Overview of the Department of Public Health

This section describes the makeup and responsibilities of the Department of Public Health.

Table of Contents


The Department of Public Health (DPH), established by Section 1 of Chapter 17 of the Massachusetts General Laws, is a regulatory agency under the Executive Office of Health and Human Services. According to its website,

DPH regulates, licenses and provides oversight of a wide range of healthcare-related professions and services. Additionally, the Department focuses on preventing disease and promoting wellness and health equity for all people.

Under DPH’s Bureau of Health Care Safety and Quality, the Division of Health Care Facility Licensure and Certification (DHCFLC) is responsible for licensing healthcare facilities,1 including nursing homes; issuing certifications for Massachusetts facilities participating in the Medicare and Medicaid programs; and monitoring these facilities to protect and promote the health and wellbeing of their residents. Because Medicare is funded with federal dollars and is administered by the Centers for Medicare & Medicaid Services (CMS), a federal entity, DHCFLC works in part as a representative for CMS, ensuring that facilities comply not only with state requirements but also with those established by CMS in accordance with CMS’s State Operations Manual.2

DHCFLC monitors nursing homes in several ways. Its Certification Unit must conduct mandatory recertification surveys at each nursing home every 9 to 15 months, following the requirements of CMS’s State Operations Manual. Surveyors who conduct the recertification surveys interview a sample of residents, observe facility personnel, and score the facility’s performance in several categories. If the surveyors note any deficiencies at the facility, the facility is cited and must correct the deficiency in a timely manner. DPH continues to follow up with the facility until all deficiencies are satisfactorily resolved.

In addition to the Certification Unit’s recertification surveys, DPH is also responsible for on-site investigation surveys in response to complaints. DHCFLC’s Complaint Unit3 manages and responds to intakes or complaints reported to DPH alleging facility noncompliance,4 substandard quality of care, and/or resident harm at its licensed facilities. According to a letter from DPH to the Office of the State Auditor (OSA),

The Complaint Unit is responsible for triaging all consumer complaints and facility-reported incidents involving licensed and/or certified health care facilities within the Commonwealth, and must determine the best response to the incidents and complaints. This response includes performing offsite and onsite surveys at licensed and certified facilities, evaluating compliance with state and federal regulatory requirements, documenting areas of concerns, and reviewing submitted corrective action plans.

DPH’s Complaint Unit Intake Process Manual outlines one of its key roles:

As a regulatory agency, [DPH is] focused on identifying and addressing abuse, neglect, misappropriation, mistreatment, quality of care and quality of life issues within nursing facilities, hospitals and other care settings, as defined by regulation.

The Complaint Unit reviews, prioritizes, and responds to thousands of intakes reported to DPH each year, screening for high-priority incidents at licensed healthcare facilities that require immediate action from DPH.

In its letter to OSA, DPH stated,

The Complaint Unit currently consists of the following staff:

  • Intake: 5 intake surveyors who are health professionals including 4 social workers that have experience in working with older adults, chronic disease and diverse populations.
  • Survey: 20 clinical professionals: 6 hospital focused and 14 non-hospital focused (including nursing homes). Survey staff are either registered nurses, social workers or pharmacists.
  • Supervisors: 1 registered nurse unit manager, 1 intake supervisor and 3 registered nurse survey staff.
  • Three clerks and one additional process staff member.

DHCFLC had annual state and federal appropriations totaling approximately $16.3 million for fiscal year 2017 and approximately $16.9 million for fiscal year 2018. In fiscal years 2017 and 2018, DHCFLC expended a combined total of approximately $32.9 million.

DHCFLC Appropriations and Expenditures




Fiscal Year 2017



Fiscal Year 2018






DPH’s Health Care Facility Reporting System

The Health Care Facility Reporting System (HCFRS) is a Web-based system that houses all intakes or complaints reported to DPH, including allegations that incidents occurred, or deficiencies existed, at licensed healthcare facilities. There are two ways an intake may be entered in HCFRS. When facility administrators are made aware of incidents at their facilities that require reporting, they are responsible for entering intakes in HCFRS for DPH’s review. Additionally, non-facility reporters can report complaints to DPH personnel, who then create new intakes and enter the information in HCFRS.

DPH uses HCFRS as its system of record to track intakes from when they are first reported to DPH to when DPH reviews and prioritizes them. HCFRS contains not only the intake information itself, but also any action taken by DPH’s intake staff, including corresponding with the reporting source, reviewing and prioritizing intakes, and designating an intake’s disposition.5

CMS’s Automated Survey Process Environment

CMS’s State Operations Manual states that all non-facility-reported complaints, regardless of disposition designation, and all intakes designated for on-site investigation surveys must be transcribed by DPH personnel from HCFRS into a separate intake and survey information system within the Automated Survey Process Environment (ASPEN), which is owned by CMS. Additionally, the results of the on-site investigation surveys and recertification surveys performed by DPH are completed to fulfill requirements put forth by CMS, as well as state laws and regulations, and entered in ASPEN. Within ASPEN, the intakes requiring on-site investigation surveys are linked with the surveys conducted, allowing DPH personnel to document in ASPEN that they were responded to appropriately.

