FLORIDA GUBERNATORIAL FELLOWSHIP PROGRAM

National Survey and Evaluation of Public Guardianship Programs Throughout the Country: A strategic plan to improve the effectiveness and

efficiency of the Statewide Public Guardianship Office in Florida

Report for the

Florida Department of Elder Affairs

July 2015

By:

Emmanuel J. Osemota

GUBERNATORIAL FELLOW CLASS X

TABLE OF CONTENTS

Introduction ... . . . .. . ...... . . ..... . . .................................... .... .. ...... ..... ... .. ...... 1

Methodology .. ....... . ... . . . . . ............... ........... .... . ............... .. . . .................. 2

Findings ...................... ..... .. .. .... ... ...... . .. .. . ..... . . .. . ... . ..... ...... .. ....... .... . .... 3

Prog~·an1 Models ... ........ . ... . . . . . ..... . . . ... . . . . . ....... . ... . . . ..... .. ..... . ............ . ... . 3

Progran1 Funding ......... .. ........ . . .. ........ . .... . .. . .. . ......... . . .... . .... . .. . ....... .... 6

Progran1 Structure .. ...... . .. .. .... . .. . . .. ...... .. . . .... .... ............. . .... . ................ 9

Progratn Monitoring ... ....... ..... ..... ... . ......................................... . ... . .. . 15

Program Services .... . .. . .. ... ... ... . . . .. . . . . . . . . .. .... ... ............. . .... . . ......... . .... . 19

Recommendations ..... ........ . .. . .... .. .... . . .. ... ..... .. ...... .... . . ... . . . .. .. .. . . . ........... 22

Appendix . . . . ........ . ... ..... ...... ........................... ...... ...... ... .. . .. . .. . . . ..... . .... 27

INTRODUCTION

Guardianship is a process designed to protect and exercise the legal rights of individuals

whose functional limitations prevent them from being able to make their own decisions. A

guardian is a person who has been appointed by the court to act on behalf of an incapacitated

person (legally known as a ward) or their property. A guardian may make some or all legal

decisions for the incapacitated person. 1 Public guardianship refers to the appointment and

responsibility of a public or publicly funded entity to serve as a legal guardian in the absence of a

will ing and responsible family member or friend to serve, or without resources to employ a

private guardian. 2

ln Florida, the Statewide Public Guardianship Office (SPGO), housed within the

Department of Elder Affairs, appoints local public guardians, monitors their activities, and

makes sure the needs of wards are dutifully and well taken care of. In the past decade, there has

been a need and concern for the establishment of statewide coverage of public guardianship

programs to adequately serve all citizens of Florida. Govemor Rick Scott's FY 2014-2015

budget included $3 million for the expansion of the Florida Department of Elder Affairs

Statewide Public Guardianship Office which adds to the existing base of $3 million. With the

availability ofthe fl.Jnd made possible by Governor Scott, the Statewide Public Guardianship

Office, in less than one year, expanded public guardianship coverage to all 67 counties in

Florida.

Soon after the recent increase of public guardianship coverage in the state, the 2014-15

Gubernatorial Fellow was placed at the Florida Department of Elder Affairs. The Fellow was

provided the opportunity to review the plan recently developed that identifies how the $3 million

will be spent, as well as review existing SPGO policies, processes, and program structure, in

order to come up with ideas and plans for !'he enhancement of SPGO. To accomplish this task,

the 2014-15 Gubernatorial Fellow took the initiative to study and conduct a thorough analysis of

operations of public guardian offices across the cotmtry. The Fellow used the results from Lhe

study, along with interviews of SPGO staff and Public Guardianship Offices across Florida, to

create a strategic plan that outlines recommended steps that will help improve SPGO's

effectiveness and efficiency as well as help deal with expected program growth.

1Floriun Bnr Association 2Bcll, W., Schmidt, W., & Mi ller, K. (198 1). Public guardianship ami the elderly: findings from a national study. The Gerontologist, 21, 194-202

Pngc 1

METHODOLOGY

The following is the methodology used in the research study of the public guardian programs across the country:

Data Collection Procedures

A national survey to learn more about public guardianship programs throughout the

country was developed. Although there are 50 states in the country, not all have a pl.lblic

guardianship program 29 states public guardian programs participated in the online survey. (See

the appendix for the list of states that responded to the survey). The evaluation of guardianship

programs throughout the country took place fi'om August 2014 - May 2015. Data were collected

using SurveyMonkey online.

Data Collection Measures

l. General processes of rnogram models. Program models are analyzed by gathering

infonnation on the mission and population of the public guardian programs they serve.

2. Funding. Program funding is analyzed by gathering information on budget size, funding

sources, and criteria used in distributing funds.

3. Structure of programs. The structure of programs is analyzed by exploring program

administrative duties.

4. Monitoring. Monitoring services are analyzed by gathering information on program

services provided and program standards.

5. Services. Program services are analyzed by gathering inforn1ation on types of services

provided toward wards.

Data Analysis

All data manipulation analyses were performed with Microsoft Excel. Only states with

completed survey results were used in data analyses. Also, only survey responses that were

pettinent to each question in the study were reported.

FINDINGS

Findings are organized into the following sections: description of the program models,

data on program funding, structure, monitoring, and services provided.

!!RDGRAM MODELS

Page 2

Most public guardianship programs are state programs like those in lllinois and Delaware, while

some states have county-by-county programs like those in Michigan and Maryland (Exhibit 1).

