COFAR blog

Charles Dickens named his ultimate bureaucratic agency the Circumlocution Office because the public’s business just got passed around in circles in the department.

At least some of that appears to be going on among state agencies when it comes to investigating abuse of persons with developmental disabilities in Massachusetts, according to a review of public records of three state agencies by COFAR.

It appears to be the case with all forms of abuse that the referral and investigation process starts and ends with the Department of Developmental Services (DDS).

In fact, one of the agencies involved – the Executive Office of Elder Affairs (EOEA) –  referred 25 years ago to the process of investigating abuse involving DDS and Department of Mental Health clients as “circuitous,” and stated that attempts to change it through legislation had not been successful in the previous two years. That memo, which we recently received from EOEA, was written in 1994.

COFAR requested and reviewed data and other information on investigations from DDS, the Disabled Persons Protection Commission (DPPC), and EOEA of financial and other types of abuse. We requested the information from each agency under the state’s Public Records Law.

How the circular process appears to work

The circularity appears to start with the fact that DDS is required by state regulations to report all abuse allegations to DPPC, the state’s only independent agency for investigating abuse of disabled adults. But DPPC lacks jurisdiction to investigate financial abuse, in particular, according to the agency’s assistant general counsel, so it refers those cases back to DDS to investigate.

DPPC also lacks jurisdiction to investigate abuse of the elderly, so it refers allegations of all types of abuse involving persons over the age of 59 to EOEA. But EOEA then also refers those same allegations to DDS to investigate if they involve persons living in DDS facilities, according to EOEA officials we talked to and to the 25-year-old memo.

In the May 6, 1994 memo, then Secretary of Elder Affairs Franklin Olivierre stated that under a then newly effective policy, EOEA would send all abuse allegations referred to it from DPPC to EOEA’s “protective service agencies” for investigation. However, if an allegation involved anyone living in either a DDS or DMH-funded residence, the protective service agencies were advised to contact either DDS or DMH, and, in either case, to “screen out” the allegation, meaning not to investigate it themselves.

“Although both Elder Affairs and DPPC recognize that this system is circuitous, attempts to change the statute through legislation have not been successful in the past two years,” Olivierre wrote.

A bill filed by DPPC at that time would have allowed the DPPC to investigate all reports of abuse of persons in DDS and DMH facilities. That bill never passed, and the circuitous referral process continues to exist to this day.

In other words, while abuse of the developmentally disabled largely occurs in DDS-funded facilities, it is DDS that ultimately ends up investigating most of the cases.

Our diagram below depicts the circular flow of referrals of abuse allegations involving victims with developmental disabilities, according to the records we reviewed.

Beyond the apparent conflict of interest that DDS has in investigating fraud in its own funded and managed programs, it isn’t clear that DDS has the resources to adequately investigate those cases and all of the other forms of abuse that get referred to it.

No centralized record keeping or tracking

It’s not easy to track the circularity of the abuse referral and investigation process because there appears to be no central record keeping or tracking system for abuse complaints and investigations, whether financial or other forms of abuse. Each agency keeps some of the records regarding the abuse investigation process, but no agency appears to have them all.

For instance, while DDS, as noted, is required to refer all abuse allegations it receives to  DPPC, that latter agency tracks the outcomes of investigations only of those allegations that fall under its jurisdiction.

If DPPC receives an allegation of abuse involving a victim with an intellectual disability 60 years old or older, or receives any allegation involving financial abuse, the agency keeps records of the referral of those cases, but not the outcomes.

DDS has two investigative divisions, only one of which even keeps records on the number of abuse allegations reported to it or referred by it to DPPC, according to a response we received from DDS to a Public Records Request.

EOEA, meanwhile, has no records on the number of abuse allegations it receives involving people with intellectual or developmental disabilities, according to a response from an official in that agency regarding a Public Records Request.

Also, EOEA only began keeping records on the number of abuse cases referred to it by DPPC in Fiscal 2018. Similarly, EOEA only began keeping records in Fiscal 2018 on the number of cases it refers to DDS.

DDS, for its part, said it has no records on cases referred to it by EOEA. 

Tracking financial abuse referrals

Within DDS, it appears there are two separate divisions or units that are concerned with  abuse issues – the Investigation Division, which was established in 1993, and the Bureau of Program Integrity (BPI), which was established in 2018.

According to DDS records, the Investigation Division has a staff of 33, including 26 full-time staff investigators.

