Overview
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 Disabled Persons Protection Commission (DPPC) for the period July 1, 2017 through June 30, 2019.
We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.
Below is a list of our audit objectives, indicating each question we intended our audit to answer; the conclusion we reached regarding each objective; and, if applicable, where each objective is discussed in the audit findings.
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Objective |
Conclusion |
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No; see Finding 1 |
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Yes |
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Yes |
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No; see Finding 4 |
DPPC has made some improvements in the areas reviewed since our prior audit (No. 2015-0046-3S). Specifically, DPPC has assessed its operating procedures related to how alleged abusers are advised of their rights based on its regulatory requirements and operational needs. It has also established and implemented policies and procedures to help ensure that when required filing deadlines are not met, evidence of the reasons for the delays is documented and retained in case files.
To achieve our audit objectives, we gained an understanding of the internal controls we deemed significant to the objectives by reviewing agency policies and procedures and conducting inquiries with DPPC’s staff members, management, and shareholders. We tested the controls’ operating effectiveness over the following areas: advisement of alleged abuser rights, manager approval of screening decisions during intake, extension requests and notices sent for overdue reports, and 19C report completeness. We identified an issue with DPPC oversight officers’ review and approval of investigator responses in 19C reports as an internal control for ensuring that investigators provided an explanation when alleged abusers were not advised of their interview rights in accordance with DPPC’s investigation policy “Invest-137” (Finding 1).
We performed the following procedures to obtain sufficient, appropriate audit evidence to address the audit objectives.
Abuser Interview and Petition Rights
To determine whether investigators informed alleged abusers of their interview rights, we selected a statistical random sample of 60 cases from a population of 3,291 cases completed during the audit period, with a 95% confidence level, 5% tolerable error rate, and 0% expected error rate. We reviewed the corresponding 19C reports for evidence that each investigator had noted that the alleged abuser was given a copy of the Notice of Alleged Abuser’s Rights or was informed of his/her rights by phone or mail. In instances where notice of rights was not provided, we determined whether an explanation for this was noted in the 19C report.
To determine whether abusers were notified of their right to contest the findings of abuse investigations, we selected a nonstatistical random sample of 50 cases out of a population of 640 cases with substantiated abuse that were completed during the audit period. We verified that notification letters were mailed to abusers. We also verified that DPPC maintained a Recommendation to Withhold Abuser Notification Form approved by DPPC’s Legal Unit for instances where DPPC determined that notifying the abuser might pose a risk to the victim. Since we used a nonstatistical approach, we did not project our results to the entire population.
Determination of Jurisdiction for Abuse Investigations
To assess DPPC’s determination of jurisdiction for abuse reports screened in for investigation, we selected a random statistical sample of 30 cases from a population of 3,445 cases screened in during the audit period, with a 95% confidence level, 10% tolerable error rate, and 0% expected error rate. These cases were designated in FileMaker Pro as “screening decision 4B” (cases where the alleged abuser was employed by a state agency, which would require DPPC to conduct the abuse investigation) or “screening decision 4C” (cases where the alleged abuser was not employed by a state agency) based on the relevant sections of Chapter 19C of the General Laws. We reviewed each case’s intake data to determine whether the alleged victim was a person with a disability, whether the alleged abuser was a caretaker of the alleged victim, and whether Intake Department personnel noted that an act or omission of the caretaker resulted in the alleged victim’s injury in accordance with 118 CMR 4.03.
To assess DPPC’s determination of jurisdiction for abuse reports screened out at intake for not meeting the requirements of 118 CMR 4.03, we selected a random statistical sample of 30 cases from a population of 19,342 cases screened out during the audit period, with a 95% confidence level, 10% tolerable error rate, and 0% expected error rate. These cases were designated in FileMaker Pro as “screening decision 4A” or “OUT.” Screening decision 4A includes reports involving a hospital or nursing/long-term-care facility,4 referred to the Department of Public Health; reports involving a victim under the age of 18, referred to the Department of Children and Families; and reports involving a victim over the age of 59, referred to the Executive Office of Elder Affairs. We reviewed each case’s intake data to confirm that the reported abuse did not meet the criteria to be screened in for DPPC investigation.
DPPC received 25,002 abuse reports during the audit period.
Initial Response and 19C Report Statutory Timeframes
To determine whether the DPPC Oversight Unit received Initial Responses (IRs) for non-emergency cases within 10 days of reported abuse, we selected a random statistical sample (with a 95% confidence level, 5% tolerable error rate, and 0% expected error rate) of 60 of the 2,925 cases that had not been referred to law enforcement,5 within a total population of 3,291 cases completed during the audit period. We compared the IR due date of each case to the IR received date to determine whether any IRs were submitted late.
