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Audit

Audit  Audit of the Massachusetts Department of Correction

Our office conducted a performance audit of certain activities of the Massachusetts Department of Correction (DOC) for the period July 1, 2022 through June 30, 2024.

Organization: Office of the State Auditor
Date published: December 19, 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 Massachusetts Department of Correction (DOC) for the period July 1, 2022 through June 30, 2024.

The purpose of our audit was to determine the following:

  • whether DOC provided verbal and written instructions to incarcerated individuals (I/I), upon admission, that explain the procedures for gaining access to healthcare services within a timely manner, including to I/Is with learning barriers1 and/or limited English proficiency (LEP), to ensure that they understood their rights before the initiation of any healthcare services in accordance with Sections 630.02(3), 630.08, and 630.09(1) and (2) of DOC’s Medical Services Policy and Section 650.03 of DOC’s Mental Health Services Policy regarding informed consent and
  • whether DOC provided educational counseling and placement for criminally sentenced I/Is with Americans with Disabilities Act (ADA) accommodations and/or LEP, as required by Section 48 of Chapter 127 of the General Laws and Sections 441.04, 441.05, and 441.10 of DOC’s Inmate Training and Education Policy.

Below is a summary of our findings, the effects of those findings, and our recommendations, with hyperlinks to each page listed.

  
Finding 1
DOC did not always retain evidence of completed orientation forms and informed consent for healthcare services during admission, as required by its I/I admission policies.
EffectIf DOC management does not follow record retention requirements, which should include the establishment of internal policies and procedures requiring the retention of all healthcare forms and records, DOC cannot ensure that its I/Is received proper healthcare.
Recommendations
 
  1. DOC management should establish record retention requirements by developing and documenting internal procedures, or modifying existing policies, regarding the processing and retention of informed consent and orientation forms (for general orientation and mental health orientation). For example, DOC could modify its health orientation policy to require that DOC collect signed acknowledgement forms from I/Is and maintain these records as evidence that I/Is understood the admission policies.
  2. DOC management should monitor the record retention process it establishes by periodically reviewing healthcare records to ensure that employees adhere to the record retention procedure. Further, DOC should reevaluate the record retention procedure as changes to the process become necessary.
  3. DOC management should provide training for its staff members and vendor employees on newly created record retention requirements to ensure that all employees adhere to these requirements.
Finding 2
DOC did not always retain evidence of interpreter services being used during initial healthcare orientations and informed consent meetings, potentially affecting the ability of I/Is to make informed healthcare decisions.
EffectIf DOC management does not follow record retention requirements, which should include the establishment of internal policies and procedures requiring the retention of all evidence that interpreter services were performed, DOC cannot ensure that its I/Is understand the healthcare information presented to them so that they can make informed healthcare decisions.
Recommendations
 
  1. DOC management should establish record retention requirements by developing and documenting internal procedures regarding the use of qualified bilingual staff members, including employees, contractors, and vendor employees, to ensure that records are retained for the use of staff interpreter services when working with non-English-speaking I/Is.
  2. DOC management should monitor the record retention process it establishes by periodically reviewing all interpreter service records to ensure that employees adhere to the record retention procedure. Further, DOC should reevaluate the record retention procedure as changes to the process become necessary.
  3. DOC management should ensure that all employees, contractors, and vendor employees are trained in the policies and procedures for all types of interpreter services used by DOC and that they are trained in how to properly document and retain the use of these services in PPD and in I/Is’ electronic medical records.
Finding 3
DOC did not always retain evidence of annual hardcopy personalized program plans in I/Is’ six-part folders, as required by 103 CMR 155.00.
EffectIf DOC management does not ensure that existing record retention policies are being adhered to or does not establish new policies or procedures regarding the proper filing of records in a timely manner to ensure compliance with record retention policies, DOC cannot ensure that its I/Is are receiving proper educational, vocational, or behavioral program recommendations.
Recommendations
 
  1.  DOC management should establish record retention requirements by developing and documenting internal procedures, or modifying existing policies, regarding the processing and retention of PPPs in I/Is’ six-part folders. Furthermore, DOC should consider implementing the review, signing, and filing of PPPs electronically rather than as hardcopy files in I/Is’ six-part folders and should consider updating 103 CMR 155.00 accordingly.
  2. DOC management should monitor the record retention process it establishes by periodically reviewing I/Is’ six-part folders to ensure that employees adhere to the record retention procedure. Further, DOC should reevaluate the record retention procedure as changes to the process become necessary.
  3. DOC should provide training for its staff members on the newly created record retention requirements to ensure that all employees adhere to these requirements.
Finding 4
 		DOC did not always retain evidence of interpreter services being used during program review meetings, potentially affecting the ability of I/Is to understand available educational opportunities.
EffectIf DOC management does not follow record retention requirements, which should include the establishment of internal policies and procedures requiring the retention of all evidence that interpreter services were performed, DOC cannot ensure that its I/Is understood the information presented to them during the program review meetings so that they could understand the available educational opportunities.
Recommendations
 
  1.  DOC management should establish record retention requirements by developing and documenting internal procedures regarding the use of interpreter services to ensure that records are retained for the use of all interpreter services when working with non-English-speaking I/Is.
  2. DOC management should monitor the record retention process it establishes by periodically reviewing all interpreter service records to ensure that employees adhere to the record retention procedure. Further, DOC should reevaluate the record retention procedure as changes to the process become necessary.
  3. DOC management should ensure that all employees are trained in the policies and procedures for all types of interpreter services used by DOC and that they are trained in how to properly document and retain documentation about the use of these services in PPD.

In addition to the conclusions we reached regarding our audit objectives, we also identified issues not specifically addressed by our objectives. For more information, see Other Matters.


 

1.    For our audit purposes, learning barriers included the following Americans with Disabilities Act accommodation, selected from DOC’s I/I accommodation list: auditory, visual, cognitive, psychological, and/or neurological impairments. 

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