The Elder Justice Act: Background and Issues for Congress

The Elder Justice Act: Background and Issues for Congress Kirsten J. Colello Specialist in Health and Aging Policy September 3, 2014 Congressional Research Service 7-5700 www.crs.gov R43707 The Elder Justice Act: Background and Issues for Congress Summary Elder abuse is a complex issue that often requires a multifaceted policy response that combines public health interventions, social services programs, and criminal law enforcement for abusive behavior. To address this complexity, the Elder Justice Act was enacted as part of the Patient for Congress

January 20, 2015 (R43707)

Contents

• Legislative History
• Elder Justice Act
• Elder Justice Provisions
• National Coordination of Elder Justice Activities and Research
• Programs to Promote Elder Justice
• Protecting Residents of Long-Term Care Facilities
• National Training Institute for Surveyors
• Reporting to Law Enforcement of Crimes Occurring in Federally Funded Long-Term Care Facilities
• National Nurse Aide Registry
• Funding for Elder Justice Activities
• Issues for Congress
• Federal Leadership
• Elder Abuse Data Collection
• Elder Abuse Prevention
• Concluding Observations

Tables

• Table 1. Funding for Elder Justice Activities for FY2012-FY2015
• Table 2. Elder Abuse Prevention Interventions Program
• Table A-1. Elder Justice Act: Authorizations of Appropriations

Appendixes

• Appendix A. Elder Justice Act: Authorizations of Appropriations
• Appendix B. Elder Justice Resources

Summary

Elder abuse is a complex issue that often requires a multifaceted policy response that combines public health interventions, social services programs, and criminal law enforcement for abusive behavior. To address this complexity, the Elder Justice Act was enacted on March 23, 2010 as part of the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended). The act attempts to provide a coordinated federal response by emphasizing various public health and social service approaches to the prevention, detection, and treatment of elder abuse. The Elder Justice Act also represents Congress’'s first attempt at comprehensive legislation to address abuse, neglect, and exploitation of the elderly at the federal level. To date, most activities and programs authorized under the Elder Justice Act have not received federal funding through the annual appropriations process. Moreover, the authorizations of For the first time, Congress appropriated $4 million for a new Elder Justice Initiative in FY2015. However, the authorizations of appropriations for most provisions under the act expire on September 30, 2014. As a result of this limited federal funding, the federal government has not substantially developed and expanded its role in addressing the prevention, detection, and treatment of elder abuse. Despite the lack of discretionary appropriations, some elder justice activities have received funding from mandatory funding appropriated through the ACA Prevention and Public Health Fund (PPHF). expired on September 30, 2014. Despite the lack of discretionary appropriations prior to FY2015, some elder justice activities have received funding from mandatory funding appropriated through the ACA Prevention and Public Health Fund (PPHF). As a result of this limited federal funding, the federal government has not substantially developed and expanded its role in addressing the prevention, detection, and treatment of elder abuse. For FY2012, the Secretary of the Department of Health and Human Services (HHS) transferred $6.0 million to the Administration for Community Living (ACL) from the PPHF for new grants to states and tribes to test elder abuse prevention strategies. Funded projects included using forensic accountants to prevent elder financial exploitation, increasing medication adherence to prevent elder self-neglect, and developing screening tools to identify elder abuse. For FY2013, $2.0 million was transferred to ACL from the PPHF for elder justice activities, which funded development of the National Adult Protective Services Data Reporting System Project. No PPHF funds were transferred to ACL for elder justice activities for FY2014. For FY2015, the President’'s budget request includesincluded $25.0 million in discretionary funding for the Elder Justice Initiative that would be used to fund Adult Protective Services, research, and evaluation activities. The 2015 budget request doesdid not specify an intended transfer of funding from the PPHF for elder justice activities. On June 10, 2014For FY2015, the Senate Appropriations Subcommittee on the Departments of Labor, Health and Human Services, and Education (DOLHHS-ED) approved its FY2015 bill by voice vote. The subcommittee recommendsDOL-HHS-ED) recommended $10.0 million for the Elder Justice Initiative. The House has yet to see in its FY2015 appropriations bill. The House did not take legislative action in the subcommittee or full committee for its FY2015 DOL-HHS-ED appropriations bill. This report provides a brief legislative history of the Elder Justice Act, summarizes elder justice provisions enacted as part of ACA, and administrative efforts related to implementation and funding. The report then describes several issues for Congress with respect to the act’s reauthorization. Congressional Research Service The Elder Justice Act: Background and Issues for Congress Contents Legislative History........................................................................................................................... 3 Elder Justice Act .............................................................................................................................. 4 Elder Justice Provisions ............................................................................................................. 4 National Coordination of Elder Justice Activities and Research......................................... 4 Programs to Promote Elder Justice ..................................................................................... 7 Protecting Residents of Long-Term Care Facilities................................................................... 9 National Training Institute for Surveyors............................................................................ 9 Reporting to Law Enforcement of Crimes Occurring in Federally Funded Long-Term Care Facilities ............................................................................................. 10 National Nurse Aide Registry .................................................................................................. 10 Funding for Elder Justice Activities............................................................................................... 11 Issues for Congress ........................................................................................................................ 14 Federal Leadership .................................................................................................................. 14 Elder Abuse Data Collection ................................................................................................... 15 Elder Abuse Prevention ........................................................................................................... 15 Concluding Observations............................................................................................................... 15 Tables Table 1. Funding for Elder Justice Activities for FY2012, FY2013, FY2014, and FY2015 Budget Request ........................................................................................................................... 12 Table 2. Elder Abuse Prevention Interventions Program ............................................................... 12 Table A-1. Elder Justice Act: Authorizations of Appropriations .................................................... 17 Appendixes Appendix A. Elder Justice Act: Authorizations of Appropriations ................................................ 17 Appendix B. Elder Justice Resources ............................................................................................ 19 Contacts Author Contact Information........................................................................................................... 20 Congressional Research Service The Elder Justice Act: Background and Issues for Congress T herethe FY2015 DOL-HHS-ED appropriations bill. P.L. 113-235, the Consolidated and Further Continuing Appropriations Act, 2015, provides $4 million in FY2015 discretionary funding for a new Elder Justice Initiative to provide competitive grants to states to test and evaluate innovative approaches to preventing and responding to elder abuse.

This report provides a brief legislative history of the Elder Justice Act, summarizes elder justice provisions enacted as part of ACA, and administrative efforts related to implementation and funding. The report then describes several issues for Congress with respect to the act's reauthorization.

The Elder Justice Act: Background and Issues for Congress

There is growing attention to elder abuse as a public policy issue in the United States. While the extent of such abuse is largely unknown, there is some indication that the problem is serious and that many incidents of abuse are never reported. A 2011 study of the extent of elder abuse in the United States found that 11% of individuals ages 60 and older who reside in the community reported some type of abuse in the past year.11 Another 2008 study found that 9% of community-residing older adults ages 57 to 85 reported verbal mistreatment; 3.5% reported financial mistreatment; and 0.2% reported physical mistreatment by a family member in the past year.2 2 Yet, studies such as these are likely to underestimate the full extent of elder abuse as they do not include all categories of abuse, exclude individuals who reside in institutional settings such as nursing facilities, and generally exclude individuals with significant cognitive impairment (for more information see text box “"What is Elder Abuse?”"). In addition, incidents of elder abuse may go unreported as older individuals can be reluctant to report abuse by an individual they also rely upon for their personal care and well-being.33 Moreover, a number of studies have associated physical and mental health problems among victims of elder abuse as well as inadequate social supports that, if present, may assist individuals in prevention, detection, and treatment.4 4 What Is Elder Abuse? Behaviors that constitute elder abuse and neglect, also referred to as elder mistreatment, are considered to be “"intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder or failure by a caregiver to satisfy the elder’'s basic needs or to protect the elder from harm.” " Elder abuse and neglect may occur in domestic or institutional settings, and are further described. • Domestic Domestic elder abuse generally refers to any of the following types of mistreatment that are committed by someone with whom the elder has a special relationship (for example, a spouse, sibling, child, friend, or caregiver). • Institutional Institutional elder abuse generally refers to any of the following types of mistreatment occurring in residential facilities (such as a nursing facility, assisted living facility, group home, board and care facility, foster home, etc.) and is usually perpetrated by someone with a legal or contractual obligation to provide some element of care or protection. The following are generally considered the major categories of elder abuse and neglect: • Physical abuse is the use of force that may result in bodily injury, physical pain, injury or impairment. • Psychological Psychological abuse is the infliction of mental anguish, pain or distress through verbal or non-verbal acts. is the infliction of mental anguish, pain or distress through verbal or non-verbal acts. 1 Acierno, Ron, M. A. Hernandez, A. B. Amstadter, et al., “Prevalence and Correlates of Emotional, Physical, Sexual, and Financial Abuse and Potential Neglect in the United States: The National Elder Mistreatment Study,” American Journal of Public Health, vol. 100 (2011). 2 Laumann, Edward O., S. A. Leitsch, and L. J. Waite, “Elder Mistreatment in the United States: Prevalence Estimates From a Nationally Representative Study,” The Journals of Gerontology Series B: Psychological and Social Sciences, vol. 63 (2008). 3 Centers for Disease Control and Prevention, Understanding Elder Abuse: Fact Sheet, Division of Violence and Prevention, National Center for Injury Prevention and Control, 2013, http://www.cdc.gov/violenceprevention/pdf/emfactsheet-a.pdf. 4 U.S. Government Accountability Office, Stronger Federal Leadership Could Enhance National Response to Elder Abuse, GAO-11-208, Mar 2, 2011, http://www.gao.gov/assets/320/316224.pdf. Reissued on March 22, 2011. Congressional Research Service 1 The Elder Justice Act: Background and Issues for Congress • Sexual abuse is non-consensual sexual contact of any kind with an older adult. • Financial abuse Financial abuse is the illegal or improper exploitation or use of funds or resources (e.g., property, assets) of an older adult. • Neglect is the refusal or failure to fulfill any part of a person’'s obligations or duties to care for an older adult. Source:Source: Richard J. Bonnie and Robert B. Wallace, eds., Elder Mistreatment: Abuse, Neglect and Exploitation in an Aging America, National Research Council (Washington, DC: National Academy Press, 2003); National Center on Elder Abuse (NCEA), Frequently Asked Questions, Administration on Aging, http://www.ncea.aoa.gov/faq/ index.aspx; and Krug, Etienne G., et al., eds. World Report on Violence and Health: Chapter 5, Abuse of the Elderly, 2002. , 2002. Elder abuse is a complex issue that often requires a multifaceted policy response which combines public health initiatives, social services programs, and criminal law enforcement for abusive behavior. To address this complexity, the Elder Justice Act was enacted on March 23, 2010, as part of the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended).5 It provides5 It attempts to provide a coordinated federal response by emphasizing various public health and social service approaches to the prevention, detection, and treatment of elder abuse. It also represents Congress’'s first attempt at comprehensive legislation to address abuse, neglect, and exploitation of the elderly at the federal level. Enactment of the Elder Justice Act places the issue of elder abuse on par with similar legislation Congress has enacted with respect to child abuse and neglect, under the Child Abuse Prevention and Treatment Act,6 and domestic violence, under the Violence Against Women Act.7 Similar to other newly authorized grant programs under the ACA, implementation of new grants under the Elder Justice Act has been hampered by the lack of federal discretionary spending for authorized activities, which is subject to the annual appropriations process. Agency implementation of some elder justice programs and activities has moved forward without such dedicated spending. However, a coordinated federal response to the issue has thus far been limited; in part due to actions Congress has taken since FY2010 to curb federal discretionary spending.8 Elder Justice Defined Elder6 and domestic violence, under the Violence Against Women Act.⁷

