Disabled Persons Protection Commission - Other Matters

Filing of Investigation Reports

Overview

The Disabled Persons Protection Commission (DPPC) made progress in applying the recommendations from our previous audit (Audit No. 2020-0046-3S) for Finding 2, which stated, “DPPC does not always complete its investigations within the required timeframes or document the reasons for not doing so.” Specifically, since our last audit, DPPC enhanced its monitoring policy that requires it to run monthly reports and send notices to external protective service agencies to alert them of outstanding requirements. Additionally, DPPC now requires that all protective service plans and reasons for investigation delays be documented within the case notes. Our previous audit report disclosed that 56% of late abuse investigations during the prior audit period did not have any documented reasons for delays, compared to our current audit, which revealed that all late Initial Responses (IRs), Investigation Reports, and Retaliation Investigation (RI) Reports had documented reasons for delays. We commend DPPC for making progress addressing findings from our previous audit; however, there is room for improvement in order for DPPC to achieve full compliance with Section 5.02(4)(a) of Title 118 of the Code of Massachusetts Regulations (CMR). Specifically, despite DPPC appropriately documenting the reasons for delays related to the filing of Investigation Reports, we feel that enhanced collaboration with the Department of Developmental Services, the Department of Mental Health, etc., along with enhanced policies, procedures, and monitoring, could result in more timely submission of investigation reports in the first place. The following paragraphs outline detailed results from our audit.

IRs

We inspected 60 IRs (all of which were for nonemergency cases) and found that 21 were not filed with DPPC by external Adult Protective Services (APS) investigators within the required timeframe of 10 calendar days from the screening date for nonemergency cases. The delays ranged from 1 to 65 days after the due date, with an average of 10 days late. The following are the details of our results:¹⁸

• There were 9 instances where the corresponding external protective services agency was understaffed and had a large caseload, according to both case notes and explanations that DPPC’s chief of quality assurance and audit officer provided to us.
• There were 3 instances where the corresponding external protective services agency received multiple reports regarding the same alleged victim, which made repeated interviews with the alleged victim, witnesses, and alleged abuser necessary.
• There were 4 instances that involved reports of alleged sexual assault, which required additional investigation time.
• There were 4 instances that involved police investigations, which required additional investigation time.
• There were 7 instances where the protective services agency had difficulty scheduling interviews with the alleged victims and/or abusers. The following is a breakdown of these 7 instances:
  • There were 3 instances where the protective services agency received multiple reports for one alleged victim, requiring repeated interviews with the alleged victim, witnesses, and the alleged abuser.
  • There were 3 instances where the interviewee was hospitalized and unable to be interviewed.
  • There was 1 instance where the interviewee was initially unable to be found by an APS investigator due to being incarcerated.

Investigation Reports

We inspected 60 Investigation Reports and found that 31 were not filed with DPPC by the APS investigator within the required timeframe of 45 calendar days from the screening date. Of the 31 late Investigation Reports, 23 were filed with DPPC by an external APS investigator, and the remaining 8 by an internal DPPC APS investigator. The delays ranged from 1 to 166 days after the due date, with an average of 46 days late. The following are details regarding our results:¹⁹

• There were 16 instances where the corresponding external protective services agency was understaffed and had a large caseload, according to both case notes and explanations that DPPC’s chief of quality assurance and audit officer provided to us. 
• There was 1 instance that involved reports of alleged sexual assault, which required additional investigation time.
• There were 3 instances where the external protective services agency required multiple report revisions that caused the late submission.
• There were 4 instances that were deemed substantiated abuse cases, requiring additional investigatory steps.
• There were 5 instances where the protective services agency encountered difficulties accessing records involving alleged victims and abusers, such as obtaining private video recordings of abuse incidents.
• There were 5 instances where the APS investigators had difficulty scheduling interviews with the alleged victims and/or abusers. The following is a breakdown of these 5 instances:
  • There were 2 instances where an APS investigator encountered a delay in (1) obtaining victims’ health records from the hospital and (2) scheduling interviews with victims’ doctors.
  • There was 1 instance where an alleged abuser’s attorney refused interview access to their client.
  • There was 1 instance that required interviewing multiple witnesses, but scheduling some of the witness interviews was unsuccessful.
  • There was 1 instance where there was an undocumented scheduling delay.

RI Reports

We inspected 10 RI Reports and found that 1 was not filed with DPPC’s director of investigations by an APS investigator within the required timeframe of 60 business days from the screening date. This RI Report was late by 14 business days. 

Authoritative Guidance

The submission timeframe requirements for abuse investigation reports are detailed in 118 CMR 5.02(4)(a), which states,

• Requirements of Initial Response.

1. . . . The “Initial Response” . . . shall be submitted to the Commission by the investigator within . . . ten calendar days for nonemergency reports of abuse. . . .

