Overview
During the audit period, 9 (12%) of the 74 administrative reviews in our sample were not provided to the CRT coordinator within 15 business days.
When administrative reviews are not completed or are conducted improperly, DDS cannot ensure prompt implementation of actions outlined in resolution letters to address potential harm.
Authoritative Guidance
According to 115 CMR 9.11(2), “After conducting the review, the regional director or his or her designee shall issue a report of his or her findings and provide the report to the CRT coordinator within 15 days.”
Reasons for Issue
DDS stated in a response to the issue that “[Administrative Review] was completed in the required timeframe. The Resolution Letter was issued after the CRT meeting, which in some cases is held monthly and not bi-weekly depending on citizen availability.”
Recommendation
DDS should establish effective policies and procedures to schedule more frequent meetings of CRTs in order to ensure that all administrative review reports are submitted and finalized on time.
Auditee’s Response
DDS agrees with OSA’s finding and agrees with OSA’s recommendation to the extent that DDS should establish effective policies and procedures to ensure that all administrative review reports are submitted and finalized on time. However, DDS is cognizant of the practical considerations involved with holding more frequent meetings given the regulatory requirement for citizen participation in the CRT and does not agree that holding more meetings would be a feasible recommendation to implement. DDS acknowledges that it must review and improve the administrative review process to ensure that administrative review reports are provided to the CRT coordinator within 15 business days, unless an extension request is made and approved per 115 CMR 9.11(3). DDS also notes that the volume of administrative reviews has increased significantly since the 2021 audit (2020-0234-3S).
As part of the administrative review process that is currently in place and was implemented two years ago as a result of the 2021 OSA audit, harm mitigation is the very first step when an administrative review is assigned to a regional director. DDS process specifies that upon assignment of a new administrative review, the regional director or designee must first determine if any immediate protective measures are needed to ensure the safety of the alleged victim. If the answer is yes, the regional director or designee should take all steps necessary with all involved parties to ensure the safety of the alleged victim and all individuals in that location. This is an important point, particularly with regard to whether an administrative review is not provided to the CRT coordinator within 15 days. Although a late administrative review is not ideal, it does not automatically mean the health and safety of individuals is put at risk.
DDS will also review, clarify and reissue the administrative review process to all involved regional and area office staff. This updated Administrative Review Process guidance will clarify that if the 15-business day deadline cannot be met, the regional director or designee must request an extension from the Deputy Commissioner for Operations. If approved, the regional director or designee will send a notice of extension to all involved parties.
Auditor’s Reply
Based on its response, DDS has taken 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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