Adult Protective Services Report — West Virginia (Mandatory Reporter / Voluntary Report)

WEST VIRGINIA ADULT PROTECTIVE SERVICES REPORT

TABLE OF CONTENTS

1. Emergency Notice and Hotline
2. Reporter Information
3. Mandatory-Reporter Status
4. Alleged Victim (Vulnerable / Incapacitated Adult)
5. Alleged Perpetrator(s)
6. Type of Maltreatment
7. Description of Incident or Pattern
8. Indicators Observed
9. Witnesses, Other Reporters, and Collateral Contacts
10. Imminent Danger / Emergency Situation Assessment
11. Action Already Taken
12. Cross-Reports to Other Agencies
13. Reporter Certification and Signature
14. Statutory Framework and Reporter Rights
15. West Virginia Practice Notes
16. Sources and References

1. EMERGENCY NOTICE AND HOTLINE

If the adult is in immediate danger, dial 911 first.

West Virginia Centralized Intake for Abuse and Neglect (Bureau for Social Services):

• Telephone: 1-800-352-6513 (toll-free, 24/7/365)
• Online (encrypted): Centralized Intake portal via Bureau for Social Services — https://bss.wv.gov/page/centralized-intake-abuse-and-neglect
• Hours: continuous

Verbal report made on: [__/__/____] at [__:__ AM/PM]

Intake worker name / ID (if provided): [________________________________]

Intake reference / case number: [________________________________]

2. REPORTER INFORMATION

3. MANDATORY-REPORTER STATUS

(W. Va. Code § 9-6-9)

Check whichever applies:

☐ Mandatory reporter — falls within one of the categories enumerated in W. Va. Code § 9-6-9(a):

• ☐ Medical, dental, or mental-health professional
• ☐ Christian Science practitioner / religious healer
• ☐ Social-service worker
• ☐ Law-enforcement officer / peace officer
• ☐ Humane officer
• ☐ Member of the clergy (subject to clergy-penitent privilege exception)
• ☐ Employee of a nursing home, assisted-living residence, behavioral-health facility, or other residential facility
• ☐ Employee of the Department / contractor providing adult services
• ☐ Other category required to report by statute or rule: [________________________________]

☐ Permissive (voluntary) reporter — any person, including family member, friend, neighbor, or concerned citizen, may make a report under § 9-6-9 with the same immunity protection (§ 9-6-11).

Acknowledgment of timing duty (mandatory reporters only): I understand that under W. Va. Code § 9-6-9 I must report "immediately and not more than forty-eight (48) hours after suspecting" the maltreatment described herein, and that knowing failure to report is a misdemeanor under W. Va. Code § 9-6-10 punishable by up to ten (10) days in jail and a fine up to $100 (verify current penalty range).

4. ALLEGED VICTIM (VULNERABLE / INCAPACITATED ADULT)

Statutory status — check all that apply:

• ☐ Incapacitated adult (W. Va. Code § 9-6-1) — any person 18+ who by reason of physical, mental, or other infirmity is unable to independently carry out the daily activities of life
• ☐ Vulnerable adult — any person 18+ who is or may be subject to abuse, neglect, or financial exploitation due to age, infirmity, or disability
• ☐ Facility resident — current resident of a nursing home, assisted-living residence, ICF/IID, or other licensed residential setting
• ☐ Elderly person 65+ (relevant for § 61-2-29b enhanced criminal penalties)
• ☐ Protected person under guardianship / conservatorship (W. Va. Code § 44A-1-4)

Capacity / decision-making:

• ☐ Has decision-making capacity, declines services
• ☐ Lacks capacity (clinical observation: [____________])
• ☐ Subject to plenary or limited guardianship — guardian: [____________]
• ☐ Subject to durable POA — agent: [____________]
• ☐ Capacity uncertain

5. ALLEGED PERPETRATOR(S)

(Repeat block for each)

6. TYPE OF MALTREATMENT

(Check all that apply; statutory definitions at W. Va. Code § 9-6-1)

☐ Physical abuse — infliction of physical pain, injury, or mental anguish

☐ Sexual abuse / assault — any non-consensual sexual contact (W. Va. Code § 61-8B applies; cross-report to law enforcement)

