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

An overview of the purpose and process of auditing the Essex County Sheriff’s Department—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 Essex County Sheriff’s Department (ECSD) 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 ECSD comply with and implement the requirements of Section 932.17(2) of Title 103 of the Code of Massachusetts Regulations (CMR) and ECSD’s “Policy 103 ECSD 222.00 Serious Illness, Injury or Death” regarding the deaths of inmates in its custody?	Yes
Did ECSD 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 ECSD provide its inmates with admission medical screenings upon admission and a physical examination within 14 days after admission, in accordance with Sections 10 and 11 of ECSD’s “Policy 103 ECSD 220.00 Medical Services”?	No; see Finding 1
Did inmates at ECSD receive medical care after submission of a sick call request form in accordance with Wellpath’s “Nonemergency Health Care Requests and Services Policy” (HCD-100_E-07) for ECSD?	No; see Finding 2

 

To accomplish our audit objectives, we gained an understanding of the aspects of ECSD’s internal control environment that we determined to be relevant to our objectives by reviewing ECSD’s internal control plan and applicable policies and procedures, by conducting site visits, and by interviewing ECSD’s management. We evaluated the design and implementation of the internal controls related to the audit objectives. We also tested the operating effectiveness of the supervisory review controls on admission medical screenings. To obtain sufficient, appropriate evidence to address our audit objectives, we performed the following procedures.

Inmate Deaths

We inspected the list of inmate deaths that occurred during the audit period, which ECSD management provided to us. The list included four inmates who died in ECSD’s custody on November 23, 2019; April 29, 2020; October 3, 2020; and April 8, 2021, and whose causes of death were reported as suicide (two) and natural causes (two). To determine whether ECSD complied with 103 CMR 932.17(2) and ECSD’s “Policy 103 ECSD 222.00 Serious Illness, Injury or Death” regarding the deaths of inmates in its custody, we performed the following procedures:

• We inspected ECSD’s “Policy 103 ECSD 222.00 Serious Illness, Injury or Death” to determine whether ECSD 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 ECSD complied with and implemented the requirements of 103 CMR 932.17(2) and ECSD’s “Policy 103 ECSD 222.00 Serious Illness, Injury or Death” regarding the four in-custody deaths that occurred during the audit period, we performed the following procedures:                                                                                                     
• We examined the ECSD incident reports submitted by all staff members involved with and witnesses to each inmate’s death to ensure that (1) medical and administrative staff members were notified about each inmate’s death; (2) the involved staff members performed lifesaving measures, documented the lifesavings measures they took, and notified the appropriate parties about the inmate’s condition; and (3) the superintendent (or their designee) notified the inmate’s next of kin.
• We examined each investigative report, which includes all corresponding incident reports, to ensure that (1) ECSD notified the Office of the Chief Medical Examiner (OCME) of the inmate’s death and (2) the Security Investigations Unit performed an investigation of the cause(s) of death.
• We examined the list of deaths generated by the Offender Management System (OMS) and each investigative report, which includes all corresponding incident reports, to ensure that ECSD complied with the requirements of 103 CMR 932.17(2) and ECSD’s policy on reporting and documentation procedures related to each death.
• We examined each attendance sheet for each mortality review meeting to ensure that appropriate staff members participated in each review of the circumstances surrounding each inmate’s death.

We noted no exceptions in our testing; therefore, we determined that ECSD complied with and implemented the requirements of 103 CMR 932.17(2) and ECSD’s “Policy 103 ECSD 222.00 Serious Illness, Injury or Death” regarding the deaths of inmates in its custody during the audit period.

Quarterly Meetings

To determine whether ECSD held quarterly meetings with its contracted healthcare provider and reviewed quarterly reports in accordance with 103 CMR 932.01(3), we examined the minutes and attendance sheets (signed by meeting attendees) of 100% (eight) of the quarterly meetings that took place during the audit period between ECSD and its contracted healthcare provider. In addition, we inspected 100% (eight) of the quarterly reports discussed in each of the quarterly meetings, during which attendees reviewed items and topics such as risk management reports, infection control reports, inmate grievances, and medications that the contracted healthcare provider currently administers to inmates. We also inspected 100% (three) of the annual statistical summaries that the contracted healthcare provider submitted to ECSD during the audit period.