Elder Justice Defined

Elder justice is defined in statute, from a societal perspective, as efforts to (1) prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation; and (2) protect elders with diminished capacity while maximizing their autonomy. From an individual perspective, elder justice is defined as the recognition of an elder’'s rights, including the right to be free of abuse, neglect, and exploitation. Source: SSA § 2011 as amended by § 6703(a) of ACA [42 U.S.C. § 1397j] The extent of elder abuse has the potential to grow in scope as the older population continues to increase in size, and individuals live longer post-retirement. In 2012, an estimated 13.7% of the 5 § 6703(a) through (c) of ACA. For more information on the Child Abuse Prevention and Treatment Act, see CRS Report RL30923, Child Abuse Prevention and Treatment Act: Reauthorization Proposals in the 107th Congress, by Emilie Stoltzfus. 7 For more information on the Violence Against Women Act, see CRS Report R42499, The Violence Against Women Act: Overview, Legislation, and Federal Funding, by Lisa N. Sacco. 8 For more information see CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by C. Stephen Redhead. 6 Congressional Research Service 2 The Elder Justice Act: Background and Issues for Congress total U.S. population was age 65 and older. That percentage is projected to increase to 20.3% by 2030.9 Thus, Congress will likely have a continued interest in shaping the federal role and response to elder abuse going forward. This report provides a brief legislative history of the Elder Justice Act, summarizes elder justice provisions enacted as part of ACA and any administrative efforts related to implementation and funding. The report then describes several issues for Congress with respect to the act’s reauthorization. Legislative History Congressional interest in the issue of elder abuse spans more than a quarter of a century with numerous hearings and reports concerning the need for a federal response to abuse, neglect, and exploitation of the elderly. Prior to enactment of the Elder Justice Act as part of the ACA, Congress took a number of steps towards addressing elder abuse, including authorizing federal assistance to state Adult Protective Services (APS) programs through the Social Services Block Grant (SSBG) program and amendments to the Older Americans Act (OAA) to provide separate funding for elder abuse prevention and vulnerable elder rights protection activities, including establishment of the Long-Term Care Ombudsman Program (LTCOP). Provisions regarding elder 1397j]

Similar to other newly authorized grant programs under the ACA, implementation of new grants under the Elder Justice Act has been hampered by the lack of federal discretionary spending for authorized activities, which is subject to the annual appropriations process. Agency implementation of some elder justice programs and activities has moved forward without such dedicated spending. However, a coordinated federal response to the issue has thus far been limited; in part due to actions Congress has taken since FY2010 to curb federal discretionary spending.⁸

The extent of elder abuse has the potential to grow in scope as the older population continues to increase in size, and individuals live longer post-retirement. In 2013, an estimated 14% of the total U.S. population was age 65 and older; about one in every seven Americans.⁹ By 2050, the Census projects that one in every five, or 20% of the U.S. population, will be age 65 or older.¹⁰ Thus, Congress will likely have a continued interest in shaping the federal role and response to elder abuse going forward. This report provides a brief legislative history of the Elder Justice Act, summarizes elder justice provisions enacted as part of ACA and any administrative efforts related to implementation and funding. The report then describes several issues for Congress with respect to the act's reauthorization.