☐ Emotional / psychological abuse — verbal threats, humiliation, isolation, intimidation

☐ Neglect — unreasonable failure by a caregiver to provide care necessary to maintain physical or mental health

☐ Self-neglect — adult's own failure to provide for essential needs of food, clothing, shelter, medical care, hygiene, or safety

☐ Financial exploitation — illegal or improper use of an incapacitated/elderly person's funds, property, or resources for the benefit of another (W. Va. Code § 61-2-29b)

☐ Abandonment — desertion by a caregiver who has assumed responsibility

☐ Emergency situation — circumstance in which the adult is at imminent risk of death or serious physical harm

☐ Other: [________________________________]

7. DESCRIPTION OF INCIDENT OR PATTERN

Date and time of incident (or first observation of pattern): [__/__/____] at [__:__ AM/PM]

Location: [________________________________]

How reporter learned of the maltreatment: ☐ Direct observation ☐ Disclosure by victim ☐ Disclosure by third party ☐ Medical examination findings ☐ Financial-account review ☐ Hospital admission ☐ Wellness check ☐ Other: [________________________________]

Detailed factual narrative — who, what, when, where, how (use additional pages as needed):

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

Specific statements made by the victim, if any (use direct quotes where possible):

[____________________________________________________________]

[____________________________________________________________]

Pattern / recurrence:

• ☐ Single incident
• ☐ Recurring; first observed [__/__/____]; most recent [__/__/____]; frequency [____________]
• ☐ Escalating severity

Estimated dollar loss (financial exploitation): $[____]

8. INDICATORS OBSERVED

(Check all observed; describe in §7 narrative)

Physical indicators:

☐ Bruises, lacerations, abrasions ☐ Burns ☐ Pressure ulcers / bedsores ☐ Unexplained fractures ☐ Welts, bite marks ☐ Restraint marks ☐ Dehydration / malnutrition ☐ Poor hygiene / soiled clothing ☐ Untreated medical / dental conditions ☐ Over- or under-medication ☐ Weight loss ☐ Soiled or hazardous living conditions

Behavioral indicators:

☐ Fearfulness, withdrawal, agitation ☐ Inconsistent or implausible explanations ☐ Reluctance to speak in caregiver's presence ☐ Sudden change in mental status ☐ Suicidal ideation ☐ Reports being struck, threatened, or yelled at

Financial indicators:

☐ Unexplained withdrawals or transfers ☐ Recent change to will, deed, POA, or beneficiary designations ☐ Unpaid bills despite adequate resources ☐ Missing belongings, jewelry, or documents ☐ New "friend" or caregiver with access to finances ☐ Forged signatures ☐ Granting of POA under suspicious circumstances ☐ Suspicious wire transfers, gift-card purchases, or cryptocurrency

Self-neglect indicators:

☐ Inability to manage ADLs ☐ Hoarding or unsafe living conditions ☐ Refusal of necessary medical care ☐ Lack of food, water, heat, electricity ☐ Confusion or disorientation impairing safety

9. WITNESSES, OTHER REPORTERS, AND COLLATERAL CONTACTS

Other professionals already involved:

• Primary-care physician: [________________________________] / [____________]
• Hospital / facility: [________________________________]
• Home-health agency: [________________________________]
• Bank / financial institution: [________________________________]
• Bank-employee mandatory reporter (W. Va. Code § 31A-2A-1 et seq., where applicable): [____________]
• Adult Protective Services worker (prior contact): [________________________________]
• Law enforcement (prior contact, agency / officer / case #): [________________________________]
• Long-Term Care Ombudsman: [________________________________]
• Court (guardianship file # / probate court): [________________________________]

10. IMMINENT DANGER / EMERGENCY SITUATION ASSESSMENT

(W. Va. Code § 9-6-1 defines "emergency situation"; § 9-6-15 authorizes investigation and protective services)

☐ Reporter believes the adult is in imminent danger of death or serious physical harm — immediate APS / law-enforcement intervention requested

☐ Reporter believes urgent (not imminent) protective services are needed within 24-72 hours

