Overview
Our prior audit revealed that, contrary to state regulations, DPPC did not always complete Initial Responses (IRs) and 19C reports within established timeframes. Also, for investigations where IRs and/or 19C reports did not meet deadlines, the investigators did not document explanations for the unmet deadlines in the case files.
During our current audit, we found that 38 (63%) of the 60 IRs we randomly selected for review, out of a population of 2,925 cases completed and not referred to law enforcement during the audit period, were completed after the 10 days allowed by regulation. On average, DPPC completed these 60 IRs in 19 days. When IRs are not completed within required timeframes, DPPC cannot ensure prompt implementation of remedial action plans to address potential abuse.
Also, DPPC did not consistently complete 19C reports within required timeframes. Specifically, 51 (85%) of the 60 19C reports for cases we statistically sampled for testing, out of a population of 2,925 cases completed and not referred to law enforcement during the audit period, were not completed within required timeframes. Based on the results of our testing, we project—with a 95% confidence level—that at least 2,152 of the 2,925 completed 19C reports were not completed within the 30 days allowed by regulation. On average, DPPC completed the 60 19C reports in 70 days.
Finally, 1,874 (56%) of the total 3,291 abuse investigations that were completed after their deadlines, and were not referred to law enforcement, during the audit period, did not have documented explanations for the unmet deadlines in the case files. Delays can put victims at risk of further abuse; in fact, we identified six individuals whose abuse investigations (10 investigations in total) were completed after their due dates and who experienced further substantiated abuse during their ongoing abuse investigations.
Authoritative Guidance
The requirements for abuse investigation reports are detailed in 118 CMR 5.02(3)(a):
The . . . “Initial Response” . . . shall be submitted to the Commission by the investigator . . . within ten calendar days for non-emergency reports of abuse. . . .
The . . . “Investigation Report” . . . shall be submitted to the Commission by the investigator within 30 calendar days from the date the report of abuse was referred by the Commission for investigation.
DPPC’s investigation policy “Invest-109” states that if an investigation cannot be completed within the 30 days allowed by regulation,
The investigator must complete and submit a DPPC Investigation Extension Request Form . . . to the DPPC oversight manager. . . . This form must provide information that establishes good cause for the need of an extension.
Reasons for Noncompliance
DPPC had not implemented effective monitoring controls to ensure that investigators completed IRs and 19C reports within the required timeframes or that, when required filing deadlines were not met, evidence of the reasons for the delay was documented, verified, and retained in case files.
DPPC also stated that approximately 94% of abuse investigations were conducted by the Department of Developmental Services (DDS), the Department of Mental Health (DMH), or the Massachusetts Rehabilitation Commission (MRC). DPPC officials told us that DPPC worked closely with these agencies to resolve investigations and develop protective service plans (PSPs). However, they stated that the necessity of coordinating and recording information from more than one agency, along with DPPC’s limited resources, continued to cause delays in meeting deadlines. They also stated that the complexity and number of investigations had increased during the audit period.
Recommendations
- DPPC should enhance its policies and procedures by implementing effective monitoring controls to ensure that investigators complete IRs and 19C reports within the required timeframes and that when filing deadlines are not met, evidence of the reasons for the delay is documented, verified, and retained in case files.
- DPPC should continue to work with DDS, DMH, and MRC to complete IRs for emergency cases within 24 hours, IRs for non-emergency cases within 10 days, and 19C reports within 30 days.
Auditee’s Response
DPPC accepts that it does not always complete its investigations within the required timeframes but disagrees with the finding that DPPC does not document the reason for doing so. As stated in the response to the previous audit, DPPC must first emphasize that tardiness of an Initial Response (“IR”) or Investigation Report (“19C Report”) does not correlate to continued risk to an alleged victim. The assessment of risk to the victim is the DPPC’s highest priority. It is a process which begins at the intake of a report, continues through investigation, and does not conclude until completion of post-investigation protective services monitoring by our oversight officers. The DPPC also places the highest priority on emergency situations, and under no circumstances does the DPPC tolerate delays in risk assessments in situations deemed emergencies.
