Audit of the Barnstable County Sheriff’s Office—A Review of Healthcare and Inmate Deaths Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Barnstable County Sheriff’s Office.

Overview

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 Barnstable County Sheriff’s Office (BCSO) for the period July 1, 2019 through June 30, 2021.

We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Below is a list of our audit objectives, indicating each question we intended our audit to answer; the conclusion we reached regarding each objective; and, if applicable, where each objective is discussed in the audit findings.

Objective	Conclusion
Did BCSO comply with and implement the requirements of Section 932.17(2) of Title 103 of the Code of Massachusetts Regulations (CMR) and Section B of BCSO’s Policy 600.03 (Guidelines for Serious Injury, Illness or Death) regarding the deaths of inmates in its custody?	Yes
Did BCSO hold quarterly meetings with the healthcare vendor and review quarterly reports in accordance with 103 CMR 932.01(3) and Section A of BCSO’s Policy 600.01 (Health Care/Health Services/Health Services Personnel/Emergency Health Care) for inmates’ healthcare services?	Yes
Did BCSO provide admission medical screenings to its inmates upon intake, and health appraisals within seven days after admission, in accordance with Sections A and B of BCSO’s Policy 602.02 (Admission Medical Screening/Health Appraisal and Examination/Access to Health Care)?	No; see Finding 1
Did inmates at BCSO receive medical care after submission of a Sick Call Request Form in accordance with Section D of BCSO’s Policy 602.02?	Yes

 

To accomplish our objectives, we gained an understanding of BCSO’s internal control environment related to the objectives by reviewing BCSO’s internal control plan and applicable agency policies and procedures, as well as conducting interviews with BCSO management. We evaluated the design and implementation of the internal controls related to our audit objectives. We also tested the operating effectiveness of the supervisory controls on admission medical screenings. To obtain sufficient, appropriate audit evidence to address our audit objectives, we conducted the following audit procedures.

We inspected the list of inmate deaths from BCSO management for the audit period, which reflected one inmate who died in BCSO custody on January 25, 2020 and whose cause of death was reported as natural medical causes. To determine whether BCSO complied with 103 CMR 932.17(2) and its Policy 600.03 regarding the deaths of inmates in its custody, we performed the following procedures:

• We inspected BCSO’s Policy 600.03 to determine whether BCSO has established guidelines that include the following, in accordance with the requirements of 103 CMR 932.17(2):

(a)  internal notification to include medical and administrative staff;

(b)  procedures when discovering the body;

(c)  disposition of the body;

(d)  notification of next of kin;

(e)  notification of [Criminal Offender Record Information] certified individuals as soon as practicable;

(f)   investigation of causes;

(g)  reporting and documentation procedures;

(h)  procedure for review of the incident by appropriate designated staff with a final report submitted to all appropriate parties.

• To determine whether BCSO complied with and implemented the requirements of 103 CMR 932.17(2) and its in-custody death guidelines in Policy 600.03, we performed the following:
• We examined BCSO’s internal notifications for the death in custody during our audit period to ensure that medical and administrative staff members were notified about the unresponsiveness of the inmate, resulting in immediate transportation to the hospital by ambulance.
• We examined the incident report from BCSO’s responding officer to ensure that correctional officers and medical staff members performed life-saving measures on the inmate, as appropriate. We also examined the incident report to ensure that BCSO was notified of the inmate’s death and that the superintendent notified the inmate’s next of kin.
• We asked BCSO management whether a Criminal Offender Record Information notification¹⁴ was needed.
• We examined the Inmate Death Summary from Falmouth Hospital and the Correctional Electronic Medical Records (CorEMR) system report to determine whether the inmate’s cause of death was listed as natural medical causes occurring under the direct care of medical staff and/or hospital care, in which case no further investigation of causes, mortality review, or clinical review were required.

To determine whether BCSO provided healthcare services in compliance with state regulations and its policies, we examined the minutes of all eight quarterly meetings of BCSO and its healthcare vendor that occurred during the audit period. We also examined the quarterly reports (such as risk management reports, infection control reports, and continuous quality improvement monitoring reports) and annual statistical summaries that the vendor provided to BCSO during the audit period.

