The Department of Youth Services (DYS) did not demonstrate that it complied with its own policies and Section 5 of Chapter 120 of the Massachusetts General Laws regarding assessments of youths committed to its custody. The table below summarizes the issues we noted, from our sample of 60 youths, related to committed youths’ assessments.
| Issue | Number of Committed Youths from Our Sample Affected by the Issue | Percentage of Committed Youths from Our Sample Affected by the Issue |
|---|---|---|
| Youths who did not have health and dental screenings within seven days of their arrival at DYS | 5 | 8% |
| Youths who did not have names, aliases, ages, sexes, races, or dates of birth completed in their admission records | 1 | 2% |
| Youths who did not have their schools and grade levels completed in their admissions records | 1 | 2% |
| Youths who did not have identifying marks, scars, and tattoos (the body map) completed in their admissions records | 7 | 12% |
| Youths’ articles upon intake were not recorded in the client’s admission files | 4 | 7% |
| Youths where there was no record of the handbook being provided to the youths upon intake | 1 | 2% |
| Youths’ treatment plans were not provided to us | 1 | 2% |
| Youths’ treatment plans were not signed or dated by the youths’ caregivers or the people responsible for the intervention | 7 | 12% |
| Youths’ treatment plans were not reviewed at least monthly | 8 | 13% |
| Evidence that youths were meeting with caseworkers at least on a monthly meeting was not provided to us by DYS | 3 | 5% |
| Monthly progress notes were not provided to us | 3 | 5% |
| Evidence that assessment tools were used to determine whether substance use was a risk for youths was not provided to us by DYS | 1 | 2% |
| Evidence that youths were placed on either a treatment track or prevention track based on their substance use assessment was not provided to us by DYS | 1 | 2% |
| Evidence that recommendations were made at the initial staffing level for development of the youths’ monthly treatment plans was not provided to us by DYS | 2 | 3% |
| Evidence that staff members addressed youths’ substance abuse issues was not provided to us by DYS | 6 | 10% |
If DYS does not comply with Section 5 of Chapter 120 of the General Laws and its own internal policies, then youths may not be placed in appropriate programs or receive the proper support necessary to address individual needs. Additionally, if DYS does not ensure that complete intake assessments are conducted, then caseworkers may lack the information needed to set realistic goals and track progress. Lastly, youths may feel neglected or misunderstood if a proper assessment is not completed, increasing the chance of recidivism and worsening their mental health.
Authoritative Guidance
According to Section 5 of Chapter 120 of the General Laws,
(a) When a person has been committed to the department of youth services, it shall, under rules established by it, forthwith examine and study him and investigate all pertinent circumstances of his life and behavior.
(b) The department of youth services shall make periodic reexamination of all persons within its control. These examinations may be made as frequently as the department considers desirable, and shall be made with respect to every person at intervals not exceeding one year.
(c) The department of youth services shall keep written records of all examinations and of the conclusions based thereon, and of all orders concerning the disposition or treatment of every person subject to its control.
According to the “Admission/Intake” section of DYS’s “02.01.01(c): Intake Procedures” policy,
All new clients shall receive a health and dental screening within seven days of their arrival at a Location. . . .
Location personnel shall complete an admissions record for all new clients including the following:
- name, alias, age, sex, race, and date of birth;
- height, weight, and hair and eye color;
- place of birth;
- telephone number if applicable;
- school and grade level;
- parent’s/guardian’s names, address, home and work numbers;
- any medical and mental health problems;
- documentation of screening for suicide ideation;
- all identifying marks, scars, and tattoos; and
- 2 photographs taken during admission (see photograph policy).
Location personnel shall record the following offense information:
- admission date and time;
- client’s number;
- juvenile court of placement;
- name of admitting personnel; and
- summary of offenses including charges on police records, petitions, court orders, and bench warrant. . . .
Location personnel shall record all articles provided to the client in the client’s admission file.
Location personnel shall provide written orientation materials and/or translations into the client’s native language. Location personnel shall assist clients in understanding the orientation manual. Completion of this orientation process is documented by a statement signed and dated by the client.
According to the “Clinical” section of DYS’s “02.02.01(b): Treatment Plans” policy,
- All clients, upon commitment to DYS, shall be assessed for the level of risk they present to re-offend and the type of services they need to reduce their risk level. . . .