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

Admission Medical Screenings and Physical Examinations

To determine whether ECSD provided its inmates with admission medical screenings upon admission and a physical examination within 14 days after admission, in accordance with Sections 10 and 11 of ECSD’s “Policy 103 ECSD 220.00 Medical Services,” we selected a random, statistical¹⁶ sample using a 95% confidence level,¹⁷ a 0% expected error rate,¹⁸ and a 5% tolerable error rate.¹⁹ Our sample consisted of 60 out of a total population of 8,701 inmates who were admitted to one of the following facilities during the audit period: the Middleton House of Correction (HOC), the Essex County Prerelease and Reentry Center (ECPRC), or the Women in Transition (WIT) facility. Using our sample, we performed the following procedures:

• We examined each inmate’s admission medical screening form to verify the date and time it was completed and signed by a qualified healthcare professional (QHP).
• We calculated the number of days each inmate was committed at HOC, ECPRC, or the WIT facility by comparing each inmate’s admission date and release date to determine whether each inmate required a physical examination. For each inmate committed for 30 or more days, we examined the physical examination form and verified the date and time a QHP completed the physical examination. We then calculated the number of days between each inmate’s admission date and the date their physical examination was completed.

Based on the results of our testing, we determined that ECSD did not consistently provide each inmate with a physical examination within 14 days after admission during the audit period. See Finding 1 for more information.

We used statistical projection techniques to project the results of our testing to the population of inmates whom ECSD newly admitted during the audit period.

Sick Call Requests

To determine whether inmates received medical care after they submitted a Healthcare Request Form (HRF) in accordance with Wellpath’s “Nonemergency Health Care Requests and Services Policy,” we selected a random, statistical sample using a 95% confidence level, a 0% expected error rate, and 5% tolerable error rate. Our sample consisted of 60 out of a total population of 16,628 HRFs that inmates submitted during the audit period. Using our sample, we performed the following procedures:

• We examined each HRF and documented the date the form was completed by the inmate and the date it was signed by the contracted healthcare provider. We calculated the number of days between the submission date of each HRF and the date the contracted healthcare provider reviewed the HRF to determine whether the sick call request was triaged within 24 hours after its receipt.
• We examined each HRF and the corresponding medical notes within the Electronic Record Management Application (ERMA) to determine whether the QHP reviewed the HRF for the immediacy of needed intervention and referred problems beyond its expertise to the most appropriate healthcare provider external to ECSD’s contracted healthcare provider.
• We examined each medical note in ERMA 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 HRF and the date a face‑to-face meeting was held to determine whether a face-to-face meeting occurred within 24 hours.

Based on the results of our testing, we determined that ECSD did not consistently provide each inmate with medical care after each submission of a sick call request in accordance with ECSD’s policy during the audit period. See Finding 2 for more information.

We used statistical projection techniques to project the results of our testing to the population of HRFs that inmates submitted during the audit period.

Data Reliability Assessment

OMS

To assess the reliability of the inmate data that we obtained from OMS, we interviewed ECSD’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, their date of birth, the booking date, and their sex) to the information in the original source document (the mittimus). 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 information in the list of inmates in OMS for agreement. In addition, we tested the inmate admission data of 8,701 inmates for duplicate records. We also reconciled the list of in-custody deaths from OMS with the list provided to us by OCME.

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

ERMA

To assess the reliability of the sick call data that we obtained from ERMA, we interviewed officials (from ECSD and its contracted healthcare provider) who were knowledgeable about the data. We reviewed System and Organization Control reports²⁰ that covered the audit period and ensured that an independent auditor had performed certain information system control tests. In addition, we compared the inmate information contained in the sick call data from ERMA to the inmate’s booking information in OMS. We also tested the sick call data for any worksheet errors (e.g., hidden objects such as rows, headers, and other content).

To confirm the completeness and accuracy of the sick call data in ERMA, we selected a random sample of 20 records in the sick call data in ERMA and compared the information in the data (i.e., the inmate’s name, their patient identification number, and the date of the sick call request) to the information on the hardcopy HRFs for agreement. We also selected a random sample of 20 hard copies of HRFs and traced back to the sick call data in ERMA the information on the forms (i.e., the inmate’s name, their patient identification number, and the date of the sick call request).

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

16.    Auditors use statistical sampling to select items for audit testing when a population is large (usually over 1,000) and contains similar items. Auditors generally use a statistics software program to choose a random sample when statistical sampling is used. The results of testing using statistical sampling, unlike those from judgmental sampling, can usually be used to make conclusions or projections about entire populations.

17.    Confidence level is a mathematically based measure of the auditor’s assurance that the sample results (statistic) are representative of the population (parameter), expressed as a percentage. A 95% confidence level means that 95 out of 100 times, the statistics accurately represent the larger population.

18.    Expected error rate is the number of errors that are expected in the population, expressed as a percentage. It is based on the auditor’s knowledge of factors such as prior audit results, the understanding of controls gained in planning, or a probe sample. In this case, we are assuming there are relatively frequent errors in the data provided to us by the auditee.

19.    The tolerable error rate (which is expressed as a percentage) is the maximum error in the population that is acceptable while still using the sample to conclude that the results from the sample have achieved the objective.

20.   A System and Organization Control report is a report on controls about a service organization’s systems relevant to security, availability, processing integrity, confidentiality, or privacy issued by an independent contractor.

Date published:	April 18, 2024