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HomeMy WebLinkAboutMINUTES - 07082003 - C109 ...........-....I................. ............. ..................... ... ........ FHS # 45 TO: BOARD OF SUPERVISORS Contra FROM: FAMILY AND HUMAN SERVICES COMMITTEE Costa DATE: JUNE 24, 2003 SUBJECT: ELDER ABUSE PROGRAM UPDATE County SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION Recommendation: 1. ACCEPT the report presented by the EHSD Director and Staff providing a status update on the delivery of Elder Abuse and Adult Protective Services. 2. SUPPORT Department efforts to maintain essential Adult Protective Services program components in spite of staffing reductions resulting from funding limitations. Background: On June 16, 2003, the Family and'Human Services Committee heard the attached report providing an update on the status of the Adult Protective Services(APS) program. Employment and Human Services Department provides elder abuse services under the APS program that offers casework intervention to protect elders and younger dependent adults from abuse neglect, or exploitation. APS is part of a continuum of programs provided by the Aging and Adult Services Bureau of EHSD which all seek to promote maximum independent functioning for elders and adults with disabilities, assisting clients to avoid unnecessary or inappropriate institutional care. APS works in close collaboration with these other programs, which include in home supportive services (IHSS), temporary Conservatorship, multipurpose senior services, linkages case management, assistance to caregivers, health insurance counseling and advocacy, and a wide variety of Area Agency on Aging (AAA) programs. APS works closely with collocated Health Services nursing and mental health staff who provide essential consultation and evaluation for APS clients and with various Health Services programs. The long term care integration planning project jointly sponsored by EHSD and HSD is in the process of designing an action plan to redirect funding to expand availability of home and c,ommunity services for elders and adults with disabilities to enhance collaboration between the two departments and community based organizations who serve the same clients. Fiscal challenges that have led to staffing reductions in the APS and IHSS programs and curtailment of some AAA community based programs, and the limited capacity of many Health Services programs with which APS collaborates, pose serious problems for the APS program. Also, the number of individuals who need protection from abuse, neglect or exploitation is steadily increasing due to the aging of the County's population and the attendant increase in elders with physical disabilities and/or dementia. The failure of funding resources to keep up with this population growth and the inability to expand APS and related home and community based services seriously compromise the County's capacity to provide the level of services needed to protect this vulnerable population. CONTINUED ON ATTACHMENT: YES SIGN URE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE(S): FED gRAL D.GLOVER JOHhh r1101A, ACTION OF BOARD ON JULY 8, 2003 APPROVE AS RECOMMENDEDX OTHER. VOTE OF SUPERVISORS X UNANIMOUS (ABSENT IV I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF AN ACTION TAKEN AND ENTERED ON THE MINUTES OF THE BOARD AYES: NOES: OF SUPERVISORS ON THE DATE SHOWN, ABSENT:- ABSTAIN: DISTRICT III SEAT VA= ATTESTED JULY 8, 2003 JOHN SWEETEN,CLERK OF THE BOARD OF Contact Person: Dorothy Sansoe(5-1009) SUPERVISORS AND COUNTY ADMINISTRATOR CC: CAO HSD EHSD BY. DEPUTY ........................................................................1.1.11,111,111,1111, ................................................................................................................................................... ........................ EMPLOYMENT & HUMAN SERVICES CONTRA COSTA COUNTY Date: June 5, 2003 MEMO TO: FAMILY AND HUMAN SERVICES COMMITTEE FROM: John B. Cullen SUBJECT: Elder Abuse Program Update RECOMMENDATIONS ACCEPT the report presented by the EHSD Director and staff providing a status update on the delivery of Elder Abuse and Adult Protective Services. SUPPORT Department efforts to maintain essential Adult Protective Services program components in spite of staffing reductions resulting from funding limitations. SUMMARY Attached you will find a report providing an update on the status of the Adult Protective Ser- vices (APS) program. EHSD provides elder abuse services under the APS program that offers casework intervention to protect elders and younger dependent adults from abuse, neglect, or exploitation. APS is part of a continuum of programs provided by the Aging and Adult Services Bureau of EHSD which all seek to promote maximum independent functioning for elders and adults with disabilities, assisting clients to avoid unnecessary or inappropriate institutional care. APS