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EOEA Did Not Always Properly Document the Processing of Abuse Reports in APS.

Audit encourages the agency to improve its processes for documenting decisions related to the initiation of an investigation.

Table of Contents


During our audit, we identified a number of issues with the way EOEA documented the processing of abuse reports in APS. These included the following:

  • When analyzing the data in APS, we identified 669 abuse reports that EOEA had determined required investigation but that were not linked to any corresponding investigation information in APS. According to EOEA officials, the investigation information regarding these 669 reports was expunged from APS because EOEA staff members found the allegations to be unsubstantiated. Although EOEA can retain investigation information that it deems unsubstantiated for three years, it destroyed these investigation records within a year and a day after their corresponding reports were originally filed. Without the case records, there is inadequate assurance that all of these cases were properly investigated and the most appropriate decisions were made by PSAs (see Other Matters).
  • During our audit period, according to APS, 30 EOEA employees screened reports of alleged abuse of elderly people even though the employees were not authorized to conduct these screenings and make related decisions because they were not at or above supervisor or screener level. OSA determined through a record review that these screenings were actually conducted by 30 employees who were authorized to screen reports but, according to EOEA officials, “erroneously selected” different screener names from a dropdown list in APS. Because APS is EOEA’s system of record for documenting reports of alleged abuse of elderly people, it is essential that all information in this system be accurate in order for EOEA management to effectively manage this process.
  • PSA supervisors who made screening decisions did not document in APS their decisions and rationales for screening reports in or out. When a screening decision is made, there is no separate individual who reviews the screening decision or screening notes. The screening of reports is a vital decision, as it determines whether an elderly person who has allegedly been abused will have the allegations investigated by a PSA. Without having these decisions documented in APS, reviewers cannot determine whether the appropriate assessments were made, and there is a risk that the alleged abuse, which may be serious and threatening, will not be addressed by PSAs.

Authoritative Guidance

According to 651 CMR 5.18(2)(a), case record documentation should include, but is not limited to, “intake information regarding reports and collateral contacts in accordance with 651 CMR 5.08 and 5.09.”

Per our discussion with EOEA management, if an abuse report is screened in for investigation, the caseworker assigned to the investigation must link the investigation to the report in APS.

According to 651 CMR 5.09,

Upon receipt of an oral or written report (whichever is received first), a Protective Services Agency shall ensure that all reports are evaluated immediately by a Protective Services Supervisor or designated backup supervisor, in order to determine the immediacy and severity of the alleged harm or risk, and the appropriate initial response.

According to 651 CMR 5.09(2), when making screening decisions, the PSA supervisor determines “whether there is a Reportable Condition and the level of response needed, in accord with 651 CMR 5.09(1)(a) and (b).”

According to 651 CMR 5.18(1)(a)(7), PSA caseworkers shall “make casework decisions with supervisory consultation.”

The current version of 651 CMR 5.18(2)(d) states,12

(d)  Progress notes shall be added to the case file immediately following the decision to screen in the report and shall include, but not be limited to . . .

4.   Documentation of facts to support casework decisions including options weighed, supervisory input, and rationales for decisions made.

Reasons for Noncompliance

EOEA did not have monitoring controls over the abuse-reporting process. Specifically, screening PSA supervisors’ decisions about abuse reports were not reviewed or overseen by PSA managers or other PSA supervisors.

Additionally, the Protective Services Program director at EOEA told us that caseworkers and supervisors often forgot to manually link investigations that were created in APS to their associated abuse reports.


  1. EOEA should implement policies and procedures that include better documentation practices in APS. The policies should also communicate clear personnel responsibilities in APS for each investigation and should include the necessary steps for manually linking abuse reports to corresponding investigations.
  2. PSA supervisors should document their screening decision rationales in APS and assign a PSA case manager or second PSA supervisor to review each decision before the initiation of an investigation if it is screened in, or an expungement if it is screened out, by the supervisor.

Auditee’s Response

Recommendation 1

EOEA issued guidance on the proper protocol for linking intakes to investigations on July 20, 2018, and is implementing an ongoing [quality assurance] process throughout the protective services system by June 30, 2019. With respect to documentation practices in APS, EOEA is implementing several new electronic forms beginning in Spring 2019 that will promote easier tracking within the APS system.

Recommendation 2

PSA supervisors should document screening decisions in APS; EOEA’s existing policy requires that the rationale for the screening decision is documented. EOEA will address this issue within the larger training sessions that are referenced in Finding 1, Recommendation 1 of this report. With respect to assigning a PSA case manager or second PSA supervisor to review each decision or a supervisor for expungement of screened-out cases, EOEA will review supervisory processes and make adjustments where feasible, including improvements to documenting the processes.

Auditor’s Reply

Based on its response, EOEA is taking measures to address our concerns in this area.

12.    The previous version stated, “Progress notes shall begin immediately following the decision to screen in a report.”

Date published: October 9, 2018

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