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 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.
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 |
|---|---|
| No; see Finding 1 |
| No; see Finding 2 |
| No; see Finding 3 |
| No; see Finding 4 |
| Yes |
| No; see Finding 5 |
To accomplish our audit objectives, we gained an understanding of the BCSO internal control environment relevant to our objectives by reviewing applicable policies, procedures, and BCSO’s internal control plan, as well as by interviewing BCSO officials. For quarterly meetings regarding the inmate healthcare system, we evaluated the design and implementation and tested the operating effectiveness of internal controls related to the generation of meeting minutes. In addition, to obtain sufficient, appropriate evidence to address our audit objectives, we performed the procedures described below.
Inmate Deaths
To determine whether BCSO had policies that complied with the requirements of 103 CMR 932.17(2) regarding the death of inmates in its custody, we inspected BCSO’s “BCSO-111R(2)” policy to determine whether BCSO had guidelines that include the following requirements listed in 103 CMR 932.17(2):
(a) internal notification to include medical and administrative staff;
(b) procedures when discovering body;
(c) disposition of the body;
(d) notification of next of kin;
(e) [Criminal Offender Record Information] notification [sent to victim(s) of an inmate] as soon as practicable [when such notification is necessary];
(f) investigation of causes;
(g) reporting and documentation procedures;
(h) procedure for review of incident by appropriate designated staff with a final report submitted to all appropriate parties.
For this objective, we found certain issues during our testing; namely, that BCSO’s “BCSO-111R(2)” policy did not comply with the requirements of 103 CMR 932.17(2). See Finding 1 for more information.
Quarterly Healthcare Meetings and Reports
To determine whether BCSO held internal quarterly meetings and reviewed quarterly reports regarding healthcare services for inmates as required by its “BCSO-095R” policy, in accordance with 103 CMR 932.01(3), we took the following actions. We requested, and BCSO provided us with, the meeting minutes of the population of eight (100%) of the quarterly meetings that took place during the audit period. These meetings were attended by the facility administrators responsible for healthcare, the superintendent (or their designee), a physician, the mental health director, the health authority, and the Sheriff (or their designee). We then reviewed the dates on which the meetings were held, who attended, and whether inmate healthcare services were discussed. We also requested all quarterly reports that were required to be submitted during the audit period. BCSO was unable to provide these documents.
For this objective, we found certain issues during our testing; namely, that BCSO did not submit any of the required quarterly reports as required by BCSO’s “BCSO-095R(4)” policy or in accordance with 103 CMR 932.01(3). See Finding 2 for more information.
Admission Medical Screenings and Physical Examinations
To determine whether BCSO provided its inmates with medical screenings upon admission in accordance with 103 CMR 932.06 and 932.07, BCSO’s “BSCO-100R” policy, and BCSO’s “BCSO-101R” policy, we took the following actions. We selected a random, statistical4 sample of 60 inmates out of the population of 1,263 inmates who were admitted to the Berkshire County Jail and House of Correction (BCJHOC) during the audit period. We made this selection using a 95% confidence level,5 a 0% expected error rate,6 and a 5% tolerable error rate.7 We then inspected the Medical Intake Screening forms associated with our sample to determine whether all of the policy requirements were incorporated into the form and whether each field was completed for each inmate.
To determine whether BCSO provided its inmates with physical examinations within 7 or 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, we took the following actions. We selected a random, nonstatistical8 sample of 50 inmates out of the population of 744 inmates who were admitted to BCJHOC and were in custody for 30 days or more during the audit period. We then performed the following procedures:
- We inspected the Physical Assessment forms associated with our sample to determine whether all of the policy requirements were incorporated into the form and whether each field was completed for each inmate.
- We used the date on each Physical Assessment form to calculate the number of days between each inmate’s admission date and the date on which their physical examination was completed to determine whether BCSO completed each physical examination within the required timeframe.
- We determined whether the physical examination was completed within 7 days of admission, if the admission medical screening was completed by a licensed practical nurse.
- We determined whether each physical examination was completed within 14 days of admission, if the admission medical screening was completed by a physician, physician’s assistant, or registered nurse.
For the aspect of our objective regarding providing inmates with a medical screening upon admission, we found certain issues during our testing; namely, that BCSO’s Medical Intake Screening form did not include fields regarding past and present treatment or hospitalization for mental health concerns or risk of suicide or suicidal thoughts. See Finding 3 for more information.
For the aspect of our objective regarding providing inmates with physical examinations within the required timeframe, we concluded that, based on our testing, BCSO met the relevant criteria.
Medical Care After Submission of Sick Call Requests
To determine whether BCSO ensured 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, we took the following actions. First, we selected a random, statistical sample of 60 sick call requests from the population of 7,482 sick call requests made during the audit period, using a 95% confidence level, a 0% expected error rate, and a 5% tolerable error rate. We reviewed the inmate medical files associated with our sample to determine whether these inmates received a face-to-face meeting with a qualified healthcare professional (QHP) within 24 hours of submitting a sick call request.
For this objective, we found certain issues during our testing; namely, that BCSO did not consistently provide inmates with face-to-face meetings with QHPs within 24 hours of the submission of sick call requests. See Finding 4 for more information.
Initial Mental Health Screenings and Follow-Up Mental Health Assessments
To determine whether BCSO provided initial mental health screenings and, if necessary, follow-up mental health assessments, to all inmates within its custody in accordance with BCSO’s “BCSO-107R” policy and 103 CMR 932.13, we took the following actions. We selected a random, statistical sample of 60 inmates out of the population 1,263 inmates who were admitted to BCJHOC during the audit period, using a 95% confidence level, a 0% expected error rate, and a 5% tolerable error rate. We then performed the following procedures:
- For each inmate in our sample, we inspected their Initial Mental Health Screening form to determine whether each field in the form was completed.
