OIG Annual Report 2021: Bureau of Program Integrity

Part VI of the Office of the Inspector General's 2021 Annual Report

The Legislature created the Bureau of Program Integrity (Bureau) in 2013 as a division of the Office embedded within the Executive Office of Health and Human Services (EOHHS) to conduct oversight of its agencies and programs. The Bureau’s enabling statute, Section 16V of Chapter 6A of the Massachusetts General Laws, requires that the Bureau monitor the quality, efficiency and integrity of programs administered by EOHHS agencies and that it prevent, detect and correct fraud, waste and abuse. 

To accomplish its work, the Bureau conducts reviews and investigations, makes recommendations and assists with implementing those recommendations. The Bureau works collaboratively with EOHHS agencies and maintains oversight as they carry out necessary changes. 

At the outset in 2013, the Bureau focused its work primarily on the Department of Transitional Assistance (DTA). Throughout the past nine years, the Bureau has continued to work with DTA while engaging with other EOHHS agencies. Since its creation, the Bureau has issued three public reports, 24 advisory letters to EOHHS agencies and three letters to the Legislature. In addition, it has responded to 124 hotline complaints regarding EOHHS agencies and programs. Many of these hotline complaints led to reviews and investigations; two led to successful prosecutions. Finally, the Bureau has conducted trainings on internal controls, fraud prevention and contract administration at EOHHS agencies and has provided ongoing technical assistance to EOHHS agencies in the areas of fraud detection, business risk assessment and data analytics.

In 2021, the Bureau engaged with EOHHS, DTA, the Department of Developmental Services (DDS) and the Department of Children and Families (DCF) to monitor the quality, integrity and efficiency of their programs. In addition, the Bureau engaged with the Department of Veterans’ Services (DVS) and the Department of Public Health (DPH) to address several complaints related to the Holyoke Soldiers’ Home and the Chelsea Soldiers’ Home (Soldiers’ Homes).

The Bureau also collaborated with other divisions within the Office, including the Policy and Government Division (Policy Division) and Audit, Oversight and Investigations Division (Investigations Division). In 2021, the Investigations Division and the Bureau collaborated on 42 complaints relating to EOHHS and its agencies. This is the largest number of complaints that the Bureau has received since its inception in 2013; many of the complaints involved issues related to COVID-19. Of these 42 complaints, 15 of them led to an investigation or review, while 27 led to outside referrals. 

I. The Executive Office of Health and Human Services

In 2021, the Bureau continued its work to monitor how EOHHS administered COVID-19 pandemic relief funds (pandemic relief funds). The Bureau focused on the $139 million that EOHHS disbursed in April 2020 to vendors that administer congregate care programs, including group homes for DDS, the Department of Mental Health (DMH) and DCF. The Bureau reviewed whether these vendors spent the pandemic relief funds, as required, on staffing, PPE and infection control activities.  

The Bureau received several hotline complaints about EOHHS vendors’ use of the pandemic relief funds. Some complainants alleged that the vendors received excessive funding and misspent it on executive compensation. In response to these complaints, the Bureau initiated investigations and reviewed the expenditure reports that vendors submitted to EOHHS. In these reports, the Bureau found evidence that some vendors may have used the funds for unauthorized expenditures. In addition, other vendors used the funds after June 2020, which was the deadline that EOHHS had set. 

The Bureau identified several ways that EOHHS could have more effectively tracked vendors’ spending and recordkeeping. In 2020, for example, the Bureau had recommended that EOHHS require vendors to provide detailed expenditure reports so that EOHHS could identify inappropriate spending more easily. In addition, the Bureau recommended that EOHHS coordinate and share information with DDS, DCF and DMH so that these agencies could assist with reviewing expenditure reports. EOHHS did not fully implement these recommendations. Moreover, EOHHS did not coordinate with the Operational Services Division (OSD) to provide clear guidance on how vendors should have reported these expenditures on the Uniform Financial Report (UFR), a yearly report that vendors must submit to OSD.⁸

Many of the Bureau’s concerns with the spending, tracking and coordination of pandemic relief funds directly overlap with areas of risk that may arise as EOHHS administers American Rescue Plan Act (ARPA) funds.⁹ The Bureau has recommended that EOHHS closely monitor the use of ARPA funds and coordinate its efforts with other agencies, including DDS, DMH and DCF, as well as OSD and the Federal Funds Office (FFO).¹⁰ Consistent with federal guidance regarding ARPA oversight, the Bureau has also recommended that EOHHS conduct program evaluation through qualitative and quantitative analysis and that it use metrics to track outcomes.