☐ Reporter believes routine response (within 14 days) is appropriate

Specific risk factors:

• ☐ Alleged perpetrator presently in the home
• ☐ Victim has no functional ability to call for help
• ☐ Medical condition deteriorating rapidly
• ☐ Recent or threatened violence
• ☐ Active financial exploitation depleting funds
• ☐ Eviction or utility shutoff imminent
• ☐ Isolated; no known family or support
• ☐ Other: [________________________________]

11. ACTION ALREADY TAKEN

☐ Verbal report to Centralized Intake on [__/__/____] at [__:__]

☐ 911 / law-enforcement call on [__/__/____] — agency: [____________] case #: [____________]

☐ Medical evaluation arranged at [____________] on [__/__/____]

☐ Protective transport / safe placement to [____________]

☐ Notification of facility administrator (if facility employee): [____________] on [__/__/____]

☐ Notification of OHFLAC: [____________] on [__/__/____]

☐ Notification of Long-Term Care Ombudsman: [____________] on [__/__/____]

☐ Internal incident report number: [________________________________]

☐ Other: [________________________________]

12. CROSS-REPORTS TO OTHER AGENCIES

Depending on the facts, additional reports may be required or appropriate:

13. REPORTER CERTIFICATION AND SIGNATURE

I certify under penalty of perjury under the laws of West Virginia that the foregoing report is true and correct to the best of my knowledge and belief, and that I am making this report in good faith pursuant to W. Va. Code § 9-6-9 (if mandatory) or as a permissive reporter under the same article. I understand that:

• Good-faith reports are immune from civil and criminal liability under W. Va. Code § 9-6-11.
• The contents of this report are confidential under W. Va. Code § 9-6-12 and may be released only as authorized by law.
• Knowingly making a false report may itself constitute a criminal offense.
• If I am a mandatory reporter, knowing failure to report subjects me to penalties under W. Va. Code § 9-6-10.

Reporter signature: [________________________________]

Printed name: [________________________________]

Date: [__/__/____]

Notary acknowledgment (optional — typically not required for the report itself):

State of West Virginia, County of [________________________________]

Sworn to and subscribed before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public — Commission expires: [_______________]

14. STATUTORY FRAMEWORK AND REPORTER RIGHTS

Definitions (W. Va. Code § 9-6-1). Key terms include "incapacitated adult," "neglect," "abuse," "emergency situation," "facility," and "financial exploitation." Eligibility for APS services does not depend on income; the determinative test is incapacity / vulnerability and a reasonable belief of maltreatment.

Mandatory reporters (W. Va. Code § 9-6-9). The categories listed in Section 3 above must report immediately and within 48 hours. The duty is triggered by reasonable cause to believe abuse, neglect, financial exploitation, or an emergency situation has occurred or is occurring.

Method of reporting. Reports may be oral or written. The statewide Centralized Intake hotline (1-800-352-6513) accepts reports 24/7. A written follow-up form is encouraged and is required by some employers and facilities; this template fulfills that purpose.

Penalties for failure to report (W. Va. Code § 9-6-10). Knowing failure to report is a misdemeanor punishable by up to ten days in jail and a fine up to $100 (verify current statutory penalties).

Immunity (W. Va. Code § 9-6-11). Any person who makes a report in good faith is immune from civil and criminal liability that might otherwise arise from making the report.

Confidentiality (W. Va. Code § 9-6-12). Reports, the identity of the reporter, and the contents of investigative records are confidential and may be disclosed only as authorized by statute, court order, or to specifically enumerated agencies and proceedings.

Investigation (W. Va. Code § 9-6-15). APS must initiate an investigation; emergency investigations are commenced immediately. APS may petition a court for emergency protective services where the adult is at imminent risk and consent is unavailable or refused.

Cross-statutes for criminal prosecution.

• W. Va. Code § 61-2-29 — death or serious bodily injury of an incapacitated adult; felony.
• W. Va. Code § 61-2-29b — financial exploitation of an elderly person, protected person, or incapacitated adult; graduated felony based on dollar amount.
• W. Va. Code § 61-2-29a — abuse or neglect of incapacitated adult; misdemeanor / felony depending on injury.

