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