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 Department of Correction (DOC) for the period July 1, 2016 through June 30, 2018.
We conducted this performance audit in accordance with generally accepted government auditing standards, except Sections 6.56–6.59 of Chapter 6 of the US Government Accountability Office’s Government Auditing Standards, pertaining to obtaining sufficient, appropriate evidence to meet the audit objectives. See “Scope Limitation” below for details regarding the issue we encountered with access to medical files. 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.
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Objective |
Conclusion |
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1. Does DOC comply with authoritative guidance (see below) for inmate healthcare related to the following? |
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a. sick call requests |
No; see Finding 1 |
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b. doctors’ appointments, health insurance coverage, and medications during reentry preparation |
No; see Finding 2 |
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c. women’s health |
Yes; see |
Our substantive testing for each objective was based on certain sections of the following authoritative guidance:
- For objective 1a:
DOC policy “103 DOC 630—Medical Services”
Section 761.07(7) of Title 103 of the Code of Massachusetts Regulations (CMR)
National Commission on Correctional Health Care publication Standards for Health Services in Prisons
103 CMR 491 - For objective 1b:
DOC policy “103 DOC 493—Reentry Policy”
DOC policy “103 DOC 630—Medical Services” - For objective 1c:
DOC policy “103 DOC 630—Medical Services”
DOC policy “103 DOC 620—Special Health Care Practices”
Section 118 of Chapter 127 of the General Laws
We gained an understanding of the internal control environment related to our audit objectives by reviewing applicable DOC policies and procedures, reviewing laws and regulations, and making inquiries and observations. In addition, we performed the following procedures to obtain sufficient, appropriate evidence to address our audit objectives.
Scope Limitation
We encountered a scope limitation with regard to objectives 1a and 1c. Because of a mold infestation, some female inmates’ medical files that were stored at Massachusetts Correctional Institution (MCI)—Framingham were quarantined and could not be obtained for review. Further, the affected medical files could not be identified or excluded from the population; this affected our sick call request test and women’s health tests. If these medical files had been available, it is possible that our audit procedures might have identified further issues.
Sick Call Requests
We obtained a list of inmates incarcerated at all DOC facilities during the audit period from the Inmate Management System (IMS), the program DOC uses to track and process inmates. Because all inmates have initial health assessments upon arrival at DOC facilities and any identified issues should be addressed at that time, we filtered the list to include inmates who were incarcerated for more than 30 days to identify a population of inmates who might have submitted Sick Call Request Forms (SCRFs).
The filtered list of inmates who were incarcerated for more than 30 days totaled 18,394. Using a statistical sampling method and Audit Command Language (ACL) software, with a confidence level of 95% and a tolerable error rate of 5%, we selected a random sample of 60 of the 18,394 inmates. We obtained and reviewed each inmate’s hardcopy medical file/s, which contained paperwork related to the inmate’s health-related services provided by DOC, including any SCRFs. In each inmate’s medical file/s, we reviewed all SCRFs where the inmate had indicated a date that fell during our audit period. We reviewed these forms to confirm compliance with certain requirements of “103 DOC 630—Medical Services,” which is DOC’s internal policy for healthcare provided to inmates; 103 CMR 761.07(7); and the National Commission on Correctional Health Care publication Standards for Health Services in Prisons. Specifically, we reviewed each SCRF to determine the following: the date the inmate submitted it, the date it was triaged, whether it was triaged in an appropriate amount of time, the provider to which the inmate was referred, the nurse triage determination,3 the inmate’s institution (i.e., the facility where the inmate was held), the date the inmate saw a qualified healthcare professional (QHP), and whether the inmate was seen by a QHP in an appropriate amount of time.
Additionally, DOC officials gave us a list of all 24 grievances related to inmates’ access to healthcare that were filed during the audit period. We obtained and reviewed all hardcopy paperwork and electronic forms related to each grievance. The grievance information provided by DOC included the Informal Complaint Form, the Formal Grievance Form, the Grievance Appeal Form, any Grievance Extension Forms, and any case notes in IMS. We reviewed the grievance documentation to confirm compliance with certain sections of 103 CMR 491. Specifically, we confirmed compliance with the following requirements: inmates filing informal complaints before submitting formal grievances; formal grievances being submitted within 10 days of incidents; DOC documenting formal grievances in IMS; DOC responding to formal grievances in 10 days; DOC filing extensions when it could not respond to grievances within 10 days; inmates submitting appeals within 10 days of receiving their formal grievance responses; DOC documenting the appeals in IMS; and DOC responding to the appeals in 30 days unless an extension was filed.