To determine whether 19C reports were received within 30 days of reported abuse, we used the previously mentioned sample of 60 of 2,925 cases. We compared the 19C report due date of each case to the 19C report received date to identify 19C reports that were not received with 30 days of the reported abuse. We also calculated updated 19C report due dates for cases that were granted extensions6 and compared them to the 19C report received dates to determine whether those reports met the updated deadlines.
We performed an analysis comparing the screen-in dates of cases with substantiated abuse to the completion date of each victim’s previous case with substantiated abuse, if present, to produce a subset of 44 cases with substantiated abuse that occurred during ongoing investigations. Through a preliminary review, we identified nine victims, associated with 27 of the 44 cases, that we believed had experienced additional abuse during ongoing investigations.
To determine whether PSPs were received within 30 days of the completion of 19C reports, we selected a random nonstatistical sample of 60 cases from a population of 640 cases with substantiated abuse that were completed during the audit period. We compared each PSP’s received date to the due date to determine whether it was received within 30 days of the completed abuse investigation. We performed the same test for all 25 substantiated cases that included criminal prosecutions resulting in guilty verdicts. (The process for submitting PSPs for these cases is the same for those that did not include a criminal prosecution.) Since we used a nonstatistical approach, we did not project our results to the entire population.
Minimum Regulatory Requirements for Abuse Investigations
To test for regulatory compliance, we selected a random statistical sample of 30 of the 3,291 cases completed during the audit period, with a 95% confidence level, 10% tolerable error rate, and 0% expected error rate. We reviewed the 19C reports for evidence that the minimum requirements for abuse investigations had been completed. These requirements are outlined in 118 CMR 5.02(a) through (o):
(a) an interview with the person with a disability who was allegedly abused. . . .
- a visit to and evaluation of the site of alleged abuse. . . .
(c) a determination of the nature, extent, and cause or causes of the injuries, if possible; or a determination of whether abuse per se exists;
(d) use of the preponderance of evidence standard to substantiate or un-substantiate the existence of abuse leading the investigator to conclude that it is more likely than not that abuse does or does not exist;
(e) a determination or confirmation, if possible, of the identity of the alleged abuser(s), whether named or not named in the Intake. . . .
(f) a determination of the identity of the person(s) who was/were responsible for the health and welfare of the alleged victim(s) when the alleged incident occurred . . .
(g) an initial assessment of the immediate protective services needs of the person with a disability who is the alleged victim of abuse. . . .
(h) an interview with all available witnesses to the abuse. . . .
(i) an interview with the alleged abuser(s), unless such an interview would create additional risk of harm to the person with a disability;
(j) a determination that all relevant physical evidence of the alleged abuse has been preserved . . .
(k) the review and obtaining of copies of all documents which are not plainly irrelevant to the matter under investigation . . .
(l) an interview with the reporter;
(m) a determination in cases in which abuse is not substantiated as to whether the allegation reported to the Commission constitutes a false report . . .
(n) any other tasks that, in the discretion of the Commission, are deemed appropriate and are not plainly irrelevant to the investigation; and
(o) if an investigator does not perform one or more of the requirements in 118 CMR 5.02(1)(a) through (n), the investigator shall detail in the Investigation Report why the requirement was not met and the Commission shall determine whether said requirement(s) is material to the investigation.
We also determined whether investigators provided an explanation, in accordance with the regulation, for any requirements not met.
Alleged Abusers with Three or More Reports of Abuse
We performed an analysis of all 3,291 cases completed during the audit period to identify alleged abusers investigated for three or more incidents during that period that were not referred to DPPC. We reviewed the associated Intake Abuse Forms to determine whether, for cases designated as “screening decision 4B” (indicating that the caretaker is employed by a state agency) in FileMaker Pro, DPPC had been assigned as the investigating agency based on the history of multiple reports, in accordance with its intake, investigation, and oversight policies.
Data Reliability
We assessed the reliability of the data obtained from FileMaker Pro by interviewing knowledgeable DPPC personnel about the system. We tested FileMaker Pro’s system controls, which included security management, access control, and segregation of duties, and determined whether configuration management and contingency planning policies were in place during the audit period.
We observed DPPC management extracting case data from FileMaker Pro. We then traced a sample of 20 completed cases, out of our dataset of 25,521 cases, to their source documents (Intake Abuse Form, IR, 19C report, Notice of Alleged Abusers’ Rights, Investigation Extension Request Form, letter of referral to law enforcement, and/or letter of referral to a district attorney’s office) provided by DPPC to assess the accuracy of the data. We performed additional validity and integrity tests, including comparing the total number of completed cases in the dataset to the totals in DPPC’s annual reports for fiscal years 2018 and 2019, verifying that there were no missing values in key fields, summarizing abuse reports to ensure that there were no duplicates, testing for report dates outside the audit period, and validating data values for screening decisions.
Based on the results of our assessment, we determined that the data were sufficiently reliable for the purposes of our audit work.
| Date published: | June 16, 2021 |
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