Overview of the Department of Developmental Services

This section describes the makeup and responsibilities of the Department of Developmental Services.

Overview

The Department of Developmental Services (DDS), established by Section 1 of Chapter 19B of the Massachusetts General Laws, is part of the Executive Office of Health and Human Services. According to DDS’s website,

The Department of Developmental Services provides supports for individuals with intellectual and developmental disabilities including Autism Spectrum Disorder to enhance opportunities to become fully engaged members of their community.

DDS serves approximately 32,000 adults and more than 9,000 children who have intellectual and developmental disabilities. According to its website, DDS provides services and supports for this population that are “designed to promote meaningful participation and inclusion in all aspects of community life.”

During our audit period, DDS provided these services through two state-operated facilities, 287 community-based state-operated programs, and contracts with 229 providers. DDS had 7,977 employees at its 23 area offices throughout the Commonwealth, which operate within four regions,¹ and its providers employed approximately 40,000 individuals to provide services to DDS clients. These providers offer community-based services that include residential supports (group homes), individualized home supports (services provided in clients’ homes), respite supports (respite relief for caretakers), and shared living services (adult foster care). Funding for community-based services totaled approximately $1 billion in each of the two fiscal years in our audit period. Provider-operated community-based residential services, which included group homes, helped more than 10,000 individuals across the Commonwealth as of March 2019. According to data provided by DDS, there were 2,144 residential group homes, maintained by 116 of the 229 providers, during the audit period.

As part of its responsibilities, DDS conducts various types of investigations and reviews of allegations of suspected abuse, mistreatment, and other incidents that may pose a serious risk of harm to its clients. DDS is also responsible for reviewing events self-reported by providers directly to DDS, including unexpected deaths, property damage, and wrong doses of medication being administered. DDS uses the Home and Community Services Information System (HCSIS) to process, review, and monitor allegations of suspected abuse, mistreatment, and other incidents.

HCSIS

HCSIS is a Web-based system that houses all intakes and complaints reported to DDS, including allegations that incidents have occurred, or deficiencies exist, at licensed facilities. HCSIS was implemented in 2006 and is available to DDS and any provider staff members with approved access. DDS’s website states,

The Home and Community Services Information System (HCSIS) is a web based service that allows Service Providers and [DDS] to file clinical information and reports on incidents, medication occurrences, restraints, and investigations.

DDS also uses HCSIS to conduct and manage investigations and administrative reviews resulting from complaints received by the Disabled Persons Protection Commission (DPPC).

Processing of Allegations of Suspected Abuse or Mistreatment

Allegations of suspected abuse or mistreatment are reported to DPPC via its 24-hour hotline. On receiving a complaint, DPPC generates an intake form. Upon review, DPPC refers complaints to the appropriate service-providing agency. In fiscal year 2019, these agencies included DDS, the Department of Mental Health, the Executive Office of Elder Affairs, the Department of Public Health, the Department of Children and Families, the Massachusetts Rehabilitation Commission, the Department of Correction, and other agencies. According to data retrieved from HCSIS, DPPC referred 10,833 complaints to DDS during the audit period.

If DPPC determines that the complaint falls within its authority under Chapter 19C of the General Laws, it may conduct its own investigation or choose to assign the investigation to other service-providing agencies in accordance with the procedures established in Chapter 19C of the General Laws and implemented through Section 5 of Title 118 of the Code of Massachusetts Regulations (CMR). DPPC’s jurisdiction includes allegations of caretakers committing acts against victims between 18 and 59 years old that involved serious physical or emotional injury. If DPPC determines that a complaint is not in its jurisdiction, it can refer the complaint to DDS to be resolved in accordance with 115 CMR 9. DPPC initiated 2,409 investigations during our audit period, 501 of which were associated with DDS clients living at provider-operated group homes.

If DPPC refers a complaint outside its jurisdiction, the complaint is still sent to DDS for the appropriate DDS regional senior investigator to review. The regional senior investigator then chooses the approach to handling the complaint; this approach is referred to as a disposition. It could include dismissal, investigation, referral to a regional director or his/her designee for administrative review, or referral to a DDS complaint resolution team (CRT).

Below are the most frequent DDS dispositions from the audit period.

