Overview
DPPC did not always identify individuals who had been identified as alleged abusers in three or more reports of suspected abuse and document this information in the corresponding case files. In our testing of the 3,291 cases DPPC completed during our audit period, we found seven individuals who each had three or more reports of suspected abuse, but whose corresponding case files did not reflect this information: DPPC staff members had not documented it in the “Other Pertinent Information” field of the Intake Abuse Form. All seven cases had been referred by DPPC to other state agencies for investigation; however, the only information that DPPC provides to the agencies conducting this type of investigation is a copy of the individual’s Intake Abuse Form. As a result, the agencies conducting investigations of these seven individuals may not have had all the information necessary to conduct thorough and effective investigations.
Authoritative Guidance
Section B(3)(I)(7) of DPPC’s intake policy “Intake-204” describes the criteria for assigning abuse reports for investigations involving alleged abusers with multiple reports:
After two (2) previous complaints have been investigated and a third report is made, the DPPC should conduct the 19C investigation of the third report.
However, it also indicates that DPPC can refer the matter to other agencies for investigation if it does not have the resources to conduct the investigation.
DPPC told us that to comply with this policy, it had informal procedures in place requiring staff members to manually search for alleged abusers by name and determine whether they had prior cases. According to these informal procedures, if any prior history of abuse is found, it should be noted in the “Other Pertinent Information” field of the Intake Abuse Form.
Reasons for Issue
DPPC did not have formal policies and procedures in place that required staff members to identify alleged abusers who were involved with three or more reports of abuse and document this information in the “Other Pertinent Information” field of the Intake Abuse Form. In addition, there were no monitoring controls in place to ensure that DPPC’s informal process was consistently followed.
Recommendation
DPPC should establish formal policies and procedures, and develop monitoring controls, to ensure that all staff members identify alleged abusers who have been involved with three or more reports of abuse and document this information in the “Other Pertinent Information” field of the Intake Abuse Form.
Auditee’s Response
The DPPC would first like to clarify the process. The screening process is typically a multi-layered review with each reviewer responsible for identifying risk, jurisdictional criteria, and checking the database for any relevant history for the alleged abuser or alleged victim. The Intake Unit strives to be cautious in documenting only relevant information on an Intake Form so as not to bias an investigation. This process relies heavily on judgment of the screener, with a safety net being that investigators, oversight officers, and sometimes investigative and oversight supervisors will also review any related cases as part of the investigatory process. Based upon confidentiality considerations and integrity of the investigatory process, DPPC has made a conscious decision to rely upon training and judgment of its screeners. To that end, DPPC appreciates the audit’s recommendation and will assess in what way we might more effectively ensure that this process is deeply embedded in the job function.
To the extent that the audit suggests that the DPPC is not adhering to its own policy of assigning a DPPC investigator to cases where two previous complaints against an alleged abuser have been investigated, the clear caveat in the policy is that this is resource dependent. As explained to the audit teams and simply stated here, inadequate resources were the reason for not assigning such cases to the DPPC. . . .
However, as explained above, the DPPC’s new relational database has enhanced features such as unique People Records which house all data elements and related information about individuals involved in DPPC investigations. This feature will assist screeners and oversight officers in conducting historical review of information. DPPC reserves the right to determine what information to include on an Intake Form to best meet its mission requirements of protecting persons with disabilities from abuse and neglect [through] objective . . . and unbiased investigations.
Finally, [the DPPC executive director] understand[s] and appreciate[s] the value and importance of an external review process regarding State agency operations and will work diligently to continue to enhance the timeliness and efficiency of the DPPC investigation process as we strive to protect persons with disabilities throughout the Commonwealth.
Auditor’s Reply
Our testing of individuals with two previous complaints was based on DPPC’s intake policy “Intake-204,” which states,
After two (2) previous complaints have been investigated and the third report is made, the DPPC should conduct the 19C investigation of the third report.
We are aware that case assignment depends on DPPC’s available resources and noted this in the “Authoritative Guidance” section of the finding. DPPC states that reviewers check its database for any relevant history. However, we determined that alleged abusers’ histories of previous complaints were not mentioned on Intake Abuse Forms. Without documentation substantiating that a search of an alleged abuser’s history was performed, it is unclear whether DPPC personnel were aware of the previous abuse investigations. Therefore, we could not determine whether abuse history was considered when cases were referred to external agencies instead of DPPC’s own Investigation Unit.
When we discussed the matter with DPPC management, they indicated that DPPC did not feel it was important to require its intake staff to note that a history search had been performed. We respectfully disagree, since there is no guarantee that the agency to which DPPC has assigned an investigation will properly identify an alleged abuser’s previous substantiated abuse investigations.
We acknowledge that DPPC is taking measures to address our concerns on this matter.
| Date published: | June 16, 2021 |
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