Overview
In administrative resolutions and 10-day fact-finding investigations, CHD did not always investigate and resolve DMH person-served complaints in a timely manner. For the three administrative resolutions reviewed, there was one instance with no evidence that the responsible person met with the person served or complainant. There were also two instances where written notices that were due 5 days after the complaint was filed, or 2 days after the responsible person met with the person served or the complainant (whichever was later), were not provided on time: in one instance it was provided 24 days after the complaint was filed, and in the other it was provided 7 days after the responsible person met with the person served. Of the seven 10-day fact-finding investigations we reviewed, four were not completed within 10 days: two were completed in 11 days, one in 15 days, and one in 29 days. In addition, CHD did not provide a written notice for one within five days after the investigation ended.
During our assessment of internal controls related to the investigation and resolution of DMH person-served complaints, we found no evidence that 12 of 36 DMH program employees participated in the new employee orientation. CHD could not produce new employee orientation checklists for 6 of the employees, and for the other 6, the checklists did not have the required employee signatures evidencing the employees’ attendance.
Delayed complaint resolution could prolong adverse conditions for the person served and the provider. For administrative resolutions, if CHD’s responsible person does not meet with the person served about the complaint, the person served does not have an opportunity to participate in the investigation. In addition, if CHD staff members are not trained in procedures associated with the human rights of persons served and the complaint process, human rights may be violated and complaints may not be filed promptly, correctly, or at all.
Authoritative Guidance
The regulation 104 CMR 32.04 states,
(3) Administrative Resolution. . . .
(b) In resolving a complaint pursuant to 104 CMR 32.04(3), the Responsible Person or designee must meet with the client and the complainant, if different, unless the client and/or complainant declines to meet with the Responsible Person or designee, or despite reasonable efforts, cannot be located. . . .
3. The purpose of this meeting shall be to:
a. review the specific allegations in the complaint;
b. determine whether there are disagreements concerning the facts underlying the allegations that require further fact-finding; and
c. discuss and, if possible, agree upon actions, if any, that may be taken by the Responsible Person or designee to address the concerns raised by the complaint.
(d) Within five business days of the filing of the complaint, or two business days of the meeting held pursuant to 104 CMR 32.04(3)(b), whichever is later, the Responsible Person shall provide the parties with a written notice that includes a statement of the grounds for administrative resolution, the actions, if any, that will be taken by the Responsible Person, the right to request reconsideration, and the client’s right of appeal in accordance with 104 CMR 32.04(7). . . .
(4) Responsible Person Ten-day Fact Finding.
(a) [Finding of fact] shall be completed within ten days of assignment. . . .
(c) The Responsible Person shall issue a written decision within five days following completion of the fact finding.
CHD conducts new employee orientation training, which includes human rights complaint procedures. According to CHD’s unwritten policy, the employee and the employee’s supervisor must sign the new employee orientation checklist in the designated location as evidence of the employee’s attendance.
Reasons for Issue
No monitoring controls are in place to ensure that timelines are met for resolving complaints during 10-day fact-finding investigations and administrative resolutions; that the responsible person meets with the person served or the complainant during a DMH administrative resolution; or that signed new employee orientation checklists are retained.
Recommendations
- CHD should establish monitoring controls to ensure that timelines are met for 10-day fact-finding investigations and administrative resolutions.
- CHD should establish monitoring controls to ensure that the responsible person meets with the person served or complainant during any administrative resolution.
- CHD should establish monitoring controls to ensure that new employee orientation checklists are completed, have the required signatures, and are retained as evidence that human rights complaint–specific training has been provided to its new employees.
Auditee’s Response
As noted above, CHD is pursuing a comprehensive strategy of enhancing its compliance function. In addition to the hiring noted above, the organization has revamped its Compliance Committee so that internal and external investigations (which may include investigations regarding human rights violations) are brought to the attention of senior management. CHD is undertaking a comprehensive review of the investigation process across the entire agency, including persons served by our DMH contract. This process has begun by adoption of the policy noted above that requires all programs to notify the Organizational Excellence Division of complaints or incidents that require investigation. Depending on the nature of the complaint, it will be investigated either by the program or by Organizational Excellence. The agency is also looking into acquiring software that would assist staff to track and monitor investigations to ensure they are completed in a timely manner. All personnel undertaking investigations for the organization will be trained in the requirements for investigations, including interviewing the complainant.
Auditor’s Reply
Based on its response, CHD is taking measures to address our concerns regarding establishing monitoring controls to ensure that timelines are met for investigations and administrative resolutions and to ensure that the responsible person meets with the person served or complainant during any administrative resolution. We reiterate our recommendation that CHD establish monitoring controls to ensure that new employee orientation checklists are completed, have the required signatures, and are retained by CHD as evidence that training on human rights complaints has been provided to its new employees.
| Date published: | December 23, 2021 |
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