| Organization: | Office of the State Auditor |
|---|---|
| Date published: | April 15, 2026 |
Executive Summary
In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has conducted a performance audit of certain activities of the Department of Developmental Services (DDS) for the period July 1, 2022 through June 30, 2024.
The purpose of our audit was to determine whether DDS implemented the recommendations from our prior audit report (Audit No. 2020-0234-3S), issued on June 29, 2021. Specifically, we determined the following:
- Did DDS complete investigations, including their corresponding action plans and decision letters, within the timeframes required by Sections 9.10(5), 9.13(1)(d), and 9.14(3) of Title 115 of the Code of Massachusetts Regulations (CMR)?
- Did DDS conduct administrative reviews in accordance with the procedures and timeframes established in 115 CMR 9.11(1), 9.11(2), and 9.14(3)(b)?
- Did DDS implement policies and procedures to ensure that medication occurrence reports (MORs) were processed based on the recommendations from our prior audit (Audit No. 2020‑0234‑3S)?
- Did DDS implement policies and procedures to monitor the accuracy and completeness of incident reports based on the recommendations from our prior audit (Audit No. 2020‑0234‑3S)?
In addition, we determined the following:
- Did DDS develop individual support plans (ISPs) on behalf of recipients of DDS services to accommodate those who elected the self-determination option in accordance with 115 CMR 6.21 and 6.23(5) and Sections 19(b), (f), and (g) of Chapter 255 of the General Laws?
Below is a summary of our findings, the effects of those findings, and our recommendations, with hyperlinks to each page listed.
| Finding 1 | DDS did not always issue decision letters or develop action plans for its investigations within the timeframes required by regulation. |
| Effect | When investigations are not completed within required timeframes, or extensions are created without reason, there is a greater risk that recipients of DDS services may be subject to safety risks, abuse, and/or mistreatment. |
| Recommendations |
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| Finding 2 | DDS did not properly manage all administrative reviews. |
| Effect | When administrative reviews are not completed or are conducted improperly, DDS cannot ensure prompt implementation of actions outlined in resolution letters to address potential harm. |
| Recommendation | DDS should establish effective policies and procedures to schedule more frequent meetings of the complaint resolution teams in order to ensure that all administrative review reports are submitted and finalized on time. |
| Finding 3 | DDS did not ensure that medication occurrence reports were created, finalized, and reviewed within the required timeframes. |
| Effect | Without timely creation, finalization, and review of MORs, there is an increased risk of poor outcomes for recipients of DDS services who could be adversely affected by staff members who do not administer medication, make dosage mistakes, or administer the wrong medication. |
| Recommendations |
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| Finding 4 | DDS did not ensure that its providers submitted and finalized incident reports within the prescribed timeframes. |
| Effect | As a result, DDS did not act on all incident reports in a timely manner to identify and remediate safety risks for alleged victims. |
| Recommendation | DDS should continue to work with providers to ensure that all incident reports are submitted and finalized on time. |
| Finding 5 | DDS did not offer the self-determination option to all its recipients enrolled in ISPs. |
| Effect | The absence of the required self-determination option calls into question whether the proper quality of care was given to each recipient of DDS services who enrolled in an ISP. |
| Recommendation | DDS should collaborate with providers and implement standardized policies and procedures to ensure that DDS is aware that all recipients of DDS services have been offered the self-determination option and are aware of who selected the self-determination option. |
Post-audit Action
As of summer 2024, after the audit period, DDS reported to us that it had updated its formal policies to monitor the timeliness of investigations in response to our Audit No. 2020-0234-3S, issued on June 29, 2021.
DDS routinely conducts internal control and auditing activities to ensure compliance with timeframes for issuing decision letters. The [web-based system’s] “Outstanding Case List” is available to all investigations staff and contains a list of all outstanding investigations, which may be sorted and/or restricted to investigative region/office/investigator. The list includes the date of assignment, number of days overdue (if applicable), and the investigation/decision letter due date (adjusted according to extension if applicable).
In addition, senior investigators and staff investigators are required to meet “at least bi-weekly” to discuss active investigations/caseload as documented within the “Outstanding Case List”. The deputy and director of investigations meet with senior investigators monthly, to discuss active investigations/caseloads as documented within the “Outstanding Case List”. These meetings include investigative strategy and prioritization of cases based upon risk, sensitivity, and complexity.
