| Organization: | Office of the State Auditor |
|---|---|
| Date published: | November 25, 2025 |
Executive Summary
In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has conducted a performance audit of certain activities of the Berkshire County Sheriff’s Office (BCSO) for the period July 1, 2022 through June 30, 2024. When designing the audit plan for employee settlement agreements entered into by BCSO, we extended the audit period to January 1, 2019 through June 30, 2024.
The purpose of our audit was to determine the following:
- Did BCSO have policies that complied with the requirements of Section 932.17(2) of Title 103 of the Code of Massachusetts Regulations (CMR) regarding the death of inmates in its custody?
- Did BCSO hold internal quarterly meetings and review quarterly reports regarding healthcare services for inmates as required by its “BCSO-095R” policy in accordance with 103 CMR 932.01(3)?
- Did BCSO provide its inmates with medical screenings upon admission and physical examinations within 7 to 14 days after admission in accordance with 103 CMR 932.06 and 932.07, BCSO’s “BSCO-100R” policy, and BCSO’s “BCSO-101R” policy?
- Did BCSO ensure that inmates received medical care after the submission of sick call requests in accordance with BCSO’s “BCSO-103R” policy and 103 CMR 932.09?
- Did BCSO provide initial mental health screenings and, if necessary, follow-up mental health assessments, to all within its custody in accordance with BCSO’s “BCSO-107R” policy and 103 CMR 932.13?
- Did BCSO have internal policies and procedures in place for (a) the review and approval of employee settlement agreements, including the language used, and (b) the reporting of employee settlement agreements to the Office of the Comptroller of the Commonwealth (CTR)? For employee settlement agreements entered into from January 1, 2019 through June 30, 2024, did BCSO follow these policies, and did it refrain from using non-disclosure, non-disparagement, or similarly restrictive clauses as part of employee settlement agreement language?
Below is a summary of our findings, the effects of those findings, and our recommendations, with hyperlinks to each page listed.
| Finding 1 | BCSO’s internal policy for the death of an inmate in custody should contain certain guidelines regarding deaths of inmates in its custody. |
| Effect | By not establishing guidelines related to the disposition of the body of a deceased inmate, BCSO may take on a higher-than-acceptable risk of incorrectly handling the disposition of a deceased inmate’s body. Without guidelines for investigating the cause of an inmate’s in-custody death, BCSO may not be able to identify the circumstances that led to the inmate’s death. |
| Recommendation | BCSO should update its policy to establish guidelines related to the disposition of an inmate’s body and the investigation of the cause of death. |
| Finding 2 | BCSO should submit all required quarterly reports. |
| Effect | By not submitting quarterly reports regarding the healthcare environment during the audit period, BCSO may increase the risk of not identifying patterns in inmate illnesses or injuries and not receiving key information to make decisions regarding inmates’ healthcare. |
| Recommendation | BCSO should establish policies and procedures, including monitoring controls, to ensure that all quarterly reports are generated and submitted in a timely manner. |
| Finding 3 | BCSO’s Medical Intake Screening form should include fields regarding past and present treatment or hospitalization for mental health concerns or risk of suicide or suicidal thoughts. |
| Effect | Because BCSO’s Medical Intake Screening form does not inquire about past and present treatment or hospitalization for mental health concerns or risk of suicide or suicidal thoughts, there is a higher-than-acceptable risk that inmates’ mental health issues may not be identified and treated, potentially affecting the health and safety of the inmates in question, other inmates whom they interact with, BCSO employees, and BCSO vendors. While BCSO is providing mental health services to its inmates and reports that it closely monitors inmates who it suspects have mental health conditions, BCSO may not be identifying mental health concerns as early as it possibly could if it were to inquire about past or present mental health treatments in its Medical Intake Screening form. |
| Recommendation | BCSO should update its Medical Intake Screening form to ensure that it includes the inquiry of past and present treatment or hospitalization for mental health concerns or risk of suicide. |
| Finding 4 | BCSO should ensure that Inmate Request Slips for sick call requests were triaged on time. |
| Effect | If BCSO does not follow up on all sick call requests, then there is a higher-than-acceptable risk that inmates may not have their healthcare issues properly resolved, either within the required 24 hours or at all. |
| Recommendation | BCSO should ensure that its QHPs follow up on all sick call requests, and that they do so within 24 hours of receipt of the request. |
| Finding 5 | BCSO should have documented internal policies or procedures regarding state employee settlement agreements and supporting records, as would be best practice. |
| Effect | A documented, written process to handle employee settlement agreements, especially for those containing non-disclosure, non-disparagement, or similarly restrictive clauses, can help ensure that employee settlements are handled in an ethical, legal, and appropriate manner. |
| Recommendation | BCSO should develop, document, and implement a written policy related to employee settlement agreements, including prohibiting the use of non-disclosure, non-disparagement, or similarly restrictive clauses in its agreements, as recommended in the Governor’s “Executive Department Settlement Policy,” issued January 27, 2025. |
Post-audit Action
During our audit, we were informed that, and subsequently provided evidence regarding, new policies regarding the deaths of inmates in BCSO’s custody and sick call requests. We acknowledge that changes have been made to these policies, but we cannot test the effectiveness of the changes because they occurred after the end of our testing and outside the audit period. Additionally, BCSO provided a new policy on settlement agreements to us. However, the policy that was put in place does not outline any internal processes other than that BCSO will follow CTR’s policy for processing employee settlement payments. The policy does not include prohibiting the use of non-disclosure, non-disparagement, or similarly restrictive clauses in its agreements. Finally, BCSO provided meeting minutes that it believes serve as the required quarterly reports on the healthcare system. However, we do not believe that meeting minutes constitute the required reports.
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Open PDF file, 416.73 KB, Audit Report - Berkshire County Sheriff’s Office (English, PDF 416.73 KB)