Exhibit 1: States or County Public Guardianship Programs

County Programs

State Program

0 5 10 lS Number of Respondents

20 25

Note: Not all states provided a response to this question. Source: DOEA Public Guardianship Survey, 2015

The mis!,·io11 and the population servetl by public guardian program~·

The mission of most public guardian programs across the nation is to serve as guardian and/or

conservator for incapacitated and eligible adults, and tbey are usually the guardian of last resort.

The purpose of guardJanship and/or conservatorship is to protect and provide continuing care for

individuals who are unable to make or communicate responsjble decisions for themselves. The

populations served by public guardian programs arc as follows:

• Alaska: The State of Alaska's public guardian program serves as the guardjan and/or

conservator of last resm1 for individuals who are adjudicated to be in need of a guardian

and/or conservator.

• A•·izona: The Maricopa County PubHc Fiduciary is to provide guard ianship,

conservatorship, decedent services, and court-ordered investigations for vulnerable

persons so their estates and well-being are protected.

• Delaware: The office provides quality, comprehensive1 protective guardianship services

to adult citizens of Delaware who are severely mentally or physically disabled, are unable

to manage their personal and fmancial affairs, are at risk for neglect, abuse, and

victimization and have no one else able or willing to serve as a guardian.

• lllinois: The program has a dual system of public guardianship. The Office of State

Guardian (OSG) serves wards with estates of less than $25,000. The Office of Public

Guardian is a county-by-county program serving wards with estates of $25,000 and over.

Page3

30

• Indiana: Guardianship programs serve more than 300 vulnerable and incapacitated

adults in Indiana who are unable to make personal and fmancia l decisions regarding their

care.

• Kansas: The office serves adults who are without family or financial resources and who

are identified through Adult Protective Services, Department for Children and Families

(DCF), and Kansas Department for Aging and Disability Services (KDADS) state

hospital social workers as in need of a court appointed guardian or conservator. Clients

will have available a qualified, trained, and caring volunteer to serve as their legally

appointed guardian or conservator.

• Kentucl(.y: The office acts as guardian and/or conservator for more than 3,800 wards of

the state who have been found disabled in making medical, personal, and/or financial

decisions through a jury trial process by the district cotu1 in the cotmty where they reside

(Kentucky has 120 counties). The-state establishes their residence and attempts to access

benefits and services in order to assist them with their health, safety, and welfare.

• Maine: The Office ofPublic Guardian serves people age 18 or older who are adjudicated

to be incapacitated and in need of a guardian and/or conservator.

• Maryland: The Office of Public Guardian in Montgomery County serves as the public

guardian oflast res01t for people who need a medical decision maker or placement in a

more restrictive setting, after exhausting all other less restrictive measures to solve the

problem.

• Minnesota: Adult Public Guardianship acts as public guardian for an adult with a

diagnosis of developmental disability who needs this level of supervision and protection,

and has no other private party willing or able to act in this role.

• Mississippi: The Harrison County Public Guardianship Program serves individuals on

public assistance/government benefits with assets under $4,000 and who are residing in

staterrun or assisted living facilities or group llomes and have no family or others to act

on their behalf.

• Nevada: The office serves people age 18 or older determined by the comi to lack

capacity.

• New Hampshire: The office delivers the provision of guardianship, co-guardianship, and

conservatorship services for individuals found to be legally incapacitated.

Page 4

• New Jersey: The New Jersey Office of the Public Guardian serves adults who are age 60

and older.

• New Mexico: The program serves alleged incapacitated individuals over the age of 18

who are low income New Mexicans, with very limited resources.

• North Carolina: The population served is adults 18 years and older who are found to be

incompetent by the Clerk of Superior Court.

• North Dakota: The office serves clients who are deemed incapacitated and have income

at or below 100 percent of the federal poverty level or are Medicaid eligible.

• Ohio: The office serves indigent adults, 18 or older, with a mental impairment that is not

due to Mental Retardation/Development Disabilities (MR/DD), who require a current,

compelling decision to be made regarding medical, housing, and end of life.

• Oregon: The Multnomab County Public Guardian & Conservator serves adults 18 years

of age or older who are Multnomah County resjdents at the time of the petition.

• Tennessee: The Public Guardianship for the Elderly Program is designed to aid persons

age 60 and older.

• Texas: The DADS Guardianship Services program serves those who are victims of

abuse, neglect, or exploitation They also serve aging~out youth from Chi ld Protective

Services who are substantially tmable to provide for themselves and who were victims of

abuse and neglect.

• Utah: The Office of Public Guardian serves as guardian ami/or conservator for

incapacitated and eligible adults.

• Virginia: The office serves persons who cannot adequately care for themselves because

of incapacity and are ab.le to meet essential requirements for physical and emotional

health and management of financial resources with the assistance of a guardian or

conservator.

• Washington: To be eligible for a public guardian, adults age 18 and older must have

incomes under 200 percent of the federal poverty level or be receiving long-tem1 care

services.

Page 5

PROGRAM FUNDING

The budget size of public guardianship programs throughout the country ranges from thousands

to millions of dollars, although most programs' budgets are in the millions (Exhibit 2).

