Audit of the Department of Public Health (DPH)
September 11, 2019 · Department of Public Health · Read the full official report on mass.gov ↗
Published September 11, 2019 Audit covers July 1, 2016 – June 30, 2018 Under Suzanne M. Bump · 2011–2023
source
“Does DPH appropriately review and respond to reported alleged incidents, including abuse, neglect, mistreatment, and misappropriation, that negatively affect residents at licensed nursing homes?”
Read the plain-English breakdown
This is a state performance audit of how the Department of Public Health reviewed, prioritized, and investigated complaints about licensed nursing homes.
“In this performance audit, we examined DPH’s processes for reviewing, prioritizing, and responding to intakes involving allegations of deficiencies at licensed nursing homes in the Commonwealth.”
The auditor looked at whether DPH was properly responding to reports of abuse, neglect, mistreatment, misappropriation, and other problems affecting nursing home residents.
“Does DPH appropriately review and respond to reported alleged incidents, including abuse, neglect, mistreatment, and misappropriation, that negatively affect residents at licensed nursing homes?”
If DPH misses or delays investigations, serious safety or financial problems in nursing homes can continue and residents may be harmed.
“When an on-site investigation survey does not take place, there is an increased risk that significant problems may exist at the nursing home and continue to pose a threat of physical or financial harm to a resident.”
If you or someone you care about lives in a nursing home, this report matters because it checks whether complaints about resident safety and care are being acted on properly.
“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.”
DPH did not always complete required on-site investigations, meet deadlines for high-priority cases, notify the Attorney General when required, or keep adequate tracking paperwork.
“Not always; see Findings 1, 2, 3, and 4”
The auditor recommended stronger monitoring controls, better tracking, and staffing reviews so DPH can meet required timeframes and referral rules.
“DPH should review staffing needs and make any further adjustments that are needed to ensure that the prioritization and investigation survey processes are completed in the required timeframes.”
The findings are significant because the report found problems in the system meant to protect nursing home residents from abuse, neglect, poor care, and financial harm.
“When DPH does not prioritize and investigate intakes within the required timeframes, significant issues involving the health and safety of residents in these nursing homes may exist for prolonged periods and could result in physical or financial harm to residents.”
An “intake” means a complaint or incident report sent to DPH; an on-site investigation survey means DPH staff go to the facility to investigate.
““Disposition” is the term for DPH’s process of determining how it should respond to a reported intake.”
What the Auditor checked
- Partially Does DPH appropriately review and respond to reported alleged incidents, including abuse, neglect, mistreatment, and misappropriation, that negatively affect residents at licensed nursing homes?
What the Auditor found
Why it matters: Required investigations may not occur, increasing the risk that serious problems at nursing homes continue to threaten residents with physical or financial harm.
Standard: CMS’s State Operations Manual, 105 CMR 153.012, and Section 72H of Chapter 111 of the Massachusetts General Laws require investigation of relevant intakes and on-site surveys when required. ( Chapter 5 of the Centers for Medicare & Medicaid Services’ State Operations Manual; Section 153.012 of Title 105 of the Code of Massachusetts Regulations; Section 72H of Chapter 111 of the Massachusetts General Laws )
1 recommendation
- DPH should enhance its policies and procedures that define and implement monitoring controls over its intake process to ensure that all intakes requiring on-site investigation surveys are properly transcribed from HCFRS to ASPEN.
Agency response & Auditor reply
Agency: "DPH disagrees with [the] finding that “DPH does not have adequate policies and procedures in place.”"
Auditor: "Based on its response, DPH is taking measures to address our concerns in this area."
Why it matters: Delays in prioritizing and investigating high-priority intakes may leave health and safety issues unresolved for prolonged periods and could result in physical or financial harm to residents.
Standard: Chapter 5 of CMS’s State Operations Manual requires non-immediate jeopardy complaints and incidents to be prioritized within two working days and Non-IJ High intakes to be investigated within 10 days of prioritization. ( Chapter 5 of CMS’s State Operations Manual )
1 recommendation
- DPH should review staffing needs and make any further adjustments that are needed to ensure that the prioritization and investigation survey processes are completed in the required timeframes.agency: already implemented
Agency response & Auditor reply
Agency: "As of December 2018, due to hiring additional staff there is no longer a backlog of intake cases."
Auditor: "Based on its response, DPH has taken measures to address the problems we identified in this area."
Why it matters: The Attorney General’s Office was not given the opportunity to review some intake details and determine whether action was needed.
Standard: Section 72H of Chapter 111 of the General Laws requires DPH to notify the Attorney General upon receipt of reports alleging abuse, neglect, mistreatment, or misappropriation at a nursing home. ( Section 72H of Chapter 111 of the General Laws )
1 recommendation
- DPH should establish policies and procedures that define and implement monitoring controls over its intake process to ensure that all intakes requiring AGO notification are properly transcribed from HCFRS to ASPEN.
Agency response & Auditor reply
Agency: "Since this oversight was identified, DPH has taken appropriate steps to appropriately refer these two cases."
Auditor: "Based on its response, DPH has taken some measures to address these problems, but we urge the agency to implement our recommendations."
Why it matters: There is a higher-than-acceptable risk that staff may not take required actions or may lose track of an intake after it is designated for on-site survey.
Standard: DPH’s Complaint Unit Intake Process Manual requires an On-Site Cover Sheet, Complaint Processing Summary, to document the administrative life and review of a case. ( DPH’s Complaint Unit Intake Process Manual )
1 recommendation
- DPH should establish monitoring controls to ensure that its staff completes Complaint Processing Summary forms for all intakes that require on-site investigation surveys.
Agency response & Auditor reply
Agency: "DPH acknowledges that the Complaint Unit Manual requires that intake cases prioritized as requiring on-site investigations have an on-site cover sheet with them."
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