Overview
The Department of Developmental Services (DDS) was established by Section 1 of Chapter 19B of the Massachusetts General Laws and falls under the Executive Office of Health and Human Services. According to its website,
The Department of Developmental Services provides support for individuals with intellectual and developmental disabilities including Autism Spectrum Disorder to enhance opportunities to become fully engaged members of their community.
During fiscal year 2024, the agency served approximately 43,000 adults and children with intellectual and developmental disabilities throughout the Commonwealth.
During the audit period, DDS provided these services through 287 community-based state-operated programs that were delivered by two state-operated facilities and approximately 200 contracted service providers, all of which were based in the Commonwealth. DDS had annual appropriations of approximately $2.4 billion for fiscal year 2023 and $2.8 billion for fiscal year 2024. As of July 17, 2023, DDS employed 1,554 staff members in 23 area offices1 and four regional offices2.
As part of its responsibilities, DDS conducts various types of investigations and reviews into alleged abuse or mistreatment, as well as circumstances that may pose a serious risk of harm to recipients of DDS services. DDS is also responsible for reviewing self-reported events from its contracted service providers, which include issues such as deaths of recipients of DDS services, property damage, and incorrectly administered medication. In order to process, review, and monitor alleged abuse, mistreatment, and other incidents during the audit period, DDS used its web-based system that houses all intakes and complaints regarding recipients of DDS services.
Processing Alleged Abuse or Mistreatment
Public reporters3 and mandated reporters4 disclose alleged abuse or mistreatment to the Disabled Persons Protection Commission (DPPC) via its 24-hour hotline. Once DPPC receives a complaint alleging abuse or mistreatment, DPPC generates an intake form. Upon review, DPPC refers the complaint to the appropriate service-providing agency, including, but not limited to, any of the following:
- DDS;
- the Department of Mental Health;
- the Executive Office of Elder Affairs;
- the Department of Public Health; and
- the Department of Children and Families.
According to data we retrieved from DDS’s web-based system, DPPC referred 12,749 complaints to DDS during the audit period.
Once DPPC refers a complaint to DDS, according to Section 9.09(2)(a) of Title 115 of the Code of Massachusetts Regulations (CMR), the assigned DDS senior investigator determines the complaint disposition to be one of the following:
1. dismissed;
2. resolved without investigation;
3. referred to the regional director or designee for administrative review;
4. referred directly to the [complaint resolution team] for review;
5. designated as requiring investigation but deferred pending investigation by outside authorities;
6. assigned to an investigator for active investigation; or
7. referred to another state agency for review.
The table below shows the DDS complaint dispositions that originated during the audit period. Note that this audit looked at administrative reviews, dismissals, DDS investigations, and referrals to the complaint resolution team (CRT). Other data in the table above is provided for informational purposes.
DDS Complaint Dispositions from Fiscal Years 2023 and 2024
| Type of Disposition | Number of Dispositions | Percent of Dispositions |
|---|---|---|
| Administrative Review | 3,515 | 28% |
| Dismissal | 3,459 | 27% |
| DDS Investigation | 2,523 | 20% |
| Referral to Complaint Resolution Team (CRT) | 1,772 | 14% |
| Referral to Another State Agency | 1,365 | 11% |
| Resolved without Investigation | 110 | 1% |
| Investigation by Outside Authorities | 5 | <1% |
| Total | 12,749 | 100%* |
* Discrepancy in total is due to rounding.
Investigation Process for Alleged Abuse or Mistreatment
Regional senior investigators work from six DDS offices located in Danvers, Middleborough, Springfield, Waltham, Worcester, and Wrentham. As of June 30, 2024, DDS employed 38 full-time investigators.
DDS receives multiple batches of complaints daily from DPPC in the form of secure CSV files. DDS uploads these files into its web-based system and assigns each complaint to a senior investigator. The assigned investigator is required to make a complaint disposition determination within three days of being assigned the complaint, according to 115 CMR 9.09(2)(a). If the complaint disposition determination results in an active investigation by a DDS senior investigator, then an investigation report and a decision letter must be issued to the regional director within 45 days of an investigator’s assignment, according to 115 CMR 9.13(1)(d). Investigators may request an extension for more time to complete the investigation, if necessary, but only if the delay would not pose a threat to the safety of the alleged victim.
Decision letters summarize the evidence and conclusions found in the corresponding official investigation reports. The regional director forwards decision letters to a CRT to develop an action plan. The purpose of an action plan is to ensure that specific steps are taken to reduce the possible reoccurrence of the situation at the center of the complaint. An action plan must be developed within 30 days of the date the decision letter was assigned to the involved CRT.