Exhibit 2: Budget Size by Program State Budget Size

Arizona (Maricopa County} $1,150,000 Delaware $31,500 Florida $ 6,000,000 Georgia $1,800,000 Illinois $ 8,164,500 Indiana (Marion County) $500,000 Kansas $ 1,162,000 Maryland {Montgomery County) $142,000 Minnesota $100,000

--Nebraska $1,500,000 Nevada (Washoe County) $ 1,399,219 New Hampshire $ 2,500,000 New Jersey $1,000,000 New Mexico $5,000,000 North Carolina $ 17,956,187

-North Dakota $255,000 Ohio (Cuyahoga County) $1,000,000 Oregon $1,200,000 Tennessee $1,010,000 Texas $6,500,000 Utah $683,000 Virginia $2,200,000 Washington $ 1,021,000 Note; Not all states provided a response to this question. Florida Is listed for comparison with other states. North Carolina's "budget size" reflects reported expenditure for fiscal year 2013-2014 as opposed to state dollar appropriation/allocation. Source: DOEA Public Guardianship Survey, 2015

Furthermore, budget sources and percentages of budget sources of public guardianship programs

throughout the country come from either state, federal , or private sources. Despite the fact that

there is little funding from private sources, most public guardianship programs receive their

funds from their state government (Exhibit 3).

Page 6

100%

90%

80%

70%

60%

SO%

40%

30%

20%

10%

0%

Exhibit 3: Percentage of the Budget for Each State by Source

A1 DE GA IL IN KS MD ME MN NC NO NE NH NM NV OH OR SD TN TX UT VA WA

• Stat!';!% Fedefal % • Private % • Other%

Note: Not all states provided a response to this question.

Source: DOEA Public Guardianship Survey, 2015

Criteriftused in the distributiott offimds to public guardianship programs/offices

• Indiana: Funding is distributed through a county matching grant application process.

Currently, the programs must match the grant at a 50/50 ratio, meaning that at least 50

percent of the match must be cmmty cash and up to 50 percent may be in-kind services.

In extreme circumstances, a 25175 county cash/in-kind match was accepted. The

maximum amount that could be awarded for FY 2014-2015 was $38,250.

• Maine: The state of Maine has one statewide program tbat is managed centrally by state

employees and administered through eight district offices, also staffed by state

employees. The budget is divided among the central and district offices for operating

pmvoses only.

• Maryland: The Office of Public Guardian in Montgomery County provides funds to

cover guardianship services to the community and some of the budget is based on

caseloads. However, tbe budget barely covers the cost of the salary for the supervisor

and one part-time case manager. Fortunately, the progra111 is combined with Adult

Page 7

Protective Services, which has allowed the office to get funding for its case managers

from social service block grants.

• New Hampshire: NH has a "hybrid" type public guardianship program, in that the

program is a private non-profit organization approved to provide public guardianship

services in NH, along with another non-profit called Granite State Guardianship Services.

• New Mexico: The New Mexico Office of Guardianship (OOG) does not distribute funds

to other programs, but has its own program that is statewide. State statute and regulation

allow the agency to have its own contractors to handle the legal services for low income

individuals to have a guardian appointed on their behalf. OOG has four types of

conh·actors: attorneys (I) petitioning attorneys; (2) g~uardians ad litem; (3) court visitors;

and (4) corporate guardians. Some individuals served have a family member appointed

as a guardian, and if so, the incomes of the family and the individual are taken into

consideration to qualify for the program. Other individuals, without family members able

or willing to serve as guardians, have corporate guardians appointed. OOG pays

appointed corporate guardians on a monthly basis. Attomeys and court visitors are paid a

flat fee per case.

• North Carolina: ln NC, Social Services Bl.ock Grant (SSBG - federal funding) is

distributed to each county department of social services and to some state agencies.

• North Dakota: Petitioning funds go to those who have been deemed incapacitated and

meet income requirements.

• Texas: The Texas public bruardians' funds are managed by a state office program through

a budget process.

• Tennessee: Tennessee uses a weighted scale based on 11type 11 and ''placement." For

instance, plenary guardianship (full) and 11home'1 placement get the highest number of

dollars. Durable Power of Attorney gets the least amount of funding.

Page 8

PROGRAM STRUCTURE

Office staff of public guardhmship progrttms: full-time or part-time employment

Most public guardianship programs have staff who are full-time employees with benefits,

allbough some offices do operate with part-time staffwilli or without benefits (Exl1ibit 4).

Exhibit 4: Office Staffs: Full-time Employees With Benefits, Full or Part­time With limited Benefits, or Some of Each

Part-time with no benefits 15%

Part-time with limited benefits 0%

Part-time with benefits 8%

Full-time with no benefits 4%

Full-time with limited benefits

Full-time with benefits

0 2

Note: Not all states provided a response to this question.

Source: DOEA Public Guardianship Survey, 2015

6 8 10 12 14 16 18 20 22 24

Number of R!!~pondents

Brief expla1wtion of public guardia!lship office staff duties

• Delaware: Guardianship staff include tbe following; the public guardian bead of

agency/attorney; the deputy public guardian, who oversees the financial unit

(gmu-dianship of property cases); the guardianship monitor, appointed by the Court to

monitor any guanlia.nships in llie state; and the financial case manager/case manager for

property guardianships who applies for benefits and secures resources/property. Also,

there are three guardianship case managers who maintain and manage caseloads of

wards, attend care plans and visits, and oversee consent issues. Finally, there are three

support staff, an administrative officer, an account technician, and a social service

specialist.

Page 9

• Georgia: Field staff assists in making a11d expressing decisions of the person under

guardianship while state-office-level staff develop and train on policy, participate in

national professional associations to stay at the forefront of the guardianship profession,

and administer the program's budget, etc.

• Illinois: Executive staff include an agency director, program directors, CFO, and

administrative support. Guardianship representatives are generally social workers who

visit wards at their residential placements, participate in care plan conferences, placement

planning, estatv case management, and medical decision making. Intake staff process

about 5,000 refenals each year. Region~) administrators manage the field offices and

staf( Attorneys represent OSG in court and travel to all counties of probate.