works in close collaboration with these other programs, which include In Home Supportive Services, Temporary Conservatorhip, Multipurpose Senior Services, Linkages Case Manage- ment, Assistance to Caregivers, Health Insurance Counseling and Advocacy, and, a wide vari- ety of Area Agency on Aging(AAA)programs. Moreover, APS works closely with collocated Health Services nursing and mental health staff who provide essential consultation and evaluation for APS clients and with Health Services programs including Conservatorship/Guardianship, Mental Health, Public Health, Medical So- cial Services, CCHP, inpatient, and outpatient care. The Long Tenn Care Integration planning project jointly sponsored by EHSD and HSD is in the process of designing an action plan to re- direct funding to expand the availability of home and community services for elders and adults with disabilities and to enhance collaboration between our two departments and community based organizations who serve the same clients. The fiscal challenges that have led to staffing reductions in both the APS and IHSS programs and curtailment of some AAA community based programs, as well as the limited capacity of Elder Abuse Program Update June 5, 2003 Page 2 of 2 many Health Services programs with which APS collaborates, pose serious problems for the APS program. The main strategy of the APS program is to make available to the at risk indi- vidual a variety of health and social services programs to remove the risk of abuse, neglect, or exploitation. To the extent that these various services are not readily available or too limited in scope, we are not able to put in place the full range of intervention necessary to protect these individuals resulting in premature institutional care or repetition of the episodes of abuse or ne- glect. Furthermore, given the demographic challenge posed by the aging of the county's population, with the attendant increase in elders with physical disabilities and/or dementia, the number of individuals who need protection from abuse, neglect, or exploitation is steadily increasing. The failure of funding resources to keep up with this population growth and our inability to expand APS and related home and community based services seriously compromise our capacity to provide the level of services needed to protect this vulnerable population. 2 HASe"leARO&Corer Memo.FHS Elder.Abuse.0603.doc 2003 STATUS UPDATE DELIVERY OF ELDER ABUSE AND ADULT PROTECTIVE SERVICES Ct')JVM COSrA COUNTY FAMILY Bic HUMAN SERVICES COMMTfl"EE ......... ......... ......... ......... .._..._.. . ... .. ........... . ......... ......... ......... ......... ......... ......... ............_.... . _. ... ......... ......... ......... ......... . . . ............................................. 2003 UPDATE ADULT PROTECTIVE SERVICES for the CONTRA COSTA COUNTY FAMILY & HUMAN SERVICES COMMITTEE Program Overview Since the 1999 implementation of SB 2199, the County Adult Protective Services (APS) Program has been required to respond to and investigate all reports of physical abuse, fi- nancial abuse, neglect, abandonment, isolation, and abduction involving elders (age 65+) and dependent adults (18-64). The Program has grown from a minimally staffed week- day service to a 24-hour, seven days per week comprehensive response system. Attach- ment A illustrates the growth of the APS Program over the last three years. APS'jurisdiction for investigating allegations of abuse lies in other than a long-term care facility. APS will investigate people living in senior complexes, private homes, and acute care facilities. If abuse is alleged to occur in a long-term care facility, the Long-Term Care Ombudsman Program has the responsibility to investigate. Under existing law, the enhanced services of APS include the 24-hour response capabil- ity, the addition of providing tangible and non-tangible support services to assist APS workers in their service plan, the provision of emergency shelter or in-home protection, and the establishment of multidisciplinary personnel teams. At this time, there is a uni- form statewide program operating under the same Welfare and Institutions Code. There are issues pending, however, under the Governor's realignment proposal that would shift the responsibility of funding and maintaining APS to local governments. Professionals in the field are concerned that as resources dwindle, current standards and consistency will be lost, especially in data collection and in how abuse is investigated. The following report highlights changes in APS since the last report to the Family and Human Services Committee and discusses some of the challenges APS faces. Mandated Reporters Effective January 1, 2003, the definition of mandated reporters has been expanded to in- clude clergy, animal control officers and Humane Society personnel. Staffing Levels The following lists the staffing levels of APS from 1998 to the present. 