Overview
During the audit period, the Department of Developmental Services (DDS) did not always issue decision letters for its investigations within required timeframes with adequate documentation. Specifically, for 2 (3%) out of 73 investigations in our sample, an extension was created for the decision letter after the 45-day timeframe for the decision to be issued.
Further, DDS complaint resolution teams (CRTs) did not consistently develop action plans within the required 30-business-day timeframe. Specifically, 27 (37%) of the 73 completed investigations in our sample had action plans that were not developed within 30 business days. We also identified that 3 of these cases did not have any action plans at all.
When investigations are not completed within required timeframes, or extensions are created without reason, there is a greater risk that recipients of DDS services may be subject to safety risks, abuse, and/or mistreatment.
Authoritative Guidance
Section 9.13(1)(d) of Title 115 of the Code of Massachusetts Regulations (CMR) states,
The results of the investigation shall be reported and a decision letter delivered to the regional director or designee within 45 [business] days of the investigator’s assignment.
According to 115 CMR 9.10(5),
The senior investigator or investigator may submit a request for an extension of a time limit set forth in 115 CMR 9.00 upon a showing of necessity and that the delay will not pose a threat to the safety of the individual involved. A staff investigator shall submit such request to the senior investigator; a senior investigator shall submit such request to the director of investigations or designee. A request for an extension shall be in writing, explain why an extension is needed, and propose a new time limit which does not unreasonably postpone a final resolution of the matter. If approved, the extension request shall be forwarded to the director of investigations by the senior investigator or designee. The senior investigator or designee shall then send a notice of extension to the parties.
According to 115 CMR 9.14(3), CRTs must develop action plans “within 30 [business] days of an assignment to the CRT coordinator” for complaints investigated by DDS.
Reasons for Issue
DDS did not implement effective monitoring controls within its policies and procedures to ensure that decision letters and action plans were developed and issued on time.
However, it should be noted that, as of summer 2024, after the audit period for this audit, DDS reported to us that it had updated its formal policies and procedures to monitor the timeliness of investigations. See Post-audit Action for more information.
Recommendations
- DDS should continue to follow its newly updated investigations manual to ensure that all decision letters are issued within the required timeline and ensure that any necessary extensions are properly requested, documented, and approved.
- As previously recommended in our Audit No. 2020-0234-3S, DDS should properly implement effective monitoring controls to ensure that all action plans are completed timely.
Auditee’s Response
DDS agrees . . . with Finding 1 to the extent that the Department did not always issue decision letters or develop action plans within the requisite timeframes in 100% of cases. . . .
. . . Most recently DDS updated the investigator and senior investigator’s performance expectations, to highlight corrective actions to be taken when performance measures are not met. DDS’ commitment to increasing efficiency and adherence to these regulatory requirements is evidenced in the difference between the two audits: In 2021, 38% of the decision letters were late beyond extension. In 2025, 2% of the cases were late before an extension was entered. . . .
While DDS agrees with the recommendations and has implemented effective monitoring controls, DDS acknowledges that it can further improve its processes to ensure that all action plans are completed within 30 business days. DDS intends to issue guidance with clear timelines and will ensure all four regions and 23 area offices follow this guidance by standardizing the forms, retraining the field, and conducting regular spot checks. DDS reiterates that pursuant to 115 CMR 9.07, the DDS investigator notifies the regional director immediately if protective services are required to ensure the health and safety of an individual (or individuals) as a result of a complaint allegation. This point simply cannot be overemphasized, particularly with regard to whether an action plan is not completed within 30 business days. Please also note that with respect to the reference [in the “Investigation Process for Alleged Abuse or Mistreatment” section of the Overview] related to DDS’ plan to hire additional staff to address timeliness of action plans, DDS wishes to clarify that since the 2021 audit (2020-0234-3S), DDS has created and filled four Administrative Review Manager (“ARM”) positions who oversee each region’s timely completion of action plans and administrative reviews. . . .
Finally, the foremost priority of DDS investigations is risk mitigation, which begins at assignment and continues throughout the investigative process, regardless of duration. Open cases are reviewed by investigators and senior investigators at least bi-weekly, and monthly by the deputy, director, and senior to make certain there are no significant risk factors that have not been addressed. For screened-in ([Chapter 19C of the Massachusetts General Laws] cases), DPPC oversight also monitors the cases for elements of risk and is in frequent (consistent) communication with DDS investigations. In situations where DDS discovers significant risks, DDS documents such and issues written requests for protective services; DDS Investigations works with DDS Operations, DDS providers, and parties to the complaint to eliminate the significant risk and maintain such throughout the process.
Auditor’s Reply
Based on its response, DDS continues to take measures to address our concerns regarding this matter. As part of our post-audit review process, we will follow up on this matter in approximately six months.
| Date published: | April 15, 2026 |
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