If DDS conducts an investigation in accordance with both DPPC and DDS regulations, then DPPC must approve the investigation report before DDS issues the decision letter and before an action plan can be developed. If DDS conducts an investigation in accordance with only its own regulations, then a DDS regional senior investigator must approve the investigation report before DDS issues the decision letter and before an action plan can be developed.
In our previous audit of DDS (Audit No. 2020-0234-3S), our office made the following recommendations related to decision letters and action plans:
- DDS should formalize the necessary policies and procedures to require that regional senior investigators monitor investigations for timeliness and ensure that any necessary extensions are properly requested, documented, and approved.
- DDS should enhance its policies and procedures by implementing effective monitoring controls to ensure action plans are developed within required timeframes.
To address our recommendations, DDS stated in the Post-audit Review (PAR) that DDS is issuing extension requests when necessary and performing routine audits to ensure compliance with decision letters. In addition, caseloads are monitored biweekly, and this process was formalized in writing.
Furthermore, DDS formed a working group to analyze the process for issuing action plans. DDS created custom reports to help monitor the timeliness of action plans and is looking into hiring additional staff members to monitor this process.
We were able to confirm that DDS did implement our recommendation related to investigations from our previous audit.
Administrative Reviews
The regional director conducts administrative reviews for situations that do not present serious physical or emotional harm to DDS service recipients. These reviews do not involve allegations of abuse, assault, or financial exploitation, which are investigated through a different process.
If a complaint disposition determination results in an administrative review, then the assigned senior investigator refers the complaint to personnel members from the corresponding area or regional office. DDS regulations require that administrative review reports, which detail the pertinent information found during the course of the review, be submitted to the appropriate CRT coordinator within 15 days of the date of completion of the administrative review. Notably, DDS regulations do not include a timeframe in which the administrative review itself must be conducted. Once the assigned CRT receives the administrative review report, then the CRT is required to prepare a resolution letter, which may, depending on the conclusions reached upon the completion of the administrative review, state the specific action(s) to be taken in response to the administrative review report, the date by when these action(s) must be implemented, and the person responsible for implementing these action(s).
In our previous audit of DDS (Audit No. 2020-0234-3S), our office made the following recommendation related to administrative reviews:
- DDS should implement policies, procedures, and monitoring controls to ensure that administrative reviews are completed by the regional director or his/her designees.
To address our recommendation DDS stated in the PAR that it formed a working group to develop best practices, minimum standards, and training tips for performing administrative reviews. In addition, DDS stated that it identified and resolved an issue in its web-based system that was allowing staff members to enter action plans/resolutions letters without completing the section pertaining to the principal findings of the review.
The audit team was able to confirm that DDS did implement our recommendation from our previous audit related to administrative reviews.
Medication Occurrence Report Process
According to the [Medication Administration Program (MAP)] Policy Manual, a medication occurrence report (MOR) is submitted by a contracted service provider through DDS’s web-based system to DDS when a breach of any one of the following medication checklist procedures (which DDS refers to as the five Rs) occurs:
- right individual;
- right medication;
- right time;
- right dose; and
- right route5.
In addition to the medication checklist procedures listed above, missing a medication dose entirely would also generate a MOR.
Similarly to how incident reports are handled, MORs are submitted by contracted service providers through DDS’s web-based system directly to DDS. For each MOR, a MAP consultant must be contacted by the contracted service provider. A MAP consultant is a healthcare provider, such as a registered nurse, a pharmacist, or an authorized prescriber such as a physician or nurse practitioner. MORs are classified as either a hotline MOR (which indicates that medical intervention was required because illness, injury, or death resulted from the breach of medication checklist procedures) or a regular MOR (which indicates that medical intervention was not required because illness, injury, or death did not result from the breach in medication checklist procedures).
DDS’s web-based system documents key milestones regarding the MOR process, from a provider’s MOR creation and finalization to a DDS MAP coordinator’s MOR review and approval/disapproval. Contracted service providers must finalize a hotline MOR within 24 hours of discovering the breach and a regular MOR within 14 days. Both hotline and regular MORs must be reviewed by a DDS regional MAP coordinator within 14 days of the date of finalization by the contracted service provider.
There were 12,290 MORs submitted by contracted service providers to DDS during the audit period, of which, 213 were hotline MORs and 12,077 were regular MORs. The table below indicates the nature of all MORs submitted during the audit period.
