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Audit Audit of the Department of Public Health (DPH)

Audit found DPH’s unit responsible for monitoring state health care facilities did not prioritize and conduct investigations of cases of mistreatment within required timeframes, which could result in prolonged physical and financial harm to residents. The audit examined the period of July 1, 2016 through June 30, 2018.

Binder organization: Office of the State Auditor
Date published: September 11, 2019

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 the Department of Public Health’s (DPH’s) complaint intake and investigation programs for the period July 1, 2016 through June 30, 2018. In this performance audit, we examined DPH’s processes for reviewing, prioritizing, and responding to intakes involving allegations of deficiencies at licensed nursing homes in the Commonwealth.

Below is a summary of our findings and recommendations, with links to each page listed.

Finding 1
 

DPH did not always perform required on-site investigation surveys.

Recommendation
 

DPH should enhance its policies and procedures that define and implement monitoring controls over its intake process to ensure that all intakes requiring on-site investigation surveys are properly transcribed from the Health Care Facility Reporting System (HCFRS) to the Automated Survey Process Environment (ASPEN).

Finding 2
 

DPH did not always prioritize and conduct investigations for high-priority intakes within the required timeframes.

Recommendation
 

DPH should review staffing needs and make any further adjustments that are needed to ensure that the prioritization and investigation survey processes are completed in the required timeframes.

Finding 3
 

DPH did not refer some intakes to the Attorney General’s Office (AGO) as required.

Recommendation
 

DPH should establish policies and procedures that define and implement monitoring controls over its intake process to ensure that all intakes requiring AGO notification are properly transcribed from HCFRS to ASPEN.

Finding 4
 

DPH had inadequate documentation to track intakes designated for on-site investigation surveys.

Recommendation
 

DPH should establish monitoring controls to ensure that its staff completes Complaint Processing Summary forms for all intakes that require on-site investigation surveys.

 

A PDF copy of the audit of the Department of Public Health (DPH) is available here.

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Contact

Phone

Fax

(617) 727-3014

Address

Massachusetts State House
Room 230
Boston, MA 02133
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