Intake Review and Prioritization Process

In accordance with Section 155.008(A) of Title 105 of the Code of Massachusetts Regulations, DPH is required to act on complaints received by DHCFLC as follows:

Upon receipt of an oral or written report of suspected patient or resident abuse, neglect, mistreatment or misappropriation of patient or resident property made pursuant to 105 CMR 155.000, the Department shall:

(1)  immediately notify the Attorney General orally, or by electronic transmission or facsimile, of the receipt of said report;

(2)  conduct an investigation into the allegations contained in the report within 24 hours after receipt of the oral report if there is reasonable cause to believe that a patient’s or resident’s health or safety is in immediate danger from further abuse, neglect or mistreatment;

(3)  conduct an investigation into the allegations contained in the report within seven days after receipt of the written report in all other cases;

(4)  at the conclusion of the investigation, issue a written report containing the findings and recommendations of its investigation.

As previously mentioned, all complaints are processed through DHCFLC’s Complaint Unit. When a new intake is entered in HCFRS, the Complaint Unit must determine how it will respond based on the information associated with the intake. To do so, a DPH intake staff member reviews the incident narrative, allegation type, severity of the allegation, results of any internal investigations conducted by the facility, and corrective measures taken by the facility. If a duplicate intake has been reported from another source, the staff member may also review new information available from the duplicate intake. If the staff member requires additional information from the reporting source, s/he requests that information. When the staff member has sufficient information to determine how DPH should respond, s/he selects the appropriate disposition and submits it for a second review.

The staff member then reviews the information associated with the intake to assess the type and severity of the alleged incident and determines what actions DPH should take. At a minimum, DPH always reviews the intake and files it in its system of record. However, it may also determine that another action is appropriate in order to respond fully. The most common dispositions are as follows.

  • Review and File: The intake is filed in HCFRS for trend analysis and may be investigated in a future recertification survey.
  • On-Site Investigation: A Complaint Unit staff member responds to the intake by gathering additional evidence regarding the alleged incident, which s/he does by investigating on site at the facility.
  • Off-Site Investigation: A Complaint Unit staff member responds to the intake by gathering additional evidence regarding the alleged incident, without going to the facility.
  • Refer to Other Agency: The complaint falls under another entity’s jurisdiction and is referred to that entity by DPH.

Once two reviewers agree and sign off on the intake, the Complaint Unit responds to it with the disposition selected by DPH staff members during the review process. If the intake requires an on-site investigation survey, it is transcribed from HCFRS into ASPEN and assigned a priority code denoting its severity and the timeframe within which the Complaint Unit must investigate it.

On-Site Investigation Survey Process

DPH responds to the most severe intakes by conducting on-site investigation surveys to assess the validity of the intakes’ allegations and detect any facility deficiencies related to the intakes that may endanger facility residents. The Complaint Unit must complete on-site investigation surveys in timeframes that comply with both state and federal guidelines.6

CMS’s State Operations Manual provides guidance on what types of allegations warrant on-site investigation surveys. Nursing home intakes designated for on-site investigation surveys are prioritized at four different levels. The most severe code is Immediate Jeopardy (IJ), which requires an on-site investigation survey within two working days from receipt of the intake. The other high-priority code is Non-IJ High. This code is used when residents are not in immediate jeopardy, but the intake is a high priority to be investigated.

Incidents that require on-site investigation generally involve allegations of harm to residents or facility deficiencies that could cause future harm to residents if left unresolved. However, if an incident is deemed unavoidable before investigation (in cases such as an elderly resident falling when the facility has followed all care plans), the intake staff may determine that another response is more appropriate than an investigation. When concluding an on-site investigation survey, DPH cites any deficiencies noted during the survey and reports them to CMS.

The Complaint Unit is also responsible for investigating reports alleging abuse, neglect, or mistreatment of a resident, or misappropriation of a resident’s funds or property, at a facility under Section 72H of Chapter 111 of the General Laws:

The department shall . . .

(2)  investigate and evaluate the information reported in any such report. Such investigation and evaluation shall be made within 24 hours if the department has reasonable cause to believe the patient’s or resident’s health or safety is in immediate danger from further abuse or neglect and within seven days for all other such reports. The investigation shall include a visit to the facility.

When the report involves an accused nurse aide, home health aide, or homemaker, DPH concludes whether the allegations against the accused person were substantiated pursuant to Section 72J of Chapter 111 of the General Laws. Substantiated allegations may bar an accused person from working in future roles at licensed healthcare facilities.

1.    Although DPH licenses and/or certifies different types of healthcare facilities, our audit focused on nursing homes.

2.    This manual instructs state agencies on how they must conduct their intake and survey processes as representatives for CMS.

3.    As DPH stated in a letter to the Office of the State Auditor, “While this audit report focuses on nursing homes and the Complaint Unit within DPH . . . the Complaint Unit [also] responds to intake cases in other types of facilities including rest homes, dialysis units, hospitals, clinics, hospice, ambulatory surgical centers, home health agencies and adult day health programs.”

4.    Noncompliance can include assessments of performance below the expected levels for facility administration, nursing care, resident rights, food, or living environment.

5.    “Disposition” is the term for DPH’s process of determining how it should respond to a reported intake.

6.    In addition to enforcing state regulations, DHCFLC acts as the state survey agency on behalf of CMS. When an on-site investigation is warranted, Complaint Unit surveyors may investigate a facility, acting on behalf of DPH, CMS, or both.

Date published: September 11, 2019

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