Audit of the Franklin County Sheriff’s Office Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Franklin 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 the Franklin County Sheriff’s Office (FCSO) for the period July 1, 2022 through June 30, 2024. When designing the audit plan for employee settlement agreements entered into by FCSO, we extended the audit period to July 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
Did FCSO handle the deaths of inmates in its custody in accordance with its Death Protocol Directive and with Section 932.17(2) of Title 103 of the Code of Massachusetts Regulations (CMR)?	Yes
Did FCSO hold internal quarterly meetings and submit quarterly reports regarding healthcare services for inmates in accordance with FCSO Policy JA-02 “Responsible Health Authority” and with 103 CMR 932.01(3)?	Yes
Did FCSO provide its inmates with medical screenings upon admission and initial health assessments within 7 to 14 days after admission in accordance with FCSO Policies J-E-02 “Receiving Screening” and J-E-04 “Initial Health Assessment” and with 103 CMR 932.06 and 932.07?	Not always; see Finding 1
Did FCSO provide its inmates with medical care within 24 hours after submission of a sick call request in accordance with FCSO Policy J-E-07 “Nonemergency Health Care Requests and Services” and with 103 CMR 932.09?	Yes
Did FCSO provide initial mental health assessments to all inmates within its custody within 14 days of admission in accordance with FCSO Policy J-E-05 “Mental Health Screening and Evaluation” and with 103 CMR 932.13?	Yes
Did FCSO have 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 the Office of the Comptroller of the Commonwealth (CTR)? For employee settlement agreements entered into from July 1, 2019 through June 30, 2024, did FCSO follow these policies, and did it abstain from using non-disclosure, non-disparagement, or similarly restrictive clauses as part of employee settlement agreement language?	No; see Finding 2

To accomplish our audit objectives, we gained an understanding of the FCSO internal control environment relevant to our objectives by reviewing FCSO’s internal control plan, reviewing applicable policies and procedures, and conducting site visits and interviews with FCSO management. We evaluated the design and implementation of internal controls related to the internal quarterly meetings for healthcare services. We also tested the operating effectiveness of internal controls related to the internal quarterly meetings for healthcare services. In addition, to obtain sufficient, appropriate evidence to address our audit objectives, we performed the procedures described below.

Inmate Deaths

We inspected a list of inmate deaths that occurred during the audit period, which FCSO provided to us. This list showed that one inmate died in FCSO’s custody during the audit period.

To determine whether FCSO handled the deaths of inmates in its custody in accordance with its Death Protocol Directive and with 103 CMR 932.17(2), we took the following actions:

• We inspected FCSO’s Death Protocol Directive to determine whether FCSO had guidelines that include the following requirements listed in 103 CMR 932.17(2):

1. internal notification to include medical and administrative staff;
2. procedures when discovering body;
3. disposition of [i.e., the possession of] the body;
4. notification of next of kin;
5. [Criminal Offender Record Information] notification [sent to victim(s) of an inmate] as soon as practicable [when such notification is necessary];
6. investigation of causes;
7. reporting and documentation procedures;
8. procedure for review of incident by appropriate designated staff with a final report submitted to all appropriate parties.

• We obtained and reviewed documentation (i.e., FSCO employee incident reports, administrative reviews, and the multidisciplinary mortality review reports) related to the one in-custody death to determine whether the following occurred:
  • life-saving measures were started upon finding the inmate unresponsive;
  • the shift commander notified the superintendent/special sheriff, assistant deputy superintendent of health services, assistant superintendent of security, and health services director upon the death of the inmate;
  • the superintendent or their designee notified the Sheriff, the State Police Crime Prevention and Control Unit, the Office of the Chief Medical Examiner (OCME), the next of kin on record, and the Victims Services Unit and/or the Criminal Offender Record Information petitioner, if applicable, upon the inmate’s death;
  • the superintendent or their designee secured the deceased inmate’s electronic medical records, mental health records, institution file, institution log, employee reports, and any other pertinent documentation;
  • FCSO’s medical director requested and maintained copies of OCME’s report and the autopsy report;
  • FCSO fully cooperated with any investigations initiated by OCME, the District Attorney, or State Police relative to the death of the inmate;
  • FCSO conducted an investigation and prepared and submitted a report to the Sheriff, if the death appeared to be the result of homicide, suicide, substance overdose or misuse, injury relating to occupation, or any other suspicious or unnatural circumstances; and
  • FCSO initiated a multidisciplinary mortality review with the superintendent or their designee, the assistant deputy superintendent of health services, the medical director, the director of psychology, and medical practitioners and nurses, as deemed appropriate, within 30 days of the inmate’s death.

For this objective, we found no significant issues during our testing. Therefore, we concluded that, based on our testing, FCSO handled the deaths of inmates in its custody in accordance with its Death Protocol Directive and with 103 CMR 932.17(2).

