60% of Mass. DDS's Most Urgent Safety Reports Missed Deadline
Summary
Massachusetts' state auditor tested whether the Department of Developmental Services -- which serves about 43,000 people with intellectual and developmental disabilities -- had fixed the reporting gaps a 2021 audit flagged. DDS's own written response touts one improved number; the reports closest to medication errors and abuse risk are still the ones most often missed, some at double the 2021-era rate DDS cites.
The number DDS points to
In its written response to the audit, DDS cites a clear win: "In 2021, 38% of the decision letters were late beyond extension. In 2025, 2% of the cases were late before an extension was entered."⧉ That is DDS's own comparison, not one the auditors independently reproduced for 2021 -- and it uses different wording for each year ("late beyond extension" for 2021 versus "late before an extension was entered" for 2025). It also isn't quite the same thing the auditors tested this cycle: their own 2025 sample found 2 of 73 investigations (3%) had a decision-letter extension created after the 45-business-day deadline had already passed. Both readings point the same direction -- decision-letter timeliness looks genuinely better than it did in 2021. The question is what that number is standing in for.
View data as table
| 2021 (prior audit cycle) | 38% | DDS's own stated rate, cited in its 2026 response |
|---|---|---|
| 2025 (this audit cycle) | 2% | DDS's own stated rate -- a different measure than the auditors' own tested 3% figure below |
The reports closest to medication errors and abuse are still late
Decision letters aren't where DDS's abuse-and-safety reporting system does its most urgent work. Medication occurrence reports (MORs) are: a contracted provider must file one whenever a medication is given to the wrong person, at the wrong dose, at the wrong time, by the wrong route, or not at all. The most serious version -- a "hotline MOR," filed when the error was serious enough to require medical intervention -- must be created within 24 hours. The audit sampled 35 hotline MORs. 21 of them, 60%, were created after that 24-hour window. That is the single worst compliance rate anywhere in the report, in the category with the least room for delay.
The pattern holds across every other safety-adjacent category the audit tested. 27 of 75 sampled action plans (37%)⧉ -- the corrective steps ordered after a completed abuse investigation -- weren't developed within the required 30 business days, and 3 had no action plan at all. 9 of 74 administrative reviews (12%) weren't sent to the complaint-resolution team on time. 27 of 75 major-incident reports (36%) -- covering events like suspicious deaths or missing people -- were submitted late, and 23 (35%) weren't finalized on time. For 16 of 75 sampled recipients with individual support plans (21%), DDS's own system had no record that they'd been offered a legally required self-determination option.
View data as table
| Decision letters (extension after deadline) | 3% | 2 of 73 sampled investigations |
|---|---|---|
| Action plans (not done within 30 business days) | 37% | 27 of 73; 3 had no action plan at all |
| Administrative reviews (not sent to CRT within 15 days) | 12% | 9 of 74 sampled |
| Non-hotline medication reports (created late) | 21% | 16 of 75 sampled |
| Hotline medication reports (created late) | 60% | 21 of 35 sampled -- the 24-hour, medical-intervention category |
| Major incident reports (submitted late) | 36% | 27 of 75 sampled |
| Minor incident reports (submitted late) | 17% | 13 of 75 sampled |
| Self-determination option missing from file | 21% | 16 of 75 sampled ISP recipients |
The audit already said this once
This isn't the first time DDS has been told about the medication-report and incident-report gaps. The 2026 audit exists specifically to check⧉ whether DDS fixed what a prior audit (No. 2020-0234-3S, issued June 29, 2021) had already flagged. On MORs, the auditors wrote plainly: "DDS did not fully implement our recommendations during the audit period from our previous audit." On incident reports, the same conclusion: "The audit team determined that DDS did not fully implement our recommendation during the audit period from our previous audit." DDS told the auditors it has since taken new steps -- hiring a statewide Medication Administration Program director, reorganizing regional coordinators, building new compliance-tracking reports -- but those changes came after the audit period closed in mid-2024, so the auditors haven't tested them yet. For each finding, the auditors say the same thing: they'll follow up in about six months.
The scale underneath these percentages is large. DDS runs on $2.4 billion in fiscal 2023 and $2.8 billion in fiscal 2024⧉ in state appropriations, with 1,554 staff across 23 area offices. During the two-year audit period, the state's disability-abuse hotline referred DDS 12,749 complaints. Providers filed 12,290 medication occurrence reports and 57,566 incident reports. The sampled miss-rates above are drawn from small slices of those totals -- the auditors are explicit that they did not project their sample results onto the full populations -- but they're the only rates DDS has been independently tested against, twice now, on the same categories.