• Indiana: The office currently has a full-time staff attorney and part-time administrative

assistant who oversee the administration of the matching grant program and serve as a

resource to courts and the public on all matters relating to adult guardianship.

• Knnsas: The office recruits, trains, and monitors volunteers who are appointed to serve

as the court-appointed guardian or conservator for adults (only) who do not have family

willing or appropriate to serve in this capacity.

• Maine: The office staff duties include court inventory, atmual court accountings, estate

management functions (sale of real estate, cashing in of insurance policies, establishment

oftrustsJ etc.)J training, billing, income tax filing, and after-death activities.

• Maryland: The program office has nine case managers, eight social work case managers,

and one nurse case manager. Each case manager has a caseload of up to 25 clients. They

provide at least monthly visits and ensure that all clients' needs are being met in the least

restrictive environment to keep them safe.

• Minnesota: Staff duties are delegated between non-delegated powers/duties and

delegated powers/duties. The county representatives carry out the delegated duties. And

the Commissioner of Human Services and staff complete non-delegated functions.

• Mississippi: The guardianship office oversees all standard office functions (fi ling,

phones, etc.) plus scheduling of appointments and col.Jrt cases; client, attorney, medical

provider, col.Jrt personnel, witnesses, general public contact; completion of tonus for

social security/Medicare/Medicaid; completion of forms for medical and other care

Page 10

providers; annual accountings to the Comt over ward assets; drafting of annual reports to

county government.

• Ncvndn: In Nevada office assistants do the office work, while case specialists assist with

clients, shop for them, and do some office work.

• New Hampshil·c: Currently, there are 14 public guardians on staff and five estate

1nanagers who handle all the financial matters. Public guardians do not provide direct

services such as transpottation or supervision. The guardian's time is spent in getting lo

know his or her wards and their service providers, making JTtedical and treatment

decisions, advocating for and consenting to placements in the least restdctive setting, and

protecting a ward's property and assets.

• New Jersey: Staff duties are to provide legal, financial, and care management services

• New Mexico: The agency has a supervising attorney, staff attorney, two compliance

officers, and an intake coordinator. The intake coordinator accepts and reviews

applications to make recommendations to the rest of the staff to assign a Petitioning

Attorney, Guardian ad Litem, Court Visitor, and Guardian contractor. The compliance

officers oversee the contractors, review and approve invoices, and monitor tile

contractors' com pi iance.

• North Carolina: The legally appointed guardian is the Division of Social Services

director or assistant director. The guardian representative is a social worker employed by

the county DSS. Most county DSS staff are full time positions with benefits.

• Ohio: There are 18 public guardians throughout the state who serve as the assigned

guardian and/or conservator for individuals. They have one attorney, one paralegal, and

one administrative clerk who are assigned to the public guardian section as well as two

part-time "on-call" assistants who assist with pape1work. They also have an accountant

who processes disbursements and deposits from their clients' accounts. They share other

paralegals and administrative staff with other sections of the agency.

• Oregon: There are 10 full-time staff in the program. The public guardian is the program

manager who manages the program and supervises the deputies. The senior deputy

handles referrals, community outreach/education, supervises the case manager and

support staff, and does much of the court work. Four deputy public guardians carry case

loads of approximately 40 clients each and are the primary decision maker:- for these

Page ll

clients. The case manager supports the deputies and does a lot of medical escmts. The

three support staff support the program with document prep, filing, etc.

• Texas: The 12 full-time employees who are in the state office are charged with

administering the program. Staff includes one section director, three managers, and eight

program and suppmt staff.

• Utah: Provide guardianship and conservatorship case management in line with NGA

Standards of Practice and State of Utah Statutes. Provide guardianship/conservatorsbi p

assessment, surrogate decision making, advocacy, coordination of services, and financial

management. Also, provide education on guardianship and alternatives to guardianship.

• Washington: The office requires public guardianship providers to certify annually for

each individual served. The office established a system for monitoring the perfonnance

of public guardians, and office staff make in-home visits to a randomly selected sample

of public guardianship clients.

Visitation of waNts

the visitation of wards usually entails checking up on them and attending care

conferences or care meetings. This is done by public guardianship staff either monthly or

quarterly. (Exhibit 5).

Exhibit 5; Visitation of Wards

Quarterly

Monthly

0 2 4 6 8

Nun1ber of Respondents

Not@: Not all states provided a response to this question.

Source: DOEA Public Guardianship Survey, 2015

Page 12

45%

55%

10 12

Description of meetings between the guardians ami the wards (care conferences or care

meetiltgs)

• Georgia: Case managers (guardians) meet with persons under guardianship; these

meetings vary depending on the amount of input and interaction the person can have.

CMs attend care conferences and meetings. They transport persons to legal proceedings,

medical appointments, etc. The contact is frequent and varies greatly.

• lllinois: Each ward is mandated to visit quarterly. At the time of the visit, the ward's

environmental, medical, psychiatric, social, placement, and vocational needs are

reviewed. Time is spent conversing with the ward, reviewing facili ty records, and

meeting with staff.

• Mat·yland: Guardians meet the clients where they live: in the community, assisted living

facilities, group homes, nursing homes, or hospitals. They attend all care plan meetings

and interact with all tbe people involved in the client's life. They either attend doctors '

appointments or have conversations with medical personnel to stay apprised of all client

health issues. They may meet clients at the senior center or adult day center and interact

with them and staff there as well.

• New Jersey: Care managers meet with clients by appointment. Care managers' report to

the public guardian regarding care management needs of clients during care management

conferences, which also include the participation of legal and financial services units.