Quarterly Meetings

To determine whether FCSO held internal quarterly meetings and submitted quarterly reports regarding healthcare services for inmates in accordance with FCSO Policy JA-02 “Responsible Health Authority” and with 103 CMR 932.01(3), we obtained the minutes corresponding to the population of the eight (100%) quarterly meetings that took place during the audit period between FCSO and its responsible health authority. We reviewed the dates on which the meetings were held, who attended, and whether inmate healthcare services were discussed. In addition, we inspected all eight of the quarterly reports submitted throughout the audit period.

For this objective, we found no significant issues during our testing. Therefore, we concluded that, based on our testing, FCSO held internal quarterly meetings and submitted all quarterly reports regarding inmate healthcare services.

Receiving Screenings and Initial Health Assessments

Receiving Screenings

To determine whether FCSO provided its inmates with medical screenings upon admission in accordance with FCSO Policy J-E-02 “Receiving Screening” and with 103 CMR 932.06, we took the following actions. First, we selected a random, statistical sample⁷ of 60 inmates out of the population of 2,081 inmates who were admitted to the Franklin County Jail and House of Correction (FCJHOC) during the audit period, using a 95% confidence level,⁸ a 0% expected error rate,⁹ and a 5% tolerable error rate.¹⁰ We then performed the following procedures:

• For each inmate in our sample, we inspected their Intake Medical History and Screening form to determine whether each required field in the form was completed upon admission.
• We determined whether the following were on file for each inmate in our sample: a Dental Screening, an Intake Mental Health Screening and Assessment, and a COVID-19 Test Consent form.
• We reviewed inmates’ medical records to determine whether recommendations regarding housing were made when needed—for example, special housing assignments are made if an inmate presents a danger to themselves or to other inmates—and whether referrals were made to medical, dental, or mental health services if issues that required follow-up care were identified during the screening.

For this aspect of our objective, we found no significant issues during our testing. Therefore, we concluded that, based on our testing, FCSO provided its inmates with medical screenings upon admission in accordance with FCSO Policy J-E-02 “Receiving Screening” and with 103 CMR 932.06.

Initial Health Assessments

To determine whether FCSO provided its inmates with initial health assessments within 7 to 14 days after admission in accordance with FCSO Policy J-E-04 “Initial Health Assessment” and with 103 CMR 932.07, we took the following actions. First, we selected a random, nonstatistical¹¹ sample of 50 inmates out of the population of 669 inmates who were admitted to FCJHOC and were in custody for 30 days or more during the audit period. We then performed the procedures described below:

• We inspected the Physical Assessment forms for each inmate in our sample to determine whether each field in the form 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 when their physical examination was completed to determine whether FCSO completed each physical examination in the required timeframe.
  • We determined whether the physical examination was completed within 7 days of admission if the receiving screening was completed by a licensed practical nurse.
  • We determined whether the physical examination was completed within 14 days of admission if the receiving screening was completed by a physician, physician’s assistant, or registered nurse.
• We reviewed each inmate’s medical records to determine whether a qualified healthcare professional (QHP) created diagnostic and therapeutic plans for each identified medical issue, as clinically indicated, and whether a QHP documented referrals for dental, mental health, or chronic diseases in each inmate’s medical records and ordered follow-up appointments, as needed.

For this aspect of our objective, we found certain issues during our testing; namely, that FCSO did not consistently provide each inmate with an initial health assessment within the required timeframe of 7 to 14 days after admission. See Finding 1 for more information.

Sick Call Requests

To determine whether FCSO provided its inmates with medical care within 24 hours after submission of a sick call request in accordance with FCSO Policy J-E-07 “Nonemergency Health Care Requests and Services” and with 103 CMR 932.09, we selected a random, statistical sample of 60 sick call requests from the population of 17,104 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 each inmate’s medical records to determine whether they were seen by a QHP within 24 hours of submitting a sick call request.

For this objective, we found no significant issues during our testing. Therefore, we concluded that, based on our testing, FCSO provided its inmates with medical care within 24 hours after submission of a sick call request in accordance with FCSO Policy J-E-07 “Nonemergency Health Care Requests and Services” and with 103 CMR 932.09.

Initial Mental Health Screenings

To determine whether FCSO provided initial mental health assessments to all inmates within its custody within 14 days of admission in accordance with FCSO Policy J-E-05 “Mental Health Screening and Evaluation” and with 103 CMR 932.13, we took the following actions. We selected a random, statistical sample of 60 inmates out of the population of 2,081 inmates who were admitted to FCJHOC 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 when their mental health screening was completed to determine whether FCSO completed each screening within 14 days of an inmate’s admission to FCJHOC.
• For inmates in our sample who screened positive for mental health disorders, we determined whether they were referred to qualified mental health professionals for further evaluation.