2 Prior to the implementation of SB 2199 APS had 3.5 FTE social workers, .5 FTE super- visor and .5 FTE clerk When SB 2199 was implemented, APS had 17 Social Workers, 3.5 Supervisors, 1 Mental Health Specialist, 1 Public Health Nurse, 3 Clerks, 2 Senior Staff Assistants, and 1 Social Service Program Assistant. By March 2003, there were 3 fewer Social Workers, 1.3 fewer Supervisors and i less Clerk due to budget reductions. Statewide, APS caseload standards are set at a maximum of 15 carry-over cases and 10 new cases assigned each month. From 2000-2002, APS caseloads have fluctuated be- tween 20 to nearly 30 cases. Thus far in 2003, APS has averaged caseload size of 26 cli- ents, with 10-11 of them new in a given month. A graph attached to this report (Attach- ment B), illustrates this fluctuation for the past three years. Effective July 1, 2003, there will be 4 fewer APS worker positions in order to meet budget targets for FY 2003-04. Listed below are programmatic changes that will result from this reduced staffing capacity: • Delays in making initial face-to-face contact with clients. • Re-orienting the Program towards crisis intervention, closing cases sooner once the crisis is stabilized. • Simply calling a client without face-to-face contact to check whether the client's situation has changed if we had previously investigated the case. • Setting up guidelines to reduce formal APS referrals. In cases where a repeat referral comes in, we would only assign the case if the client's situation had changed. ■ Delays in making follow-up visits to clients. • Deferring to law enforcement for investigation serious financial abuse cases. • Not accepting repeat cases where there is a chronic or significant mental health or substance abuse issue. These cases tend to take the longest to serve and to be the most intransigent and resistant to change. It would not be an expeditious use of lim- ited staff time to work with these people under these circumstances. Praurammatic Activities Outreach Activities After the initial implementation of SB 2199, .5 FTE of a social worker's time was de- voted to outreach to train mandated reporters. Now due to limited staff capacity, training is conducted only as it is requested or absolutely necessary. This prevents APS from be- ing able to approach training in a systematic, thorough fashion. 3 Purchase of Service Utilization The most frequent uses of tangible services funds include. home modification, especially ramps; respite for caregivers, and home care. The most costly purchase of service has been emergency shelter (motels, board and care home or skilled nursing facility), when- ever it has been used. APS has had some significant non-recurring costs. Occasionally, APS has kept clients in their own homes through one-time payment of rent or mortgage and has assisted clients in making a successful transition through payment of first month's rent in a board and care home. Recently, APS paid the court filing fees to petition for conservatorship of one client for the first time. MDT and Confiden� The multi-disciplinary team (MDT) meets monthly. APS recently clarified and tightened confidentiality previsions in the MDT as it relates to the Welfare and Institutions Code (WIC) regulating MDT. Members of MDT signed confidentiality agreements to maintain their participation. Samples of the MDT job description, background information form and confidentiality agreement are attached to this report (see Attachments C, D and E). Communication has improved with the Court investigators under this WIC provision. Effective January 1, 2003 APS can now share information with the District Attorney's office and with the probate court under WIC §15633.5. FAST(Financial Abuse Specialist Team) APS has begun protocol development with the District Attorney's elder abuse unit, the Public Guardian's office and other entities involved in responding to financial abuse. Contra Costa County is developing a two-pronged approach to addressing financial abuse. First, a financial MDT, which will have an educational and training component in addition to case studies, will meet regularly. Second, a financial abuse specialist team will be activated to respond to immediate needs in specific cases. Most of the compo- nents of this strike team already exist, just not with formal protocols and agreements of participation. For example, one case, which made the local media, included APS, the District Attor- ney's office, and the Public Guardian's office. In the course of two hours, these public entities worked together to successfully freeze one client's account before he wired moneyoverseas in response to a scam. This individual had been home alone for some time and had responded to magazines, sweepstakes and other solicitations. The sales pressure had mounted with this victim receiving telephone calls every half hour. He thought someone was genuinely taking an interest in his welfare. The last solicitation in- 4 .... ......... ......... ......... ......... ...._.... ._. ........ _......... . ._..._.... ......... ......... ......... ......... ......... ...............__. _... _. .. ._ ......... ......... ......... ......... ........................................... formed him that he was a winner, but had to wire "taxes" on his winnings first. An alert bank teller notified the authorities when this individual asked for $70,000 to be wired overseas. This $70,000 would have exhausted his account. Although APS was able to act in concert with other public entities to protect this remaining money, this gentleman had already lost $120,000 through previous solicitations. Accounting, banking and real estate issues generally fall outside the expertise of social workers that comprise APS caseworkers. APS has an ongoing need to learn more about these fields in order to conduct effective investigations of financial abuse. APS will need to learn more about the banking and commercial codes and real estate law as the program continues to gain expertise. Forensic MDT Forensic MDT meets monthly through collaboration with county mental health services and law enforcement. APS is a standing partner of the forensic MDT. Cases discussed usually cover the chronically mentally ill and homeless individuals who have repeated contact with law enforcement. APS' participation allows for valuable interagency col- laboration. Successes Integration of health services personnel (a public health nurse and a mental health spe- cialist) into APS activities represents the gold standard of practice in bringing in an inter- disciplinary approach to casework. Cooperating with Health Services through interde- partmental service agreements has been invaluable. APS has saved hundreds of thousands of dollars of clients' assets. Some of these dra- matic situations have resulted in positive press for the County. APS saves lives when individuals are discovered who need immediate medical attention. Coordination of services needed to stabilize clients and help them remain at home is a basic APS benefit. For example, procuring In-Home Supportive Services (IHSS) for cli- ents is a huge step to stabilize many clients. By getting IHSS, family caregivers are given a service that helps alleviate stress and reduces the likelihood that the neglect or abuse continues when they know they will be getting help. APS has a Police Officers Standards Training (POST)-approved training program for law enforcement. Among the mandated reporters who have been trained are hospital/clinic 5 staff; firefighters; police officers; hospice and home health workers; and even beauty par- lor operators. There has also been community-based training on domestic violence and elder abuse in conjunction with STAND! Against Domestic Violence and Elder Abuse Prevention. These trainings have benefited EHSD employees and community attendees alike. The District Attorney's elder abuse prosecution unit has been especially supportive to APS staff and its role will only increase in significance as APS gains more expertise in uncovering financial abuse. Impacts/Issues Increase of APS services has placed additional pressure on other county programs includ- ing IHSS, County Counsel, District Attorney, Public Guardian's office, probate court in- vestigators, and Health Services. Prior reports to the Family and Human Services Com- mittee have recognized this pressure. Line workers continue to identify clients living at home with varying levels of dementia or mental health concerns who make decisions that put themselves at risk. This issue is probably the largest single issue that falls within the legal gray area that APS must navi- gate and that presents the most challenges in addressing. A majority of the calls APS receives continues to be reports of self-neglect. The APS self-neglect unit was able to hold cases open longer to put interventions in place that would last. The attached photographs (Attachments F through H) show examples of liv- ing situations that APS workers discovered needing extensive casework intervention. The living room of one home was piled so high that only a narrow path was possible through the room. Another photograph (Attachment F) shows rotten, spoiled food left out and the case narrative indicates that dead chickens and rats were found under the de- bris. Canned goods were so old that the pressure inside them had caused the cans to bulge. Since APS workers work with "voluntary" clients, it takes time to engage clients to will- ingly accept help to clear out houses like this. The severe hoarding and cluttering behav- ior evident in these photographs are indicative of several possible causative factors. Ex- cessive hoarding can be a sign of obsessive-compulsive disorder. Less severe cluttering can be a sign of depression, dementia, and simply decreased physical functioning, whereby the individual cannot keep up the house or yard. 6 .... ......._. ......... ......... ......... ......... ..........._.. . ........ .......-_ . .._...... ........... ......... ......__. ......... ......... ......... ......... .................... ............ ......... ......... We examined the assumption that longer casework intervention periods would result in longer lasting case plans. We found that of the 50% of cases referred to APS that involve self-neglect, 3'0% of the self-neglect cases are repeats. For the time period January 2002 to September 2002 there were 86 repeat self-neglect cases making the monthly average 9.5. From October 2002 through February 13, 2003, there were 55 repeat self-neglect cases making the monthly average 12. There has been a 26% increase in the recidivism rate of self-neglect cases since the dissolution of the self-neglect unit. The attached pie charts track confirmed self-neglect abuse for the last three years (see At- tachments I through K). In 2002, about one-quarter of the neglect was physical care and about one-quarter was inadequate medical care. The largest sector of neglect across all three years falls under the primary heading of"health and safety„ concerns. The exces- sive hoarding evident in the attached photographs falls in this category. We have included data (Attachments L through N) on confirmed perpetrator abuse for the last three years, which you may use to compare and contrast. The three largest types of confirmed perpetrator abuse in 2000, 2001 and 2402 generally are financial, physical, and psychological/mental abuse. Of significance is that in 2002, perpetrator neglect was con- firmed more than physical abuse. Issues 'loom around APS social workers' scope of practice and mandate. APS internal training needs must become more sophisticated in terms of developing skills to respond to all kinds of abuse reports. For example, staff needs to learn more about real estate transactions, banking, and commercial codes in tracking changes in ownership, looking at title searches, or helping assess unusual financial activities. These needs are far beyond traditional social work training. In addition, APS has to respond to people with severe mental health and substance abuse issues and mere identification of these issues is insufficient to develop and carry out meaningful service plans. APS relies extensively on other services, such as mental health, rehabilitation programs, the Regional Centers, IHSS, Contra Costa Regional Medical Center's geropsychiatric unit, and other resources. If any of these services are cut, APS loses one more option to assist the client. For example, if the geriatric unit at the county hospital was cut, elderly clients on an involuntary hold (5150) would have to go to psychiatric wards comprised of younger patients, where they would not get the care they need. They would not fit in with the acute psychiatric needs of younger schizo- phrenics or deeply delusional patients. They would be at increased risk of injury because of younger people's greater strength. 7 APS has also identified the need for an all-in-one private fiduciary. We work with one such business that can draw on money management, conservatorship, and legal counsel to address financial and elder law concerns. Community-based volunteer money manage- ment programs will only address part of the money management needs. There are houses and situations that volunteers refuse to serve. The houses may be too filthy or the situa- tion too chaotic for a volunteer. These programs also do not help clients deal with their assets,just their government issued monthly income. In the case of this private fiduciary, we recently paid the court filing fees to petition the court for conservatorship after this business agreed to be the pro bono conservator, should the judge rule in this regard. Conservators who take pro bono cases are few and far be- tween and the need to conserve non-institutionalized adults continues to confound APS. This option only came about after the case was presented at the multi-disciplinary team meeting. APS operates at the nexus of a myriad of laws pertaining to legal competency, protection versus autonomy of adults, scope of practice beyond what other social workers do, persis- tent social problems such as mental health, substance abuse, homelessness, pressures from community-based organizations to "do more", legal limitations, gaps in available resources and gaps in available funding streams to serve particular populations. APS must address issues that other social workers do not, be they medical social workers, pri- vate case managers, or clinical social workers. Yet APS has the same limited community resources as these other social workers with which to work. 