Audit of the Barnstable County Sheriff’s Office—A Review of Healthcare and Inmate Deaths Overview of Audited Entity

This section describes the makeup and responsibilities of the Barnstable County Sheriff’s Office.

Overview

The Barnstable County Sheriff’s Office (BCSO) was established as an independent state agency on August 6, 2009, pursuant to Chapter 61 of the Acts of 2009. According to Section 4 of this chapter,

All functions, duties, and responsibilities of the office of a transferred sheriff pursuant to this act, including, but not limited to, the operation and management of the county jail and house of correction and any statutorily authorized functions of that office, are hereby transferred from the county to the commonwealth.

This transition was completed on January 1, 2010. BSCO’s Sheriff became an employee of the Commonwealth but remained an elected official and retained administrative and operational control over BCSO. Under the Sheriff’s direction, the facility’s superintendent administers BCSO operations at the Barnstable County Correctional Facility (BCCF).

According to BCSO’s internal control plan,

The mission of the Sheriff’s Office is to “Protect the public from criminal offenders by operating a safe, secure and rehabilitative correctional facility, assisting local agencies and promoting public safety through our associated specialized services and enforcing the Laws of the Commonwealth of Massachusetts and the Constitution of the United States of America.”

As of June 30, 2021, BCSO had 257 employees, including 151 full-time correction officers, working at BCCF. In fiscal years 2020 and 2021, BCSO’s state appropriations were approximately $36.8 million and $33.5 million, respectively. In addition to its state appropriations, BCSO received the following federal funding to support its programs for these fiscal years.

Program/Grant	Fiscal Year 2020	Fiscal Year 2021	Total
Cops Anti-Heroin Task Force Program*	$           0	$ 10,688	$  10,688
Crime Victims Assistance Programs Grant†	76,004	77,233	153,237
Homeland Security II Grant‡	2,433	0	2,433
Vivitrol Increased Participation Services Grant§	301,956	279,646	581,601
Total	$ 380,393	$  367,567	$ 747,959

*      Cops Anti-Heroin Task Force Program funds were for overtime-related payroll expenditures of BCSO’s officers conducting investigations as part of Federal Organized Crime Drug Enforcement Task Force investigations related to heroin, fentanyl, and prescription opioid trafficking.

†      The Crime Victims Assistance Programs Grant supports victims of crime in the Barnstable county community.

‡      The Homeland Security II Grant was awarded in fiscal year 2019 to the BCSO Community Emergency Response Team Program to address disaster preparedness for hazards that may occur in Barnstable County. The fiscal year 2020 expenditure was a carryforward of these funds.

§      The Vivitrol Increased Participation Services Grant was a three-year grant, which ended on September 29, 2021, for the administration of Vivitrol, a medication used to treat substance use disorders, upon an inmate’s release from BCCF.

BCSO is located at Joint Base Cape Cod in Bourne, which opened in 2004 and is used for the care and custody of pretrial and sentenced inmates. As of June 30, 2021, there were 165 inmates in BCSO custody, including 98 pretrial inmates, of whom 89 were male and 9 were female, and 67 sentenced inmates, of whom 62 were male and 5 were female.

BCCF houses a maximum of 588 inmates, who serve sentences of no more than two and a half years, in 12 housing units. Offenders at BCCF are assigned to one of three houses. House 1 comprises 3 units and holds pretrial detainees.³ House 2 comprises 5 units to hold female inmates, high-risk inmates,⁴ and inmates who break BCSO rules. House 3 comprises the remaining 4 units to hold sentenced male inmates.

According to its website, BCSO inmates and detainees are offered the following programs and services:

• A rehabilitation program, called the Residential Substance Abuse Treatment Program, which includes a Community Reentry Council that meets to facilitate referrals and resources for each inmate six weeks after their release from custody
• Education, which includes career counseling, literacy courses, and English courses (for English-language learners)
• A community relations program, which provides inmate labor for a wide variety of services in the community, including painting, landscaping, carpentry, roofing, siding, simple construction, and demolition.

The healthcare vendor provides healthcare, including mental health, services.

Offender Management System

BCSO uses a system called the Offender Management System (OMS) to track and manage information on inmates in its custody. The information includes inmates’ names, genders, ethnicities, dates of birth, Social Security numbers, state identification numbers,5 booking numbers,⁶ booking dates, release dates, and in‑custody housing assignments.⁷ During an inmate’s admission process, BCSO’s booking officer enters information from a mittimus⁸ into OMS.

