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Christiana Blake’s fever had been raging for days.

On that day in early April last year, a doctor who examined her at an outpatient center became concerned that a family member was refusing to take her to the emergency room, even though the 76-year-old Dauphin County woman could barely keep her eyes open. In the haze of dementia brought on by a stroke, Blake couldn’t communicate or advocate for herself.

That was the first time her situation was reported to the local agency charged with protecting older adults from abuse and neglect, according to records obtained by Spotlight PA. Yet it would take nearly two months — more than twice the 20-day time frame prescribed by state regulations — for that agency to assemble a plan for Blake’s safety.

And once it did, little was done to ensure the plan was followed.

There were two more suspected abuse reports filed on Blake’s behalf over the next nine months — the last one just weeks before her death this past February. The doctor who performed an autopsy called it one of the worst cases of neglect he had seen in his 40-year career.

Most of Pennsylvania’s 52 county agencies responsible for protecting older adults are failing, in varying degrees, to swiftly review complaints of suspected abuse or neglect and craft plans to keep people safe — in some cases, even in emergencies, a Spotlight PA investigation found.

Certain county protective services agencies have taken five or more times the mandated 20 days for determinations in abuse and neglect investigations, according to data obtained from a wide-ranging public records request and analyzed by the news organization.

The deficiencies have persisted despite a 2018 report by the state inspector general’s office recommending the Department of Aging, which oversees those county agencies, develop procedures to improve timeliness in completing abuse and neglect investigations.

At the same time, there has been a staggering increase in the number of older Pennsylvanians who died during an open investigation of an abuse or neglect complaint, according to data obtained by Spotlight PA. In 2018, 888 people died under these circumstances. In 2022 (the last complete year of data), that number was nearly 1,700 — a 91% increase.

State aging officials have attributed the increase in large part to the state’s growing population of older adults, a sharp rise in abuse and neglect complaints, and the pandemic that wreaked disproportionate havoc on vulnerable populations.

But because the department does not track the cause of death for people who die during open investigations and county agencies aren’t required to report it, accountability is near impossible.

“People’s lives are at stake,” said Sheri McQuown, a protective services specialist who monitored the county agencies for seven years, adding: “If this involved children or puppies, there would be hearings.”

Despite the high stakes, the Department of the Aging has for years not made public the information needed to assess the performance of those agencies, what deadlines they are missing, and the repercussions of their failure to follow state regulations.

Protective services case files are confidential, and when things at county agencies go wrong, details about their corrective action plans are also withheld from the public.

Taken together, it is impossible to get a complete picture of how county-level failures harm older adults in Pennsylvania.

As the number of those adults continues to grow — by 2030, the population of Pennsylvanians 60 and over is projected to outnumber every other age group, according to state officials — there is an urgent and growing call for reform and transparency.

State Rep. Lou Schmitt (R., Blair) recently introduced legislation that would require the Department of Aging to publish the compliance status of each of the 52 county agencies.

“The public deserves to know,” Schmitt said. “They are where the rubber meets the road when it comes to protecting seniors.”

In an interview, Pennsylvania Secretary of Aging Jason Kavulich, appointed by Democratic Gov. Josh Shapiro to head the agency in early 2023, said the data analyzed by Spotlight PA don’t tell the whole story.

He said the county agencies have improved in other areas, including quickly getting out to conduct face-to-face interviews with older adults suspected of being abused or neglected. And he said that when investigations exceed the 20-day deadline, older adults may get some services as a final care plan is being drafted.

Kavulich also said there are outside factors that affect performance numbers, even in situations where caseworkers do everything right. Still, he said he told county agencies shortly after taking over the department that he intended to make more information about their performance public, and that the office is actively working on a plan to do that.

“We as a department have to do better,” he said, adding. “I don’t come to work every day to maintain the status quo.”

Little public information

Individual states set policies on protective services for older adults, as well as adults with disabilities. In Pennsylvania, this work is administered by 52 county-level agencies called Area Agencies on Aging.