• New Mexico: Contract guardians are required to visit their clients face to face at least

once a month. Depending on the needs of the clients, the guardian shall provide services

needed at the time.

• North Carolina; The guardian representative is primarily responsible for meetings with

the ward. These meetings may occur at case conferences or care planning n1eetings but

may also occur wherever and whenever the ward and the rep agree to meet.

Other types of guardialls i11 the state (professional guardian, fami(y, etc.)

According to the survey reports, some public guardian programs tluoughout the country

indicated that aside from public guardianship, there are other types of guardians, such as

professional and family, in their states, and at times they are monitored and overseen by the

public guardianship office (Exhibit 6).

Page 13

Exhibit 6: Office Oversees/ Monitors the Guardianship Programs/Offices

No 57%

Yes 43%

0 4 6 . 8 Number 01 Respondents

lO 12

Note: Not all states provided a response to this question. SourcE!: DOEA Public Guardianship Survey, 2.015

How outreach atul media exposure have helped public guardia11ship programs

Some public guardianship programs across the country use outreach and media outlets for

public announcements and awareness purposes, such as providing education to area hospitals,

social service agencies, and county human service partners on a regular basis. Forms of outreach

include community meet and greets, community presentations, biannual newsletters, websites,

conferences and symposiums, and the distribution of pamphlets. The program in Indiana has a

communications team that has been effective in setting up its program's website and publicizing

any events relating to its Adult Guardianship Office. Maine's program has had public service

announcements made possible by Legal Services for the Elderly. Education and outreach efforts

by the Maine Council for Senior$afe, an elder abuse prevention program, have also been

successful. New Hampshire's program is active in the National Guardianship Association and

works with the American Bar Association Section of Law and Aging in collaborating on projects

of interest toward guardianship. Also, a number of staff serve on boards and advisory committees

in addition to sponsoring and/or participating in trainings for stakeholders and others interested

in best practices in guardianship. The program in Tennessee is an administrative agency. As

such, it is required to conduct and perfmm outreach with all the judges/chancellors in its district

so that the courts are aware of available services. The public guardian programs in Tennessee's

very rural counties tend to "take care of their own," and thus do not use outreach programs as

much, as compared to the programs in urban districts, which are the highest users. The program

in Maryland sees itself as public guardian of last resort and does not advertise or provide

outreach to increase its caseload, although it focuses on conducting a great deal of outreach to

local hospitals, nursing homes, and other conununily partners so as to educate them about the

least restrictive alternatives to guardianship.

Page 1.4

14

PROGRAM MONITORING

The mo11itoring respo1lsibilities and processes for the public guardianship programs/offices

• Ahtska: Monitoring is done by the court in annual reviews as with all protective

appo.intments. Also third patty agencies, such as Adult Protective Services, the Office of

the Long Tem1 Care Ombudsman, and the state ombudsman's office, investigate concerns

regarding public guardians.

• Delaware: Tbe OPG is required to file an annual status report on individuals tbr whom it

serves as guardian of the person. The OPG is required to file an annual accounting on

individuals whom they serve as guardian of the property.

• Georgia: Per law, the state office is to keep a list of public guardians.

• Ulinois: The Office of State Guardian (OSG) files annual court reports for each ward at

the anniversary of the appointment. OSG is audited by the Auditor General every two

years. OSG is also audited by the Social Security Administration when serving as

representative payee.

• Indiana: Each program that receives grant funding signs grant terms and a Code of

Ethics and Program Standards, developed by the Adult Guardianship Office, requiring

complete compliance to best practices and the NGA Mode] Code of Ethics and Standards

of Practice.

• Maryland: All cases are reviewed twice a year by the Maryland Adult Public

Guardianship Review Board. Maryland law dictates that each jurisdiction have a board.

The board is comprised of 1 1 members who are volunteers from the coJnrnunity. There is

a physician, nurse, psychiatrist, social worker, disabilities professional, representative

from the Department on Aging, a health and human services liaison, a person with a

disability, and three public at-large positions. The Adult Public Guardianship office

presents all cases to be reviewed and then a report is written by the board and sent to the

court. Finally, the Adult Public Guardianship office only serves as guardians of persons;

they are not allowed to serve as guardians of property. The court appoints private

attorneys to serve in that capacity.

• Minnesota: County delegates provide annual reports, updating the state office of any

changes for the ward in the past year.

Page 15

• Mississippi: The Harrison County Public Guardian is overseen by the Hanison County

Board of Supervisors and the Chancery Court Clerk. The work of the public guardian is

also regularly reviewed by the Chancery Court Judges.

• Nevada: Individual to each county guardian office. Washoe County management

provides internal audits, undergoes Social Security audits, and has undergone audits from

outside experts identi.fied by NGA (approximately five over a 10-year period). Currently

working with School of Social Work at University of Nevada Reno to develop program

evaluation.

• New Mexico: Contracts are prepared and processed through the staff; the monthly

invoices are reviewed and approved by the compliance officers; and the program has

authority to visit the client and or contractor office and be provided docw11 ents at any

given time. If there are complaints, the program has a process for reviewing and

resolving issues.

• North Carolina: The Division of Aging and Adult Services (DAAS) staff utilize a

standardized guardianship monitoring tool for onsite monitoring of guardianship

provided by cotmty DSSs and guardianship provided by corporations being paid with

public dollars.

• Oregon: The Multnomah County Public Guardian & Conservator is required to file an

Annual Accounting and an Annual Guardian Report with the court, and also in the case

of conservatorships. The program has internal policies and procedures to monitor cases to

be sure programs meet the NGA practice standards and state statues.