- The Risk/Need Assessment shall become part of the client’s record, both in the Area Office and at the Location where services are provided. . . .
- Treatment plans are to be developed within the first week of a client’s intake to a program.
- The Treatment Plan shall contain a brief assessment of the problem area to be addressed, measurable short and long term goals, and specific interventions.
- Treatment Plans shall be signed and dated by both the clients, the client’s parent/guardian, and the person responsible for the intervention. . . .
- Documentation of a client’s progress on all active treatment plans shall occur weekly.
According to DYS’s “02.02.06(a): Suicide Assessment in Residential Facilities” policy,
The Intake Clinician or designee shall complete a suicide assessment as soon as possible upon a new client’s arrival, but in no case longer than six hours from the client’s arrival on the unit. The time that the suicide assessment has been completed shall be documented in the Unit Log. The completed Intake Screening assessment shall include:
- Obtaining a history of prior suicide attempts, gestures, or ideation;
- Reviewing written material on the client, including family history of suicide;
- Recording verbal communication from transportation staff and prior placements;
- Completing the approved intake screening forms;
- Requesting information on a history of mental health problems, self-destructive behavior, or suicide attempts, gestures, or ideation from parents or guardians;
- Administering the MAYSI-II test.
According to the “Clinical” section of DYS’s “02.02.04(b): Progress Reports” policy,
Treatment meetings or caseworker visits shall be held at a minimum on a monthly basis at the site where the client is placed. . . .
Progress reports shall serve as the documentation of treatment meetings and shall be completed within ten working days of the meeting. . . .
The monthly progress report form shall be filed in the client’s record at both the Program and Area Office.
According to DYS’s “02.03.06(c): Youth Substance Use Assessment, Prevention and Treatment” policy,
During the assessment period for all newly committed youth, clinical staff shall administer an assessment tool as approved by Director of Substance Use Services to determine if substance use is a risk factor for the individual youth.
Youth who are identified as having substance use disorders or at high risk for developing substance use disorders will be recommended to receive substance use treatment services and placed on the Treatment Track. Those who are assessed and found not to have potential substance use disorders will be recommended to receive prevention services upon placement and placed on the Prevention Track.
These recommendations should be made at the initial staffing for development of the youth’s monthly treatment plan. . . .
During monthly treatment review meetings, the caseworker, the program representative and clinical staff will, as part of the treatment plan review, specifically address the issue of substance use and insure that services are consistent with the youth’s assessments, as well as revise or update the monthly treatment plan based on treatment progress and needs of the youth.
Reasons for Issue
In a memorandum sent to us, dated July 30, 2025, DYS stated,
In response to missing body maps, incomplete entries related to inventory or issuance of handbooks, or missing health summaries, could be a result of human error or a faxing error. As you may recall, items are entered into [DYS’s online document management system] via fax machine. If a fax machine is not working or a fax line is busy, the items may not get in the same day.
Additionally, information related to dental health is self-reported by youth and may not have been available at the time of intake and is therefore missing from the intake file.
Recommendation
DYS should demonstrate compliance with Section 5 of Chapter 120 of the General Laws and its own internal policies regarding assessments and reassessments of youths.
Auditee’s Response
While DYS agrees with [the Office of the State Auditor’s (OSA’s)] recommendation and shares the auditor’s concern about missing information, it disagrees with this finding in part and disagrees with the impact as described.
DYS disagrees that it was not in compliance with the assessment and reassessment of youth described in [Section 5 of Chapter 120 of the Massachusetts General Laws]. DYS complies with its statutory obligation when it completes its 45-day comprehensive evaluation of each committed youth. [Section 4.0 of Title 109 of the Code of Massachusetts Regulations.] During the assessment process, DYS collects hundreds of documents about the youth, their medical history, their psychosocial history, their educational history, and their family history, and conducts testing and evaluations to determine the best treatment for the youth. This 45-day assessment forms the basis for a youth’s treatment plan and is the foundation for the youth’s rehabilitation at DYS. The reassessment process is an ongoing daily and weekly process for every committed youth. Clinicians meet regularly with youth and record their clinical notes, advocates meet daily with youth and record their interactions, and teachers see youth daily and record educational progress. Monthly treatment meetings occur with a youth, their parents/guardians, clinicians, and caseworkers as well as other program staff.