- DDS's own written response highlights a real improvement: its stated decision-letter lateness rate fell from 38% in 2021 to 2% in 2025 -- though that comparison is DDS's own, worded differently for each year, and distinct from the auditors' own 2025 test (3% of a 73-case sample).
- The category with the least room for delay had the worst compliance: 60% of sampled hotline medication-error reports -- filed when a medication error was serious enough to require medical intervention -- missed their 24-hour deadline.
- Every other safety-adjacent category the audit tested also missed its deadline at double-digit rates: action plans (37%), major incidents (36%), minor incidents (17-29%), administrative reviews (12%), non-hotline medication reports (21%), and self-determination documentation (21%).
- This is a repeat finding, not a new one. The audit exists to test whether DDS fixed gaps a 2021 audit already flagged on medication reports and incident reports; on both, the auditors concluded DDS "did not fully implement" its prior recommendations during the period tested.
- DDS says it has since made changes -- a new statewide medication-program director, reorganized regional coordinators, new compliance reports -- but those came after the audit period ended in mid-2024, and the auditors have not yet tested them; they say they'll follow up in about six months.
- Scale: DDS served about 43,000 people on a $2.4-2.8 billion annual budget across the two fiscal years audited, with 12,749 abuse/neglect complaints referred to it and over 69,000 medication-occurrence and incident reports filed in that span.
Figures are drawn from the Massachusetts Office of the State Auditor's Official Audit Report: Department of Developmental Services (Audit No. 2025-0234-3S, issued April 15, 2026), read in full via direct PDF fetch from mass.gov, with a fresh Wayback capture confirmed live at read time. Sample sizes and population totals are stated as reported; the audit's own methodology section states its sample results were not projected onto the full populations tested, and this piece does not extrapolate them either. Every finding here is attributed to DDS, its Medication Administration Program, or its complaint-resolution and investigations functions in an official capacity -- never to a named individual; no private person is named as a wrongdoer anywhere in this piece.
Sources(2) ▾
- Massachusetts Office of the State Auditor (Diana DiZoglio, Auditor of the Commonwealth), Official Audit Report: Department of Developmental Services, For the Period July 1, 2022 through June 30, 2024 (Audit No. 2025-0234-3S) (2026-04-15) — Sole source for: the audit's objective (testing whether DDS implemented the recommendations of prior Audit No. 2020-0234-3S, issued June 29, 2021) and scope (July 1, 2022-June 30, 2024 audit period); DDS's FY2023/FY2024 appropriations, staffing, and service population; the number of DPPC complaints referred to DDS and the complaint-disposition breakdown; all five detailed findings and their sample sizes, rates, and population totals for investigations, administrative reviews, medication occurrence reports (MORs), incident reports, and individual support plans (ISPs); DDS's own auditee-response comparison of 2021 vs. 2025 decision-letter lateness; and the audit's explicit statement that its sample results were not projected onto the full populations tested. mass.gov · original document
- Commonwealth of Massachusetts, Commission for the Protection of Persons With Disabilities, Commission for the Protection of Persons With Disabilities (CPPD) -- public abuse/neglect reporting page (2026-07-21) — Sole source for: the identity, founding date, jurisdiction, and 24-hour phone number of the state's public abuse/neglect reporting hotline for adults with disabilities -- used only for the article's call-to-action, not for any audit finding. The page identifies itself as 'Established in 1987 as an independent state agency,' the same founding year and mass.gov URL slug (disabled-persons-protection-commission) as the Disabled Persons Protection Commission (DPPC) named throughout the audit -- confirming CPPD is DPPC operating under a current rebrand, not a different body. The page states its own protective jurisdiction as adults with disabilities ages 18 through 59 (a narrower age band than DDS's full ~43,000-person population of adults and children), which the article's call-to-action reflects. mass.gov · original document
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A performance audit⧉ by the Massachusetts Office of the State Auditor set out to check one thing: whether the Department of Developmental Services (DDS) -- which serves about 43,000 people with intellectual and developmental disabilities -- had fixed the reporting gaps a prior audit flagged in 2021. DDS's written response to the new audit highlights a real improvement in one narrow metric. But on the reports that most directly track medication errors and abuse risk for the people DDS serves, the audit found DDS still missing deadlines at rates as high as 60%, unchanged from what a near-identical 2021 finding already told it to fix.