Legislative History Congressional interest in the issue of elder abuse spans more than a quarter of a century with numerous hearings and reports concerning the need for a federal response to abuse, neglect, and exploitation of the elderly. Prior to enactment of the Elder Justice Act as part of the ACA, Congress took a number of steps towards addressing elder abuse, including authorizing federal assistance to state Adult Protective Services (APS) programs through the Social Services Block Grant (SSBG) program and amendments to the Older Americans Act (OAA) to provide separate funding for elder abuse prevention and vulnerable elder rights protection activities, including establishment of the Long-Term Care Ombudsman Program (LTCOP). Provisions regarding elder justice were also incorporated in the OAA reauthorization of 2006 (P.L. 109-365).¹¹ ).10 In 2002, the 107th107^th Congress first introduced the Elder Justice Act (S. 2933) by then Senator John Breaux. Since then, Elder Justice Act legislation was re-introduced in subsequent Congresses with Senate Finance Committee action on bills in the 108th, 109th, and 110th Congresses.11 In the 111th 108^th, 109^th, and 110^th Congresses.¹² In the 111^th Congress, Senator Orrin Hatch introduced the Elder Justice Act of 2009 (S. 795) which addressed public health and social services approaches to the issue. A separate bill (H.R. 2006) was introduced in the House by Representative Peter T. King, which, in addition to the public health and social services provisions also included criminal justice provisions. The Senate bill (S. 795) ) was incorporated into the Senate Finance Committee’'s health reform bill (S. 1796) and subsequently adopted in the Senate health reform bill (H.R. 3590) which became the ACA (P.L. 111-148). ). It is important to note that the elder justice provisions enacted under the ACA did not achieve the multidisciplinary approach (public health, social services, and criminal justice) fully envisioned in earlier versions of introduced legislation. Enactment of the Elder Justice Act under the ACA contains provisions that address certain public health and social services approaches to prevention, detection, and treatment of elder abuse primarily under the Department of Health and 9 U.S. Census Bureau, Profile America: Facts for Features, May 2014 Older Americans Month, Department of Commerce, U.S. Census Bureau News, CB14-FF.07 March 24, 2014, http://www.census.gov/newsroom/releases/pdf/ cb14ff-07_older_americans.pdf and U.S. Census Bureau, “2012 National Population Projections: Summary Tables,” Table 3, Middle Series, http://www.census.gov/population/projections/data/national/2012/summarytables.html. 10 Congress included several provisions related to elder justice activities in the OAA Amendments of 2006 (P.L. 109365). For example, the law added various elder justice activities to be carried out by the Assistant Secretary for Aging. These provisions include responsibility for Administration on Aging (AoA) to develop and implement systems for elder justice and to conduct an elder abuse national incidence study. It also added a requirement that the Assistant Secretary award funds for competitive grants to states for development and implementation of elder justice activities under Title VII of OAA. 11 The Elder Justice Act has been introduced in the 108th Congress (S. 333; H.R. 2490), 109th Congress (S. 2010; H.R. 4993), and 110th Congress (S. 1070; H.R. 1783). Congressional Research Service 3 The Elder Justice Act: Background and Issues for Congress prevention, detection, and treatment of elder abuse primarily under the Department of Health and Human Services (HHS) authorities and administration. It does not include a criminal justice response which would address the prevention, detection, and prosecution of elder abuse crimes under various Department of Justice (DOJ) authorities and administration. Earlier versions of the Elder Justice Act included such a multidisciplinary approach that incorporated criminal justice provisions. With enactment of the Elder Justice Act under the ACA, criminal justice provisions have been were incorporated into a separate stand-alone bill, most recently introduced by introduced in the 113^th Congress by Representative Peter T. King as the Elder Abuse Victims Act in the 113th Congress (H.R. 861) on February 27, 2013(H.R. 861). This bill was referred to the House Committee on Judiciary with no further action taken to date. . Elder Justice Act The Elder Justice Act provisions enacted under the ACA authorize entities and programs that address federal coordination of elder abuse and administration of new grant activities, as well as certain protections for residents of long-term care facilities, and other specified studies. 1213 The following describes these provisions in greater detail. Elder Justice Provisions Several of the Elder Justice provisions enacted under the ACA amended the Social Security Act (SSA) which incorporated Elder Justice into a renamed Title XX entitled Block Grants to States for Social Services and Elder Justice. The ACA subsequently reorganized the structure of SSA Title XX, by placing previously existing sections (i.e., Sections 2001-2007) under a new Subtitle A, Block Grants to States for Social Services, and adding a new Subtitle B, Elder Justice. . National Coordination of Elder Justice Activities and Research Several SSA Elder Justice provisions address federal coordination and research activities. Specifically, SSA Title XX, Subtitle B establishes an Elder Justice Coordinating Council and an Advisory Board on Elder Abuse, Neglect, and Exploitation. It also addresses research protections and awards grants to establish and operate stationary and mobile forensic centers. These provisions and any administrative or other actions to implement authorized programs or activities are further described below.13 14 Elder Justice Coordinating Council The Elder Justice Act established the Elder Justice Coordinating Council at HHS. The Council includes the HHS Secretary as chair and the U.S. Attorney General, as well as the head of each federal department or agency, identified by the chair, as having administrative responsibility or administering programs related to elder abuse, neglect, and exploitation.14 The Council is required 12 § 6703(a) through (c) of the ACA. Prior to Part I, new Subtitle B begins with Sections 2011 (Definitions) and 2012 (General Provisions), which are not discussed here. 14 The Elder Justice Coordinating Council members include heads of the following departments and agencies: U.S. Department of Health and Human Services (Chair), Consumer Financial Protection Bureau, Corporation for National and Community Service, U.S. Department of Housing and Urban Development, U.S. Department of Justice, U.S. (continued...) 13 Congressional Research Service 4 The Elder Justice Act: Background and Issues for Congress 15 The Council is required to submit a report to the appropriate committees of Congress within two years of enactment and every two years thereafter that describes its activities and challenges; and make recommendations for legislation, model laws, and other actions deemed appropriate. There are authorized to be appropriated such sums as necessary to carry out the Council’'s functions. (See report section entitled “"Authorizations of Appropriations”" for further appropriations information.) On Oct. 11, 2012, the HHS Secretary convened the inaugural meeting of the Elder Justice Coordinating Council. The Council is a permanent group, anticipated to meet twice a year. The HHS Secretary has assigned responsibility for implementing the Council to the Administration for Community Living (ACL). The work of the Council is supported by a staff-level Elder Justice Interagency Working Group also led by ACL which was established prior to ACA. Since the inaugural meeting, the Council has convened several times. During these meetings Elder Justice Interagency Working Group members presented proposals for federal action and a summary of steps for federal involvement in the prevention, detection, and prosecution of elder abuse. The working group also coordinated a report of federal activities in elder justice since 2010.1516 At the May 2014 meeting the Council agreed to a set of eight recommendations for increased federal involvement in addressing elder abuse (see text box “"Elder Justice Coordinating Council: Recommendations for Increased Federal Involvement in Elder Abuse”). "). Advisory Board on Elder Abuse, Neglect, and Exploitation The The Advisory Board on Elder Abuse, Neglect, and Exploitation is established to create a shortandshort- and long-term multidisciplinary plan for development of the field of elder justice and make recommendations to the Elder Justice Coordinating Council. The Advisory Board must be composed of 27 members from the general public appointed by the Secretary and must have experience and expertise in prevention of elder abuse, neglect, and exploitation. The Advisory Board is required to submit a report to the Elder Justice Coordinating Council and the appropriate committees of Congress within 18 months of enactment and annually thereafter that contains information on the status of federal, state, and local elder justice activities; and makes specified recommendations. There are authorized to be appropriated such sums as necessary to carry out the functions of the Advisory Board. On July 14, 2010, HHS published a notice establishing the Advisory Board;1617 however, no subsequent public announcement by HHS has been made about Board appointments or activities. (See report section entitled “"Authorizations of Appropriations” " for further appropriations information.) Research Protections