II. Soldiers’ Homes

In 2021, the Bureau collaborated with the Investigations Division to produce the Office’s report, Holyoke Soldiers’ Home, May 2016 to February 2020. The Office issued this report on April 29, 2022. The Office focused on leadership, management and oversight at the Holyoke Soldiers’ Home during the period May 2016 to February 2020. The report identified critical shortcomings in the management of the Holyoke Soldiers’ Home as well as concerns regarding the supervision of former Superintendent Bennett Walsh. The report also outlines a comprehensive blueprint for lasting improvements. 

In addition, throughout 2021, the Bureau addressed numerous hotline complaints regarding the Holyoke Soldiers’ Home and the Chelsea Soldiers’ Home. The complaints involved clinical issues, such as infection control, as well as allegations of poor management practices. The Bureau prioritized concerns about health, safety and infection control and provided DPH with timely information to address these issues while protecting the confidentiality of complainants. Under the statutory scheme that was in effect during 2021, there was no statutory mandate for DPH to provide clinical oversight to the Soldiers’ Homes but agreed to the Office’s request to do so on a voluntary basis. 

The Bureau also collaborated with the Investigations Division and the Policy Division to comment on proposed legislation regarding reforms to the structure, governance and oversight of the Soldiers’ Homes.¹¹ The Office recommended critical changes to their clinical oversight, governance structure and management practices. In addition, to create channels for communication, the Office recommended the creation of an ombudsperson and hotline to receive and address complaints about the Soldiers’ Homes. Additionally, the Office recommended that the Legislature provide a new mandate and appropriate funding for DPH to provide ongoing clinical oversight and support for the Soldiers’ Homes. Thus far, in drafting proposed legislation, the Legislature has adopted many of the Office’s recommendations.¹²

III. Department of Developmental Services

A. State-Operated Group Homes

In 2021, the Bureau and DDS continued to investigate complaints about overtime abuse in state-operated group homes. In response to the Bureau’s recommendations, DDS implemented new processes and procedures to monitor group home managers’ overtime, including mining payroll data, reviewing data reports, tracking overtime trends and monitoring reporting of overtime. DDS’s internal Bureau of Program Integrity led DDS’s efforts in this area as part of its overall work to build internal controls within the agency.

The Bureau also continued to work with DDS on mitigating fraud risks and fiscal vulnerabilities related to high compensatory time balances. The Bureau recommended that DDS correct inaccurate compensatory leave balances and establish consistent practices to pay employees for their compensatory time. In response to the Bureau’s recommendations, DDS began a manual review of high compensatory time balances and outlined plans to conduct a quarterly manual review of balances. In addition, DDS is in the process of correcting inaccurate compensatory leave balances. 

Overall, the Bureau found that DDS improved its internal controls for state-operated group homes by implementing recommendations the Bureau made in 2020 and 2021. For DDS to continue on this track, the Bureau recommended that DDS should:

• Maintain and support its new payroll-monitoring activities to prevent and address overtime abuse. 
• Regularly monitor and implement controls to mitigate the agency’s liability for compensatory time. 
• Monitor the quality of data entry in the payroll system.
• Continue to expand its data analytics capacity to assess and help manage DDS’s business risks.

B. Vendor-Operated Group Homes

In 2021, the Bureau continued to work collaboratively with DDS to strengthen its oversight of vendor-operated group homes by building its data analytics capacity, improving coordination among units within DDS and pursuing external partnerships. Responding to the Bureau’s recommendations, DDS took significant steps to strengthen its vendor management and contract administration.