DDS hired Assistant Senior Investigators” (“ASI”) for each investigative office. The ASI complete high-profile cases and help the senior investigator, monitor and mentor staff investigators who struggle to keep pace with the high volume of investigations the department receives. To further prioritize efficiency, the senior investigator and staff investigator’s performance objectives were updated for the current evaluation period to place more emphasis on timeliness.
A portion (25%) of the senior investigator’s responsibility pertains to ensuring efficiency and productivity. Senior investigators ensure the productivity and quality of work for supervisees are at optimum levels through intense supervision and mentoring that include regular meetings, and by providing support, and encouraging professional development opportunities.
As all cases must be completed within the prescribed regulatory timeline or approved extension date, any case remaining open beyond 90 days of assignment, regardless of extension, will undergo increased scrutiny. Senior investigators create and implement a performance improvement plan (“PIP”) that includes a dedicated weekly in-office “writing day” for any staff investigator who maintains a case beyond 90 days of assignment, without clearly documented acceptable explanation. The Deputy Director of Investigations and the Director of Investigations shall be the sole arbiters of what constitutes an acceptable explanation.
DDS provided evidence of the updated investigation manual, an example of the “Outstanding Cases List” report, evidence of a senior investigators biweekly meeting, and evidence that it worked with employees to improve agency performance related to these matters.
In addition, to ensure that providers create and finalize MORs, and that MAP coordinators review them, within the prescribed timeframes, DDS reported to us that it took the following actions in 2025, after the audit period:
DDS created and filled a dedicated position of Statewide Director of the Medication Administration Program, with centralized oversight of the Medication Administration Program (“MAP”). The DDS Statewide Director of MAP has become an important leader and participant in MAP training, MAP testing, and MAP communications, together with the other state MAP agencies (Department of Mental Health, Department of Public Health (“DPH”), Department of Children and Families, and MassAbility, formerly known as Massachusetts Rehabilitation Commission). These activities include updating the MAP Policy Manual (see https://www.mass.gov/lists/map-policy-manual, updated periodically), a joint effort between all state MAP agencies, and issuing an RFR to procure the services of a single qualified vendor to manage the MAP Certification and Recertification Testing Processes (see https://www.commbuys.com/bso/external/bidDetail.sdo?docId=BD-24-1023-1023C-1023L-91823&external=true&parentUrl=close). The DDS Statewide Director of MAP is also engaged with the DPH-led effort to offer an electronic medication administration record (eMAR) system, free of charge, to all provider agencies, enhancing safe medication administration and documentation.
In January 2025, DDS reorganized the Regional MAP Coordinators to report directly to the DDS Statewide Director of MAP, enhancing standardization and statewide coverage and improving timeliness. The DDS Statewide Director of MAP reviews timeliness requirements with Regional MAP Coordinators during staff meetings and supervision.
DDS, spearheaded by the Statewide Director of MAP, the Assistant Commissioner of Quality Management, and the newly hired Provider Compliance Manager, is developing reporting and monitoring capability of medication occurrences at the site level as part of the overall implementation of a provider compliance management system.
As a matter of practice, DDS Regional MAP Coordinators remind providers of MAP Policy requirements to report Hotline MORs within one day of discovery and other MORs within seven days of discovery, when the Coordinators review the details for MORs in [the web-based system]. Regular ongoing webinars, required for MAP Trainers, also provide reminders about timeliness requirements.
Regarding incident reporting, DDS noted, “DDS recently hired a Provider Compliance Manager who is reviewing, and revising and updating, as necessary, the reporting and monitoring capability for incident reporting.”
Table of Contents
- List of Abbreviations
- Overview of Audited Entity
- Objectives, Scope, and Methodology
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- DDS did not always issue decision letters or develop action plans for its investigations within the timeframes required by regulation.
- DDS did not properly manage all administrative reviews.
- DDS did not ensure that medication occurrence reports were created, finalized, and reviewed within the required timeframes.
- DDS did not ensure that its providers submitted and finalized incident reports within the prescribed timeframes.
- DDS did not offer the self-determination option to all its recipients enrolled in individual support plans.
Downloads
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Open PDF file, 542.16 KB, Audit Report - Department of Developmental Services (English, PDF 542.16 KB)