Audit of the Bristol 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 Bristol County Sheriff’s Office—A Review of Healthcare and Inmate Deaths.

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 Bristol County Sheriff’s Office (BCSO) for the period July 1, 2020 through June 30, 2022.

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 12.08.07 (Death of an Inmate) of BCSO’s Policy 12.08.00 (Terminal Illness, Advance Directives and Death) regarding the deaths of inmates in its custody?	Yes
Did BCSO hold quarterly meetings with its contracted healthcare provider and review quarterly reports regarding healthcare services for inmates in accordance with 103 CMR 932.01(3)?	Yes
Did BCSO provide its inmates with intake medical screenings upon admission and a physical examination and initial health assessment within 14 days after admission, in accordance with Sections 12.02.04 (Intake Medical Screenings Procedures) and 12.02.06 (Comprehensive Physical Examination and Health Assessment) of BCSO’s Policy 12.02.00 (General Inmate Medical Procedures)?	Yes
Did inmates at BCSO receive medical care after submission of a sick call request form in accordance with Section 12.02.09 (Clinical Services) of BCSO’s Policy 12.02.00?	No; see Finding 1

 

To accomplish our objectives, we reviewed BCSO’s internal control plan and applicable policies and procedures, conducted site visits, and interviewed BCSO’s management. In this way, we gained an understanding of BCSO’s internal control environment in areas relevant to the audit objectives. We evaluated the design and implementation of the internal controls related to our audit objectives. We also tested the operating effectiveness of internal controls (specifically, supervisory review) for intake medical screenings. To obtain sufficient, appropriate evidence to address our objectives, we conducted the following audit procedures.

Inmate Deaths

We inspected the list of inmate deaths that occurred during the audit period, which BCSO management provided to us. This list included three inmates who died in BCSO’s custody on August 25, 2021, October 23, 2021, and October 28, 2021, and whose causes of death were reported as suicide (two) and natural causes (one). To determine whether BCSO complied with 103 CMR 932.17(2) and Section 12.08.07 of BCSO’s Policy 12.08.00 regarding the deaths of inmates in its custody, we performed the following procedures:

• We inspected Section 12.08.07 of BCSO’s Policy 12.08.00 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.

• To determine whether BCSO complied with and implemented the requirements of 103 CMR 932.17(2) and Section 12.08.07 of BCSO’s Policy 12.08.00 regarding the three in-custody deaths that occurred during the audit period, we performed the following procedures:
• We examined each BCSO incident report submitted by all BCSO responding contracted healthcare providers and witnesses to the inmates’ deaths to ensure that medical and administrative staff members were notified about the deaths, including the superintendent and the Special Investigations Unit (SIU).
• We examined each BCSO incident report and each investigative report corresponding to each death to ensure that the responding contracted healthcare provider documented the lifesaving measures and notified the appropriate parties about the inmate’s condition.
• We examined each death certificate from the Office of the Chief Medical Examiner (OCME) and any applicable email correspondence from SIU to BCSO’s superintendent to ensure that BCSO notified OCME of the inmate’s death.
• We examined each BCSO incident report and any applicable email correspondence to ensure that the superintendent (or their designee) notified each deceased inmate’s next of kin.
• We examined the victim notification registry from the Criminal Justice Information System to ensure that, if applicable, BCSO sent a Criminal Offender Record Information notification¹⁶ to any victim(s) of each inmate as soon as possible.
• We examined each BCSO incident report and each investigative report to ensure that SIU performed an investigation of the cause(s) of death.
• We examined each death report generated by the Offender Management System (OMS), each BCSO incident report, and each investigative report to ensure that BCSO complied with CMR and BCSO’s policy on reporting and documentation procedures related to each death.
• We examined each SIU investigative report, each incident report, and each morbidity and mortality review to ensure that appropriate staff members reviewed the circumstances surrounding the inmate’s death and that a final report was submitted to all appropriate parties.

We noted no exceptions in our testing. Therefore, we determined that BCSO complied with and implemented the requirements of 103 CMR 932.17(2) and Section 12.08.07 of BCSO’s Policy 12.08.00 regarding the deaths of inmates in its custody during the audit period.

Quarterly Meetings

To determine whether BCSO held quarterly meetings with its contracted healthcare provider and reviewed quarterly reports in accordance with 103 CMR 932.01(3) and BCSO’s policies, we examined the minutes of 100% (eight) of the quarterly meetings that took place during the audit period between BCSO and its contracted healthcare provider. In addition, we inspected 100% (eight) of the quarterly reports discussed in each of the quarterly meetings, which covered topics such as audits and accreditation, staffing levels, infection control reports, significant inmate injuries, grievances, suicide attempts, deaths, mental health concerns, and high-risk inmates. We also inspected the contents of 100% (three) of the annual statistical summaries that the contracted healthcare provider submitted to BCSO during the audit period. We also examined the program attendance sheets, signed by meeting attendees from both BCSO and its contracted healthcare provider.

We noted no exceptions in our testing. Therefore, we determined that BCSO held quarterly meetings with the contracted healthcare provider and reviewed quarterly reports in accordance with 103 CMR 932.01(3) during the audit period.