The statutory assessment and reassessment process is distinct from an “intake”, which occurs each time a youth enters a residential facility and is governed by DYS policy. There is an initial intake the first time a youth comes to DYS, and each time a youth returns from court, a doctor’s visit, or moves from one program to another. The initial intake may not be the intake done at the time the youth is first committed, since most youth spend some amount of time in detention prior to commitment. A detained youth will have their initial intake at the time they are first detained.
The first time an intake is conducted for a youth, the initial information collected is from the youth themselves or retrieved from court documents. Information like last dental visit, last doctor’s visit, and last grade completed, is all obtained—or in some cases, not obtained from a youth—either because they do not know the information or refuse to provide it. While these fields are important, they are not mandatory to complete the intake and the initial intake is not the sole source of information for any of these fields. There are many opportunities to obtain this information from the youth’s parent/guardian or other collaterals including during the statutorily required assessment.
The intake reviewed by the audit team was the intake at the time of the youth’s first commitment, which for most of the youth in the test group was not the initial intake, as most of the youth had been detained previously by DYS. The majority of data identified as missing in the audit report are items missing from a single youth intake, information which is frequently duplicated elsewhere in the database, often multiple times, and often in another intake. While DYS acknowledges that the instances of missing data identified by the OSA may not have been in compliance with its internal policies, DYS notes that the missing data items—in multiple cases only one data field—does not mean that the information is not present in other locations within a youth’s file.
DYS always strives to have complete information about a youth at each intake. [DYS’s online document management system], the DYS database which went online in 2012, allows all DYS locations access to detained and committed youth information—for each time a youth enters a DYS program. [DYS’s online document management system] contains over 7,000 fields of data entry. In addition to the data entry fields, there are dozens and sometimes hundreds of documents faxed into each youth’s file. DYS also notes that [DYS’s online document management system] was designed to have redundancy. The failure to enter a youth’s grade level on initial intake does not mean that the educational process for collecting a youth’s records is not followed, as that process is enshrined in an agreement with the Department of Elementary and Secondary Education (DESE) and designated to an Education and Career Coach. Similarly, a Treatment Plan with 5 signatures instead of six is still implemented; the youth whose age was not entered on a particular day’s intake does not mean that information is not in the youth’s file, typically multiple times, collected in the myriads of other data fields and documents DYS receives with the youth on arrival and that are collected during the assessment process.
DYS agrees with the importance of maintaining policies and processes to ensure the caseworkers have all appropriate information to support individuals’ needs. Data entry by employees is subject to human error as well as unforeseen circumstances. DYS understands that human error can occur, and because of that understanding, DYS strives to meet the goal of ensuring that every data field is completed. To that end, since 2014, DYS has had a daily Quality Assurance report that identifies any critical data points missing. This Quality Assurance report is emailed daily to Regional Directors who are responsible for ensuring any missing data fields are completed. DYS also has dedicated [online document management system] Regional Administrators . . . in each region to assist and train DYS staff with entering information in [DYS’s online document management system] as well as provide written job aids to staff about entering information into [DYS’s online document management system].
Auditor’s Reply
While we acknowledge DYS’s clarification concerning missing intake and assessment information, we uphold our recommendations. Although DYS complied with its statutory obligation of completing its 45-day assessment process for each committed youth, incomplete entries related to youth holistic history may prevent appropriate support of individual needs. DYS responded that the initial intake is not the only source of information for all data points and that data can be in multiple locations within its online document management system; however, we informed DYS of the specific missing information listed in the table on page 16 (in August 2025) and provided adequate time for DYS to locate and provide us with the missing information, but DYS did not provide evidence to address our concerns. We accept that DYS collects an extensive number of documents necessary for youth evaluations; however, mandatory youth information should be readily accessible to all staff members, including those less proficient in navigating multiple, isolated case folders. Partial or absent mandatory data fields—such as omitted entries related to inventory, the issuance of handbooks, or health summaries—may cause unforeseen concerns. DYS works with youth through a multidisciplinary team, and given the number of staff members involved, it is essential that all personnel members are aligned regarding each youth’s needs, goals, and progress. Essential information stored in disparate locations within a youth’s file may cause staff members to spend additional time trying to locate that information, potentially leading to gaps in understanding, oversight, or decision-making.
We recognize DYS’s dedication and ongoing efforts to ensure that quality assurance reports capture critical data points to effectively serve youths through interdisciplinary collaboration.
| Date published: | April 24, 2026 |
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