Overview
DDS did not ensure that medication occurrence reports (MORs) were created, finalized, and reviewed by DDS Medication Administration Program (MAP) coordinators within the required timeframes. Sixteen (21%) out of 75 non-hotline MORs that we reviewed were created after the established seven-calendar-day timeframe. Also, 5 (6%) out of 75 non-hotline MORs were not finalized by the provider within the required seven-calendar-day timeframe. DDS MAP coordinators did not review 3 (4%) out of the 75 non-hotline MORs within the established 14-calendar-day timeframe.
In addition, 21 (60%) of 35 hotline MORs we reviewed were created after the established 24-hour timeframe. Finally, DDS MAP coordinators did not review 3 (9%) of these 35 hotline MORs within the established 14-calendar-day timeframe.
Without timely creation, finalization, and review of MORs, there is an increased risk of poor outcomes for recipients of DDS services who could be adversely affected by staff members who do not administer medication, make dosage mistakes, or administer the wrong medication.
Authoritative Guidance
DDS’s MOR Overview Guide requires all providers to create and finalize non-hotline MORs within seven calendar days after MOR events are discovered and hotline MORs within 24 hours after events are discovered. Once a provider finalizes either a non-hotline or hotline MOR, it must be reviewed by a DDS MAP coordinator for approval within 14 calendar days.
Reasons for Issue
DDS did not fully implement our recommendations during the audit period from our previous audit (Audit No. 2020-0234-3S). However, after the audit period for our current audit, DDS reported to us that it had implemented monitoring policies and procedures to ensure that providers create and finalize MORs, and that MAP coordinators review MORs, within the prescribed timeframes. See Post-audit Action for more details.
Recommendations
- DDS should continue to follow its newly updated policies and procedures to ensure that providers create and finalize MORs, and that MAP coordinators review them, within the prescribed timeframes.
- DDS should implement corrective actions related to audit findings in a timely manner.
Auditee’s Response
DDS agrees with the finding related to timely medication occurrence reports and appreciates the recommendations given by the OSA to improve and strengthen the medication occurrence reporting process. However, it is important to note that MAP operates in concert with a number of DDS risk management systems, procedures, and processes (including DPPC allegations and investigations, incident reporting, and site monitoring), so the effect of any one medication occurrence report not being timely submitted may be mitigated by coexisting processes.
DDS takes its responsibility to safeguard the welfare of individuals it supports seriously and will carefully consider the recommendations to enhance MAP’s ability to monitor, address, and prevent medication occurrences.
As noted earlier in the draft report, DDS has already initiated several strategic and structural improvements related to MAP and medication occurrences. Some of these were implemented during the audit period (for example, the hiring of a Statewide MAP Director), while others occurred after the current audit period (the restructuring of the reporting relationships of the regional MAP Coordinators). The initial effects of some of these strategies can be seen in comparison of the 2021 audit findings to the 2025 audit findings, in which there was an increase in compliance rates for regional MAP Coordinators as well as for providers across both hotline and non-hotline MOR review and submission.
Specifically, DDS created and filled a dedicated position of Statewide Director of MAP, with centralized oversight of MAP. In January 2025, DDS reorganized the Regional MAP Coordinators to report directly to the DDS Statewide Director of MAP, enhancing standardization and statewide coverage and improving timeliness.
DDS will continue to follow newly updated policies and procedures to ensure that providers create and finalize MORs, and that MAP coordinators review MORs, within the prescribed timeframes. Further, DDS is in the process of developing and implementing the following additional corrective actions related to the audit findings in a timely manner:
- DDS regional MAP Coordinators will document reminders in non-timely MORs in the MOR itself for the provider to review;
- DDS plans to create a quarterly report on compliance with timelines for MORs at a provider level. These quarterly reports, once created, will be used by the MAP Director to monitor, flag, and inform providers and DDS staff on areas of noncompliance;
- DDS plans to create a quarterly report on compliance with timelines for MORs at the regional MAP coordinator level. These quarterly reports, once created, will be used by the MAP Director to monitor, flag, and inform DDS staff on areas of noncompliance; and,
- Regular ongoing webinars, required for MAP Trainers, also provide reminders about timeliness requirements. DDS is exploring other communication strategies to assure that all appropriate MAP-related staff are reminded of timeliness requirements.
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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