Office of Program Integrity & Accountability

Office of Program Integrity & Accountability

Office of Investigations

Investigating Serious Incidents

The Department of Human Services (DHS) Office of Investigations (OI) conducts civil investigations into the most serious allegations involving abuse, neglect, or exploitation of individuals served through DHS programs.

Most of these cases are assigned directly to OI based on the type of allegation. However, incidents not directly assigned to OI may be referred by the Critical Incident Management Unit (CIMU) after further review.

Note: Certain allegations of abuse, neglect, and exploitation must be investigated by OI.  A detailed list of allegations and events is outlined on the Incident Reporting Levels and Categories Grid.

Provider Responsibilities

  • Mandatory Internal Investigation
    For all allegations of abuse, neglect, or exploitation, providers must immediately initiate an internal investigation, unless directed otherwise by law enforcement or OI.
  • Other Incident Investigations
    Some events—such as operational emergencies—may also require investigation or follow-up based on the incident code and service setting.
  • Referral Exceptions
    On a case-by-case basis, incidents normally handled by the Critical Incident Management Unit (CIMU) or another division may be escalated to OI for a full investigation.

Law Enforcement Notification Requirements

While DHS does not determine what constitutes a criminal offense, providers are required to notify law enforcement immediately for any incidents involving:

  • Death
  • Physical Abuse
  • Sexual Abuse
  • Assault with Injury
  • Sexual Assault
  • Exploitation
  • Neglect with Injury
  • Unapproved Restraint with Injury
  • Certain Operational Events (e.g., Theft, Fire)

OI also notifies law enforcement through the Division of Criminal Justice (DCJ) for all applicable Division of Developmental Disabilities (DDD) cases. In cases involving individuals dually served by the Division of Mental Health and Addiction Services (DMHAS) and DDD, DCJ is likewise notified. DCJ may forward these referrals to the County Prosecutor’s Office for potential criminal review.

Overview: OI Investigative Process

  1. Assignment and Review
    The incident is reviewed and an investigation plan is developed, typically through a case conference.
  2. Law Enforcement Coordination
    If needed, OI contacts law enforcement to request clearance before initiating the civil investigation.
  3. Guardian Notification
    If applicable, guardians are notified and invited to attend the interview with the individual.
  4. Provider Communication
    The OI Investigator contacts the provider agency as part of the investigative process.
  5. On-Site Investigation
    The Investigator visits the location, conducts interviews, and collects all relevant documentation.
  6. Ongoing Oversight
    Investigators hold regular case conferences with Supervisors. Drafts are submitted at 15-day intervals and reviewed by Supervisors.
  7. Evidence Review
    All evidence is reviewed using a preponderance of the evidence standard. Preponderance of evidence means there is evidence sufficient to generate a belief that conclusion is likely and more probable than not.​
  8. Health & Safety Alerts
    Any urgent concerns regarding the individual’s well-being are immediately reported to OI leadership and shared with the provider agency.
  9. Case Closure
    The case is formally closed by the Supervisor, Chief, or Director depending on the findings.
  10. Findings & Corrective Action
    Providers receive a detailed findings letter.
  11. In all cases where OI has identified related concerns, providers are required to submit a Plan of Correction to the DDD Office of Risk Management (ORM). The Plan of Correction must address each allegation or concern, identify corrective actions, and include target dates for completion.