DDS Dispositions

Dispositions Fiscal Years 2018–2019	Number of Dispositions	Percent of Total*
Administrative Review	3,076	31%
Dismissal	2,854	29%
DDS Investigation	2,409	24%
Referral to CRT	1,672	17%
Total	10,011	100%

*     Because of rounding, the percentages do not total 100%.

 

Investigation Process

Regional senior investigators work from six DDS offices, in Danvers, Middleborough, Springfield, Wrentham, Worcester, and Waltham. At the time of our discussion with DDS Investigations Unit management, DDS employed 25 full-time investigators. DDS receives complaints daily from DPPC. When a complaint is received, staff members at DDS’s central office in Boston assign it to one of six regional senior investigators based on the region where the allegation occurred. Regional senior investigators must make a disposition determination within three business days after they are assigned a complaint, which typically occurs the same day it is received. If the complaint is assigned for active investigation by a DDS regional senior investigator, an investigation report and decision letter have to be issued within 45 business days after an investigator is assigned, according to 115 CMR 9.13(1)(d). A decision letter summarizes the evidence, findings of facts, and conclusions of the official investigation report. Investigators can request an extension to provide more time to complete the investigation if it is necessary and if the delay would not pose a threat to the safety of the alleged victim.

If DDS conducts an investigation under only its own regulations, the investigation report only requires approval by a DDS regional senior investigator before a decision letter can be issued and an action plan can be developed. If DDS conducts an investigation in accordance with both DPPC and DDS regulations, DPPC must approve the investigation report before DDS can issue a decision letter.

Once issued, a decision letter is assigned to a CRT to develop an action plan. DDS regulations (115 CMR 9.12[b]) state,

Each CRT shall consist of the following:

1. Area or facility director or designee;
2. CRT coordinator;
3. A minimum of one citizen member; and
4. Additional members and consultants as deemed appropriate by the area or facility director.

Action plans are created to reduce the chance of the events in the complaint happening again, and CRTs must develop them within 30 business days of assignment. According to DDS regulations, an investigation is considered complete when an action plan is issued.

Administrative Reviews

In an email to us dated January 26, 2021, DDS described an administrative review as “an internal administrative review process designed to address situations that do not present with serious physical or emotional harm.” Administrative reviews are not conducted for any complaints with allegations such as abuse, assault, or financial exploitation.²

After designating a complaint for administrative review, a regional senior investigator refers it to area or regional office personnel. DDS regulations require that an administrative review report be submitted to the appropriate CRT coordinator within 15 business days after a review is conducted. There is no timeframe for completion of the administrative review itself. Once the administrative review report is received in HCSIS, CRTs are alerted and are required to prepare a resolution letter, which states specific action/s to be taken in response to the administrative review report, the date/s for them to be implemented, and the person responsible for implementing them. DDS management told us in interviews that administrative reviews were conducted at area offices, usually by program monitors. Program monitors are responsible for gathering information and processing administrative reviews for area directors. They may also be responsible for following up on resolution letters by requesting documentation from providers when training is required or when disciplinary action has been taken. However, DDS stated that processes could vary by area office.

Incident Reporting and Review Process

For any reportable event, a provider must generate an incident report and submit it to DDS via HCSIS. To provide clarity on what is a reportable event, DDS organizes events into categories: minor- and major-level incidents. For example, a minor-level incident may include an alleged incident where a victim was verbally abused or where property damage occurred. Major-level incidents may include suspicious or sudden deaths or missing persons about whom law enforcement has been contacted. For minor-level incidents, an area office management review is required. Major-level incidents require area office and regional management review. DDS has provided guidance documents and literature about incident reporting for providers and about incident review for DDS staff members.

Four dates are recorded in HCSIS regarding the incident reporting process: (1) when an incident report is created, (2) when it is submitted, (3) when it is finalized, and (4) when it is reviewed by DDS. After these four dates, a report is designated as either complete (if no additional information is needed) or incomplete (if the provider is required to submit additional information).

