Audit: Kansas agencies’ lists of abuse perpetrators fragmented and may be incomplete

Legislative Post Audit told the Committee on Social Services Budget on Monday that state agencies’ records of alleged perpetrators of abuse, neglect and exploitation (A and E) are fragmented and may not be complete.

"Our work suggests that agencies' registries may not be complete," said Josh Luthai, a Legislative Post Audit analyst, summarizing the audit. He told the committee the system of reporting, referrals and registries is complex and spread across multiple agencies and licensing boards.

The audit explained that state law requires KDADS, KDHE and the Department for Children and Families (DCF) to take allegations of A and E and investigate. But Luthai and his team drew a distinction between "registers"—inventories of reports and investigations—and "registries," which the report defined as lists of identified perpetrators. That difference, auditors said, contributes to inconsistent recordkeeping and makes it hard for the public or other agencies to determine whether an individual has been identified as a perpetrator.

According to the presentation, KDADS investigates allegations in adult care homes and maintains the Kansas nurse aide registry mandated by federal and state rules; KDHE investigates allegations in medical facilities but told auditors it does not investigate individual perpetrators or maintain a perpetrators registry (citing limited authority, resources and an agreement with the Centers for Medicare & Medicaid Services); and DCF investigates allegations involving vulnerable adults in the community, residents of state psychiatric hospitals and child abuse by family members, and maintains two separate registries for adult and child cases.

The auditors flagged several referral practices that can prevent alleged perpetrators from being investigated and therefore from appearing on any state list. Luthai said auditors reviewed cases showing KDHE referred 17 allegations to DCF in 2024 and that DCF declined to investigate 14 of those, often because the incidents occurred in hospitals or did not appear to require protective services. Auditors also reviewed 13 KDHE referrals to law enforcement in 2024–25 that involved 25 alleged perpetrators—most employed by home health agencies—cases that may have been more appropriately handled by DCF, the report said. In two reviewed cases, auditors found DCF had inadvertently notified itself rather than KDADS, preventing KDADS from updating the nurse aide registry.

"The system is really complicated," Luthai said, pointing to a flowchart showing at least seven places the public might need to check to determine whether someone was identified for A and E. The audit noted some of those sources charge fees or have access barriers.

The report makes four recommendations: one to the legislature to consider amending state law to clarify agency responsibilities, and three to KDHE, KDADS and DCF asking them to consult with each other, the committee and CMS as needed to clarify roles and reduce cases slipping through referral gaps. Agencies generally agreed with the recommendations; KDHE said it may need legislative action to implement some changes.

Matt Edsall, performance audit manager at Legislative Post Audit, told the committee the office will track agency responses on a six‑month schedule starting in July and that the committee could request a follow‑up audit if it wants independent verification of actions taken.

The committee questioned whether the audit identified rates of law‑enforcement investigation and asked about limits on agency authority and next steps. The chair also noted agencies planned to revisit a 2013 memorandum of understanding to better define responsibilities.

The committee scheduled a site visit to the Kansas Neurological Institute in connection with related budget items and adjourned.