• Requirements of Investigation Report.

1. . . . The “Investigation Report” . . . shall be submitted to the Commission by the investigator within 45 calendar days from the date the report of abuse was referred by the Commission for investigation.

The submission timeframe requirement for RI Reports is detailed in 118 CMR 5.03(2), which states,

The Investigation Report of the investigation . . . shall be submitted to the Commission’s Director of Investigations within 60 business days from the date on which the allegation of retaliation was assigned for investigation.

The documentation requirements for abuse Investigation Reports and RI Reports are detailed in Section II(E) of DPPC’s Retaliation Investigations Procedure and Section III(E) of DPPC’s Investigation Assignment, Monitoring and Timeframes Procedure.

Section II(E) of DPPC’s Retaliation Investigations Procedure states, “All steps and actions . . . shall be documented in the Retaliation Investigation Report section of the database.”

Section III(E) of DPPC’s Investigation Assignment, Monitoring and Timeframes Procedure states,

Throughout the submission and approval process . . . the status and location of an IR or 19C Investigation Report will be tracked in the [case management system (CMS)]. The Oversight Officer or designee will send status requests on IR or 19C Investigation Reports that have not met the established timeframes to the Investigator and Investigations Manager who must respond to the request . . . with the . . . reason for delay. . . . The status of each Oversight Officer’s assigned cases will be reviewed weekly and updated as needed in the CMS.

Reasons for Late Reports

IRs and Investigation Reports

DPPC stated that IRs for nonemergency cases and Investigation Reports can be delayed for various reasons, many of which are beyond the control of DPPC or the protective services agency. These reasons include potential difficulties with the following:

• locating and/or interviewing witnesses, alleged victims, and/or alleged abusers;
• accessing critical third-party records from medical examiners or facilities such as hospitals;
• coordinating with law enforcement or other agencies conducting parallel investigations;
• delays in receiving evidence such as DNA and sexual assault results; and
• prioritizing risky cases while balancing high caseloads and investigatory staffing shortages at protective service agencies.

DPPC also stated that its regulations permit adjustments to timelines because, in certain instances, delays are inevitable and even necessary to ensure thorough investigations.

RI Reports

DPPC stated that the one RI Report delay occurred because the alleged retaliation victim did not identify a specific alleged retaliator, which required additional time for an in-depth investigation. This investigation ultimately indicated that the claims were unsubstantiated.

Recommendation

DPPC should continue to work with the Department of Developmental Services, the Department of Mental Health, the Massachusetts Rehabilitation Commission, and its internal APS investigators to meet required timeframes by filing IRs for nonemergency cases within 10 calendar days, Investigation Reports within 45 calendar days, and RI Reports within 60 business days

Auditee’s Response

for submitting initial responses or investigation reports. As observed and documented by the audit team throughout our several sessions during the audit and the audit team’s review of numerous agency Policies & Procedures, DPPC prioritizes immediate safety and risk mitigation through:

• Immediate Safety Measures: Protocols for swift actions upon identifying potential abuse (e.g., removal of alleged abuser, alternative placement, or care). These occur before formal reports are issued.
• Ongoing Risk Assessment and Mitigation: Continuous risk assessment occurs from initial hotline contact throughout issuance of the formal report. Immediate remedial protective service measures are implemented if risks are identified, regardless of report status.
• Interim Actions: DPPC and partner agencies implement interim remedies during ongoing investigations (e.g., changes in supervision or training based on preliminary findings).

The DPPC’s ability to act promptly is not dependent on the submission of documentation associated with the investigation. Our existing protocols prioritize individual safety and wellbeing, ensuring prompt action when necessary. However, the DPPC agrees with the Auditor’s Recommendation to continue to work with existing partners to ensure adherence to timelines to the full extent possible. DPPC is committed to improving efficiency and will take the following steps:

• Enhanced Collaboration: Streamlining information sharing and coordination with [the Department of Developmental Services], [Department of Mental Health], and MassAbility through system enhancements, joint meetings, and improved notifications.
• Internal Process Review: Identifying and addressing bottlenecks in investigation workflows (case assignment, evidence gathering, notifications, report review).
• Resource Allocation Assessment: Ensuring adequate staffing and support for effective caseload management.
• Improved Tracking and Monitoring: Implementing enhanced mechanisms (e.g., updates to our [case management system], progress reports) for proactive delay identification and intervention.
• Reinforced Training and Accountability: Emphasizing adherence to timelines and protocols for all investigators.

Auditor’s Reply

We commend DPPC for taking steps to continue to improve upon its policies and procedures in these areas. 

18.    Some of the 21 IRs in question had more than one instance of delay. Because of this, in total, there were 27 instances of delays.

19.    Some of the 31 Investigation Reports in question had more than one instance of delay. Because of this, in total, there were 34 instances of delays.

Date published:	June 30, 2025