Research Protections

The HHS Secretary is required to promulgate guidelines to assist researchers working in the areas of elder abuse, neglect, and exploitation with issues relating to human research subject protections. For the purposes of the application of certain specified federal regulations to research (...continued) Department of Labor, U.S. Department of the Treasury, U.S. Department of Veterans Affairs, U.S. Postal Inspection Service, Federal Trade Commission, and the Social Security Administration. 15 For a copy of the report, a list of EJCC members, and more information on EJCC meetings and proposals, see http://www.aoa.gov/AoA_programs/Elder_Rights/EJCC/Index.aspx. 16 U.S. Department of Health and Human Services, “Establishment of the Advisory Board on Elder Abuse, Neglect, and Exploitation,” 75 Federal Register 40838, July 14, 2010. Congressional Research Service 5 The Elder Justice Act: Background and Issues for Congress conducted under this subpart it defines “"legally authorized representative”" to mean, unless otherwise provided by law, the individual, or judicial or other body authorized under the applicable law to consent to medical treatment on behalf of another person. No public information on the status of guidance promulgated by HHS Secretary was found. (See report section “"Authorizations of Appropriations”" for further appropriations information.) Elder Justice Coordinating Council: Recommendations for Increased Federal Involvement in Elder Abuse 1. Support the Investigation and Prosecution of Elder Abuse Cases—Support the investigation and prosecution of elder abuse, neglect, and financial exploitation cases by providing training and resources to federal, state, and local investigators and prosecutors. 2. Enhance Services to Elder Abuse Victims—Support and protect elder abuse victims by improving identification of elder abuse and enhancing response and outreach to victims. 3. Develop a National Adult Protective Services (APS) System—Develop a national APS system based upon standardized data collection and a core set of service provision standards and best practices. 4. Develop a Federal Elder Justice Research Agenda—Establish a coordinated research agenda across federal agencies to identify best practices for prevention of and intervention in elder abuse and elder financial exploitation. 5. Develop a Broad-Based Public Awareness Campaign—Develop a comprehensive, strategic, and broadbasedbroad-based national public awareness campaign, with clear and consistent messaging to raise awareness and understanding of elder abuse, neglect, and exploitation. 6. Cross-disciplinary Training on Elder Abuse—Develop training to educate stakeholders across multiple sectors and disciplines on preventing, detecting, intervening in, and responding to elder abuse, neglect, and exploitation. 7. Combat Elder Financial Exploitation, including Abuse by Fiduciaries—Prevent, detect, and respond to elder financial exploitation through federal enforcement activities, policy initiatives, coordination, oversight and education, and by collaborating with industry to enhance fraud detection and provide resources for victims. 8. Improve Screening for Dementia and Cognitive Capacity, Financial Capacity, and Financial Exploitation— Improve the ability of APS and first responders to screen for diminished capacity, diminished financial capacity, and vulnerability to or victimization of financial exploitation. Source: Source: Administration for Community Living, Eight (8) Recommendations from the Elder Justice Coordinating Council for Increased Federal Involvement in Addressing Elder Abuse, May 2014, http://aoa.gov/AoARoot/ AoA_Programs/Elder_Rights/EJCC/docs/Eight_Recommendations_for_Increased_Federal_Involvement.pdf. . Authorizations of Appropriations To carry out the above functions of the Elder Justice Coordinating Council, (SSA Section 2021), Advisory Board on Elder Abuse, Neglect, and Exploitation (SSA Section 2022), and research protection guidelines for human subjects (SSA Section 2023) a new SSA Section 2024, Authorization of Appropriations, authorizes to be appropriated $6.5 million for FY2011, and $7.0 million for each of FY2012 through FY2014. To date, Congress has not provided discretionary funding for these activities through the annual appropriations process. However, the Elder Justice Coordinating Council has convened several times, as previously mentioned. Elder Abuse, Neglect, Exploitation Forensic Centers SSA Elder Justice provisions also added a section regarding establishment and support of elder abuse, neglect, and exploitation forensic centers. This provision requires the HHS Secretary, in Congressional Research Service 6 The Elder Justice Act: Background and Issues for Congress consultation with the U.S. Attorney General, to award grants to eligible entities to establish and operate both stationary and mobile forensic centers and to develop forensic expertise pertaining to elder abuse, neglect, and exploitation. It authorizes to be appropriated $4 million for FY2011, $6 million for FY2012, and $8 million for each of FY2013 and FY2014 to carry out these activities. To date, Congress has not provided discretionary funding for these activities through the annual appropriations process. Elder Abuse Forensic Centers Elder abuse forensic centers bring together multidisciplinary teams of professionals in health care, social services, and criminal justice (e.g., law enforcement, attorneys, and victim advocates). In this context, forensic science involves utilizing elder abuse experts from different disciplines to investigate and resolve cases of abuse or neglect. Developed out of a need to integrate services that have been historically fragmented and difficult to navigate, the forensic center model is an entity that can bridge these different disciplines by employing a full-time staff, conducting regular face-to-face meetings to review cases of abuse and neglect, engaging in problem-solving, and facilitating recommended actions. Multidisciplinary team members, who may either work for the center or a participating organization, may conduct joint visits, trainings, and engage in frequent and ongoing collaboration and consultation. Source: Cafaro Shneider, Diana, Laura Mosqueda, Erika Falk, et al. “"Elder Abuse Forensic Centers,” Journal " Journal of Elder Abuse & Neglect, vol. 22 (2010); Navarro, Adria E., K. H. Wilber, J. Yonashiro, et al., “"Do We Really Need Another Meeting? Lessons From the Los Angeles County Elder Abuse Forensic Center,” The Gerontologist" The Gerontologist, vol. 50 (2010). Programs to Promote Elder Justice SSA Elder Justice provisions establish several grant programs and other activities to promote elder justice through various enhancements to the workforce and electronic health record technology, grants to adult protective services programs and training for long-term care ombudsman, among other activities. These provisions are described below. Enhancement of Long-Term Care The Elder Justice Act required the HHS Secretary, in coordination with the Secretary of Labor, to carry out activities that provide incentives for individuals to train for, seek, and maintain employment providing direct care in long-term care (LTC). In doing so, the HHS Secretary is required to award grants to eligible entities to conduct programs that offer direct care employees continuing training and varying levels of certification. The act further authorized the HHS Secretary to make grants to LTC facilities for specified activities that would assist such entities in offsetting costs related to purchasing, leasing, developing, and implementing certified electronic health records (EHR) technology designed to improve patient safety and reduce adverse events and health care complications resulting from medication errors. This section also requires the Secretary to adopt electronic standards for the exchange of clinical data by LTC facilities and, within 10 years of enactment, to have in place procedures to accept the optional electronic submission of clinical data by LTC facilities pursuant to such standards. The standards adopted must be compatible with standards established under current law, as specified, and with general health information technology standards. The section authorizes to be appropriated $20.0 million for FY2011, $17.5 million for FY2012, and $15.0 million for each of FY2013 and FY2014 to carry out the activities under this section. Congressional Research Service 7 The Elder Justice Act: Background and Issues for Congress To date, Congress has not provided discretionary funding for these activities through the annual appropriations process. Adult Protective Service Functions and Grant Program Adult Protective Services (APS) programs are social services programs established through legislation enacted in all 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. APS programs serve seniors and adults with disabilities by offering a system for reporting and investigating abuse as well as providing social services to assist victims. State APS laws vary in the age of eligibility for APS assistance, definition of abuse, types of abuse covered, classification of the abuse as criminal or civil, mandatory reporting requirements, investigative procedures, and remedies for abuse. Prior to enactment of the Elder Justice Act, there was no dedicated federal funding authority for state APS programs. However, some states have used federal funding provided under the OAA and the Social Services Block Grant program to supplement state and local funding for APS programs. Several SSA Elder Justice provisions addressed federal funding and additional resources for state APS programs. Specifically, SSA Title XX requires the HHS Secretary to ensure that the Department (1) provides authorized funding to state and local APS offices that investigate reports of elder abuse, neglect, and exploitation; (2) collects and disseminates data in coordination with DOJ; (3) develops and disseminates information on best practices regarding, and provides training on, carrying out APS; (4) conducts research related to the provision of APS; and (5) provides technical assistance to states and other entities that provide or fund APS. To carry out these functions, the section authorizes to be appropriated $3 million for FY2011 and $4 million for each of FY2012 through FY2014. To dateFor FY2015, Congress has not providedprovided $4 million in discretionary funding for these activities through the annual appropriations process. 18 The HHS Secretary is also required to establish two grant programs. The first are grants to enhance APS programs provided by states and local governments. The second are grants to states for APS demonstration programs. Annual grants awarded to states to enhance APS programs are to be distributed to states based on a formula. For each of FY2011 through FY2014, the section authorizes to be appropriated $100.0 million for annual grants to enhance APS programs and $25.0 million for the APS demonstration grants. To date, Congress has not provided discretionary funding for these activities through the annual appropriations process. Long-Term Care Ombudsman Program Grants and Training The Long-Term Care (LTC) Ombudsman Program is a consumer advocacy program that aims to improve the quality of care, as well as the quality of life, for residents in long-term care settings by investigating and resolving complaints made by, or on behalf of, such residents. Established under Title VII of the Older Americans Act (OAA), the Administration on Aging (AoA) within the Administration for Community Living (ACL) under HHS administers the nationwide program. As of 2010, there were 53 state LTC Ombudsman Programs operating in all 50 states, the District of Columbia, Guam, and Puerto Rico, and 578 local programs. States and territories receive an annual allotment for ombudsman activities based on a statutory funding formula.17 For FY201419 For FY2015, the total appropriated funding for the LTC Ombudsman Program was $15.9 million. 17 For more information on OAA funding formulas see, CRS Report RS22549, Older Americans Act: Funding (continued...) Congressional Research Service 8 The Elder Justice Act: Background and Issues for Congress 20 SSA Elder Justice provisions require the HHS Secretary to award grants to eligible entities with relevant expertise and experience in abuse and neglect in LTC facilities or state LTC ombudsman programs to (1) improve the capacity of state LTC ombudsman programs to respond to and resolve abuse and neglect complaints; (2) conduct pilot programs with state or local LTC ombudsman offices; and (3) provide support for such state LTC ombudsman programs and such pilot programs. It authorizes to be appropriated $5 million for FY2011, $7.5 million for FY2012, and $10 million for each of FY2013 and FY2014. The section also requires the Secretary to establish programs to provide and improve ombudsman training with respect to elder abuse, neglect, and exploitation for national organizations and state LTC ombudsman programs. It authorizes to be appropriated $10 million for each of FY2011 through FY2014. To date, Congress has not provided discretionary funding for these activities through the annual appropriations process. Protecting Residents of Long-Term Care Facilities Provisions enacted under the Elder Justice Act establish (1) a National Training Institute for Surveyors and grants to state survey agencies; and (2) requirements for reporting crimes in federally funded LTC facilities.18 21 National Training Institute for Surveyors As specified under SSA Titles XVIII (Medicare) and XIX (Medicaid), each state has a licensing and certification agency that inspects long-term care facilities that participate in Medicare and/or Medicaid. These state agencies conduct standard surveys, extended surveys and, under certain circumstances, impose remedies for noncompliance. The surveys they conduct examine both the facility's processes for delivering care and the outcomes of residents' care to ensure the minimum standards are met. CMS’' Survey & Certification Group provides some instruction and training to state and federal surveyors through classroom and web-based training applications.19 22 The Elder Justice Act requires the HHS Secretary to enter into a contract to establish and operate the National Training Institute for federal and state surveyors to carry out specified activities that provide and improve training of surveyors investigating allegations of abuse, neglect, and misappropriation of property in programs and LTC facilities that receive payments under Medicare or Medicaid. It authorizes to be appropriated $12 million for the period of FY2011 through FY2014 to carry out these activities. The HHS Secretary is also required to award grants to state survey agencies that perform surveys of Medicare or Medicaid participating facilities to design and implement complaint investigation systems. It authorizes $5 million for each of FY2011 through FY2014 to carry out these activities. To date, Congress has not provided discretionary funding for these activities through the annual appropriations process. (...continued) Formulas, by Kirsten J. Colello. 18 ACA Section 6703(b). 19 Centers for Medicare and Medicaid Services, Survey & Certification – Surveyor Training, http://cms.hhs.gov/ Medicare/Provider-Enrollment-and-Certification/SurveyorTraining/index.html. Congressional Research Service 9 The Elder Justice Act: Background and Issues for Congress Reporting to Law Enforcement of Crimes Occurring in Federally Funded Long-Term Care Facilities The Elder Justice Act amended SSA Title XI, Part A by adding a new Section 1150B, requiring the reporting of crimes occurring in LTC facilities that receive at least $10,000 in federal funds during the preceding year. It requires owners, operators, employees, managers, agents, or contractors of nursing facilities (covered individuals) to report any reasonable suspicion of a crime (as defined by the law of the applicable political subdivision) against a resident or individual receiving care from the facility to the appropriate entities. Failure to report suspicion of a crime would result in a civil monetary penalty and the Secretary may make a determination to exclude the covered individual from participation in any federal health care program. If an individual is classified as an “"excluded individual,”" a LTC facility that employs that person is not eligible to receive federal funds under the SSA. Section 1150B also requires applicable nursing facilities to annually notify covered individuals that they are required to report any reasonable suspicion of a crime to the appropriate entities. It prohibits a LTC facility from retaliating against an employee for making a report. If retaliation occurs, the LTC facility may be subject to a civil money penalty or the HHS Secretary may exclude them from participation in any federal health care program for a period of two years, or both. In addition, each LTC facility is required to post conspicuously, in an appropriate location, a sign specifying the rights of employees under this section. In June 2011, CMS issued guidance to state survey agency directors describing the regulations related to the reporting of reasonable suspicion of a crime in applicable nursing facilities and provided responses to frequently asked questions.2023 A 2014 report by the HHS Office of Inspector General found that 61% of nursing facilities (9,487 facilities) had documentation to support meeting both reporting requirements: (1) to annually notify covered individuals of their obligation to report reasonable suspicion of crime, and (2) to clearly post a sign specifying the rights of employees to make such reports.21 24 National Nurse Aide Registry Nurse aides generally work in nursing facilities under the direction of a nurse and provide the majority of direct care to residents, helping with activities of daily living (ADLs) (i.e., eating, bathing, dressing, toileting, transferring, and mobility). They may also provide health-related and other housekeeping tasks such as administering medications, checking vital signs, assisting with medical equipment such as oxygen or a ventilator, making a resident’'s bed, or cleaning a resident’ resident's room. However, the scope of work performed by nurse aides can vary according to state licensing requirements and the provider. Federal regulations require each state and DC to establish and maintain a nurse aide registry of individuals who have completed training and are registered to work as nurse aides in that state.22 20 CMS, Reporting Reasonable Suspicion of a Crime in a Long-Term Care Facility (LTC): Section 1150B of the Social Security Act, S&C: 11-30-NH, June 17, 2011 (revised January 201, 2012), see http://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/SurveyCertificationGenInfo/Downloads/SCLetter11_30.pdf 21 HHS, Office of Inspector General, Nursing Facilities’ Compliance with Federal Regulations for Reporting Allegations of Abuse of Neglect, OEI-07-00010, August 2014. 22 42 CFR § 483.156. Congressional Research Service 10 The Elder Justice Act: Background and Issues for Congress 25 State-based nurse aide registries also must include individuals who have been prohibited from employment as nurse aides in LTC facilities due to substantiated findings of abuse, neglect, or misappropriation of property. Nurse aide registries are utilized by LTC providers to conduct background checks on potential employees as LTC facilities are required to check their state nurse aide registry and other state-based registries that are believed to include information on the potential employee. Such databases can be an effective resource in identifying individuals with a history of abuse. The HHS Secretary is required, in consultation with appropriate government agencies and private sector organizations, to conduct a study on establishing a national nurse aide registry.2326 No later than 18 months after the date of enactment, the Secretary is required to submit a report to the Elder Justice Coordinating Council and appropriate congressional committees containing the findings and recommendations of the study. It authorizes to be appropriated such sums as necessary to carry these activities, with funding for the study not to exceed $500,000. To date, Congress has not provided discretionary funding for this activity through the annual appropriations process and no study has been completed or report submitted to these entities. Funding for Elder Justice Activities To date, most programs and activities authorized under the Elder Justice Act have not received funding.2427 The President’'s budget request in each of fiscal years 2012 through 2014 requested funding for adult protective services grants. However, Congress has not provideddid not provide discretionary funding for this activity nor any other Elder Justice Act authorized program or activity through the annual appropriations process. through the annual appropriations process in these years. For the first time, Congress appropriated $4 million for a new Elder Justice Initiative in FY2015. Despite the lack of discretionary appropriations, some elder justice activities have received funds transferred from mandatory appropriations to the Prevention and Public Health Fund (PPHF; see Table 1). In ). In ACA, Congress provided the PPHF with a permanent annual appropriation.2528 PPHF funds are to be transferred by the HHS Secretary for prevention, wellness, and public health activities and are available on October 1, the beginning of each new fiscal year.26 23 ACA Section 6703(c). The ACA reauthorized funding for numerous existing discretionary programs administered by HHS. The ACA also created many new discretionary programs, including those authorized under the Elder Justice Act, and provided for each an authorization of appropriations. While most of those existing discretionary programs continue to receive an annual discretionary appropriation, albeit at levels below the amounts authorized by the law, few of the new grant programs authorized under the ACA have received any discretionary funding. For more information see CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by C. Stephen Redhead. 25 ACA Section 4002; 42 U.S.C. §300u-11. 26 For more information about the Prevention and Public Health Fund (PPHF) see Appendix C of CRS Report R43304, Public Health Service Agencies: Overview and Funding, coordinated by Amalia K. Corby-Edwards and C. Stephen Redhead. 24 Congressional Research Service 11 The Elder Justice Act: Background and Issues for Congress Table 1. Funding for Elder Justice Activities for FY2012, FY2013, FY2014, and FY2015 Budget Request ($ in millions) FY2012a (appropriated) FY2013b (appropriated) FY2014 (appropriated) FY2015 President’s Budget (requested) $6.0 $2.0 — $25.0 Elder Justice/Adult Protective Services Source: HHS, ACL, Fiscal Year 2014 Justification of Estimates for Appropriations Committees, April 10, 2013, http://www.acl.gov/About_ACL/Budget/docs/FY2014_ACL_CJ.pdf; HHS, ACL, Fiscal Year 2015 Justification of Estimates for Appropriations Committees, http://acl.gov/About_ACL/Budget/docs/FY_2015_ACL_CJ.pdf. a. FY2012 available on October 1, the beginning of each new fiscal year.²⁹ Table 1. Funding for Elder Justice Activities for FY2012-FY2015