The DDS BPI only has 3 people on its staff — a director of internal controls, a senior manager, and a risk analyst. The purpose of the BPI is to support the Investigation Division in its financial abuse investigations, develop internal control procedures for DDS, manage a “DDS Theft and Fraud Hotline,” and related matters.

In response to a Public Records Request that we filed specifically seeking data on financial abuse from Fiscal 2016 to the present, DDS informed us that the department does not keep records on the number of financial abuse allegations received by the Investigation Division. The reason given was that all of those allegations must be reported to the DPPC.

However, DDS does apparently keep those records regarding the BPI. DDS stated that the BPI, which is also required to report all allegations to DPPC, received 62 complaints of financial fraud either directly or via its Fraud Hotline since the BPI was established in Fiscal 2018.

DDS did not explain that apparent inconsistency in record-keeping between the Investigation Division and the BPI.

According to DPPC’s own records, from Fiscal 2016 through 2019, DPPC received 1,172 allegations of financial abuse involving DDS clients. It appears that many, if not most, of those allegations were referred to DPPC either by DDS, DDS-funded facilities, the DDS Investigation Division, or the BPI (after the start of Fiscal 2018).

Between Fiscal 2016 and 2019, DPPC, due to its lack of jurisdiction, reported that it referred 895, or 76%, of those 1,172 financial abuse allegations back to DDS to investigate. DPPC also referred an additional 261, or 22%, of the financial abuse allegations it received to EOEA.

EOEA then appears to have referred those 261 allegations back to DDS as well, although we were not able to verify that number through any of the three agencies’ records.

In any case, it would appear that in cases of financial abuse of elderly persons in DDS facilities, those cases are first routinely referred by DDS to DPPC, which then refers them to EOEA, which then refers them back to DDS.

Low level of completed financial abuse investigations

Although DDS did not have records on the number of allegations referred to or received by the Investigation Division, DDS did state that the Division “completed” a total of 96 investigations of allegations of “financial misconduct” referred by DPPC to DDS from Fiscal Year 2016 to the date of COFAR’s Public Records Request in September 2019.

It was not clear why DDS would have records of the number of referred investigations that the Investigation Division completed, but would not have records of the number of cases referred by DPPC to the Investigation Division. Given the staffing of each of the two DDS investigative divisions, it would appear that the Investigation Division would or should have investigated most, if not all, of the 895 referrals.

If the DDS Investigation Division completed a total of only 96 out of 895 financial fraud investigations referred to it by DPPC in that 4-year period, that would amount to a completion rate of only about 11% of the cases. DDS substantiated a total of 12 of those 96 allegations.

EOEA and DPPC records may not line up 

Of the 1,172 financial abuse allegations it received from Fiscal 2016 through 2019, DPPC referred 261 of them, as noted, to EOEA, according to DPPC’s response to our Public Records Request. Given that those cases all involved DDS clients, it would appear that EOEA, according to its 25-year-old policy, would or should have referred all of those cases to DDS.

It was actually not possible for us to verify, based on DDS and EOEA records, that all of those 261 cases referred by DPPC to EOEA were, in fact, subsequently referred by EOEA to DDS.

As noted, DDS said it has no records of the number of abuse cases referred to it by EOEA. EOEA, as noted, only began tracking the number of cases referred to DDS in Fiscal 2018.

In fact, DPPC’s and EOEA’s records don’t appear to line up in that respect. EOEA responded to us that in Fiscal 2018, it referred zero abuse cases to DDS. However, according to DPPC’s records, DPPC referred 42 allegations of financial abuse involving DDS clients to EOEA in Fiscal 2018. According to EOEA’s policy, it should have referred those 42 cases to DDS that year.

The solution to the circular referral process lies with DPPC

Our recommended solution to the overall referral and investigation problem is to revive and enact the legislation that DPPC proposed 25 years ago.  DPPC should have the resources and authority needed to investigate all forms of abuse of the developmentally disabled, including persons over 60 years of age.

Right now, the investigative process involving abuse and neglect of persons with developmental disabilities is split among at least three agencies. It is a circuitous system rife with potential conflicts of interest and one in which record-keeping and apparently cooperation in undertaking investigations among the agencies is dispersed and spotty.

We plan to share these findings and our recommendation with the Legislature’s Children, Families, and Persons with Disabilities Committee. The current abuse investigation and referral system appears to be set up for failure and needs to be reformed.