Some are nonprofits that contract with counties, while others are government-run. Collectively, they cover all of the state’s 67 counties, providing services from recreational programs to transportation to meals. One of their most critical functions, however, is investigating allegations of abuse against older Pennsylvanians and providing them with services.

In Pennsylvania, state regulations require county aging agencies to make “all reasonable efforts” to complete investigations of suspected abuse or neglect as soon as possible, but “at least within 20 days.” An investigation is complete only when the allegation has or has not been substantiated; and if substantiated, after necessary steps have been taken to reduce imminent risk to the older adult.

Earlier this year, Spotlight PA requested a broad swath of data from the Department of Aging dating back eight years. The request sought information on the number of reports of suspected abuse and neglect (called “reports of need”) that were filed with the county agencies, as well as the length of time it took to investigate them and determine a plan of action.

The news organization also requested information, by county agency, on how many investigations each year were completed within the 20-day time frame, how many blew that deadline, and by how long.

Spotlight PA’s analysis found that, in the best year, nearly a third of total cases investigated annually by the 52 county agencies either missed the 20-day deadline or contained faulty paperwork that made it impossible to determine how they performed.

Some years were far worse. In the 2016-17 fiscal year, 49.5% of abuse and neglect investigations missed the deadline or lacked proper paperwork to know. The year after that, it was 46%. That number decreased to 35.4% in 2022-23, the most recent complete year of data.

Though that is an improvement since the inspector general’s 2018 report, serious deficiencies persist, especially in Pennsylvania’s largest counties that serve more people and have the highest number of reports of suspected neglect and abuse.

Allegheny County’s aging agency launched 3,850 abuse and neglect investigations between July 2022 and June 2023. Of those, no determinations were made within 20 days in 1,460 cases — or nearly 38%. Another 18.5% of the cases the county handled contained faulty or incomplete information, so it is unknown if they missed the deadline.

Of the 1,460 cases that didn’t meet the deadline, nearly 8% were classified as emergencies, the records show, meaning the older adult was at imminent risk of death or serious physical harm.

In Delaware County, nearly 45% of the 952 investigations handled by the agency there in 2022-23 weren’t completed within 20 days. Another 34% of the county’s cases contained faulty or incomplete information.

In fact, Delaware County’s combined percentage of investigations that missed the deadline or had faulty or incomplete paperwork — nearly 79% — was the highest in the state, followed by Westmoreland (67%), Allegheny (56%), Dauphin (55%), and Philadelphia (53.7%).

The head of the Delaware County agency, Barbara S. Nicolardi, referred questions about its performance to her deputy director, who lacked authorization to speak to a reporter. County spokesperson Ryan Herlinger said in an email that its aging agency’s challenges stem from “documentation” issues that “are not reflective of the immediate outreach and connection we make with clients.”

The Department of Aging monitors compliance of county agencies by randomly selecting investigations completed in a given year to see how they were handled, and then assigning a performance score.

But few of its findings are readily available to the public.

If the bureau finds deficiencies, it can cite the county agency for noncompliance and require it to submit a plan to correct the problems. That plan is not a public record, according to a department spokesperson. As a result, the public cannot know what deficiencies exist, what is being done to fix them, or the ramifications they might have had on the people affected.

Kavulich told lawmakers at his department’s budget hearing this past February that some information about noncompliance (including which counties fall into that category and why) would be released in May. The department’s most recently released report did not contain that information.

At Spotlight PA’s request, the Department of Aging provided a list of county agencies that are currently in noncompliance status, meaning their unsatisfactory performance left older adults at risk: Allegheny (16 deficiencies), Delaware (six deficiencies), Lehigh (six deficiencies), Mercer (10 deficiencies), Philadelphia (16 deficiencies), and Westmoreland (four deficiencies).