Correctional Electronic Medical Records

BCSO uses the Correctional Electronic Medical Records (CorEMR) system to manage inmates’ medical records, appointment scheduling, and offsite healthcare.

Inmate Deaths

Section 932.17 of Title 103 of the Code of Massachusetts Regulations (CMR) requires county correctional facilities such as BCSO’s to establish guidelines for notifications, investigations, reports, and documentation regarding the deaths of inmates or BCCF employees. According to its Policy 600.3 (Guidelines for Serious Illness, Injury or Death), in the event of an inmate’s death, the employee who is first made aware of the incident notifies the Health Services Department, the shift supervisor, the contracted healthcare vendor, and healthcare staff members⁹ to report to the incident location. The notification order then follows the chain of command: The shift supervisor notifies the shift captain, who notifies the duty officer, and the duty officer notifies the superintendent. The superintendent then notifies the Sheriff, the Massachusetts Office of the Chief Medical Examiner, the District Attorney’s office, and the Massachusetts State Police.

If there were no employees present at the time of the death, the superintendent conducts an internal investigation and submits a preliminary report to the Sheriff. The superintendent also submits a final report with a copy of the Office of the Chief Medical Examiner’s report within five days of the incident to the Sheriff. In addition, the responding healthcare staff members complete incident reports and document the time they were notified, the time they arrived at the scene of the incident, the location of the incident, and the medical treatment / emergency medical aid provided (if any). Finally, the Cape and Islands Critical Incident Stress Team debriefs employees who responded to the death of an inmate.

Healthcare

During the audit period, healthcare at BCCF was contractually provided by two third-party vendors (Correctional Psychiatric Services from July 1, 2019 to November 2020 and Wellpath, LLC from November 2020 to June 30, 2021). At BCCF, these contractors accept overall responsibility of healthcare services, including medical, dental, and mental health services.

Attachment A of BCSO’s Inmate Health Care Services Contract, dated October 28, 2020, outlines the following responsibilities of its healthcare vendor:

[The contractor] shall conduct an ongoing health and mental health education and training program for the BCSO staff in accordance with the needs mutually established by the BCSO and the contractor. . . .

[The contractor] will provide a healthcare delivery system that is specifically tailored to Barnstable County’s needs and requirements. . . . [The contractor] will implement a managed care system that will promote efficiency and reduce cost by eliminating unnecessary services and encouraging preventive health measures in the patient population. . . . [The contractor’s] staff will be responsible for identifying all patient healthcare needs and scheduling appropriate treatment, as well as coordinating all emergency and non-emergency on-site and off-site medical services.

According to the contract, BCSO’s Medical Records Department monitors services provided by the healthcare vendor continuously. BCSO is also responsible for establishing effective policies and procedures, including policies and procedures about information technology security, for the healthcare vendor and its employees. The contract requires the healthcare vendor to meet quarterly with BCSO and submit quarterly healthcare reports about the overall operation of healthcare services to BCSO. Additionally, BCSO conducts background checks on healthcare vendor’s proposed healthcare staff members providing services at BCCF to ensure that they do not constitute a security risk.

Administrative Oversight of Healthcare Services

According to 103 CMR 932.01(3), county correctional healthcare vendors must meet with the Sheriff, facility administrator, or a designee selected by BCSO at least quarterly and submit quarterly reports on the healthcare delivery system and health environment, as well as annual statistical summaries¹⁰ to BCSO. The healthcare vendor documents and maintains meeting minutes which is reviewed by BCSO staff at the next quarterly meeting. The meetings cover quality improvement, emergency drills, mortality review findings, and other statistical reports used to monitor trends in the delivery of healthcare at BCSO.