Reentry Services
From the list of inmates mentioned above, we identified a total of 4,800 who were paroled or released and had a Criminal designation in IMS (indicating that they had been sentenced) as opposed to a Pre-Trial or Out of State designation. Using a statistical sampling method and ACL, with a confidence level of 95% and a tolerable error rate of 5%, we selected a random sample of 60 of the 4,800 inmates. We obtained and reviewed reentry screenshots from IMS to confirm compliance with certain requirements of “103 DOC 493—Reentry Policy” and “103 DOC 630—Medical Services.” Specifically, we determined whether each inmate was given an Individual Reentry Plan; each inmate signed an Authorization for Release of Medical Records; medical appointments were arranged, if necessary; each inmate was given enough medication to last until his/her post-release appointment, if necessary; a Medicaid Management Information System (MMIS) check was conducted 30 days before each inmate’s release; a secondary MMIS check was conducted within 5 days of each inmate’s release; and each inmate was given a MassHealth card (if eligible) or instructions on how to follow up with MassHealth upon release.
Women’s Health
From the list of inmates mentioned above, we identified a total of 4,629 female inmates at the MCI—Framingham or South Middlesex Correctional Center facilities. Using a statistical sampling method and ACL, with a confidence level of 95% and a tolerable error rate of 5%, we selected a random sample of 60 of these 4,629 inmates. To conduct our testing of medical services provided specifically to the female inmates, we obtained and reviewed the hardcopy medical files for the selected inmates. These files contained hardcopy paperwork related to services requested, and provided to the inmate, during incarceration. We reviewed the medical files to determine whether DOC had complied with certain requirements of “103 DOC 630—Medical Services,” including providing annual pelvic and breast examinations to inmates, providing mammograms every two years to inmates aged 40 through 49, and providing annual mammograms to inmates aged 50 and above.
We obtained a list from DOC officials of 67 female inmates who had a pregnancy designation in IMS at any point during the audit period. Using a nonstatistical sampling method and ACL, we selected a random sample of 20 of the 67 inmates. Because our sampling methodology is nonstatistical, we cannot project the results of our testing to the entire population. To conduct our testing of health services for pregnant inmates, confirming compliance with certain portions of Section 118 of Chapter 127 of the General Laws and “103 DOC 620—Special Health Care Practices,” we obtained the medical files for the inmates selected. These contained hardcopy documentation of medical services requested and provided during the inmates’ incarceration. Specifically, we determined whether each inmate was given information about pregnancy options and DOC facility policies regarding care and labor; a Treatment Plan; specialty care if necessary; a postpartum evaluation by a mental health clinician within two business days of return to DOC custody; and mental healthcare if suffering from postpartum depression, as well as whether there was a documented need for restraint if the inmate was restrained.
Data Reliability Assessment
We reviewed certain general information technology controls, including access controls, security training, personnel screening, and account management, over IMS to determine the reliability of the data therein. In addition, for the list of inmates extracted from IMS, we ran data integrity tests to identify any missing data or data outside our audit period and traced inmate data to and from inmate medical files to confirm the accuracy and completeness of the inmate list.
For the list of pregnant inmates extracted from IMS, we selected a sample of 10 inmates and reviewed the medical files for evidence indicating that they were pregnant during the audit period. There could be inmates on the list who were not pregnant during the audit period because re-incarcerated inmates with a pregnancy designation in IMS could have had their information copied to their new inmate files. Therefore, this list is of undetermined reliability. However, the list is relevant and the sole source available to identify the population of pregnant inmates during the audit period to conduct our audit.
Despite these uncertainties, we believe the list of pregnant inmates sufficiently captures all pregnant inmates during the audit period for the purpose of identifying our population for audit testing.
We determined that the data were sufficiently reliable for the purposes of our audit work.
| Date published: | January 9, 2020 |
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