Audit finds Kansas abuse, neglect and exploitation reporting system fragmented; registries may be incomplete

Legislative auditors told the Legislative Post Audit Committee that the statesystem for reporting and registering perpetrators of abuse, neglect and exploitation (A&E) is complex, inconsistently interpreted and may leave gaps that make it hard to determine whether registries are complete.

The audit reviewed responsibilities and practices across several agencies that handle A&E allegations: Kansas Department for Aging and Disability Services (KDADS), Kansas Department of Health and Environment (KDHE), and the Department for Children and Families (DCF). Auditors concluded statutory language is unclear about whether agencies should maintain inventories of reports (registers of allegations and investigations) or separate lists of substantiated perpetrators (registries). Each agency interpreted its obligations differently, and registries that do exist tend not to overlap, making cross-checking difficult.

Josh Luthai, the audit presenter, summarized the core finding: "State law is unclear in some respects and agencies understand their responsibilities differently and have different practices," and he said that uncertainty and referral practices increase the risk that alleged perpetrators will not be investigated or placed on any state registry if they should be. The audit traced how jurisdictional rules and memoranda of understanding shape who investigates what, and found several specific referral and information flow issues auditors say increase the risk of incomplete registries.

Auditors described four referral-practice issues that increase risk. First, KDHE referred allegations to DCF that DCF then declined to investigate because they fell outside DCFjurisdiction (for example, allegations arising in hospitals); auditors found many of those referrals did not receive follow-up investigation by any state agency. Second, KDHE sometimes referred allegations only to law enforcement; because law enforcement may not refer outcomes back to state agencies for administrative registries, a criminal investigation might not result in a placing of the perpetrator on a regulatory registry even if A&E occurred. Third, DCF often refers allegations of child abuse by third parties to law enforcement and said it may not learn the outcome of those criminal investigations, creating a gap that can prevent a registry update. Fourth, DCF did not always notify KDADS when a certified nurse aide was found to have perpetrated A&E, and even when DCF notified KDADS, KDADS sometimes said it lacked documentation needed to update the Kansas Nurse Aide Registry.

The audit also reviewed the role of professional licensing boards (for example, the Board of Healing Arts and the Board of Nursing) and found boards routinely publish disciplinary actions but are not charged with keeping registries solely for perpetrators of A&E; board lists may include some perpetrators but are not dedicated registries and do not provide a complete, focused source.

Auditors recommended the Legislature consider clarifying state law to define agency responsibilities, and they recommended that KDHE, KDADS and DCF consult with one another and the Legislature as needed to clarify roles so alleged perpetrators are appropriately investigated or referred and, where appropriate, placed on a registry. Auditors said the agencies generally agreed with the recommendations, though KDHE told auditors it would need legislative changes to implement some steps.

Committee members raised several questions about how many individuals appear on various registries and whether criminal findings are propagated back into administrative registries. Josh Luthai told the committee auditors did not find a single consolidated place to count perpetrators and that, as a result, the overall scope of registries could not be determined from agency records alone. Deputy commissioner Frank Harwood and representatives from KDHE and KDADS joined the committee for discussion; KDHE representatives said their role is regulatory oversight and that they often refer allegations to law enforcement or licensing boards, while KDADS representatives described notification practices for guardians and family members in long-term care settings.

The audit emphasizes that inconsistent laws and practices, fragmented registries and gaps in referral and notification processes may limit the statesystemability to protect vulnerable populations. The report urges legislative clarification and improved interagency processes to reduce the identified risks.