To determine whether BCSO provided its inmates with admission medical screenings upon intake and health appraisals within seven days of admission, in accordance with Sections A and B of its Policy 602.02, we selected a statistical, random sample with a 95% confidence level, 5% tolerable rate, and 0% expected error rate. Our sample consisted of 60 inmates out of a total population of 1,228 who were admitted to the Barnstable County Correctional Facility (BCCF) for more than seven days during the audit period. We performed the following tests:

• We examined the Medical Entrance Exam Report (for admission medical screenings) for each inmate in our sample to document the date and time it was completed and signed by a healthcare staff member. For inmates who refused the admission medical screening upon intake, we examined the signed inmate refusal form. We then calculated the number of hours after arrival at BCCF the inmate received the admission medical screening to determine whether inmates received the admission medical screening upon intake as required by Section A of BCSO’s Policy 602.02.
• We examined each inmate’s Physical Examination/Initial Chronic Disease Form (for health appraisals) to document the date and time it was completed and signed by a healthcare staff member. We then calculated the number of days after the inmate’s arrival to BCCF the health appraisal was completed to determine whether inmates received the health appraisal within 7 days (or extended to 14 days in some cases) as required by Section B of BCSO’s Policy 602.02 .

To determine whether inmates received medical care after submission of Sick Call Request Forms in accordance with Section D of BCSO’s Policy 602.02, we selected a statistical, random sample with a 95% confidence level, 5% tolerable rate, and 0% expected error rate. Our sample consisted of 60 Sick Call Request Forms out of a total population of 1,243 Sick Call Request Forms submitted by inmates during the audit period. We performed the following procedures:

• We examined each Sick Call Request Form submitted by an inmate and documented the date the form was completed by the inmate and the date it was signed by a healthcare staff member.
• We calculated the number of days between the submission date of the Sick Call Request Form and the date a healthcare staff member reviewed the Sick Call Request Form.
• We examined each Sick Call Request Form and the corresponding CorEMR sick call entry notes to determine whether the healthcare vendor (1) reviewed the Sick Call Request Form for the immediacy of need, (2) suggested treatment that was documented and attached to the inmate’s medical record in CorEMR, and (3) referred problems beyond their scope to the appropriate provider.

Data Reliability Assessment

Offender Management System

To assess the reliability of the inmate data obtained from the Offender Management System (OMS), we interviewed BCSO information technology (IT) personnel who were responsible for oversight of the system. We tested the general IT controls, including access and account management controls. We selected a random sample of 20 inmates from the list of inmates in OMS and agreed each full name, date of birth, booking date, gender, age, and race from the original source document (the mittimus). We also selected 20 random samples from hard copies of the mittimi and traced the inmates’ same information (full name, date of birth, booking date, gender, age, and race) from them to OMS. In addition, we tested the inmate data for duplicate records and matched the death in custody list from OMS with the list the Office of the Chief Medical Examiner provided.

Based on the results of these data reliability procedures, we determined that the OMS data were sufficiently reliable for the purposes of our audit.

CorEMR

We assessed the reliability of the sick call data obtained from CorEMR by conducting interviews with BCSO and Wellpath officials with knowledge about the data. We tested the general IT controls, including access and account management controls. In addition, we tested the sick call data for duplicate records and for any errors to determine the data’s integrity and confirm the completeness and accuracy of it. Additionally, we matched the state identification numbers in CorEMR to the state identification numbers of inmates who were admitted during the audit period listed in OMS.

To confirm the completeness and accuracy of the sick call data in CorEMR, we selected a random sample of 20 Sick Call Request Forms from the sick call list in CorEMR and agreed the patient name, state identification number, date of request, and date of service by the healthcare vendor to the hardcopy Sick Call Request Forms filed by inmates. We also selected a random sample of 20 hardcopy Sick Call Request Forms and traced this information back to the sick call list in CorEMR.

Based on the results of these data reliability procedures, we determined that the CorEMR data were sufficiently reliable for the purposes of our audit.

14.    Criminal Offender Record Information notifications are made to victims of the inmate regarding a change of status, such as the inmate’s release or death.

Date published:	March 16, 2023