The State Auditors’ Office uncovered a litany of issues with the Department of Developmental Services (DDS) in its 2021-2022 report, released earlier today. Perhaps the two most concerning findings outlined in the report were DDS’s inconsistent follow up on reports of abuse or neglect, and its lengthy backlog of client death reviews.
In addition, DDS was found to have a lack of proper controls and documentation regarding promotion and hiring, overtime, workers compensation, compensatory time, time reporting codes, procurement, contracting, and state mandated reporting.
The Auditors reviewed 353 complaints involving intellectually disabled people under DDS care and found that in 70 of these complaints, investigations began anywhere from one to 439 days late. Three cases which were opened in January 2022, had still remained un-updated in DDS’s database as of March 2024. Additionally, DDS did not document the completion dates of 25 investigations. In 10 investigations which substantiated abuse or neglect, DDS was unable to provide the auditors with copies of investigation reports.
“DDS did not complete the abuse and neglect investigations in accordance with its policy, which increased the risk of delayed detection of abuse and neglect,” read the report. “The absence of an investigation report can lead to a lack of accountability.”
The auditors said that DDS’s issues with investigation oversight likely stems from “a lack of management oversight, staffing shortage, and poor recordkeeping.” The auditors recommended that DDS should “strengthen its internal controls and monitoring efforts to ensure the prompt completion and adequate documentation of abuse and neglect investigations.”
DDS responded by saying that it “agrees in part with the findings.” In the report, DDS said that “while 90 days is the guideline for completing a case; there are legitimate reasons why this cannot always be met, such as police involvement.” DDS attributed its shortcomings in investigation reporting as being the result of a DDS liaison retiring and staff turnover.
“Region Liaisons continue to work on ensuring cases are closed correctly in the database and that investigation reports are scanned and saved electronically,” said DDS.
The report also found there to be a backlog of mortality reviews, which are reports conducted after a client in DDS care dies, with some of these reviews being submitted to the Independent Mortality Review Board (IMRB) significantly later than the 90-day time frame required of DDS personnel. The auditors found that all 66 mortality reviews conducted by DDS from 2021-2022 were completed anywhere from 85 to 1,251 days late. Auditors also found DDS to have provided no explanations or documentation for these late reporting delays.
“According to the department’s tracking log, as of January 2024, 31 of the 66 cases were still open, 11 needed responses from other state agencies, and the remaining 20 were waiting for IMRB meeting minutes,” read the report.
The auditors asserted that the lack of timely reviews “increases the risk that unexpected deaths due to abuse or neglect were not promptly identified.” Auditors again cited lack of managerial oversight, poor recordkeeping and staff shortages as reasons for DDS’s shortcomings, and recommended it strengthen internal controls and update its outdated policies and procedures regarding its mortality reviews.
“The agency agrees with the finding,” responded DDS. “The mortality review process is quite involved and has been challenged by resource limitations, leadership changes and the COVID-19 pandemic. While centralized tracking records lacked status information and did not comply with DDS policy, there were no open cases that were unexpected deaths caused by abuse or neglect.”
Regarding the other administrative issues, the auditors found that poor documentation and record-keeping practices put the department at increased risk for improper hires and promotions and heightened expenditures due to improperly documented overtime, accrual of paid leave, and severance pay. In addition, auditors discovered instances of DDS overworking employees given lighter work assignments due to injury or illness, overpayment of severance pay, inadequate management of departmental purchasing, contracting and deposits of state funding, and late submission of legally mandated state reports.
In conclusion, the auditors said they “identified deficiencies in internal controls, identified apparent noncompliance with laws, regulations, contracts and grant agreements, policies or procedures.” That being said, the report also noted that it, “did not identify a need for improvement in management practices and procedures that we deemed to be reportable.”
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