15. WEST VIRGINIA PRACTICE NOTES

• Hotline is the legally operative report. The verbal call to 1-800-352-6513 (Centralized Intake for Abuse and Neglect) starts the statutory clock and triggers the 48-hour deadline. This written form documents and supplements the call; it does not replace it.

• DHHR / DoHS reorganization. The legacy "Department of Health and Human Resources" (DHHR) split effective January 1, 2024. The Department of Human Services (DoHS) now houses the Bureau for Social Services (BSS), which administers Adult Protective Services. Many statutes and rules still refer to "DHHR." The hotline number is unchanged.

• Clergy-penitent privilege. Members of the clergy are mandatory reporters but the clergy-penitent privilege under W. Va. Code § 57-3-9 applies to confidential communications made for spiritual counsel; consult counsel where the reporter learned of the maltreatment in such a communication.

• HIPAA. Reports of suspected abuse, neglect, or financial exploitation made consistent with state law are permitted disclosures under 45 C.F.R. § 164.512(c) and do not require the patient's authorization.

• Capacity-respecting principle. APS services to a competent adult are voluntary. A capacitated adult may refuse APS intervention even where the reporter believes maltreatment is occurring.

• Facility maltreatment. When the alleged perpetrator is paid staff in a licensed facility, also notify (a) OHFLAC for survey/enforcement and (b) the Long-Term Care Ombudsman for resident advocacy. Facilities have parallel federal reporting duties under 42 U.S.C. § 1320b-25 (reasonable suspicion of crimes against residents).

• Financial exploitation by a fiduciary. If the alleged perpetrator is a guardian, conservator, or POA agent, the appropriate court of jurisdiction (county circuit court for guardianship; probate for fiduciaries) should also be notified, and an emergency motion for accounting, removal, or supervision may be appropriate.

• Workplace retaliation protections. Several reporter categories (notably nursing-home employees) are protected from retaliation by federal nursing-home reform act regulations (42 C.F.R. § 483.12) and by W. Va. Code § 9-6-11 immunity. Document any retaliation immediately.

• Self-neglect. A substantial portion of WV APS caseload is self-neglect of capacitated or marginally capacitated older adults. The same hotline and process applies.

16. SOURCES AND REFERENCES

• WV Bureau for Social Services — Centralized Intake — https://bss.wv.gov/page/centralized-intake-abuse-and-neglect
• WV DHHR Adult Protective Services — https://dhhr.wv.gov/bcf/Services/Pages/Adult-Protective-Services.aspx
• WV APS Hotline — 1-800-352-6513 (24/7)
• W. Va. Code Chapter 9, Article 6 (Social Services for Adults Act) — https://code.wvlegislature.gov/9-6/
• W. Va. Code § 9-6-9 (Reporting required) — https://code.wvlegislature.gov/9-6-9/
• W. Va. Code § 9-6-11 (Immunity) — https://code.wvlegislature.gov/9-6-11/
• W. Va. Code § 9-6-12 (Confidentiality) — https://code.wvlegislature.gov/9-6-12/
• W. Va. Code § 61-2-29, § 61-2-29a, § 61-2-29b (criminal abuse/neglect/financial exploitation) — https://code.wvlegislature.gov/61-2/
• W. Va. C.S.R. Title 78 (DoHS rules) — https://apps.sos.wv.gov/adlaw/csr/
• OHFLAC (Office of Health Facility Licensure & Certification) — https://ohflac.wvdhhr.org/
• WV Long-Term Care Ombudsman — http://www.wvseniorservices.gov/StayingSafe/LongTermCareOmbudsmanProgram/
• Legal Aid of WV (Long-Term Care Advocacy) — https://legalaidwv.org/our-programs/long-term-care/
• DOJ Elder Fraud Hotline — 1-833-372-8311
• HIPAA disclosures permitted to government authorities re: abuse/neglect — 45 C.F.R. § 164.512(c)

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Mandatory-reporter categories, time limits, immunity provisions, and contact numbers change. Verify all citations and the current Centralized Intake hotline before submitting a report, and consult a West Virginia-licensed attorney for advice in any individual case.