Intake Medical Screenings and Health Assessments

To determine whether BCSO provided its inmates with intake medical screenings within 24 hours of each inmate’s admission and initial health assessments within 14 days after admission in accordance with Sections 12.02.04 and 12.02.06 of BCSO’s Policy 12.02.00, we selected a random, statistical sample using a 95% confidence level, 0% expected error rate, and a 5% tolerable error rate. Our sample consisted of 60 inmates out of a total population of 15,509 inmates who were admitted to either the Bristol County House of Correction and Jail or the Ash Street Jail and Regional Lock-Up during the audit period. Using our sample, we performed the following procedures:

• We examined each inmate’s Receiving Screening Form to verify the date and time it was completed and signed by a qualified healthcare professional. We then compared the date of each inmate’s admission to the date the receiving screening was completed to determine whether BCSO complied with its policy.
• We calculated the number of days each inmate was committed at either the Bristol County House of Correction and Jail or the Ash Street Jail and Regional Lock-Up by comparing the inmate’s admission date and release date to determine whether the inmate required an initial health assessment. We examined the initial health assessment form and verified the date and time a qualified healthcare professional completed the initial health assessment. We then calculated the number of days between each inmate’s admission date and the date their initial health assessment was completed to determine whether BCSO complied with its policy.

We noted no exceptions in our testing. Therefore, we determined that during the audit period, BCSO provided each of its inmates with an intake medical screening within 24 hours of each inmate’s admission and an initial health assessment within 14 days after admission, in accordance with BCSO’s Policy 12.02.00.

Sick Call Requests

To determine whether inmates received medical care after they submitted a Sick Call / Medical Encounter Request Form (MERF) in accordance with Section 12.02.09 of BCSO’s Policy 12.02.00, we selected a random, statistical sample using a 95% confidence level, 0% expected error rate, and a 5% tolerable error rate. Our sample consisted of 60 MERFs out of a total population of 17,245 MERFs that inmates submitted during the audit period. Using our sample, we performed the following procedures:

• We examined each MERF and documented the date the form was completed by the inmate and the date it was signed by the contracted healthcare provider (which indicates that the medical care was provided). We then calculated the number of days between the submission date of each MERF and the date the contracted healthcare provider reviewed the MERF to determine whether the sick call request was triaged within 24 hours after its receipt.
• We examined each MERF and the corresponding Electronic Health Record (EHR) system progress notes to determine whether the contracted healthcare provider reviewed the MERF for the immediacy of needed intervention and provided required intervention.
• We examined each progress note in the EHR system and documented the dates of face-to-face meetings between the inmates and the contracted healthcare provider. We then calculated the number of days between the date the contracted healthcare provider received the MERF and the date a face-to-face meeting was held to determine whether a face-to-face meeting occurred within 72 hours.
• We examined each progress note in the EHR system and determined whether the qualified healthcare professional suggested a treatment and referred problems beyond their expertise to a more appropriate qualified healthcare professional, either internal or external as needed.

Based on the results of the testing performed, we determined that during the audit period, BCSO inmates did not consistently receive medical care after submission of a sick call request in accordance with Section 12.02.09 of BCSO’s Policy 12.02.00. Please see Finding 1 for more information.

Data Reliability Assessment

OMS

To assess the reliability of the inmate data that we obtained from OMS, we interviewed BCSO’s information technology employees who oversee the system. We tested general information technology controls (e.g., access and security management controls). We selected a random sample of 20 inmates from the list of inmates in OMS and compared the inmates’ information from this list (i.e., their full name, date of birth, booking date, and sex) to the information in one of the original source documents (e.g., the mittimus, probation warrant, arrest report, or warrant from the state police) for agreement. We also selected a random sample of 20 hard copies of the mittimuses and compared the inmates’ information from the mittimuses (i.e., their full name, date of birth, booking date, and sex) to the OMS new inmate admission data for agreement. In addition, we compared OMS new inmate admission data to OMS inmate census data and tested the OMS new inmate admission data of 15,509 inmates for duplicate records. We reconciled the list of in-custody deaths from OMS with the list provided to us by OCME.

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

EHR System

To assess the reliability of the sick call data that we obtained from the EHR system, we interviewed officials (from BCSO and its contracted healthcare provider) who were knowledgeable about the data. We tested general information technology controls (e.g., access and security management controls). In addition, we compared the inmate information contained in the sick call data from the EHR system to the inmate’s booking information in OMS. We also tested the sick call data for any worksheet errors (i.e., hidden objects such as rows, headers, and other content) and for sick call requests that were submitted outside of the audit period.

To confirm the completeness and accuracy of the sick call data in the EHR system, we selected a random sample of 20 records in the sick call data in the EHR system and compared the information in the data (i.e., the inmate’s name, their patient identification number, the date of the sick call request, and the date of service by the contracted healthcare provider) to the information on the hardcopy MERFs for agreement. We also selected a random sample of 20 hardcopies of MERFs and traced the information on the forms (i.e., the inmate’s name, their patient identification number, the date of the sick call request, and the date of service by the contracted healthcare provider) back to the sick call data in the EHR system.

Based on results of the data reliability assessment procedures described above, we determined that the EHR system data was sufficiently reliable for the purposes of our audit.

16.   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:	February 2, 2024