alleged Perpetrator Information
5. Nature of Allegations
6. Statement of Facts
7. Risk Assessment and Immediate Safety Concerns
8. Oral Report Confirmation
9. Witnesses and Corroborating Evidence
10. Mandatory Reporter Acknowledgment
11. Confidentiality and Immunity
12. Distribution and Filing
13. Sources and References

1. STATUTORY TRACK SELECTION

Check the applicable track based on the subject's age and disability status:

• ☐ Older Adults Protective Services Act (OAPSA) — 35 P.S. § 10225.101 et seq. — Subject is 60 years of age or older.
• ☐ Adult Protective Services Act (APSA) — 35 P.S. § 10210.101 et seq. — Subject is 18-59 with a physical or mental disability substantially limiting one or more major life activities.
• ☐ Both — subject is 60+ and disabled (default to OAPSA; APS Hotline cross-routes if needed).

Receiving agency:

• ☐ Local Area Agency on Aging (AAA) — county: [________________________________]
• ☐ Pennsylvania Department of Aging — Statewide Elder Abuse Hotline — 1-800-490-8505
• ☐ Pennsylvania Department of Human Services — APS for adults 18-59 with disabilities — 1-800-490-8505 (same hotline cross-routes APS calls)
• ☐ Local law enforcement (also notified) — agency: [________________________________]
• ☐ Pennsylvania Department of Health — Bureau of Long-Term Care (if facility-based) — 1-800-254-5164

2. REPORTER INFORMATION

Reporter category:

• ☐ Mandatory reporter — facility employee or administrator under 35 P.S. § 10225.701
• ☐ Mandatory reporter — contracted caregiver in the older adult's place of residence
• ☐ Mandatory reporter — APSA employee under 35 P.S. § 10210.701
• ☐ Voluntary reporter (any other person) — anonymity may be requested
• ☐ Reporter requests confidentiality of identity to the extent permitted by 35 P.S. § 10225.303(d)

3. SUBJECT (ALLEGED VICTIM) INFORMATION

4. ALLEGED PERPETRATOR INFORMATION

If multiple alleged perpetrators, attach an addendum listing each.

5. NATURE OF ALLEGATIONS

Check all that apply (definitions per 35 P.S. § 10225.103 and 35 P.S. § 10210.103):

Abuse:

• ☐ Physical abuse (infliction of injury, unreasonable confinement, intimidation, punishment)
• ☐ Sexual abuse / sexual harassment
• ☐ Emotional / psychological abuse
• ☐ Use of restraints or chemical sedation contrary to physician's order or facility policy

Neglect:

• ☐ Failure to provide food, clothing, shelter, hygiene
• ☐ Failure to provide medical care, medications, or therapy
• ☐ Failure to supervise (resulting in elopement, falls, or harm)
• ☐ Caregiver neglect (paid or unpaid)
• ☐ Self-neglect

Exploitation:

• ☐ Theft of money, property, or assets
• ☐ Misuse of bank account, debit card, or credit card
• ☐ Forgery or fraudulent use of power of attorney
• ☐ Coerced gifts, deed transfers, or contract execution
• ☐ Financial scam (telemarketing, romance, lottery, IRS, contractor)
• ☐ Misappropriation of Social Security or pension benefits

Abandonment:

• ☐ Caregiver desertion
• ☐ Hospital or facility "patient dumping"

6. STATEMENT OF FACTS

6.1. How and when reporter learned of the allegations:

[________________________________]

6.2. Date(s) and time(s) of incident(s):

[________________________________]

6.3. Location(s):

[________________________________]

6.4. Detailed factual narrative (attach additional pages as needed):

[________________________________]

6.5. Statements made by the subject:

[________________________________]

6.6. Statements made by the alleged perpetrator (if any):

[________________________________]

6.7. Observable injuries, conditions, or evidence:

[________________________________]

6.8. Photographs / documents preserved:

• ☐ Photographs (date stamped) — location: [________________________________]
• ☐ Medical records — custodian: [________________________________]
• ☐ Bank statements, checks, or financial documents
• ☐ Surveillance video / audio
• ☐ Other: [________________________________]