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JOB DESCRIPTION CONTRA COSTA COUNTY APS MULTIDISCIPLINARY TEAM MEMBER The California Welfare and Institutions Code §15610.55 defines the Multidisciplinary Team as "any team of two or more persons who are trained in the prevention, identification, and treatment of abuse of elderly or dependent persons and who are qualified to provide a broad range of services related to abuse of elderly or dependent persons, as defined in Section 15753.5." The WIC lists five types of professionals who could comprise an MDT. This list is not exclusive and includes: psychiatrists, psychologists or other trained counseling personnel; police officers or other law enforcement agents; medical personnel with sufficient training to provide health services; social workers with experience or training in prevention of abuse of elderly or dependent persons; and public guardians. Contra Costa County's APS MDT seeks to provide a high-level forum in which to discuss specific cases where consultation and coordination could be of benefit in resolving the issues of elder and dependent adult abuse occurring in such cases. The MDT shall be a safe space where discussion can occur freely and without concern for negative outcomes, such as a breach of confidentiality. Accordingly, the following is a job description for persons wishing to participate in MDT meetings. Role: ➢ To serve as a trained professional at MDT meetings. Resilons bilities: ➢ Complete a confidentiality agreement to participate and maintain confidentiality in accordance with the W& I Code. ➢ Attend MDT meetings as regularly as possible. ➢ When approved by the chair to present a case, prepare a written case summary and present the case and case updates at the meeting, as required. ➢ Participate during meetings by seeking clarification from the presenter as needed, providing advice and information, and recommending specific actions. ➢ Follow-up as appropriate on case consultation received at MDT meetings. Review meeting minutes. December,2002 CONTRA COSTA COUNTY APS MULTIDISCIPLINARY TEAM CASE PRESENTATION BACKGROUND INFORMATION DATE PRESENTED: PRESENTER: AGENCY: HOW LONG PRESENTER HAS HAD THIS CASE: VICTIM INFORMATION INITIALS ❑ 9 ❑d AGE: RESIDENT OF❑WEST ❑CENTRAL ❑EAST TYPES OF ABUSE: PERPETRATOR ABUSE SELF-INFLICTED ABUSE ❑ABANDONMENT ❑NEGLECT ASSAULT/BATTERY ❑FINANCIAL ❑CONSTRAINT ©SUBSTANCE ABUSE ❑DEPRIVATION ®MEDICAL ❑ISOLATION ❑OTHER (specify) ❑FINANCIAL ❑MENTAL SUFFERING ❑NEGLECT ❑SEXUAL ❑OTHER(specify) OTHER AGENCIES INVOLVED: NATURE OF INVOLVEMENT: VICTIM'S PERCEPTION OF PROBLEM: VICTIM'S HEALTH HISTORY: PHYSICAL (VISION,HEARING,MOBILITY,ALZHEIMER'S,CANCER,DIABETES,OTHER CHRONIC DISEASES OR CONDITIONS,USE OF DRUGS/ALCOHOL,NUTRITION PROBLEMS,MEDICATIONS) MENTAL/PSYCHOLOGICAL (MENTAL STATUS,DEGREE OF DEMENTIA,DISORIENTATION,CONFUSION,IMPAIRED JUDGMENT,MEMORY LAPSES,DEPRESSION,PSYCHOSIS,DENIAL,FEAR,GUILT,PERSONALITY TRAITS/DISORDER) CONTINUED ON REVERSE CONTRA COSTA COUNTY APS MULTIDISCIPLINARY TEAM PAGE TWO FAMILYISOCIAL SUPPORTS(HOUSEHOLD COMPOSITION,FAMILY,NEIGHBORS,CHURCH,DEGREE OF INVOLVEMENT IN COMMUNITY OR ISOLATION) FINANCIAL AND LEGAL(INCOME AND ASSETS,CONSERVATORSHIP,P OF A,WHO MANAGES FINANCES,WILLS, TRUSTS,REP PAYEES) PROBLEMS AND ISSUES YOU WANT THE PANEL TO ADDRESS: COMMENTS FROM PANEL MEMBERS: SIGNATURE OF PANEL MEMBER. MDT CASE PRESENTATION SHEET.doc 6/5/2003 1:35 PM Acgreernent of Confidentiality to Participate In the Contra Costa County APS Multidisciplinary Team (APS MDT) In accordance with the California Welfare and Institutions Code § 15633, (2) (A) "Persons who are trained and qualified to serve on multidisciplinary personnel teams may disclose to one another information and records that are relevant to the prevention, identification, or treatment of abuse of elderly or dependent persons." I, ,agree to the following as a condition of my participation in the MDT: 1. Not to disclose, or permit to cause to be disclosed, the identity of any person discussed at the APS MDT meeting. 2. Not to disclose,or permit to be disclosed any confidential information pertaining to a person discussed at the APS MDT meeting. 3. Not to remove from the premises any written material containing confidential information pertaining to the cases discussed. I recognize that violation of the confidentiality provisions of the California Welfare and Institutions Code §10850 is a criminal misdemeanor. SIGNED: / Professional serving as MDT member Date SIGNED: I MDT Coordinator Date December,2002 d 4 f .f f;. •j J. f---------------- x/."f lffJl 14 fr' : ,ff�� �v N •� f, t f f � - �• f. f � IN y: P 1 r� if ATTACHMENT G tl � M.. ' rc ��(• Y Ix. v ' { : } {-0 i � )) ... 4 Y •t ... " y3o-f I i } f -0'Y/i S •t ��.^fG•�fi�� 'AR } DY 4< }t 3 ..t .. 0 k :• rye }r ,�fa'.. .„ -0w ,fit. :.. t.� y` S II � I p , f i:H}fr:fL . f f f ,L ' f r }}` Kx. } r Wx: fliJlllf��.. !.•Ijrif� rf fr,�f>F�.•. rF'•l f f f rf,fel,,{l r.l l' frr .•f : ii:lt�ftrf $s'i, r_ :,vf�:r%'err•� , r l <; ri l rjlr �`t. y rrf., l %! 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