Staffing and resources within the DPPC and Executive Office of Health and Human Services referral agencies have long been contributing factors in DPPC’s ability to timely complete investigations, as have the complexities of investigations and the need to prioritize high risk investigations. In our effort to secure critically needed funds to support DPPC’s continuously increasing caseload, DPPC has doggedly and finally successfully promoted its mission to the Legislature and the Administration resulting in a long needed increase in appropriation in the last budgetary session. However, with this increase in appropriation came a massive undertaking of designing and implementing an Abuser Registry. To that end, DPPC has filed bills to amend the DPPC’s statute as well as noticed for comment proposed amendments to its regulations, which include a proposed regulatory amendment to extend the investigation timeline from 30 to 45 days—a still aggressive but more realistic goal. Also, DPPC will continue to work with its own investigations unit as well the investigations units at the Department of Developmental Services (DDS), Department of Mental Health (DMH) and the Massachusetts Rehabilitation Commission (MRC), to ensure that investigations are completed as timely as possible.
To more specifically address Finding Two, following recommendations in the previous audit, DPPC created a new Extension Request process whereby documentation of the reason for an extension of a timeframe for an IR or 19C Report was required to be provided by the investigator. Although this process proved ineffective due to the difficulty of relying upon referral agencies to adhere to a new administrative process, DPPC’s Quality Assurance Unit categorized and documented the reason for delays based upon available information. As previously mentioned and in conjunction with the design of a new database, DPPC created web-based investigations forms and coordinated with its three partner agencies to work on the same report form in the web portal. These forms are automatically directed to DPPC when submitted by the investigations manager and as a result the entire process has been digitized and streamlined. There is a built-in workflow where oversight officers can communicate directly with the investigators and supervisors.
With its database enhancements, DPPC has increased monitoring of timeframes by focusing on systemic issues, including ad hoc outreach and notices to all four investigative agencies, following identification of patterns of overdue IRs or 19C Reports; and assessed and continued with the process of oversight officers routinely documenting the reason for investigation delays in the DPPC’s database. Additionally, DPPC updated its Investigations Timeframes policy, Invest-109, in July 2020, and instituted a periodic case status request process. Throughout the investigative process, the status and location of an investigation report is tracked in DPPC’s database in a portal designed specifically for this process where it is monitored by oversight officers.
Most troublesome with regard to the finding related to timeframes is the audit’s assertion that through a preliminary review, nine victims were identified as believed by the auditor to have experienced additional abuse during an ongoing investigation. First, as we understand the government standards of an audit review process pursuant to M.G.L. c. 11, sec 12, findings are not based upon preliminary reviews but rather upon an analysis of specific data. DPPC met with the audit team on November 4, 2020 and discussed what we believe to be the nine cases to which the audit report refers. DPPC staff reviewed with the audit team each case and determined that although these alleged victims were involved in simultaneous investigations, in each instance the specific risk issues were immediately identified and addressed throughout the entire DPPC process. The statement in the audit report that nine victims were believed by the auditor to have experienced additional abuse during an ongoing investigation is misleading as it suggests fault on the part of the DPPC which is absolutely incorrect. The Commission is also charged with ensuring that protective services are provided to persons with a disability in the least restrictive and most appropriate manner possible, balancing protection with freedom. Unfortunately, persons with disabilities are extremely vulnerable to abuse from a variety of sources for a variety of different reasons. Some may experience a separate incident of abuse, despite the fact that protective services related to an ongoing investigation were in place—that was the situation in each of these nine cases as discussed during the November 4, 2020 meeting.
Auditor’s Reply
DPPC contends that it documents the reasons for delays in 19C investigations. However, our testing determined that this was not the always the case. According to DPPC’s investigation policy “Invest-109,” the investigator must submit an Investigation Extension Request Form when an investigation cannot be completed within 30 days. This form must establish good cause for the need of an extension. As stated previously, approximately half the cases completed during the audit period were submitted late and did not have Investigation Extension Request Forms. Although DPPC did state that it would no longer use this form, our testing involved assessing compliance with the requirements that were in place during our audit period, and we found significant issues in this area.
We do not dispute DPPC’s assertion that “DPPC also places the highest priority on emergency situations, and under no circumstances does the DPPC tolerate delays in risk assessments in situations deemed emergencies.” However, during our audit, we asked DPPC officials to show us examples of cases it deemed emergencies so that we could assess the timeliness of its IRs and the included risk assessments. According to the data extract DPPC provided to us, of the 3,291 cases completed during the audit period, there was only 1 with an “Urgency” designation of “Emergency,” and its IR and 19C report were completed after their due dates.
Regarding the victims of additional abuse, our comment that delays in processing of abuse investigations could put victims at risk of further abuse is accurate and is not disputed by DPPC. As previously noted, some individuals did experience additional abuse while previous investigations were ongoing and overdue.
Based on its response, DPPC is taking measures to address our concerns on this matter.
| Date published: | June 16, 2021 |
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