• Tennessee: Monitoring tool basically consists of the following: Are U1e clients eligible to

receive P.G. services (60 and older)? Are the program activities allowable, i.e., within the

scope of the contract? Does the program meet "best practices"? Are the SAMS reporting

requirements timely? Is there evidence ofbackground checks with the program

volunteers and evidence of outreach to the court system in their district? Are court orders

followed? Evidence of the program staff on the blanket bond? What is the number of

"indigent clients"? Number of fee based clients? Are they using the TCAD sliding fee

scale if a fee based client? Are any/all fees used for the P.G. Program only? Verify that

bills are paid responsib ly, tjmely and verified to the general ledger.

Page 16

• Texas: The Department of Aging and Disability Services (DADS) bas a monitoring

process in place for the wards served by the program and through contract providers.

DADS has established monitoring protocols for both processes.

• Uhth : The Office ofPubl ic Guardian (OPG) tmst fund is monitored by the Department of

Human Services lJHemaL Audit and Review. OPG's case management records are

monitored by Department ofHuman Services Office of Service Review. OPG monitors

its contractor and is also monitored by the state agency that also provides services to the

same clients, Division of Services for People with Disabilities.

• Vil'ginia: On au annual basis, Virginia Public Guardian and Conservator mooitors the

programmatic operation of each local/regional guardianship program with special

emphasis on tbeir compliance with state law and regulations and federal law. Monitoring

includes annual on-site review of agency operations, a review of about 25 percent of

randomly selected client files, and home visits to about 10 percent of clients served, 5

percent of which are to be randomly selected. Completes monitoring reports in a timely

manner. Develops and implements recommendations for program enhancements.

Maintains files in an orderly and organized fashion, in accordance with applicable agency

policies. Complies with agency policies regarding documentation and reporting.

Specific laws govemittg the monitori11g process

Public guardianship programs across the country are either governed by their state>s

guardianship statutes, agency statutes or by the court system.

Programs accaptrmce of appointments/wards (referrals, appointment from the courts, sister

agencies, etc.)

According to the survey, public guardianship programs receive their

referrals/appointments from the judicial court system and sister agencies such as Adult Protective

Se1vices, Social Set-vices, senior centers, the Mental Health & Addictions Services Division,

Developmental Disabilities, and Guardian Ad Litem. Also, some programs receive referrals from

hospitals, attorneys, and private individuals.

Page 17

Description of the standards in place

Most public guardian programs adopt and implement policies and procedures that are

consistent with the National Guardianship Association Standards ofPractice, though some like

North Carolina have a guardianship manual which includes statutory requi1·ements and best

practices. ln Mississippi, there are state statutes concerning the duties and obligations of

guardians/conservators as well as the general ethical rules regarding attorney conduct. Finally,

Texas DADs has developed standards for the provision of guardianship services and holds both

internal and contract provider staff accountable for those standards. Furthermore, in most public

guardianship programs serving wards throughout the country, there exists a uniform standard of

practice and accountability that applies to their statewide pubJic guardianship programs/offices

(Exhibit 7).

Exhibit 7: Uniformity of Standards for Practices and Accountability

No 14%

Yes

0 2 4 6 8 10 12

Number of Respondents

Note: Not all states provided a response to this question. Source: DOEA Public Guardianship Survey, 2015

Page 18

86%

111 16 1$ 20

PROGRAM SERVICES

Most public guardianship programs across the countr y provide their wards with activities

such as emotional assistance and socialization programs. These activities for the most part

positively affects wards quality of life and wellbeing (Exhibits 8 & 9).

Exhibit 8: Provision of Activit ies That Wards Participate in and Positively Affect their Quality of Life

No 21%

Yes

0 2 4 6 8 10 12 Number of Respondent>

Note: Not all states provided a n~sponse to this question. Source: DOEA Public Guardianship Survey, 2015

HI 16

Exhibit 9: Different Activities That Programs Provide for Wards to Participate in and the Effect on Their Quality of Life

Establish residences for homeless 86%

individu<~ls

Make appropriate placement from home to facility

Arrange client funerals 86%

79%

18

100%

Re-establish relationships with 95%

family and friends

Enhance client socia lization

Secure needed medical care and/or equipment

Provido client emotional support

0 5

Note: Not all stat€!S provided a response to this question. Source: DOEA Public Guardianship Survey, 2015

Page 19

81%

100%

86%

10 15 20

Number of Respondents

20

25

U11met needs ami strategy for mitigating unmet needs

In some states' public guardianship programs, there are wards with unmet needs for

public guardianship services (Exhibit 1 0). Furthem10re, various programs across the country

specify that in order to mitigate unmet needs of wards, their agency continuously requests full

funding, seeks additional funding from their state legislature to expand capacity. Though the

program in Maryland specifically indicated that their program, in order to mitigate unmet needs,

makes sure all referrals they receive are appropriately in need of guardianship services. Also,

they strive to fi11d the least restrictive interventions as possible because guardianship is a very

restrictive process and should only be sought when there are no other alternatives. In Indiana,

they have made every effort to develop and expand the number of volunteer-based guardianship

programs throughout the state. Also, Tennessee does have a viable volunteer component that

allows them to serve more people that have no money/means.

Exhibit 10: Estimation of Wards With Unmet Needs - -

State Estimate -

Tennessee New Mexico Nebraska Ohio Virginia Washington Texas Note: Not all states provided a response to th•s question. Source: DOEA Public Guardianship Survey, 2015

How waitlists are manage([

100 200 600

1,000+ 1,000+

4,000 25,000

While most programs reported having no waitlist for guardianship services, the following states

reported ways they strive to manage whatever form ofwaitlist list they have.