($ in millions)

  FY2012^a FY2013^b

FY2014

FY2015

Elder Justice/Adult Protective Services

$6.0

$2.0

—

$4.0

Source: For FY2012 to FY2014, HHS, ACL, Fiscal Year 2014 Justification of Estimates for Appropriations Committees, April 10, 2013, http://www.acl.gov/About_ACL/Budget/docs/FY2014_ACL_CJ.pdf; For FY2014, HHS, ACL, Fiscal Year 2015 Justification of Estimates for Appropriations Committees, http://acl.gov/About_ACL/Budget/docs/FY_2015_ACL_CJ.pdf; Division G of the joint explanatory text to Rules Committee Print 113-59, cited in "Explanatory Statement Submitted by Mr. Rogers of Kentucky, Chairman of the House Committee on Appropriations Regarding Amendment to the Senate Amendment on H.R. 83, Consolidated and Further Continuing Appropriations Act, 2015," House of Representatives, Congressional Record, vol. 160, no. 151 Book II (December 11, 2014), pp. H9838, H9878-H9880. a. FY2012 appropriated amounts to the Public Health and Prevention Fund (PPHF) transferred to ACL; amounts reflect the 0.189% rescission required by P.L. 112-74, Division F, Sec. 527. b. FY2013 b. FY2013 appropriated amounts to the PPHF transferred to ACL; amounts are the final year funding amounts after rescissions, sequestration, and transfers. For FY2012, the HHS Secretary transferred $6.0 million to ACL from the PPHF for new grants to states and tribes to test elder abuse prevention strategies (authorized under SSA Section 2042 and Section 751 of the OAA OAA Section 751). ACL awarded a total of eight grants, including grants to states, tribal organizations, and for an evaluation of the state grantees (see Table 2 for state grant activities). Projects included using forensic accountants to prevent elder financial exploitation, increasing medication adherence to prevent elder self-neglect, and developing screening tools to identify elder abuse. In addition to grants to states, three tribal organizations received grant funding totaling $700,000 for the development of a multi-disciplinary team to address elder abuse in Indian Country; development and testing of culturally appropriate evidence based screening tools; and culturally appropriate train-the-trainer modules to improve skills on addressing and intervening with elder abuse issues.27 30 Table 2. Elder Abuse Prevention Interventions Program State Grant Summaries and FY2012 Award Amounts Grantee Intervention University of Texas Health Science Center at Houston (on behalf of the State of Texas)

Grantee

Intervention

Award Amount

University of Texas Health Science Center at Houston (on behalf of the state of Texas)

Pilot an intervention to increase medication adherence in older adults who have chronic health conditions and also experience self-neglect

$1,018,000

Texas Department of Family & Protective Services Demonstrate the effectiveness of an approach to embed APS specialists within a primary care physician group to provide technical assistance and support for increased elder abuse prevention using the Elder Abuse Suspicion Index (EASI), a validated screening tool for physicians.

$907,000

University of California, Irvine (on behalf of the state of California) Pilot and asses the effectiveness of a new approach to elder abuse prevention based on a multi-dimensional intervention that mitigates key factors associated with risk for elder abuse and neglect in adults with dementia. Award Amount $1,018,000 $907,000 $1,020,000 27 Administration for Community Living, Protecting American’s Seniors: The Elder Abuse Prevention Interventions Program, at http://acl.gov/NewsRoom/Publications/docs/Protecting_Americas_Seniors%20The_%20Elder_%20Abuse_%20Prevention_%20Interventions_%20Program.pdf. Congressional Research Service 12 The Elder Justice Act: Background and Issues for Congress Grantee Intervention Award Amount New York State Office for the Aging neglect in adults with dementia.

