During the audit period, DYS did not institute formal disciplinary guidelines for its employees or contractors for its 51B report resolution process. During the audit period, there were a total of 30 supported 51B reports against either DYS employees or employees contracted to work with DYS. Of these 30 51B reports, there were 28 reports for which DYS did not ensure that adequate steps were taken to prevent reoccurrence of incidents of abuse and/or neglect of children in its custody in accordance with Section 4.35(2) of Title 110 of the Code of Massachusetts Regulations (CMR). For example, when an employee was found with contraband at a DYS facility or found using unnecessary force or restraints on a youth, DYS would terminate the employee, but take no further action, such as additional training for other employees.
Without formal disciplinary guidelines, DYS may not be preventing the reoccurrence of similar incidents. Although terminating the employee involved in the 51B report may appear to resolve the issue, it does not prevent other employees from continuing the same or similar behavior. Additionally, without guidelines, DYS may be providing unfair treatment to employees, such as suspending some employees and terminating others or even not disciplining some at all for substantially similar policy violations.
Authoritative Guidance
According to 110 CMR 4.35(2),
After the Department [DCF] provides a copy of the 51A report and 51B response to any agency pursuant to 110 CMR 4.34, the agency in question is responsible for any further action to ensure that adequate steps have been or will be taken to prevent re-occurrence of incidents of abuse or neglect of children in the institution in question.
Reasons for the Issue
In a memorandum sent to us, dated July 30, 2025, DYS stated that contracted employees involved in a 51B report “are not DYS employees and as such, DYS cannot independently take action against them.”
This memorandum went on to state,
The DYS Investigations Unit has always identified programmatic concerns in their reports where they are present. Beginning in late 2024, any time an investigation reveals programmatic concerns, a separate memorandum is generated and shared with the Regional Director so they can create a corrective action plan. When programmatic concerns are found in a provider program, the Regional Director also receives an administrative memorandum with those concerns for follow up in their regularly scheduled provider meetings.
Recommendation
DYS should take additional measures, beyond just terminating and/or suspending employees upon supported allegations of neglect and/or abuse of youths. Such measures may include providing written guidelines for all staff members to follow when a supported 51B report is received, mentoring all employees beyond their first year of service to provide a supportive environment, and/or providing trainings on areas where there are frequently identified policy violations.
Auditee’s Response
DYS generally agrees with the recommendation and has implemented processes to identify programmatic concerns and increase trainings related to supported 51Bs. However, DYS does not agree with the finding that it did not have “sufficient disciplinary guidelines instituted for its 51B report resolution process.”
DYS shares the auditor’s concern about supported 51Bs in DYS programs. DYS is committed to ensuring the safety of the youth in its care and custody and to identifying and investigating allegations of abuse and/or neglect. In accordance with DYS Advisory on 51As and 51Bs, all state staff who have a 51A filed against them are placed on paid administrative leave. In this case, each of the state and provider employees identified with supported 51Bs by the Audit Team had their employment terminated.7
All DYS employees receive 80 hours of Basic Training, a two-week course of study that includes hands-on training in defensive disengagement, de-escalation, and boundary training. In addition, all DYS residential staff attend an annual review program to recertify and reinforce their training in critical areas—including defensive disengagement—each year. New DYS staff are enrolled in the Mentor Program, where they are coached by a Mentor out of the DYS Training Academy through their first year, with additional support provided to their supervisors to aid their onboarding.
Beginning in January 2024, DYS implemented a new investigative process to identify programmatic concerns during investigations. If a DYS investigator identifies programmatic concerns during an investigation, those concerns are written up in an additional report and given to the Regional Director to address. The Regional Director is required to respond to the programmatic concerns with a corrective action plan filed with the Investigations Unit.
At the same time, DYS recognizes that even where programmatic concerns are not identified as a part of an investigation, additional refreshers in DYS policies can buttress the robust training DYS employees receive. To this end, DYS recently implemented a new process for any supported 51B. Moving forward, the Investigative Report for all supported 51Bs will include a separate programmatic concerns report, regardless of whether the involved employees were terminated. That report will identify policies that should be reviewed with staff and whether additional training of staff is necessary. The applicable Regional Director will receive the Investigative Report and will be required to confirm for the Investigations Unit within 30 days that the policies have been reviewed by staff and that any recommended retraining has occurred. These new processes are in addition to the long-standing process of DYS program monitoring by three DYS program monitors who conduct onsite monitoring visits of every DYS residential program twice a year and evaluate every aspect of the program and its staff.
Finally, based on the training DYS provides, staff understand that when DCF supports a 51B, DYS imposes discipline in accordance with DYS Policies, Advisories, and procedures.
[Footnote:]
7. In accordance with regulation, an individual with a supported 51B cannot work in a DYS or provider program without a waiver.
Auditor’s Reply
We acknowledge DYS’s response and commend its efforts to strengthen oversight, training, and investigative follow-up procedures for supported 51B reports since our last audit (Audit No. 2019-0512-3S). Specifically, during the audit period, DYS implemented a new investigation process to identify programmatic concerns during investigations. However, DYS was unable to provide proof that it addressed these identified programmatic concerns. For example, during our review of supported 51B reports, we noted instances in which contraband was brought into DYS facilities. In addition, during the audit period, DYS did not have written disciplinary guidelines outlining consistent procedures for addressing supported 51B report findings, beyond termination. The absence of such documentation limits accountability and increases the risk of inconsistent disciplinary response across DYS’s programs.
Based on its response, DYS is continuing 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 24, 2026 |
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