• Alaska: Anyone who is concerned about the welfare of an individual can petition the

court for a protective order for that person, and the public guardian office must accept all

lawful appointments.

• Illinois: Generally in the Illinois public guardianship program, there is no waiting list tbr

guardianship services, and they do not have maximmn caseload thresholds or the ability

to decline new appointments. There may be waiting lists for community- based

Page 20

residential services and suppo1ts for wards in need. The waiting list is called PUNS and

those io crisis are prioritized.

• Nevada: Referral petitions are processed in order of needs assessed with assist of a Red

Flag Indicator tool.

• New Hampshire: List is maintained by the coutract administrators who are attorneys and

paralegals for the State of New Hampshire.

• New Mexico: Based on the rating, the program is contacting the requesting individual

and moving forward with providing guardianship. The staff is working with the entire

waiting list to move tb1ward in providing guardianship to all on the list with a goal of

eliminating the waiting list.

• Vit·ginia: Monitored through quarterly accounting to make certain the list is current (by

removing those individuals who have di ed or otherwise no longer need a guardian).

Page 21

RECOMMENDATIONS

Based on public guardianship programs findings and infom1ation analyzed above, along

with interviews of SPGO Headquarters staff and staff in Public Guardianship Offices across

Florida, 1 am presenting the following recommendations with the goal of enhancing the

effectiveness and efficiency of the Statewide Public Guardianship Office (SPGO) in Florjda..

1. Oversight of professional guardians

In Florida, there is no single entity that is responsible for oversight of professional

guardians, and there is no central intake point for professional guardian complaints. This

makes it difficult for people to report issues with specific guardians. Most people are

directed to the Department of Children and Families Adult Protective Services Hotline, or

to write to their judge or clerk, or other resources, when they have a complaint. As such,

SPGO should become the central point for all calls related to public and professional

guardiansbips. Futtbennore, SPGO should work in conjunction with the clerk of cout1s

when necessary so as to review and investigate, if detennined appropriate, an allegation

that a professional guardian has violated an applicable statute, fiduciary duty, standard of

practice, rule, regulation, or other requirement goveming the conduct of professional

guardians.

2. Usc of guardian advocacy

In many cases, wards referred to the Public Guardianship Office are individuals who have

been abandoned by their families in part because they are severely developmentally

disabled, and they lack an agent with the authority to perfonn the duties of a guardian.

These individuals generally suffer from additional debilitations such as blindness, which

have been identified and detem1ined to render the person pennanently incapable since

childhood. Nonetheless, F.S. 744 clearly refers to tbe use of guardian advocacy and

specifies that guardian advocacy proceedings are a less restrictive option. The Public

Guardianship office must file incapacity proceedings with respect to these individuals as

their last resort, when no guardian advocate is available and will.ing to serve. Also, the

natme of guardianship proceedings is quite expensive, and without the adjudication of

incapacity, the cost for examiners fees are substantially lower. By allowing public

guardian programs in Florida to use a guardian advocate for persons with developmental

disabilities eligible under F.S. 393.12, there will be a decrease in cost for the state

Page 22

because this option decreases the amount of state funds spent on legal fees, or the amount

of legal services provided by the state to public guardian programs who conh-act with

Florida Legal Services in their area. Although less restrictive and less costly, the state

will not be able to implement this recommendation through rule writing or a change in

contract language alone. Therefore, SPGO with DOEA must oblige the legislature to

include language to address the exist-ing F.S. 744.7021 so to allow for the public

guaJdianship programs to use this lesser-restlictive option: guardian advocacy.

3. Adjudication by The Department of Childn.m and Families (DCF)

Many public programs spend resources allocated from the state for legal fees associated

with guardianship. In many cases, the initial costs of guardianship may be the most

costly. Prograrns prioritize referrals made by DCF, Adult Protective Services_ The Florida

Department of Children and Families has the ability to adjudicate incapacity and initiate

guardianship proceedings. As such, the state of Florida and SPOO can improve public

guardianship services and decrease costs by developing a memorandum of understanding

between SPGO and DCF for DCF to initiate proceedings for referrals to public guardian

programs. Assisting DCF in adj\.1dicating with staff attomeys on behalf of the potential

wards ofthe public guardian programs would decrease the amount of money spent on

legal fees while also decreasing the time spent in guardianship proceedings. Public

guardians would be able to allocate those funds toward case management, and the state

would reduce costs spent on other legal advocacy paid for by general revenue ftmding.

4. Usc of nurse consultants or staff with nursing backgrounds

PGs often make complicated medical decisions and need independent advice to give

infonned consent. Nurse consultants could assist in choosing the least restrictive, cost­

effective, residential setting appropriate to a person's needs. Nurse consultants would also

be helpful in monitoring the medical condition of a person living in the community when

home health services are unavailable or unaffordable. Furthermore, il would be helpfltl

to have the extra oversight and advice provided by nurse consultants especially in ce1tain

instances where a ward is medically fragile and/or in the hospital. Also, another benefit of

using nurse consultants is that PG social workers could directly or indirectly learn from

nurses and use the learned knowledge in making decisions about medical procedures or

other options on their wards' behalf.

Page 23

5. Consolidate staff positions

SPGO has two Regulatory Specialist II positions which are both basically doing the same

work for the most pmt, and their duties sometime overlap each other. I.n order to increase

efficiency, both positions should be consolidated into one. By consolidating both

positions into one, SPGO and DOEA will save money and also increase efficiency of

SPGO, whereby the person in the position will know the assigned duties without any

work overlap or conflicts.