MOR Submissions by All Contracted Service Providers During Fiscal Years 2023 and 2024
| Nature of MOR | Number of Submitted MORs | Percent of Submitted MORs |
|---|---|---|
| Medication Omission | 8,146 | 66% |
| Wrong Dose | 1,923 | 16% |
| Wrong Individual | 246 | 2% |
| Wrong Medication | 543 | 4% |
| Wrong Route | 8 | <1% |
| Wrong Time | 1,424 | 12% |
| Total | 12,290 | 100% |
In our previous audit of DDS (Audit No. 2020-0234-3S), our office made the following recommendation related to medication occurrence reports:
- DDS should implement effective monitoring controls in its policies and procedures to ensure that provider-operated group homes create and finalize MORs, and MAP coordinators review them, within the prescribed timeframes.
To address our recommendations, DDS stated in the PAR that it would update its guidance and training materials related to creating and finalizing MORs and outlining timeliness and responsibilities of providers. In addition, DDS would develop guidance for providers to clarify requirements of hotline MORs. Furthermore, DDS stated that it has worked with the regional MAP coordinators to ensure that all reviews are done within the required timeline.
DDS did not fully implement our recommendations during the audit period from our previous audit (Audit No. 2020-0234-3S). However, after the audit period for our current audit, DDS told us that it had implemented monitoring policies and procedures to ensure that providers create and finalize MORs, and that MAP coordinators review MORs, within the prescribed timeframes after. See Post-audit Action for more details.
Incident Reporting and Review Process
When an incident meets the threshold of a reportable event, a provider must generate an incident report and submit it to DDS through its web-based system. DDS organizes these reportable events into incident categories, which are classified as either minor- or major-level incidents. As examples, minor-level incidents may involve verbal abuse of a victim or property damage, while major-level incidents may involve suspicious or sudden deaths or missing people. For minor-level incidents, an area office management review is required. For major-level incidents, both an area office and a regional management review are required.
There were 57,566 incident reports submitted to DDS by providers during the audit period; 49,714 were minor-level incidents and 7,852 were major-level incidents.
In our previous audit of DDS (Audit No. 2020-0234-3S), our office made the following recommendation related to incident reporting and the review process:
- DDS should work with provider-operated group homes and establish effective monitoring controls to ensure that all incident reports are submitted and finalized on time.
To address our recommendation, DDS stated in the PAR that it would create custom reports to send to providers with the number of incident reports open. In addition, DDS senior investigators would use the reports to identify and address concerns directly with those provides.
The audit team determined that DDS did not fully implement our recommendation during the audit period from our previous audit (Audit No. 2020-0234-3S). DDS provided evidence of sending custom reports, showing open incidents at the provider and DDS level to the area and region levels; however, there was no follow-up on the reports until after the audit period. See Post-audit Action for more details.
Individual Support Plans
Individual support plans (ISPs) establish goals with recipients of DDS services based on their unique interests and needs as part of their overall support. ISPs are created using a coordinated process to ensure that those who support the recipients of DDS services have a clear understanding of the individual’s current circumstances and the support in place to meet their needs.
In order to create an ISP, collaboration and participation is necessary from multiple parties, including the recipients of DDS services, their family or guardian(s), their designated representative, a service coordinator, and contracted service providers. A service coordinator consults with the aforementioned parties within 15 days of services being provided or at least 45 days before the ISP initial meeting, during which the purpose of the ISP and the process for its development is discussed. According to 115 CMR 6.20, an ISP’s goals, objectives, and services must include strategies to advance the following for the recipients of DDS services:
- rights and dignity;
- individual control and freedom of choice relating to self-determination;
- community membership;
- relationships;
- personal growth and accomplishments; and
- personal well-being.
A provider documents assessments, develops objectives and support strategies, and provides all these to the service coordinator at least 15 days in advance of the ISP meeting. In addition, the provider must document and report ISP implementation to the service coordinator, the individual, and the individual’s family or guardian(s). After consulting with the service coordinator, the provider must implement the ISP by providing the agreed-upon services.
A recipient of DDS services also has the ability to participate in self-determination. Self-determination is an approach where a recipient of DDS services is given control and an active role over the decision-making process for services provided to them to support their needs. DDS offers self-determination as an option to all recipients of DDS services who are eligible for services.
Forty-five days after the ISP meeting, the area director or facility director must review the ISP in order to approve or disapprove it. The director may approve or disapprove parts of the plan. If the ISP is disapproved, then that decision must be communicated with the service coordinator.
Once the ISP is created, the service coordinator must then take the lead in coordinating the services to be provided to the recipients of DDS services. The service coordinator must also semi-annually review the ISP to ensure that it has been implemented and tailored to the needs of the recipients of DDS services and their family or guardian(s). Subsequently, a review takes place on an annual basis, at least within one year of the date when the ISP was developed, to reflect any changes in the DDS service recipients’ abilities and circumstances.
| Date published: | April 15, 2026 |
|---|