In 2020, the Bureau recommended several ways for DDS to integrate data into its decision-making processes. In 2021, DDS started developing its own data warehouse, enabling DDS to combine data from a variety of sources for analysis and data-driven decision-making. The Bureau also helped DDS identify additional sources of data for monitoring the quality of services that vendors provide. For example, the Bureau recommended that DDS obtain from EOHHS the expenditure reports for pandemic relief funds for DDS vendors, and DDS implemented this recommendation.

The Bureau also continued to recommend and help implement best practices for contract administration. For example, the Bureau encouraged DDS to break down internal silos and promote an integrated approach to problem-solving. While responding to multiple hotline complaints about vendors’ spending of pandemic relief funds, the Bureau invited DDS to collaborate on several reviews and investigations so that DDS could leverage agency-wide resources and practice holistic review. 

To further support contract administration, the Bureau facilitated collaboration between DDS and the Office of the State Auditor (OSA). In 2021, the Bureau assisted DDS with supporting the OSA’s audit process for the Center for Human Development. In addition, the Bureau worked with DDS to follow up on the OSA’s audit findings and outline potential corrective action for another vendor, Berkshire County Arc.

Finally, the Bureau facilitated partnerships with other agencies. For example, the Bureau hosted and facilitated meetings with DDS and OSD in order to build a mutual understanding of each agency’s role in monitoring the revenue and expenses reported by vendors. In particular, DDS and OSD shared information about how to utilize the UFRs submitted annually by provider agencies as a resource for vendor monitoring. The Bureau also continued working with DDS to further develop its relationships with the Disabled Persons Protection Commission and the Attorney General’s Office. 

For DDS to continue to improve contract administration and vendor management, the Bureau recommended that DDS:

• Explore and implement additional ways to correlate data to evaluate and manage vendor services. 
• Document procedures to develop a new infrastructure across multiple divisions within the agency to support contract administration.
• Expand external partnerships for reviewing potential vendor mismanagement and misconduct. 
• Coordinate with other EOHHS agencies, particularly DMH, to manage vendors that provide services to multiple agencies.
• Actively oversee vendors’ expenditure of state and federal pandemic relief funds to prevent fraud, waste and abuse.

IV. Department of Transitional Assistance

In 2021, the Bureau continued to work with DTA on prioritizing program integrity within the agency and improving the quality of DTA’s data. Fulfilling its statutory mandate to consult with DTA’s Program Integrity Division, the Bureau met regularly with members of that division to work collaboratively on projects. The Bureau’s statutory mandate also specifically requires the Bureau to coordinate datasharing between DTA and other agencies; as a result, the Bureau assisted DTA with data-matching with the Department of Unemployment Assistance (DUA). At quarterly meetings with DTA’s senior management, the Bureau presented recommendations aimed at enhancing DTA’s program integrity and data-matching. 

A. Program Integrity

In 2021, the Bureau consulted extensively with DTA on program integrity issues related to the Supplemental Nutrition Assistance Program (SNAP), including trafficking of SNAP benefits, out-of-state benefit spending and fraudulent benefit applications. The Bureau also coordinated meetings with external agencies regarding cybersecurity, identity fraud, ATM skimming and potential criminal referrals. 

Previously, in 2015, the Bureau evaluated DTA’s processes for identifying and investigating suspected SNAP trafficking cases and made recommendations about documenting procedures and using data to identify suspected trafficking. SNAP trafficking is a program violation in which a recipient allows a retailer to redeem their SNAP benefits in exchange for cash. In 2021, in response to concerns about an uptick in SNAP trafficking, the Bureau revisited this work. The Bureau consulted with DTA on ways to use SNAP transaction data to identify recipients and retailers that may present a high risk for SNAP trafficking. 

The Bureau also reviewed transaction data regarding recipients’ out-of-state benefits spending. The Bureau determined that certain transaction patterns could indicate fraud, depending on which type of benefits were involved, and consulted with DTA on how to use transaction data to identify individuals who may be misusing their benefits. The Bureau worked collaboratively with DTA to develop models for monitoring out-of-state purchases. 