- We used the date on the Initial Mental Health screening form to calculate the number of days between each inmate’s admission date and the date on which their initial mental health screening was completed to determine whether BCSO completed these screening upon each inmates’ admissions to BCJHOC.
- For each inmate in our sample who was identified as potentially mentally ill, disabled, or posing a risk to themself or others, we determined whether they were referred to qualified mental health professionals for further evaluation.
- For each inmate in our sample, we inspected their Mental Health Assessment form to determine whether each field in the form was completed, and whether the assessment was reviewed by a mental health administrator.
- For each inmate in our sample, we reviewed their Mental Health Assessment form to determine whether recommendations regarding housing monitoring, treatment, and transfer were made to shift commanders or unit managers if issues were identified during the assessment that required follow-up care.
For this objective, we found no significant issues during our testing. Therefore, we concluded that, based on our testing, BCSO met the relevant criteria regarding providing inmates with initial mental health screenings and, if necessary, follow-up mental health assessments.
Employee Settlement Agreements
To determine whether BCSO had 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 CTR, we inquired with the BCSO superintendent regarding the process of entering into settlement agreements and the use of non-disclosure, non-disparagement, or similarly restrictive clauses. According to the BCSO superintendent, every settlement agreement is managed on a case-by-case basis.
To determine whether BCSO refrained from using non-disclosure, non-disparagement, or similarly restrictive clauses as part of employee settlement agreements, we reviewed the language in the population of two (100%) employee settlement agreements that BCSO entered into during the extended audit period.
To determine whether BCSO properly reported monetary settlements to CTR, we requested and reviewed copies of the two settlement agreements.
For the aspect of our objective regarding non-disclosure, non-disparagement, or similarly restrictive clauses within state employee settlement agreements and the use and reporting of such settlement agreements to CTR, we concluded that, based on our testing, BCSO refrained from entering into employee settlement agreements that contained such language. We also concluded that BCSO was not required to report these settlement agreements to CTR because they were non-monetary. However, we found certain issues during our testing; namely, that BCSO did not have documented internal policies or procedures regarding state employee settlement agreements and supporting records. See Finding 5 for more information.
We used a combination of statistical and nonstatistical sampling methods for testing. Where we used nonstatistical sampling methods, we did not project the results of our testing to the corresponding populations.
Data Reliability Assessment
Inmate Deaths
To assess the reliability of the list of inmate deaths that occurred during the audit period, we interviewed BCSO staff members who were knowledgeable about the process following an inmate’s death. We requested a list of all in-custody deaths that occurred during the audit period, and the person who was the assistant deputy superintendent of the medical department at the time of our inquiry informed us that there were no inmate deaths that occurred during the audit period. We also requested a list of inmate deaths that were processed by the Office of the Chief Medical Examiner during the audit period to determine whether there were any deaths during the audit period. The Office of the Chief Medical Examiner confirmed that there were no deaths of inmates in BCSO’s custody during the audit period.
Quarterly Healthcare Meetings and Reports
To assess the reliability of the list of quarterly healthcare meetings held during the audit period, we interviewed BCSO medical staff members who were involved in the quarterly meetings. We requested, and BCSO provided us with, copies of the meeting minutes for all eight of the quarterly meetings that were held during the audit period.
Inmate Information System
To assess the reliability of the inmate data we obtained from BCSO’s inmate information system, we interviewed the information technology staff members who were knowledge about the system. We tested general information technology controls (i.e., access and security management controls). We selected a random sample of 20 inmates from the list of inmates in the inmate information system and compared the inmates’ information from the list to the information in the original source documentation (i.e., the mittimuses or booking records) for agreement. We also selected 20 random hard copies of the mittimuses or booking records and compared the inmates’ information from that documentation to the information on the list of inmates from the inmate information system for agreement. In addition, we tested all 1,792 lines of inmate data to ensure that it did not contain certain dataset issues (i.e., duplicate records, missing values in necessary data fields, and data corresponding to dates outside the audit period).
Medical Record Management System
To assess the reliability of the list of sick call requests that originated from BCSO’s medical record management system, we interviewed the assistant deputy superintendent of the medical department, who was knowledgeable about the system. We tested general information technology controls (e.g., access and security management controls). We ensured that the total number of lines of data related to sick call requests in the list that BCSO sent to us matched the total number of lines of data that BCSO’s real-time query of sick call requests within the medical record management system produced.
In addition, we tested the list to ensure that it did not contain certain dataset issues (i.e., duplicate records, missing values in necessary data fields, improper formatting for columns containing dates, and data corresponding to dates outside the audit period). The sick call request data that originated from the medical records management system was the only data used for this aspect of our data reliability assessment since it was the only source of data available.
Employee Settlement Agreements
BCSO’s superintendent provided us with the population of two (100%) employee settlement agreements that BCSO entered into during the extended audit period of July 1, 2019 through June 30, 2024.
To ensure the accuracy of the list, we requested all legal expenses that BCSO incurred during the extended audit period and reviewed the invoices associated with each legal expense to determine whether they were related to employee settlements. We reviewed CTR’s settlements and judgments data to determine whether there were any additional employee settlements entered into by BCSO during the extended audit period. Further, we queried the Commonwealth Information Warehouse[1] for any settlements paid out to BCSO employees.
Based on the results of the data reliability assessment procedures described above, we determined that the information we obtained during the course of our audit was sufficiently reliable for the purposes of our audit.
[1]. The Commonwealth Information Warehouse contains historical budget, human resources, and payroll information, as well as financial transaction data from the Massachusetts Management Accounting and Reporting System, which is the state’s official accounting system.
| Date published: | November 25, 2025 |
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