Overview
During the audit period, DDS did not ensure that its providers met the timeframes for submitting and finalizing incident reports. Specifically, of the 75 major-incident reports we sampled, 27 (36%) were submitted late, after the one business day allowed. In addition, 23 (35%) out of the 75 major-incident reports were not finalized after the established seven-calendar-day timeframe.
Furthermore, 13 (17%) minor-incident reports out of our sample of 75 minor-incident reports submitted by providers to DDS during the audit period were submitted late, after the three business days allowed. Also, DDS did not ensure that providers finalized 22 (29%) of the 75 minor-incident reports that we sampled within the seven calendar days allowed.
As a result, DDS did not act on all incident reports in a timely manner to identify and remediate safety risks for alleged victims.
Authoritative Guidance
Section VI(A)(1) of DDS’s Incident Management Guidelines states,
[An] Initial Report [is] 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 did not fully implement our recommendation during the audit period from our previous audit (Audit No. 2020-0234-3S). DDS provided evidence of sending custom reports, showing open incidents at the provider and DDS levels to the area and region levels; however, there was no follow up on the reports until after the audit period. See Post-audit Action for more details.
Recommendation
DDS should continue to work with providers to ensure that all incident reports are submitted and finalized on time.
Auditee’s Response
DDS agrees with the finding related to timely incident reports and appreciates the recommendations given by the OSA to improve and strengthen the incident reporting process. Incident reporting is an important risk management process; however, it is important to note that it is not the sole reporting and monitoring process for sentinel events and/or emerging safety risks. For example, any unsafe situation, at any time, may be identified by families/guardians; DDS service providers; other public agencies (courts, schools, child protection agency, elder services); other internal staff ( e.g., licensure and certification surveyors, area office nurses, human service coordinators, DDS investigators); and external stakeholders such as neighbors, police, or health care providers. As such, DDS is able to identify, mitigate, and prevent safety risks using a holistic proactive approach.
Incident reporting at DDS operates together with a number of DDS risk management systems, procedures, and processes, such as general risk screening and formal individual clinical risk plan development and tracking at the area, region, and central office levels. Routine risk management reports, DPPC complaint and investigation outcome summaries, site monitoring, and ongoing “real time” communication between individuals, providers, and DDS staff operate in an integrated, systemic manner, so the effect of any one incident report not submitted as timely as required may be mitigated.
DDS takes its responsibility to safeguard the safety and welfare of the individuals it supports very seriously and will carefully consider the recommendations to enhance DDS’ ability to monitor, address, and mitigate risks presented in incident reporting. Ongoing DDS improvement efforts since the 2021 audit period have already resulted in an increase in compliance rates for the timeliness of major and minor incident submission and finalization by providers. While DDS is gratified to see improvement, as noted by the OSA, there is more work to be done. To that end, DDS agrees with and will be implementing the recommendation that DDS continue to work with providers to ensure that all incident reports are submitted and finalized on time.
DDS has been meeting regionally with staff to identify root causes of delays and determine potential strategies and resources to address the challenges with timely reporting of incidents. Specific strategies and resources may include reporting/data analytics, training/job aids and web application improvements. Concurrently, the DDS Director of Risk Management is implementing enhancements to the DDS Comprehensive Risk Management System, of which incident reporting and incident management are integral. These revisions will include an evaluation of workflow barriers to achieving quality, timely incident reporting. As these streams of activities progress, DDS will be implementing specific action steps to ensure that providers submit and finalize all incident reports on time.
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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