$1,020,000

New York State Office for the Aging

Pilot an intervention that addresses the prevention of elder financial exploitation and abuse through a coordinated enhanced multi-disciplinary team (E-MDT) with forensic accountants to investigate and intervene in complex cases. $1,020,000

$1,020,000

Alaska Department of Health and Social Services Implement, test, and measure the performance of the Critical Time Intervention (CTI) case management model in preventing elder abuse, neglect, and exploitation through identification of high risk elders, reducing reports of abuse to APS, and increasing support systems through community collaborations. $1,005,000

$1,005,000

Source: Personal communication from the Administration for Community Living, July 10, 2013; award amounts rounded to the nearest thousand. For FY2013, $2.0 million was transferred to ACL from the PPHF for elder justice activities which funded development of the National Adult Protective Services Data Reporting System Project (see text box below). No PPHF or other funds were transferred to ACL for elder justice activities for FY2014. National Adult Protective Services (APS) Data Reporting System For FY2013, $2.0 million was transferred to ACL from the PPHF for elder justice activities. Through an interagency agreement between ACL and HHS’' Office of the Assistant Secretary for Planning and Evaluation (ASPE), these funds were used for the National APS Data Reporting System Project. Together with ASPE, ACL is overseeing a two-year project to design, develop, and pilot a National APS Data Reporting System. The key function of the system will be to collect case-level client data from state or local APS agency investigations, both systematically and efficiently. Data will be used to report national statistics on the characteristics of clients and perpetrators of maltreatment; types of maltreatment allegations and related findings; risk and protective factors associated with clients; services received or identified; and client outcomes, based upon the knowledge available to APS agencies. The multiphase project includes a first phase to define system content and scope system functionality. The second phase includes system design and development of functionality to pilot state participation in a national data collection system. Piloting the system will include gathering information on the administrative burden associated with voluntary state participation and future recommendations to ACL. Subsequent phases of the project will include expanding the national data collection system to additional states. However, the timing and scope of such expansion is subject to completion of the first two phases and evaluation of the pilot, as well as the availability of resources to support states’ ' continued participation. The project has a multiagency steering committee with representatives from ACL, ASPE, DOJ, and the Centers for Disease Control and Prevention (CDC). In addition, the National Center on Elder Abuse and the National Adult Protective Services Association are providing consulting expertise. To date, approximately 15 states have participated in discussions of the national data report system. Approximately 50 stakeholders from other organizations have also provided input into project planning. The project’'s technical support contract ends in September 2015. Subject to OMB approval, ACL anticipates the first phase of national data collection to occur at the end of 2016, with a report available for release in mid-2017. Source: CRS communication with ACL, July 10, 2014. For FY2015, the President’'s budget requested $25 million in discretionary funding for the Elder Justice Initiative which would be used to fund Adult Protective Services, research, and evaluation activities (authorized under SSA Section 2042, and OAA Sections 411 and 751). The 2015 budget request did not specify an intended transfer of funding from the PPHF to ACL for elder justice activities. On June 10, 2014For FY2015, the Senate Appropriations Subcommittee on the Departments of Labor, Health and Human Services, and Education (DOL-HHS-ED) approved their FY2015 bill Congressional Research Service 13 The Elder Justice Act: Background and Issues for Congress by voice vote. The Subcommittee recommends $10 million for the Elder Justice Initiative “to develop partnerships across disciplines for the prevention, investigations and prosecution of abuse, including financial abuse against the elder.”28 The House has yet to take legislative action in the subcommittee or full committee for their FY2015 DOL-HHS-ED appropriations bill. Issues for Congress Labor, Health and Human Services, and Education (DOL-HHS-ED) recommended $10.0 million for the Elder Justice Initiative in its FY2015 appropriations bill.³¹ The House did not take legislative action in the subcommittee or full committee for the FY2015 DOL-HHS-ED appropriations bill. P.L. 113-235, the Consolidated and Further Continuing Appropriations Act, 2015, provides $4 million in FY2015 discretionary funding for a new Elder Justice Initiative to provide competitive grants to states to test and evaluate innovative approaches to preventing and responding to elder abuse.³² Issues for Congress The ACA created many new discretionary programs, including those authorized under the Elder Justice Act, and provided for each an authorization of appropriations. Among these new grant programs, few have received any discretionary funding.2933 The authorizations of appropriations for most Elder Justice Act provisions expireexpired on September 30, 2014 (see Table A-1 of Appendix A for information on specific Elder Justice Act authorizations of appropriations). Most elder justice programs and activities have yet to receive funding through the annual congressional appropriations process limiting the administration’'s response to implementation. Furthermore, no legislation has been introduced in the 113th Congress to reauthorize the Elder Justice Act. In the 113^th Congress, Representative Peter King introduced the Elder Justice Reauthorization Act (H.R. 5515), which would extend the authorizations of appropriations under the act through FY2019. The bill was referred to the House Ways and Means, Energy and Commerce, Judiciary, and Education and the Workforce Committees but saw no further legislative action. In considering reauthorization of the Elder Justice Act, Congress faces a decision whether or not to extend the authorizations of appropriations associated with existing programs and activities. Some policy makers may consider new language to modify or delete existing authorities as well as authorize new programs or activities. Congress may also want to consider the relationship between Elder Justice Act authorities and other similar or related authorities in other statutes. For example, the OAA establishes the LTC Ombudsman Program, administered by AoA within ACL. The Elder Justice Act authorizes grants under SSA to improve capacity and provide assistance to state LTC Ombudsman Programs as well as provide training to ombudsman. As authorized these programs have different committees of jurisdiction responsible for program authorization and oversight. In the context of these legislative actions, policy makers may look to existing administrative activities for areas of continued legislative emphasis. A discussion of selected issues follows. Federal Leadership Federal Leadership The lack of federal funding has hampered the ability of the federal government to further develop and expand its role in addressing the prevention, detection, and treatment of elder abuse. The OAA first called attention to the importance of federal leadership in the area of elder justice. Under the OAA, the AOA has primary responsibility for federal leadership in carrying out elderly justice activities.3034 However, funding under the OAA for such activities has also been limited. According to GAO, the Elder Justice Act “"reaffirmed the importance of federal leadership of elder justice activities and provides a vehicle for establishing and implementing national priorities in this area.”" While the Elder Justice Coordinating Committee has appointed members and convened several times, an Advisory Board on Elder Abuse, Neglect, and Exploitation tasked to 28 U.S. Senate, Committee on Appropriations, FY15 LHHS Subcommittee Markup Bill Summary, June 10, 2014, http://www.appropriations.senate.gov/news/fy15-lhhs-subcommittee-markup-bill-summary. 29 For more information see CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by C. Stephen Redhead. 30 42 U.S.C. 3011 Congressional Research Service 14 The Elder Justice Act: Background and Issues for Congress put forth a plan to develop the field of elder abuse has yet to be established. Further federal efforts to develop objectives, priorities, policy, and a long-term planning on these issues may be limited by available funding. Elder Abuse Data Collection Federal efforts to collect data on elder abuse at the national level are compounded by variation in state statutory definitions of elder abuse that make it difficult to identify actions that constitute elder abuse, and by the absence of a uniform reporting system across states. A 2011 GAO report recommended the HHS Secretary conduct a pilot study to collect, compile, and disseminate APS administrative data.3135 To this end, ACL has utilized funding from the PPHF to begin the process of designing, developing, and eventually pilot testing the National APS Data Reporting System. Policymakers Policy makers may have a continued interest in this initiative and further funding efforts to expand these activities based on findings and recommendations from the administration. Elder Abuse Prevention According to ACL, “"most communities do not have comprehensive elder abuse prevention efforts that engage a broad set of individuals and institutions that can play a role in combating abuse, such as health professionals, law enforcement and legal services agencies, social workers, clergy, and community organizations.”32"³⁶ To implement the Elder Justice Act, the ACL is currently funding several grants to states and tribal organizations that test interventions designed to prevent elder abuse, neglect, and exploitation. These multidisciplinary models draw on prevention strategies from other family violence prevention programs and can assist in developing the evidence base for more widespread dissemination. ACL has invested in an evaluation of such grants. Based on findings from the evaluation, such initiatives could be disseminated more broadly to other states and entities through federally funded web-siteswebsites such as the National Center for Elder Abuse, federal technical assistance, and further funding opportunities. Concluding Observations Concluding Observations The Elder Justice Act represents one set of policies that exist in the broader context of domestic social policy to address the complex issue that is elder abuse. That is, as a federal legislative response, the Elder Justice Act may best serve as a catalyst for further federal coordination and action that can bring about greater public awareness and attention to the needs of a growing, and potentially vulnerable, aging population. According to GAO, the Elder Justice Act “"provides a vehicle for setting national priorities and establishing a comprehensive, multidisciplinary elder justice system in this country.”33 Such a response touches on a range of domestic policy programs 31 Ibid. Administration for Community Living, Protecting American’s Seniors: The Elder Abuse Prevention Interventions Program, at http://acl.gov/NewsRoom/Publications/docs/Protecting_Americas_Seniors%20The_%20Elder_%20Abuse_%20Prevention_%20Interventions_%20Program.pdf. 33 U.S. Government Accountability Office, Stronger Federal Leadership Could Enhance National Response to Elder Abuse, GAO-11-208, Mar 2, 2011, http://www.gao.gov/assets/320/316224.pdf; U.S. Government Accountability Office, Survey of Adult Protective Services Program Administrators (GAO-11-129SP, March 2011), an E-supplement to GAO-11-208, GAO-11-129SP, Mar 2, 2011, http://www.gao.gov/products/GAO-11-129SP. 32 Congressional Research Service 15 The Elder Justice Act: Background and Issues for Congress "³⁷ Such a response touches on a range of domestic policy programs and issues that are not specific to one congressional committee’'s jurisdiction or area of expertise. Furthermore, congressional oversight into federal administration, implementation, and related activities must rely on different committees of jurisdiction as well as the experience of select committees such as the Senate Special Committee on Aging. According to subject matter experts, elder abuse is not an easy problem to address as it is a complex cluster of distinct but related phenomena involving health, legal, social service, financial, public safety, aging, disability, protective services, and victim services, aging services, policy, research, education, and human rights issues. It therefore requires a coordinated multidisciplinary, multi-agency, and multi-system response.34 38 Achieving such a response will likely require congressional interest in overseeing the range of elder justice programs and activities that currently exist across federal agencies. In addition, further research may assist policy makers to address areas where service delivery is either fragmented or lacks sufficient resources, or both. According to stakeholders, there are numerous challenges in responding to elder abuse, including lack of coordination, data, and resources.3539 Addressing these challenges could assist in developing an informed strategic and coordinated federal response. 34 Connolly, Marie-Therese, B. Brandl, R. Breckman, The Elder Justice Roadmap: A Stakeholders Initiative to Respond to an Emerging Health, Justice, Financial and Social Crisis, 2014, at http://ncea.acl.gov/Library/Gov_Report/ index.aspx. 35 Ibid. Congressional Research Service 16 The Elder Justice Act: Background and Issues for Congress Appendix A. Elder Justice Act: Authorizations of Appropriations Appropriations Table A-1 provides a section-by-section list of those Elder Justice Act provisions with an authorization of appropriations. Table A-1. Elder Justice Act: Authorizations of Appropriations ACA Section Statutory Authority 6703(a) SSA Sec. 2021 Elder Justice Coordinating Council Such sums as necessary (no years specified), see also new SSA Sec. 2024 below 6703(a) SSA Sec. 2022 Advisory Board on Elder Abuse, Neglect, and Exploitation Such sums as necessary (no years specified), see also new SSA Sec. 2024 below 6703(a) SSA Sec. 2024 Authorization of appropriations $6.5 million for FY2011, and $7.0 million for each of FY2012 through FY2014 6703(a) SSA Sec. 2031 Forensic centers and expertise $4 million for FY2011, $6 million for FY2012, and $8 million for each of FY2013 and FY2014 6703(a) SSA Sec. 2041(a) Incentives for LTC staffing 6703(a) SSA Sec. 2041(b) Certified EHR technology grant program For new SSA Sec. 2041: $20 million for FY2011, $17.5 million for FY2012, and $15 million for each of FY2013 and FY2014 See above authorization of appropriations for SSA Sec. 2041 6703(a) SSA Sec. 2041(c) Standards for transactions involving clinical data by LTC facilities See above authorization of appropriations for SSA Sec. 2041 6703(a) SSA Sec. 2042(a) Adult protective service functions $3 million for FY2011, and $4 million for each of FY2012 through FY2014 6703(a) SSA Sec. 2042(b) Grants to enhance provision of adult protective services $100 million for each of FY2011 through FY2014 6703(a) SSA Sec. 2042(c) Adult protective services demonstration grants $25 million for each of FY2011 through FY2014 6703(a) SSA Sec. 2043(a) Long-term care ombudsman program grants 6703(a) SSA Sec. 2043(b) Ombudsman training programs $5 million for FY2011, $7.5 million for FY2012, and $10 million for each of FY2013 and FY2014 $10 million for each of FY2011 through FY2014 6703(b) New authority National Training Institute for Surveyors Provision Congressional Research Service Authorization of Appropriations $12 million for the period of FY2011 through FY2014 17 The Elder Justice Act: Background and Issues for Congress ACA Section Statutory Authority 6703(b) New authority Grants to state survey agencies $5 million for each of FY2011 through FY2014 6703(c) New authority National nurse aide registry study and report Such sums as necessary (no years specified) to carry out these activities, with funding not to exceed $500,000 Provision Authorization of Appropriations Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and

