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

An overview of the purpose and process of auditing the Hampden 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 Hampden County Sheriff’s Office (HCSO) for the period July 1, 2022 through June 30, 2024. When designing the audit plan for employee settlement agreements entered into by HCSO, 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 HCSO handle the deaths of inmates in its custody in accordance with its “3.1.15—Death of a Person” policy and with Section 932.17(2) of Title 103 of the Code of Massachusetts Regulations (CMR)?	Yes
Did HCSO hold internal quarterly meetings and submit quarterly reports regarding healthcare services for inmates in accordance with its “4.5.1—Health Services Governance and Administration” policy and with 103 CMR 932.01(3)?	Yes
Did HCSO provide its inmates with receiving screenings upon admission, as well as an initial health assessment and a physical examination within 7 to 14 days after admission, in accordance with its “4.5.7—Health Care and Treatment” policy and with 103 CMR 932.06 and 932.07?	Not always; see Finding 1
Did HCSO provide its inmates with medical care after submission of a sick call request in accordance with HCSO’s “4.5.7—Health Care and Treatment” policy and with 103 CMR 932.09?	Yes
Did HCSO provide initial mental health assessments to all inmates within its custody within 14 days of admission in accordance with its “4.5.12—Mental Health Services” policy and with 103 CMR 932.13?	Yes
Did HCSO 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 HCSO follow these policies, and did it refrain 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 HCSO internal control environment relevant to our objectives by reviewing HCSO’s internal control plan, reviewing applicable policies and procedures, and conducting site visits and interviews with HCSO 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 HCSO management provided to us. This list showed that five inmates died in HCSO’s custody during the audit period.

To determine whether HCSO handled the deaths of inmates in its custody in accordance with its “3.1.15—Death of a Person” policy and with 103 CMR 932.17(2), we took the following actions:

• We inspected HCSO’s “3.1.15—Death of a Person” policy to determine whether HCSO 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 [i.e., the possession 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.

• We reviewed documentation (i.e., HCSO employee incident reports, administrative reviews, and multidisciplinary mortality reports) related to the five in-custody deaths to determine whether the following occurred:
  • life-saving measures were started upon finding the inmate unresponsive;
  • a QHP assessed the situation, provided necessary treatment, and reported to the special operations supervisor;
  • the inmate was transported to the hospital by ambulance;
  • staff members notified the shift commander, who notified the Sheriff;
  • the special operations supervisor assigned security staff members to do the following:
    • accompany and remain with the inmate until a medical diagnosis was made or a time of death was declared;
    • notify the shift commander with the time of death; and
    • prepare an incident report containing the names of any involved ambulance attendants, paramedics, and physicians, as well as the date and time of the inmate’s death and the name of the physician who declared their death;
  • HCSO notified the appropriate county’s Sheriff of the inmate’s situation, if that inmate was being held for a county other than HCSO’s;
  • HCSO notified any of the inmate’s victims listed in the Victim Notification Registry of the inmate’s death, if there were any listed;
  • the incident commander filed an incident report with the assistant superintendent of operations;
  • HCSO conducted a death review within 30 days that included the following:
    • an administrative review;
    • a clinical mortality review document that includes the following: the review’s date and time, the names of those in attendance, a summary of the items discussed, and recommendations and actions to be taken; and
    • a psychological autopsy, if the death was by suicide.

For this objective, we found no significant issues during our testing. Therefore, we concluded that, based on our testing, HCSO handled the deaths of inmates in its custody in accordance with its “3.1.15—Death of a Person” policy and with 103 CMR 932.17(2).

Quarterly Meetings

To determine whether HCSO held internal quarterly meetings and submitted quarterly reports regarding healthcare services for inmates in accordance with its “4.5.1—Health Services Governance and Administration” policy and with 103 CMR 932.01(3), we took the following actions. First, we requested, and HCSO provided us with, the meeting minutes corresponding to the population of the eight (100%) quarterly meetings that took place during the audit period between the facility administrator and HCSO’s health authority (or their designee). We reviewed the dates on which the meetings were held, who attended, and whether inmate healthcare services were discussed. In addition, we reviewed reports on the health department and environment, which were sent to the Sheriff on at least a quarterly basis.

For this objective, we found no significant issues during our testing. Therefore, we concluded that, based on our testing, HCSO held internal quarterly meetings and submitted quarterly reports regarding healthcare services for inmates in accordance with its “4.5.1—Health Services Governance and Administration” policy and with 103 CMR 932.01(3).

Receiving Screenings and Initial Health Assessments

Receiving Screenings

To determine whether HCSO provided its inmates with receiving screenings upon admission in accordance with its “4.5.7—Health Care and Treatment” policy and with 103 CMR 932.06, we took the following actions. First, we selected a random, statistical sample⁴ of 60 inmates out of the population of 7,261 inmates who were admitted to the Hampden County Jail and House of Correction (HCJHOC) 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 performed the following procedures:

• We reviewed the medical forms (i.e., the Admission Screening form, the Oral Screening form, the Medical Intake form, and the Substance Abuse Assessment form) used by HCSO as part of the receiving screening to determine whether each required field in the surveys were completed upon admission.
• We compared the date when the receiving screening was performed to the date when the inmate was booked to determine whether the inmate received their receiving screening upon admission.

For this aspect of our objective, we found no significant issues during our testing. Therefore, we concluded that, based on our testing, HCSO provided its inmates with receiving screenings upon admission in accordance with its “4.5.7—Health Care and Treatment” policy and with 103 CMR 932.06.