The department sent letters to those agencies between last summer and the start of this year informing them of their status. None of the letters described the actual problems. Nor did they say what the repercussions were, including whether older adults were harmed, or in what way.

Kavulich said he has mandated monthly meetings with the county agencies with the worst compliance rates. The hope, he said, is to hear what may be causing the problems and provide technical assistance.

He also said he’s launching a “fatality review” process for cases where the circumstances surrounding an older adult’s death are suspicious.

McQuown said that process existed under the previous administration. After Kavulich took over, she said, responsibility for those reviews was transferred out of the department to the county protective agencies — effectively letting the agencies monitor themselves.

Asked about the change, a department spokesperson said the prior administration had no formal protocol for conducting those reviews. And though the counties are now the ones who are responsible for the reviews, the department has laid out specific standards for them to follow.

An unrealistic standard?

Investigating cases of abuse and neglect is neither easy nor foolproof, according to interviews with protective services staffers and administrators.

County caseworkers receive training in a set curriculum that includes information on a range of topics, including how to manage older adults who may be resistant to care or who may be incapacitated, as well as requirements under state law. They also receive in-service training annually.

Once on the job, the work can be mentally and emotionally challenging, leading to high turnover in staff. In larger counties, caseloads sometimes exceed what is permissible under the law, which says that protective services investigators should not be handling more than 30 cases at any time.

JR Reed, who heads Lehigh County’s agency, said expecting 100% compliance with the law, 100% of the time, for every caseworker is unrealistic. Reed’s agency met the 20-day benchmark in nearly 87% of the cases it investigated in fiscal year 2022-23.

Reed said many factors can prevent investigators from meeting the 20-day deadline, including getting timely access to doctors or medical records, or dealing with older adults who are incapacitated and thus difficult to interview.

“Black and white data doesn't always tell the full story,” he said.

Reed said he would like to see Pennsylvania’s protective services code updated, and would support the 20-day requirement being lengthened by up to 10 days. Kavulich also told Spotlight PA the regulations need to be “modernized,” though he stopped short of saying county agencies should have more time to investigate reports of abuse and neglect.

Still, he acknowledged that quickly making determinations in cases is critical to keeping older adults safe, and that counties should strive to meet that and other benchmark

In 2018, Pennsylvania’s Office of State Inspector General conducted an extensive investigation of protective services in the commonwealth. The inquiry centered on whether the Department of Aging was properly monitoring the county agencies, as well as whether it was enforcing regulations on how quickly they were responding to reports of alleged abuse — including the 20-day deadline to investigate those allegations.

It found that in nearly half the alleged abuse cases reported in the 2016-17 fiscal year, county agencies either failed to meet that deadline or provided incorrect or missing information.

Among its 12-point list of recommendations for the Department of Aging: consider implementing a system for the department to review county agencies in real-time, in addition to its annual monitoring, to spot deficiencies more quickly.

McQuown, who worked as a protective services specialist at the Aging Department at the time the report was released, said the findings spurred changes. There was more robust data collection and analysis to better understand how the county agencies were performing. The department also created a bench of experienced caseworkers — including retired protected services employees — who could quickly step in to help ease staffing shortages and increased caseloads.

But McQuown said she quit her job at the department last summer because she believed that Kavulich, a one-time county agency director himself, was diluting its watchdog role, and making changes she did not believe were beneficial to older adults. The department’s protective services bureau, she said, no longer refers to its work as monitoring.

Instead, workers there refer to it as “evaluations.”

Kavulich dismissed the criticisms, saying they don’t reflect the difficult realities of people doing protective services work in the field.

“You can't walk into somebody's office and say, ‘You need to do better, because I've said you need to do better.’ That doesn't make someone better,” he said. If that were the case, he added, there would have been more significant improvement in county agency compliance with the 20-day deadline following the inspector general’s findings.

“If you don't have buy-in from the people doing the work in the field, or the people in the field don't trust that you are supporting them to make positive changes, you're not going to get the change that you want,” Kavulich said.