6. Institute and promote uniform practices

In order to fully serve wards, SPGO should promote uniform practices among all

contracted PGs in the state. SPGO does have a guardianship manual which includes

statutory requirements and best practices. SGPO should continue to promote that all PGs

in Florida be guided by principles of good faith, honesty, and professionalism while

honoring each ward's individual choices to the maximum extent possible. SPGO should

also promote unifonn practice by requiring that programs abide by complete compliance

with the National Guardianship Association (NGA) Best Standards ofPractice and the

NGA Model Code of Ethics.

7. Institute volunteer programs

SGPO can help mitigate the unmet need of wards across Florida by encouraging and

recommending lhat public guardianship programs in Florida institute volunteer programs.

By developing and expanding the number ofvolunteerwbased guardianship programs

throughout the state, unmet needs will be reduced, and more people who have no money

or means will be served. Also, SPGO should be responsible for providing training

materials, direction, and resources to assist public programs with volunteers so as to have

uniform practices.

8. Begin and cultivate the nature of staff meetings

''As no man is an island/' there exists the need to build camaraderie among SPGO staff.

Whether it is the Executive Director of SPGO or the monitoring team staff, every person

in SPGO has to consider himself or herself as part of the team. One specific way of doing

that is through staff meetings. As such, having one staff meeting each month can foster

camaraderie; provide opportunity to share infom1ation, and encourage teamwork among

SPGO staff.

Page 24

9. Raise public awat·cness

The use of public out1·eacb can bring h·emendous contributions and volunteer support

from the public in the fom1 of pro bono attorneys to represent the petitioner and find safe

places for poor people to live. It can also help newly expanded public guardian programs

in Florida become known by the appropriate referral. sources. As such, DOEA/SPGO

should aid in creating different outreach outlets such as a consistently updated website, a

quarterly newsletter, SPGO news in Elder Update, community meet and greets,

community presentations, distribution of pamphlets, and attendance at conferences and

symposia by SPGO staff. Also, these approaches can be used to educate the general

public, elder care communities, area hospitals, social service agencies, and county human

services partners on a regular basis.

10. Standardize and prioritize waitlist of wards

In order to fully manage the waitlist of wards in Florida, SPGO must encourage waitlist

standardization and prioritization. One way to do this is for PGs to review the intake fonn

and obtain additional information as needed from referral sources to assess need, then

assign a priority to the ward. Prioritization Criteria I: Cases where the lack of

guardianship is likely to result in the physical harm to an incapacitated person or to

others. This includes cases where abuse and/or neglect have been alleged or proven.

Prioritization 2: Cases that require a guardian to approve residential placements.

Prioritization 3: Cases where the needs of the incapacitated person are not being met.

This includes individuals who are without family. Prioritization 4: Cases where decision

making is required in limited situations that do not require ongoing intervention. This

includes the need to resolve property issues for new wards.

11. Promote activities for wa•·ds that are beneficial to thcil· health

Promoting activities that a1·e beneficial for wards c~m improve their quality of life. As

such, SPGO should continually promote community-based services for wards, faci litate

placement changes from more restrictive to less restrictive environments, and promote

activities that wards can participate in that affect their quality of life and client emotional

support, securing needed medical care and/or equ ipment. This can include referrals for

client socialization, re-establishing relationships with family and friends, establishing

Page 25

residences for homeless individuals, making appropriate placement from home to facility,

and when necessary an-anging wards' funerals.

12. Annual on-site monitoring and quarterly reports

Having an annual on-site visitation of each program in the state will help SPGO to

monitor programmatic operation of each guardiansh.ip program to see whether these

programs are complying with SPOO contract terms, state law and regulations, and federal

law. Therefore, it is recommended that SPGO monitoring should include an annual on­

site review ofPG operations, a review of about 25 percent of randomly selected ward

files, and home visits to about 10 percent of wards served, half of which are to be

randomly selected and the other half are fi·aiJty wards. Also, through quarterly reports

from PGs, SPGO will. become more aware of PGs and their wards and also see the

current waitlist. This will allow SPGO to successfully manage the waitlist, working in

conjtmction with all PGs in the state.

Page26

APPENDIX

List of states or counties in a state that responded to all or some of the survey questions:

State Program County J. Alaska State 2. Arizona County Maricopa 3. Delaware State 4. Geo~gia State 5. lllinois State 6. Indiana County Marion 7. Kansas State 8. Kentucky State 9. Maine State Keru1ebec 10. Maryland County Montgomery 11 . Michigan County Arenac 12. Minnesota State L3. Mississippi County Harrison 14. North Carolina State 15. Nebraska State 16. Nevada County Washoe 17. New Hampshire State 18. NewJersey State 19. New Mexico State 20. North Dakota State 21. Ohio Non-profit faith based Cuyahoga 22. Oregon County Multnomah 23. South Dakota State Hughes 24. Tennessee State 25. Texas State 26. Utah State 27. Vermont State 28. Virginia State 29. Washington State

Page 27

List of states not in the survey:

1. Alabama 2. Arkansas 3. Califomja 4. Colorado 5. Cmmecticut 6. Haw au 7. ldaho 8. Iowa 9. Louisiana 10. ~assachusetts 11. Missouri 12. Montana 13. New York 14. Oklahoma 15. Pennsylvania 16. Rhode Island 17. South Carolina 18. West Virginia 19. Wisconsin 20. Wyoming

Page 28