Initial Health Assessments and Physical Examinations

To determine whether HCSO provided its inmates with an initial health assessment and a physical examination within 7 to 14 days after admission, in accordance with its “4.5.7—Health Care and Treatment” policy and with 103 CMR 932.07, we took the following actions. First, we selected a random, statistical sample of 60 inmates out of the population of 3,608 inmates who were admitted to HCJHOC and were in custody for 30 days or more during the audit period. We made this selection using a 95% confidence level, a 0% expected error rate, and a 5% tolerable error rate. We then performed the following procedures:

• We inspected the medical forms used as part of the initial health assessment for each inmate in our sample to determine whether each field in each form was completed.
• We used the date on each Physical Exam 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 HCSO 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.

For this aspect of our objective, we found certain issues during our testing; namely, that HCSO did not consistently provide each inmate with a physical examination as part of their initial health assessment within the required timeframe of 7 to 14 days after admission during the audit period. See Finding 1 for more information.

Sick Call Requests

To determine whether HCSO provided its inmates with medical care after submission of a sick call request in accordance with HCSO’s “4.5.7—Health Care and Treatment” policy and with 103 CMR 932.09, we took the following actions. First, we selected a random, statistical sample of 60 sick call requests out of the population of 60,907 sick call requests submitted 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 the inmate was 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, HCSO provided its inmates with medical care after submission of a sick call request in accordance with HCSO’s “4.5.7—Health Care and Treatment” policy and with 103 CMR 932.09.

Initial Mental Health Screenings

To determine whether HCSO provided initial mental health assessments to all inmates within its custody within 14 days of admission in accordance with its “4.5.12—Mental Health Services” policy and with 103 CMR 932.13, we took the following actions. First, we selected a random, statistical sample of 60 inmates out of the population of 7,261 inmates who were admitted to HCJHOC during the audit period. We made this selection 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 medical records to determine whether the following occurred:
  • the results of the initial mental health screening were documented and the screening occurred upon booking; and
  • the inmate was referred for further evaluation if their screening indicated that they had a mental health concern.
• For each inmate in our sample who was referred for further evaluation, we used the date on the Mental Health Intake Survey to calculate the number of days between the completion of the survey and the date when they received their follow-up evaluation to determine whether it was completed within 10 business days.

For this objective, we found no significant issues during our testing. Therefore, we concluded that, based on our testing, HCSO provided initial mental health assessments to all inmates within its custody within 14 days of admission in accordance with its “4.5.12—Mental Health Services” policy and with 103 CMR 932.13.

Employee Settlement Agreements

To determine whether HCSO 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 about this with HCSO officials, who stated that they do not have policies over the use non-disclosure, non-disparagement, or similarly restrictive clauses in employee settlement agreements.

To determine whether HCSO entered into employee settlement agreements from July 1, 2019 through June 30, 2024, and if it did, whether it refrained from using non-disclosure, non-disparagement, or similarly restrictive clauses as part of employee settlement agreement language, we took the following actions. First, we reviewed the language in the one employee settlement agreement from the audit period.

For this objective, we found certain issues during our testing; namely, that HCSO did not have policies regarding the use of employee settlement agreements and reporting of monetary settlements to CTR. See Finding 2 for more information.

We used statistical sampling methods for testing and projected 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 HCSO staff members who were knowledgeable about the process following an inmate’s death. We requested a list of all in-custody deaths that took place during the audit period and were informed that there were five inmate deaths that occurred during the audit period. In addition, we requested a list of inmate deaths that were processed by the Office of the Chief Medical Examiner during the audit period and compared this list to the deaths reported by HCSO for agreement.

Quarterly Healthcare Meetings and Reports

To assess the reliability of the population of quarterly healthcare meetings regarding healthcare services for inmates held during the audit period, we interviewed HCSO medical staff members who were involved in the meetings and responsible for providing the quarterly healthcare reports. We requested the meeting minutes and reports for all eight of the quarters that were during the audit period.

Inmate Information System

To assess the reliability of the inmate data we obtained from HCSO’s inmate information system, we interviewed the assistant superintendent of information systems and technology, who was 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 inmate information system and compared these inmates’ information from the list to the information in the original source document (i.e., the mittimus) for agreement. We also selected 20 random hard copies of the mittimuses and compared for agreement the inmates’ information from these mittimuses to the information in the list of inmates from the system. In addition, we tested all 8,390 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 Call Requests

To assess the reliability of the list of sick call requests that originated from HCSO’s medical record management system, we interviewed the assistant superintendent of information systems and technology, who is 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 HCSO sent to us matched the total number of lines of data that HCSO’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 record management system was the only data used for this aspect of our data reliability assessment, since it was the only source of such data available.

Employee Settlement Agreements

To determine the population for the employee settlement agreements that occurred during the extended audit period of July 1, 2019 through June 30, 2024, we requested a list of all such employee settlement agreements. HCSO’s administrator of standards provided copies of the seven employee settlement agreements HSCO entered into during the audit period.

We requested all legal expenses that HCSO 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 HCSO during the extended audit period. Further, we queried the Commonwealth Information Warehouse⁸ for any settlements paid out to HCSO 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.

4.    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.

5.    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.

6.    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.

7.    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.

8.    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, which is the state’s official accounting system.

Date published:	November 25, 2025