In 2021, DTA experienced an uptick in fraud schemes related to online benefits applications. The Bureau and investigators from DTA’s Program Integrity Division worked collaboratively to identify red flags indicating that an online application was likely fraudulent. Based on this work, DTA developed and implemented strategies for monitoring online applications and detecting fraud. 

A commitment to program integrity is essential for maintaining the public’s confidence in the important programs that DTA administers. The Bureau has consistently recommended that DTA prioritize and continue to develop program integrity. To do this, the Bureau recommended that DTA commit to the following steps to support program integrity: 

• Communicate that program integrity is a priority for the agency.
• Document its standard operating procedures for identifying and investigating SNAP trafficking and misuse of SNAP benefits.
• Use data analytics to monitor out-of-state benefits spending and identify high-risk recipients.
• Train case managers on current best practices for the early detection of potential eligibility fraud. 

B. Review of EAEDC Applications

In 2021, the Bureau evaluated the quality, integrity and efficiency of the intake and eligibility determination process for applicants to the Emergency Aid for Elderly, Disabled and Children (EAEDC) program. The EAEDC program provides cash benefits to certain categories of low-income recipients, including those who are over 65 or who have a disability. The Bureau focused on adults who applied for EAEDC benefits during the pandemic between January 2021 and July 2021. More specifically, the Bureau reviewed applicants’ case records to ensure that the applicants complied with program rules and provided mandatory documentation to DTA case managers before they received benefits. The Bureau found that in November 2020, DTA amended program rules in response to the pandemic and allowed applicants to “self-declare” their proof of disability, along with proof of other eligibility criteria, such as identity and Massachusetts residency. In other words, applicants only had to tell their case managers that they met eligibility criteria, and case managers did not verify this information with external sources. Further, the Bureau found that DTA kept the flexible program rules in place and accepted self-declarations long past the time when access to medical professionals to certify a disability was hampered by the COVID-19 pandemic; they remained in place when the Bureau conducted its review in August 2021. 

The Bureau determined that by accepting self-declarations, DTA made itself vulnerable to eligibility fraud and failed to correct the issue in a timely manner. The Bureau recommended that DTA stop accepting self-declarations of disability and limit its flexibility regarding other eligibility criteria to extraordinary circumstances. The Bureau also recommended that DTA train case managers to document their eligibility reviews in a detailed manner. In response to the Bureau’s recommendations, DTA indicated that it would update its policies and procedures for EAEDC eligibility determinations. 

C. Data Matching with the Department of Unemployment Assistance

In 2021, the Bureau continued its work with DTA to improve data matching with other state agencies and focused specifically on DTA’s data matching with DUA. The purpose of DTA’s data matching with DUA is to identify whether any DTA benefit recipients also receive unemployment insurance benefits. In September 2021, DTA and DUA conducted a data match to identify recipients who received both DTA benefits and Pandemic Unemployment Assistance (PUA) benefits between March 2020 through August 2021. DTA recipients who failed to report their PUA benefits as a source of income present a risk of fraud or program violations. The Bureau assisted DTA with analyzing the results of this data match and found a substantial population of recipients who failed to report their PUA benefits to DTA. The Bureau worked with DTA to develop methodologies for identifying those recipients who intentionally withheld information about their PUA benefits from DTA and may have committed program violations. 

Following up on this collaborative work, the Bureau presented recommendations to DTA’s senior management team and sent an advisory letter to the DTA commissioner. The Bureau recommended that DTA consult with DUA to develop a clear understanding of DUA data. In addition, the Bureau recommended that DTA continue to use DUA data to identify recipients who may have committed program violations. Finally, the Bureau recommended that DTA prioritize and expedite the investigations of recipients who present a high risk of fraud, and the Bureau assisted with identifying those recipients. 

The Bureau also recommended ways for DTA to implement long-term plans to incorporate DUA data into its eligibility database. The Bureau cautioned that DTA should maintain the integrity of the DUA data while incorporating it into the eligibility database and conduct extensive testing and validation before automating processes that rely on it. 

DTA responded positively to these recommendations. To mitigate fraud risks while DTA incorporates DUA data into its database, DTA agreed to instruct case managers to take additional steps to verify whether a DTA applicant or recipient is also receiving DUA benefits.