‘One of the worst cases of neglect’

The forensic pathologist who helped perform Blake’s autopsy after her death in February said the wounds on her body “could be one of the worst cases of neglect he has seen during his career spanning 40 years,” according to court records in what is now a criminal case in Dauphin County.

The head of Dauphin County’s county agency, Benjamin Knox, referred questions about the case to the county’s spokesperson, saying he could not comment on “pending litigation or investigations.” He did not elaborate.

The spokesperson did not respond to requests for comment. The Department of Aging declined to comment on whether it is reviewing Blake’s case, or whether it has an opinion on how Dauphin County handled her situation, citing the pending criminal prosecution.

Blake’s daughter and caregiver, Yeawah Sanu, was charged in mid-May by law enforcement in Dauphin County with criminal homicide and neglect of a care-dependent person. Court officials said she has not yet entered a plea in the case, and Sanu’s lawyer did not respond to calls requesting comment. Spotlight PA also left a message with Sanu’s husband, who did not return the call.

The pressure sores on Blake’s back were up to 2-½ inches deep, court records say. Her legs were decomposing and “mummified,” and had open wounds and exposed bones. One of her feet was on the verge of falling off her body shortly before her death.

Doctors, according to the criminal complaint against Sanu, had advised in the months prior to Blake’s death that her lower legs be amputated. But Sanu, who made medical decisions on her mother’s behalf, rejected the recommendation.

Protective service records in Blake’s case obtained by Spotlight PA indicate it was Sanu’s refusal to take steps to help her mother that led to the first report of suspected neglect to Dauphin County’s protective services in early April 2023.

According to those records:

Sanu had taken Blake to an outpatient center on April 10 last year due to a high fever that had been ongoing for a week. Medical staff there recommended Blake be taken to the emergency room, but Sanu allegedly resisted until a doctor threatened to call 911 to report her.

Sanu then allegedly refused ambulance transport to the emergency room even though her car battery was dead, opting to instead wait for family members to jump her car before taking her mother to Hershey Medical Center.

The records do not make it clear who contacted Dauphin County’s protective services bureau, which received the report of suspected neglect on April 11. The report was listed as priority, which under state regulations calls for meeting with the older adult within 24 hours.

The Dauphin County protective services worker assigned to the case met that guideline, visiting Blake in the hospital — and substantiating the report of neglect — that same day.

But it took nearly two months, until June 1, 2023, for a care plan to be presented to Blake’s daughter, the records show. The plan, which included in-home services for Blake, was assembled minutes after a social worker informed Dauphin County’s protective services unit that Blake had missed several follow-up doctor’s appointments, and that Sanu had reported feeling overwhelmed with managing her mother’s care.

The protective services record obtained by Spotlight PA shows just one other entry until late October, when another person reported suspicions of caregiver neglect to Dauphin County’s protective services unit. The report was classified as an emergency.

By then, Blake had landed in the hospital again because her feeding tube had become dislodged — and medical staff there diagnosed her with pressure wounds, a kidney injury, and a gangrenous black foot that looked “mummified.”

Again, a Dauphin County protective services worker visited Blake in the hospital the same day the report was made, but there is no entry showing whether the allegation of caregiver neglect was substantiated, or that there was a care plan put in place — that is, until a third and final report of suspected neglect was made to Dauphin County on Jan. 2.

Blake had again landed in the emergency room with “terrible wounds of unknown cause,” “wounds down to exposed bones,” as well as one “necrotic” leg and another on the verge of complete decay. She had pneumonia, was struggling to breathe, and her room smelled badly because as the nurse there put it: “Gangrene and infection smells rotten.”

Subsequent entries in Blake’s protective services reports are fast and furious: Police are alerted; a request for guardianship is made; neighbors of Blake’s are contacted; medical records are requested and reviewed.

At 4:30 p.m. on Feb. 20, Blake died. Dauphin County protective services closed her case three days later.

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