For this objective, we found no significant issues during our testing. Therefore, we concluded that, based on our testing, FCSO provided initial mental health assessments to all inmates within its custody within 14 days of admission in accordance with FCSO Policy J-E-05 “Mental Health Screening and Evaluation” and with 103 CMR 932.13.

Employee Settlement Agreements

To determine whether FCSO 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 now-former FSCO Sheriff, who stated that, while they do not have policy over the process of entering into settlement agreements or the use of non-disclosure, non-disparagement, non-publication or confidentiality requests, it is their practice not to include these items. According to FCSO’s general counsel, FCSO follows CTR’s “Settlements and Judgments Policy” for any employee settlement agreements.

To determine whether FCSO entered into employee settlement agreements that included non-disclosure, non-disparagement, or similarly restrictive clauses, we reviewed the language in the one employee settlement agreement from the audit period.

To determine whether FCSO properly reported this monetary employee settlement agreement to CTR, we requested from FCSO, received, and reviewed a copy of the settlement agreement documentation (i.e., the settlement agreement, the SJ Authorization Form, and emails). We determined whether the employee settlement agreement was signed by authorized representatives of both the employee and FCSO. We determined whether the SJ Authorization Form detailed the terms of the settlement claim payment and was signed by FCSO’s chief financial officer and general counsel. We also determined whether the emails between CTR and FCSO documented the review and approval of the settlement claim for payment. These emails served as evidence that FCSO reported the required documentation to CTR.

For the aspect of our objective regarding entering into employee settlement agreements that included non-disclosure, non-disparagement, or similarly restrictive clauses, we concluded that, based on our testing, FCSO abstained from using these clauses. For the aspect of our objective regarding the reporting of employee settlement agreements to CTR, we concluded that, based on our testing, FCSO appropriately reported the monetary employee settlement to CTR for approval, as required by 815 CMR 5.00. However, we found certain issues during our testing regarding FCSO’s lack of policies over the use of employee settlement agreements. See Finding 2 for more information.

We used a combination of statistical and nonstatistical sampling methods for testing, and 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 FCSO 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 were informed that there was one inmate death that occurred during the audit period. We also requested a list of inmate deaths that were processed by OCME during the audit period and compared this list to the deaths reported by FCSO for agreement.

Quarterly Health Care Meetings and Reports

To assess the reliability of the list of quarterly healthcare meetings held during the audit period, we interviewed FCSO medical staff members who were involved in the meetings and responsible for providing the quarterly healthcare reports. We requested, and FCSO provided us with, copies of the meeting minutes and reports 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 FCSO’s inmate information system, we interviewed FCSO information technology employees who were knowledgeable 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 system and compared the inmates’ information from the list to the information in the original source documentation (i.e., the mittimus) for agreement. We also selected a random sample of 20 hard copies of the mittimuses and compared for agreement the inmates’ information from the mittimuses to the information from the list of inmates in the system. In addition, we tested all 2,523 lines of inmate data to ensure that they 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).

Sick Calls

To determine the reliability of the sick call logs for the audit period, we input the number of sick calls documented on each of the daily logs for both the day and evening shifts into a spreadsheet to calculate the total number of sick calls during the audit period. We then selected a random sample of 20 sick call requests documented on the sick call logs and compared the sick call request information to PDF copies of the original sick call slips. Further, we selected a random sample of 20 sick call slips and compared the information from the sick call slips to the information documented on the sick call logs.

Employee Settlement Agreements

To determine the population for the employee settlement agreements that occurred during the extended audit period, July 1, 2019 through June 30, 2024, we interviewed FCSO’s general counsel and requested a list of all employee settlement agreements. According to FCSO’s general counsel, FCSO entered into one employee settlement agreement during the extended audit period.

We requested all legal expenses that FCSO incurred during the extended audit period and reviewed the invoices associated with each legal expense to determine whether they were related to employee settlement agreements. We reviewed CTR’s Settlements and Judgments data to determine whether there were any additional employee settlement agreements entered into by FCSO during the extended audit period. Further, we queried the Commonwealth Information Warehouse¹² for any settlements paid out to FCSO 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.

7.    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.

8.    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.

9.    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 year results, the understanding of controls gained in planning, or a probe sample.

10.    Tolerable error rate is the maximum error in the population that auditors would be willing to accept and still conclude that the result from the sample has achieved the audit objective.

11.    Auditors use nonstatistical sampling to select items for audit testing when a population is very small, the population items are not similar enough, or there are specific items in the population that the auditors want to review.

12.    The Commonwealth Information Warehouse contains budget, human resources, and payroll information as well as financial transaction data from the Massachusetts Management Accounting and Reporting System.

Date published:	November 25, 2025