D. Quality Management of Data

In 2020, the Bureau identified the poor quality of data in DTA’s eligibility database as a longstanding vulnerability and recommended that DTA prioritize improving it. The Bureau also recommended sustainable quality management practices and procedures. The Bureau provided the following recommendations in an advisory letter to the DTA commissioner:

• Set an appropriate “tone at the top” about the importance of maintaining high-quality data. 
• Leverage supervisors for quality control at the point of data entry.
• Develop performance management and training strategies to improve data quality.
• Conduct regular data scans.
• Implement regular data monitoring processes.
• Continuously evaluate and improve data collection fields and processes. 

Throughout 2021, the Bureau followed up with DTA on its response to these recommendations. However, DTA reported that it was not able to prioritize this work due to limited information technology resources and other demands related to the pandemic. The Bureau continued to emphasize to DTA that poor data quality creates fraud vulnerabilities and undercuts DTA’s ability to implement, evaluate and improve benefit programs. 

V. Department of Children and Families

In 2021, the Bureau continued working with DCF to improve the administration of the agency’s contract with the Judge Baker Children’s Center (JBCC) to run DCF’s after-hours hotline. The after-hours hotline is an emergency response system which operates between the hours of 5:00 p.m. and 9:00 a.m. It receives calls of possible child-at-risk situations, including child abuse or neglect, and provides support services to families caring for children who are under DCF custody or care. DCF redesigned its after-hours hotline services in 2019 and selected JBCC, which has held the contract to run the hotline since 1982, to remain as the service provider under a new 10-year, $45 million contract. The Bureau monitored the initial stages of implementation of this contract, recommending ways in which DCF and JBCC could work together to support continuous quality improvement (CQI) of after-hours services. In early 2021, the Bureau established a partnership with the Office of the Child Advocate (OCA); the OCA has contributed valuable leadership and clinical expertise to this oversight work. 

The Bureau and OCA met with DCF and JBCC on a quarterly basis in 2021 for status updates and to discuss recommendations. DCF and JBCC took the initiative to develop and test CQI tools and implemented many of the recommendations that the Bureau and OCA presented. Despite the challenges of the pandemic, DCF and JBCC implemented regular, collaborative processes for reviewing JBCC’s performance and improving after-hours services. 

Additional Resources

OIG 2021 Annual Report

⁸ The Uniform Financial Report is a reporting mechanism established by the Operational Services Division whereby a human or social service organization that delivers services to the Commonwealth is required to report its annual financial statement, including a general breakdown by program of the organization’s revenue and expenses. 

⁹ The American Rescue Plan Act, Pub. L. 117-2, passed by the federal government in March 2021, is an economic stimulus bill intended to respond to the public health and economic impacts caused by the COVID-19 pandemic. Massachusetts public entities are administering $25 billion of American Rescue Plan Act funds.

¹⁰ As part of the Executive Office for Administration and Finance, the Federal Funds Office manages and monitors the distribution of federal funding in response to the COVID-19 public health emergency.

¹¹ The Office sent three legislative letters on Soldiers’ Homes, including: January 12, 2022 – Letter to the Joint Committee on Health Care Financing on House 4298, An Act Relative to the Governance, Structure and Care of Veterans at the Commonwealth’s Veterans’ Homes; February 17, 2022 – Letter to the Senate Committee on Ways and Means on House 4441, An Act Relative to the Governance, Structure and Care of Veterans at the Commonwealth’s Veterans’ Homes; and March 25, 2022 – Letter to the Conference Committee on Senate 2761 and House 4441, An Act Relative to the Governance, Structure and Care of Veterans at the Commonwealth’s Veterans’ Homes.

¹² As of publication of this report, there are two bills pending in the Conference Committee, including: Senate 2761, An Act Relative to the Governance, Structure and Care of Veterans at the Commonwealth’s Veterans’ Homes; and House 4441, An Act Relative to the Governance, Structure and Care of Veterans at the Commonwealth’s Veterans’ Homes.

Date published:	April 29, 2022