Overview
During our audit period, DDS did not ensure that its provider-operated group homes met DDS timeframes for submitting and finalizing incident reports. Specifically, of the 60 major-incident reports we sampled that were submitted to DDS by provider-operated group homes during our audit period, 31 (52%) were submitted late (1 to 202 business days after the 1 business day allowed). These 31 reports were also finalized by the group homes 1 to 546 business days5 after the established 7-calendar-day timeframe. Finally, 17 minor-incident reports submitted by group-home providers to DDS during our audit period (28% of our sample of 60) were submitted 1 to 269 business days after the 7 calendar days allowed. Also, DDS did not ensure that provider-operated group homes finalized 24 (40%) of the 60 minor-incident reports we sampled; these 24 reports were finalized 1 to 269 business days after the 7-calendar-day timeframe. As a result, DDS cannot act on all incident reports in a timely manner to identify and remediate any safety risks to alleged victims.
Authoritative Guidance
Section VI(A)(1) of DDS’s Incident Management Guidelines states,
Initial Report—to be completed and submitted to the appropriate state agency either on a paper incident report form or electronically in one (1) business day for incidents initially classified as major review incidents or three (3) business days for incidents initially classified as minor review incidents. . . .
The Final Report for most incident categories is to be completed by the provider and submitted to the involved state agency within seven (7) calendar days following the discovery of the incident.
Reasons for Issue
DDS had not implemented effective monitoring controls to ensure that provider-operated group homes submitted the required reports in accordance with DDS guidelines. DDS asserted that it was understaffed and that the volume of incident reports submitted by provider-operated group homes during the audit period (22,628) was very difficult to manage with its current staff.
Recommendation
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.
Auditee’s Response
DDS agrees with the Finding that provider-operated group homes did not timely submit incident reports. . . .
A workgroup has been formed to include the Bureau of Program Integrity, Office of Quality Management, and operations staff, as well as [Executive Office of Health and Human Services information technology, or IT] staff, to develop a process for enhanced monitoring of the timeliness of report submissions, and to evaluate the current timeline requirements for the submissions. Furthermore, the timeliness of incident reporting and strategies to improve timeliness are topics at the Statewide Risk Review Committee.
DDS also sent an advisory to its Providers (June 4, 2021) reiterating the requirements of meeting incident report timelines.
In addition, DDS implemented a data exchange agreement with MassHealth that matches emergency room claims with incident reports on a quarterly basis to verify that reportable events are being reported and is presently pursuing more frequent reporting through MassHealth data exchanges. As under-reporting providers are identified, DDS staff inform these providers of the issue and work with providers to develop corrective actions to address issues.
Auditor’s Reply
Based on its response, DDS is taking measures to address our concerns in this area.
| Date published: | June 29, 2021 |
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