7. RISK ASSESSMENT AND IMMEDIATE SAFETY CONCERNS

7.1. Imminent danger? ☐ Yes ☐ No — If yes, describe: [________________________________]

7.2. Has 911 / law enforcement been contacted? ☐ Yes ☐ No — Agency / report number: [________________________________]

7.3. Is the subject still in the alleged perpetrator's care or presence? ☐ Yes ☐ No

7.4. Medical attention needed or rendered? ☐ Yes ☐ No — Provider: [________________________________]

7.5. Subject's stated wishes regarding intervention (capacity permitting): [________________________________]

7.6. Recommended emergency action: ☐ AAA emergency response ☐ Law enforcement ☐ Hospital admission ☐ Emergency guardianship ☐ Court order under 35 P.S. § 10225.307 (involuntary intervention)

8. ORAL REPORT CONFIRMATION

Mandatory reporters under § 10225.701 must make an immediate oral report and file this written report within 48 hours.

9. WITNESSES AND CORROBORATING EVIDENCE

Documents and exhibits to be produced upon request:

• ☐ Reporter's contemporaneous notes
• ☐ Facility incident reports
• ☐ MAR / nursing notes / progress notes
• ☐ Bank or brokerage records
• ☐ Photographs / video
• ☐ Other: [________________________________]

10. MANDATORY REPORTER ACKNOWLEDGMENT

I, [REPORTER NAME], declare under penalty of perjury under the laws of the Commonwealth of Pennsylvania that the foregoing is true and correct to the best of my knowledge and belief, and that I make this report in good faith pursuant to 35 P.S. § 10225.701 / 35 P.S. § 10210.701. I understand that:

• A mandatory reporter who willfully fails to report is guilty of a summary offense for a first violation and a misdemeanor of the third degree for a subsequent violation (35 P.S. § 10225.704);
• Good-faith reporters are immune from civil and criminal liability and from professional licensure discipline (35 P.S. § 10225.302(b));
• Retaliation against a reporter or against an older adult who has been the subject of a report is unlawful (35 P.S. § 10225.303(d.1));
• The identity of a reporter is confidential and may be disclosed only with the reporter's consent or by court order (35 P.S. § 10225.303(d)).

Reporter signature: [________________________________]

Print name: [________________________________]

Date: [__/__/____]

11. CONFIDENTIALITY AND IMMUNITY

11.1. Confidentiality. Records of reports and investigations under OAPSA / APSA are confidential under 35 P.S. § 10225.303 and 6 Pa. Code § 15.51 et seq. Disclosure is permitted only as authorized by statute or court order.

11.2. Reporter immunity. A person who participates in good faith in making a report, cooperating with an investigation, or testifying in any judicial proceeding shall have immunity from civil and criminal liability and from any professional disciplinary action. The immunity does not apply where the report is made in bad faith or with malicious purpose.

11.3. Anti-retaliation. Employers may not discharge, discipline, or retaliate against an employee who in good faith files a report. Aggrieved employees have a private right of action under 35 P.S. § 10225.303(d.1) for reinstatement, back pay, and attorney's fees.

12. DISTRIBUTION AND FILING

Original — Receiving agency (AAA or PA Dept. of Aging Hotline)

Copy 1 — Reporter's confidential file (retain for not less than five years)

Copy 2 — Reporter's employer compliance officer (if facility-based)

Copy 3 — Law enforcement (if criminal conduct alleged)

Copy 4 — Pennsylvania Department of Health, Bureau of Long-Term Care (if licensed facility involved)

13. SOURCES AND REFERENCES

• Older Adults Protective Services Act, 35 P.S. § 10225.101 et seq. — https://www.legis.state.pa.us/
• Adult Protective Services Act (Act 70 of 2010), 35 P.S. § 10210.101 et seq.
• 6 Pa. Code Chapter 15 — Protective Services for Older Adults — https://www.pacodeandbulletin.gov/
• Pennsylvania Department of Aging — Protective Services — https://www.aging.pa.gov/
• Pennsylvania DHS — Adult Protective Services — https://www.pa.gov/agencies/dhs/report-abuse/adult-protective-services
• Statewide Elder Abuse / APS Hotline: 1-800-490-8505 (24 hours / 7 days)
• PA Department of Health complaints (facilities): 1-800-254-5164
• 18 Pa.C.S. § 2713 / § 2713.1 — Criminal neglect / abuse of a care-dependent person
• Mandatory Reporter Informational Guidance (PA Providers Coalition) — https://www.paproviders.org/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Failure to make a timely required report carries criminal and licensure exposure. When in doubt, call 1-800-490-8505 immediately and follow up in writing.