There were 57,658 incident reports submitted during the audit period; 52,587 were minor-level incidents and 5,071 were major-level incidents. We identified 22,628 major- and minor-level incidents as associated with provider-operated group homes by comparing addresses for such homes that DDS provided to addresses from HCSIS data related to incident reports during the audit period. We identified 20,355 (35%) of the 57,658 incident reports as minor-level incidents and 2,273 (4%) as major-level incidents, while 35,030 (61%) major-level and minor-level incidents were not associated with provider-operated group homes.

Medication Occurrence Report Process

A medication occurrence report (MOR) is submitted by provider personnel through HCSIS when a violation of one of the “five Rs” occurs. The “five Rs” are Right Individual, Right Medication, Right Time, Right Dose, and Right Route.³ An MOR can also be submitted when a staff member forgets to give medication to a client (this is referred to as a medication omission in the table below).⁴ For each MOR, the provider must contact a DDS Medication Administration Program (MAP) consultant. A MAP consultant can be a registered nurse, a pharmacist, or an authorized prescriber such as a physician or nurse practitioner. MAP consultants provide technical assistance, recommend appropriate actions, and provide staff members with guidance on the MOR process if needed. Each MOR is classified as either a hotline MOR or a regular MOR. A hotline MOR indicates that medical intervention was required and/or that an illness, injury, or death was involved. A regular MOR indicates that the MOR event did not require medical intervention. HCSIS documents key milestones regarding the MOR process, including creation, finalization, review by a MAP coordinator, and approval or rejection. Providers must finalize hotline MORs within 24 hours of discovering MOR events and regular MORs within 14 calendar days. MAP coordinators must review both regular and hotline MORs within 14 calendar days after providers finalize them. DDS reported that there were four MAP coordinators for each region and one statewide MAP coordinator specifically for MORs involving clients with preexisting brain injuries. There were 12,007 total MORs submitted during the audit period, of which 11,822 were regular MORs and 185 were hotline MORs. The table below indicates the natures of all MORs for our audit period.

MOR Submissions by All Providers

Nature of MOR	Total Submitted During Fiscal Years 2018–2019	Percent of Total*
Medication Omission	7,223	60%
Wrong Dose	2,622	22%
Wrong Time	1,455	12%
Wrong Medication	474	4%
Wrong Individual	226	2%
Wrong Route	7	<1%
Total	12,007	100%

*   Because of rounding, the percentages do not total 100%.

 

For provider-operated group homes, there were 8,407 regular MORs and 136 hotline MORs submitted during the audit period.

Mandatory Training Requirements

Like DDS personnel, provider staff members must meet certain training requirements. As of December 12, 2018, providers were required to complete the following mandatory training.

Training Type	For All Employees	For Some Employees
First Aid and Cardiopulmonary Resuscitation Certification	X
Basic Human Rights	X
DDS Mandated-Reporter Training	X
MAP Training (for All Administering Medications)	X
Signs and Symptoms of Illness	X
Executive Order 509 Food Standards*	X
Unique Support Needs (e.g., to Help with Cultural and Linguistic Barriers)	X
Individualized Plans and Protocols	X
Positive Behavior Supports	X
Human Service Worker Safety	X
Fire Safety		X
Restraint Training		X
Human Resources Advocates/Officers Class		X

*     Executive Order 509 states that food purchased and served by state agencies such as DDS must meet certain nutritional standards set by the Department of Public Health.

 

To track the training of more than 40,000 provider employees during its licensing and certification reviews, DDS’s Licensure and Certification Unit reviews provider systems. Providers receive two-year licenses, receive two-year licenses with mid-cycle review, or have their license applications put on hold depending on scores received during licensing and certification reviews. During this process, DDS randomly selects 10% of provider-operated group home employees and reviews their training documentation. For example, if there were 100 provider employees, DDS would examine training records for 10 employees. Provider licensing reports are publicly available on DDS’s website.

1.     DDS designates these as the Central West Region, Metro Region, Northeast Region, and Southeast Region.

2.     DDS regulations (115 CMR 9.02) define financial exploitation as “the illegal or improper use of an individual’s financial resources in an amount over $250 for personal profit or gain.”

3.     Right Route is the mechanism for administering the medication (e.g., orally or by injection).

4.     A violation of one of the “five Rs,” or a medication omission, is referred to herein as an MOR event.

 

Date published:	June 29, 2021