ACA Section

Statutory Authority

Provision

Authorization of Appropriations

6703(a)

SSA Sec. 2021

Elder Justice Coordinating Council

Such sums as necessary (no years specified), see also new SSA Sec. 2024 below

6703(a)

SSA Sec. 2022

Advisory Board on Elder Abuse, Neglect, and Exploitation

Such sums as necessary (no years specified), see also new SSA Sec. 2024 below

6703(a)

SSA Sec. 2024

Authorization of appropriations

$6.5 million for FY2011, and $7.0 million for each of FY2012 through FY2014

6703(a)

SSA Sec. 2031

Forensic centers and expertise

$4 million for FY2011, $6 million for FY2012, and $8 million for each of FY2013 and FY2014

6703(a)

SSA Sec. 2041(a)

Incentives for LTC staffing

For new SSA Sec. 2041: $20 million for FY2011, $17.5 million for FY2012, and $15 million for each of FY2013 and FY2014

6703(a)

SSA Sec. 2041(b)

Certified EHR technology grant program

See above authorization of appropriations for SSA Sec. 2041

6703(a)

SSA Sec. 2041(c)

Standards for transactions involving clinical data by LTC facilities

See above authorization of appropriations for SSA Sec. 2041

6703(a)

SSA Sec. 2042(a)

Adult protective service functions

$3 million for FY2011, and $4 million for each of FY2012 through FY2014

6703(a)

SSA Sec. 2042(b)

Grants to enhance provision of adult protective services

$100 million for each of FY2011 through FY2014

6703(a)

SSA Sec. 2042(c)

Adult protective services demonstration grants

$25 million for each of FY2011 through FY2014

6703(a)

SSA Sec. 2043(a)

Long-term care ombudsman program grants

$5 million for FY2011, $7.5 million for FY2012, and $10 million for each of FY2013 and FY2014

6703(a)

SSA Sec. 2043(b)

Ombudsman training programs

$10 million for each of FY2011 through FY2014

6703(b)

New authority

National Training Institute for Surveyors

$12 million for the period of FY2011 through FY2014

6703(b)

New authority

Grants to state survey agencies

$5 million for each of FY2011 through FY2014

6703(c)

New authority

National nurse aide registry study and report

Such sums as necessary (no years specified) to carry out these activities, with funding not to exceed $500,000

Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended). Notes: Notes: EHR = Electronic Health Records; LTC = Long-Term Care; SSA = Social Security Act. Congressional Research Service 18 The Elder Justice Act: Background and Issues for Congress Appendix B. Elder Justice Resources The resources below provide further information on elder justice issues. • Appendix B. Elder Justice Resources

The resources below provide further information on elder justice issues.

National Center on Elder Abuse (U.S. Administration on Aging)http://www.ncea.aoa.gov/

The National Center on Elder Abuse (NCEA) compiles and publishes resources for policy makers, consumers, researchers, and social service, justice, and health care workers on elder abuse and neglect. The website includes frequently asked questions, research briefs on topics such as the mistreatment of LGBT elders and the abuse of people with dementia, and annotated bibliographies of recent published research on elder abuse and neglect.

State Resources (National Center on Elder Abuse) http://www.ncea.aoa.gov/Stop_Abuse/Get_Help/State/index.aspx A directory of state hotlines and agencies for reporting suspected elder abuse, neglect, or exploitation. If the situation is serious, threatening, or dangerous, constituents should call 911 or the local police for immediate help. This directory also lists state laws, agencies, and statistics related to elder abuse and neglect. • National Center on Elder Abuse (Centers for Disease Control and Prevention)http://www.cdc.gov/violenceprevention/elderabuse/

Includes statistics, prevention strategies for practitioners, and the consumer fact sheet "Understanding Elder Abuse."

Elder Justice Initiative (U.S. Department of Justice)http://www.justice.gov/elderjustice/

A collection of elder justice resources for victims and families (including a state and local directory for reporting elder abuse), prosecutors (including databases of federal pleadings and corporate integrity agreements, state pleadings, and elder justice statutes), and researchers (including a bibliographic database of elder justice article summaries).

