Audit of the Department of Children and Families
December 7, 2017 · Department of Children and Families · Read the full official report on mass.gov ↗
Published December 7, 2017 Audit covers January 1, 2014 – December 31, 2015 Under Suzanne M. Bump · 2011–2023
source
“In this performance audit, we examined DCF’s process for reporting critical incidents and fatality investigations.”
Read the plain-English breakdown
This is a Massachusetts State Auditor performance audit of the Department of Children and Families covering January 1, 2014 through December 31, 2015.
“This report details the audit objectives, scope, methodology, findings, and recommendations for the audit period, January 1, 2014 through December 31, 2015.”
Auditors reviewed whether DCF properly reported serious incidents and completed required child death reviews.
“Below is a list of our audit objectives, indicating each question we intended our audit to answer, the conclusion we reached regarding each objective, and where each objective is discussed in the audit findings.”
If DCF misses or fails to report serious harm to children, other oversight agencies may not be able to step in or check whether children are being protected.
“Without proper reporting by DCF, OCA cannot perform its oversight function to ensure that children receiving DCF services are appropriately cared for.”
For ordinary residents, this matters because DCF is supposed to protect children at risk of abuse or neglect, including children in foster care and other placements.
“According to its website, DCF “is charged with protecting children from abuse and neglect and strengthening families.””
The auditor concluded that DCF did not properly identify, investigate, or report some serious incidents, and did not finish fatality review reports on time.
“DCF does not effectively identify and investigate all occurrences of serious bodily injury to children in its care.”
The report recommends that DCF improve policies, monitoring, reporting standards, and its process for completing fatality reviews.
“DCF should take the measures necessary to ensure that all fatality review reports are completed and submitted to OCA within the established timeframe.”
The stakes are high because missed reports can leave children exposed to more harm and can prevent prosecutors or oversight agencies from acting.
“This can put children at risk of further abuse, neglect, and bodily injury.”
A “critical incident” means a child death, near death, serious injury, or situation suggesting a state agency failed to protect a child from serious harm.
“Section 1 of Chapter 18C of the General Laws defines a critical incident as follows:”
What the Auditor checked
- Did not comply Does DCF properly report critical incidents to the Office of the Child Advocate (OCA) when required?
- Did not comply Is the fatality review report completed, approved, and disseminated on request as required by Section 13.02(4) of Title 110 of the Code of Massachusetts Regulations (CMR)?
What the Auditor found
Why it matters: Unreported critical incidents may go undetected, putting children at risk of further abuse, neglect, and bodily injury.
Standard: Section 1.02 of Title 110 of the Code of Massachusetts Regulations requires DCF to seek to ensure children's safety. ( Section 1.02 of Title 110 of the Code of Massachusetts Regulations )
1 recommendation
- DCF should establish policies and procedures requiring staff to routinely monitor MMIS data to identify and investigate medical occurrences that appear to be critical incidents involving children in its care.
Agency response & Auditor reply
Agency: "While the responsibility to report remains with mandated reporters, DCF will determine the feasibility of accessing MassHealth claims data in its MMIS system to identify medical treatment that may indicate a child was abused or neglected and should have been reported to DCF (either by our providers or by mandated reporters such as doctors and hospital staff)."
Auditor: "Therefore, the Office of the State Auditor (OSA) believes that DCF, as the state agency charged with overseeing the protection of children, is responsible for taking whatever measures it has available, including reviewing the MassHealth data regularly to ensure that it is aware of all potential instances of neglect or abuse of a child and can act on these situations appropriately."
Why it matters: OCA cannot perform its oversight function to ensure children receiving DCF services are appropriately cared for.
Standard: Sections 1 and 5 of Chapter 18C of the Massachusetts General Laws define critical incidents and require DCF to inform OCA when one occurs. ( Section 1 of Chapter 18C of the Massachusetts General Laws; Section 5 of Chapter 18C of the Massachusetts General Laws )
2 recommendations
- DCF should establish a single consistent standard for defining and reporting critical incidents that matches the General Laws.agency: agreed
- DCF should develop policies, procedures, controls, and monitoring activities for adequate oversight of critical incident reporting.agency: agreed
Agency response & Auditor reply
Agency: "DCF takes its reporting obligation to the Office of Child Advocate earnestly and agrees with the OSA’s recommendations that our critical incident reporting process needs to be simplified and streamlined."
Auditor: "Without complete critical incident information, OCA cannot effectively meet its mission of ensuring that every child involved with state agencies in Massachusetts is protected from harm and receives quality services."
Why it matters: Failure to report substantiated cases may prevent alleged abusers from being prosecuted.
Standard: Section 51B of Chapter 119 of the General Laws requires DCF to notify the appropriate district attorney when early evidence indicates reasonable cause to believe a child has been physically or sexually abused or sexually exploited as a result of abuse or neglect. ( Section 51B of Chapter 119 of the General Laws )
3 recommendations
- DCF should update policies and procedures with clear and consistent criteria and reporting standards and establish monitoring activities over all parties.agency: agreed
- DCF should establish monitoring controls to ensure staff comply with policies and procedures for reporting critical incidents to district attorneys' offices.agency: agreed
- DCF should schedule regular meetings with district attorneys' offices to ensure reported incidents are applicable and prosecutors have needed information.agency: agreed
Agency response & Auditor reply
Auditor: "This assertion is not supported by our audit work: the DAs’ offices themselves reported to us that they were never contacted either formally or informally by DCF and were unaware of each incident."
Why it matters: Without timely fatality review reports, OCA cannot properly evaluate DCF casework, policies, regulations, training, contracted services, and case management.
Standard: 110 CMR 13.02(4) requires DCF to finalize fatality review reports within 30 days for unnatural deaths or 60 days for natural deaths and obtain commissioner approval. ( 110 CMR 13.02(4) )
1 recommendation
- DCF should ensure all fatality review reports are completed and submitted to OCA within the established timeframe by streamlining current processes and updating policies.agency: agreed
Agency response & Auditor reply
Agency: "In any event, DCF agrees with the OSA’s recommendations regarding streamlining our fatality investigation report process to ensure more timely completion and submission to the Office of the Child Advocate."
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