Admission Medical Screening

Section A of BCSO’s Policy 602.02 (Admission Medical Screening/Health Appraisal and Examination/Access to Health Care) requires an admission medical screening, which is documented with the Medical Entrance Exam Report, by a healthcare staff member for each inmate upon intake at BCCF before placement in the general population to ensure that their health needs are identified and addressed. The screening consists of a structured inquiry and observation to identify potential emergencies and to ensure that inmates with known illnesses, health needs, and medications are identified for further assessment and continued treatment while in custody. A healthcare staff member immediately records the findings of the screening upon completion in CorEMR. Upon arrival at BCCF, if an inmate is determined to be in an emergency condition, they are transported by either ambulance or BCSO transport vehicle to Falmouth Hospital’s emergency department for evaluation and treatment. Any inmate who is determined to pose a serious risk of communicable or infectious disease is confined apart from the general population until they have medical clearance.¹¹

According to BCSO Policy 602.02, an inmate has the right to waive the admission medical screening by signing a Refusal of Medical Care Form.

Access to healthcare services is communicated both verbally and in writing to all inmates upon admission. Special procedures, including the use of a translation service,¹² ensure that inmates who may have difficulty communicating with employees understand how to access healthcare services.

Health Appraisal / Physical Examination

According to Section B of BCSO’s Policy 602.02, each inmate committed to BCCF for 30 days or more is required to have a health appraisal, which is documented with the Physical Examination/Initial Chronic Disease Form, no later than 7 days after admission. This timeframe can be extended to 14 days if the admission medical screening was performed by a physician or registered nurse. If the inmate’s medical file indicates that they received a health appraisal within the last 90 days at BCCF, the appraisal is not required. A healthcare staff member completes the health appraisal, which includes, but is not limited to, reviewing the inmate’s medical record, examining the inmate for any signs of trauma (mental or physical) or disease, conducting medically indicated tests, and reviewing findings and any follow-up services with inmates who require further treatment. The healthcare vendor collects and records inmates’ health appraisal data in the inmate’s medical record in CorEMR, which is approved by a qualified healthcare professional.¹³

Sick Call Requests

According to Section D of BCSO’s Policy 602.02, “All inmates shall have the opportunity to request medical assistance by completing a Sick Call Request Form and submit it to the Health Services Department.” During our audit period, BCSO’s healthcare vendor administered the sick call process.

To request access to healthcare, an inmate completes a Sick Call Request Form that states the type of service requested (medical, dental, or mental health); the date the form is completed; and the nature of the problem or request. They also add their name, state identification number, date of birth, and signature. They submit the Sick Call Request Form by putting it in a secure lockbox in their housing unit or handing it directly to a healthcare staff member during a medication pass, which occurs at least twice a day. Healthcare staff members pick up the Sick Call Request Forms daily to evaluate and triage the requests. Any request that requires the attention of the physician is attached to the inmate’s medical record and given to the attending physician. Sick calls are available to inmates five days a week and qualified healthcare professionals provide treatment according to clinical priorities and schedule follow‑up appointments. All Sick Call Request Forms are filed in inmates’ medical records in CorEMR.

3.    A detainee is a person held in custody before their trial.

4.    BCSO determines the risk level of an inmate based on their current offense, the severity of any prior convictions, any history of escapes and/or escape attempts, or any prior violent behavior.

 

5.    A state identification number is a unique number assigned to an inmate from a court system.

6.    A booking number is a unique number assigned by BCSO to an inmate upon their arrival to BCCF.

7.    A housing assignment is an inmate’s specific unit, cell, and bed within BCCF.

8.    A mittimus is a written court-issued document that follows an inmate through their time in the criminal justice system.

9.    According to BCSO’s healthcare vendor WellPath’s Policy HCD-100_E-02 (Receiving Screening), healthcare staff members are “qualified health care professionals as well as administrative and supportive staff (e.g., health records administrators, laboratory technicians, nursing and medical assistants, and clerical workers).”

10.       The statistical summary contains data related to inmate health records and provides a comprehensive overview of medical services delivered to inmates during the year.

 

11.    According to WellPath’s Policy HCD-100_E-02 (Receiving Screening), medical clearance is “a clinical assessment of physical and mental status before an individual is admitted into the facility. The medical clearance may come from the on-site health care staff or may require sending the individual to the hospital emergency room. The medical clearance is to be documented in writing.”

12.    The translation service provides support in 240 languages and is available 24 hours a day, 7 days a week, to BCSO correctional officers and medical staff members.

13.    According to Wellpath’s Policy HCD-100_A-02, qualified healthcare professionals include “physicians, physician assistants, nurses, nurse practitioners, dentists, . . . mental health professionals, and others who by virtue of education, credentials, and experience are permitted by law to evaluate and care for patients.”

Date published:	March 16, 2023