(U.S. Administration on Aging) http://www.ncea.aoa.gov/ The National Center on Elder Abuse (NCEA) compiles and publishes resources for policy makers, consumers, researchers, and social service, justice, and health care workers on elder abuse and neglect. The website includes frequently asked questions, research briefs on topics such as the mistreatment of LGBT elders and the abuse of people with dementia, and annotated bibliographies of recent published research on elder abuse and neglect. • Elder Abuse (Centers for Disease Control and Prevention) http://www.cdc.gov/violenceprevention/elderabuse/ Includes statistics, prevention strategies for practitioners, and the consumer fact sheet “Understanding Elder Abuse.” • Key Issues: Elder Abuse (U.S. Government Accountability Office) http://www.gao.gov/key_issues/elder_abuse/issue_summary A summary of types of elder abuse, and diagrams of federal agency missions and responsibilities to combat elder financial exploitation. Click the “"Key Reports”" tab for GAO reports on elder justice issues. • Participating Federal Departments and Agencies Activities Relevant to Elder Justice (Elder Justice Interagency Working Group, June 2014) http://www.aoa.gov/AoA_programs/Elder_Rights/EJCC/docs/ AgencyDescriptions.pdf Describes federal elder justice programs, initiatives, web pages, and other activities within the U.S. Department of Health and Human Services, the U.S. Department of Justice, the Consumer Financial Protection Bureau, the Federal Trade Commission, the Social Security Administration, the U.S. Department of Housing and Urban Development, the U.S. Department of the Treasury, the U.S. Postal Inspection Service, and the U.S. Securities and Exchange Commission. • Statute Compilations Statute Compilations (U.S. House of Representatives, Office of the Legislative Counsel) legcounsel.house.gov/HOLC/Resources/comps_alpha.html Congressional Research Service 19 The Elder Justice Act: Background and Issues for Congress The statutory text of the Elder Justice Act appears at Title VI, Subtitle H, sections 6701 through 6703 of the Patient Protection and Affordable Care Act, which is listed under “P” on this web page. Author Contact Information Kirsten J. Colello Specialist in Health and Aging Policy kcolello@crs.loc.gov, 7-7839 Congressional Research Service 20 "P" on this web page.

Footnotes

1.	Acierno, Ron, M. A. Hernandez, A. B. Amstadter, et al., "Prevalence and Correlates of Emotional, Physical, Sexual, and Financial Abuse and Potential Neglect in the United States: The National Elder Mistreatment Study," American Journal of Public Health, vol. 100 (2011).
2.	Laumann, Edward O., S. A. Leitsch, and L. J. Waite, "Elder Mistreatment in the United States: Prevalence Estimates From a Nationally Representative Study," The Journals of Gerontology Series B: Psychological and Social Sciences, vol. 63 (2008).
3.	Centers for Disease Control and Prevention, Understanding Elder Abuse: Fact Sheet, Division of Violence and Prevention, National Center for Injury Prevention and Control, 2013, http://www.cdc.gov/violenceprevention/pdf/em-factsheet-a.pdf.
4.	U.S. Government Accountability Office, Stronger Federal Leadership Could Enhance National Response to Elder Abuse, GAO-11-208, Mar 2, 2011, http://www.gao.gov/assets/320/316224.pdf. Reissued on March 22, 2011.
5.	§6703(a) through (c) of ACA.
6.	For more information on the Child Abuse Prevention and Treatment Act, see CRS Report RL30923, Child Abuse Prevention and Treatment Act: Reauthorization Proposals in the 107th Congress (pdf), by [author name scrubbed].
7.	For more information on the Violence Against Women Act, see CRS Report R42499, The Violence Against Women Act: Overview, Legislation, and Federal Funding, by [author name scrubbed].
8.	For more information see CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by [author name scrubbed].
9.	CRS analysis of 2013 Census data of the population age 65 and older.
10.	Federal Interagency Forum on Aging-Related Statistics, Older Americans 2012, p. 82.
11.	Congress included several provisions related to elder justice activities in the OAA Amendments of 2006 (P.L. 109-365). For example, the law added various elder justice activities to be carried out by the Assistant Secretary for Aging. These provisions include responsibility for Administration on Aging (AoA) to develop and implement systems for elder justice and to conduct an elder abuse national incidence study. It also added a requirement that the Assistant Secretary award funds for competitive grants to states for development and implementation of elder justice activities under Title VII of OAA.
12.	The Elder Justice Act has been introduced in the 108th Congress (S. 333; H.R. 2490), 109th Congress (S. 2010; H.R. 4993), and 110th Congress (S. 1070; H.R. 1783).
13.	§6703(a) through (c) of the ACA.
14.	Prior to Part I, new Subtitle B begins with Sections 2011 (Definitions) and 2012 (General Provisions), which are not discussed here.
15.	The Elder Justice Coordinating Council members include heads of the following departments and agencies: U.S. Department of Health and Human Services (Chair), Consumer Financial Protection Bureau, Corporation for National and Community Service, U.S. Department of Housing and Urban Development, U.S. Department of Justice, U.S. Department of Labor, U.S. Department of the Treasury, U.S. Department of Veterans Affairs, U.S. Postal Inspection Service, Federal Trade Commission, and the Social Security Administration.
16.	For a copy of the report, a list of EJCC members, and more information on EJCC meetings and proposals, see http://www.aoa.gov/AoA_programs/Elder_Rights/EJCC/Index.aspx.
17.	U.S. Department of Health and Human Services, "Establishment of the Advisory Board on Elder Abuse, Neglect, and Exploitation," 75 Federal Register 40838, July 14, 2010.
18.	FY2015 funding was allocated under the Elder Rights Support Activities line item appropriation, which includes $7.874 million for such activities, of which $4.0 million is for a new Elder Justice Initiative to provide competitive grants to states to test and evaluate innovative approaches to preventing and responding to elder abuse. Funding under this initiative may also be used for activities authorized under OAA Sections 411 and 751. (Division G of the joint explanatory text to Rules Committee Print 113-59, cited in "Explanatory Statement Submitted by Mr. Rogers of Kentucky, Chairman of the House Committee on Appropriations Regarding Amendment to the Senate Amendment on H.R. 83, Consolidated and Further Continuing Appropriations Act, 2015," House of Representatives, Congressional Record, vol. 160, no. 151 Book II [December 11, 2014], p. H9838.)
19.	For more information on OAA funding formulas see, CRS Report RS22549, Older Americans Act: Funding Formulas, by [author name scrubbed].
20.	Personal communication from Steve Hagy, Director, Office of Budget and Finance, Administration for Community Living, U.S. Department of Health and Human Services, January 13, 2015.
21.	ACA Section 6703(b).
22.	Centers for Medicare and Medicaid Services, Survey & Certification – Surveyor Training, http://cms.hhs.gov/Medicare/Provider-Enrollment-and-Certification/SurveyorTraining/index.html.
23.	CMS, Reporting Reasonable Suspicion of a Crime in a Long-Term Care Facility (LTC): Section 1150B of the Social Security Act, S&C: 11-30-NH, June 17, 2011 (revised January 201, 2012), see http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/SCLetter11_30.pdf.
24.	HHS, Office of Inspector General, Nursing Facilities' Compliance with Federal Regulations for Reporting Allegations of Abuse of Neglect, OEI-07-00010, August 2014.
25.	42 C.F.R. §483.156.
26.	ACA Section 6703(c).
27.	The ACA reauthorized funding for numerous existing discretionary programs administered by HHS. The ACA also created many new discretionary programs, including those authorized under the Elder Justice Act, and provided for each an authorization of appropriations. While most of those existing discretionary programs continue to receive an annual discretionary appropriation, albeit at levels below the amounts authorized by the law, few of the new grant programs authorized under the ACA have received any discretionary funding. For more information see CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by [author name scrubbed].
28.	ACA Section 4002; 42 U.S.C. §300u-11.
29.	For more information about the Prevention and Public Health Fund (PPHF) see Appendix C of CRS Report R43304, Public Health Service Agencies: Overview and Funding, coordinated by [author name scrubbed].
30.	Administration for Community Living, Protecting American's Seniors: The Elder Abuse Prevention Interventions Program, at http://acl.gov/NewsRoom/Publications/docs/Protecting_Americas_Seniors-%20The_%20Elder_%20Abuse_%20Prevention_%20Interventions_%20Program.pdf.
31.	U.S. Senate, Committee on Appropriations, FY15 LHHS Subcommittee Markup Bill Summary, June 10, 2014, http://www.appropriations.senate.gov/news/fy15-lhhs-subcommittee-markup-bill-summary.
32.	Division G of the joint explanatory text to Rules Committee Print 113-59, cited in "Explanatory Statement Submitted by Mr. Rogers of Kentucky, Chairman of the House Committee on Appropriations Regarding Amendment to the Senate Amendment on H.R. 83, Consolidated and Further Continuing Appropriations Act, 2015," House of Representatives, Congressional Record, vol. 160, no. 151 Book II (December 11, 2014), p. H9838.
33.	For more information see CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by [author name scrubbed].
34.	42 U.S.C. 3011
35.	Ibid.
36.	Administration for Community Living, Protecting American's Seniors: The Elder Abuse Prevention Interventions Program, at http://acl.gov/NewsRoom/Publications/docs/Protecting_Americas_Seniors-%20The_%20Elder_%20Abuse_%20Prevention_%20Interventions_%20Program.pdf.
37.	U.S. Government Accountability Office, Stronger Federal Leadership Could Enhance National Response to Elder Abuse, GAO-11-208, Mar 2, 2011, http://www.gao.gov/assets/320/316224.pdf; U.S. Government Accountability Office, Survey of Adult Protective Services Program Administrators (GAO-11-129SP, March 2011), an E-supplement to GAO-11-208, GAO-11-129SP, Mar 2, 2011, http://www.gao.gov/products/GAO-11-129SP.
38.	Connolly, Marie-Therese, B. Brandl, R. Breckman, The Elder Justice Roadmap: A Stakeholders Initiative to Respond to an Emerging Health, Justice, Financial and Social Crisis, 2014, at http://ncea.acl.gov/Library/Gov_Report/index.aspx.
39.	Ibid.