Audit of the Office of the Chief Medical Examiner Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Office of the Chief Medical Examiner.

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 Office of the Chief Medical Examiner (OCME) for the period July 1, 2021 through June 30, 2023.

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 OCME ensure that it completed 90% of autopsy reports within 90 calendar days after the date of the autopsy, in accordance with the Medical Examiners section (3.05[E][4]) of the Office of the Chief Medical Examiner: Policy Manual?	No; see Finding 1
Did OCME ensure that death certificates were completed, in accordance the Medical Examiners section (3.05[E][3–4]) of the Office of the Chief Medical Examiner: Policy Manual, that were in effect during the audit period?	Yes
Did OCME confirm that the legal next of kin was notified of the decedent’s death and that communication was established with investigating agencies in accordance with the Medicolegal Investigators section (3.01[B][1–2]) of the Office of the Chief Medical Examiner: Policy Manual?	Yes
Did OCME ensure that it released decedents’ bodies to the people with the proper legal authority to receive them in accordance with Section 13 of Chapter 38 of the General Laws?	Yes
Did OCME account for COVID-19 funds received in accordance with the Office of the Comptroller of the Commonwealth’s “COVID-19 Revenue and Grants” directive that was effective April 1, 2020?	Yes

To accomplish our audit objectives, we gained an understanding of the aspects of the internal control environment relevant to our objectives by reviewing applicable policies and procedures, interviewing OCME management, conducting walkthroughs, and reviewing key processes. In addition, to obtain sufficient, appropriate evidence to address our audit objectives, we performed the procedures described below.

Autopsy Reporting

To determine whether OCME ensured that 90% of autopsy reports were completed within 90 calendar days after the date of the autopsy, in accordance with the Medical Examiners section (3.05[E][4]) of the Office of the Chief Medical Examiner: Policy Manual, we took the following actions.

We chose a random, statistical sample of 60 autopsy cases from our population of 3,842 autopsy cases reported during the audit period, using a 95% confidence level, a 0% expected error rate, and a 5% tolerable error rate. We calculated the amount of time from autopsy date to autopsy sign-off by subtracting the relevant fields in the Case Management Tracking System (CMTS), then tabulated the results.

Death Certificate Reports

To determine whether OCME completed death certificates, in accordance with the Medical Examiners section (3.05[E][3–4]) of the Office of the Chief Medical Examiner: Policy Manual, that were in effect during the audit period, we took the following actions.

• We chose a random, statistical sample of 60 cases out of 16,958 cases reported to OCME during the audit period where OCME had accepted jurisdiction over the case and issued a death certificate, using a 95% confidence level, a 0% expected error rate, and a 5% tolerable error rate.
• We verified that an initial death certificate was signed by a medical examiner on the day of examination.
• We calculated the amount of time from the exam date to the final death certificate date by using exam date and death certificate sign-off date fields in CMTS.

Next of Kin Communications

To determine whether legal next of kin was notified of the decedent’s death and that communication was established with investigating agencies in accordance with the Medicolegal Investigators section (3.01[B][1–2]) of the Office of the Chief Medical Examiner: Policy Manual, we took the following actions.

• We chose a random, statistical sample of 60 cases from our population of 13,270⁵ cases reported to OCME during the audit period where OCME had accepted jurisdiction over the case, took custody of the decedent, and issued a death certificate, using a 95% confidence level, a 0% expected error rate, and a 5% tolerable error rate.
• We reviewed notes, intake sections, and communication sections in CMTS to verify that legal next of kin had been notified of the decedents’ deaths.
• We reviewed notes, intake sections, and reports in CMTS to verify that communication was established with investigating agencies.

Decedent Releases

To determine whether OCME ensured that it released decedents’ bodies to the people with the proper legal authority to receive them in accordance with Section 13 of Chapter 38 of the General Laws, we took the following actions.

• We chose the same sample as the previous objective for our test.
• We verified that the following forms were completed:

• Statement of Identification Form: We determined whether it was signed by an appropriate party—e.g., a spouse or legal next of kin—(if applicable) or whether OCME completed the identification verification form.

• Funeral Home Acknowledgment Form: We determined whether it was signed by a funeral home staff member.

• Release Form (from the funeral home): We determined whether it was signed by an appropriate party—e.g., a spouse or legal next of kin—and whether the person signing the decedent’s release form was listed as one of the decedent’s contacts in CMTS.

Accounting of COVID-19 Funds

To determine whether OCME accounted for COVID-19 funds received in accordance with the Office of the Comptroller of the Commonwealth’s “COVID-19 Revenue and Grants” directive that was effective April 1, 2020, we took the following actions.

• As a result of the small number of expense postings and associated dollar amounts, we tested 100% of the COVID-19 purchases that occurred during the audit period. The total number of expenditures was four. We obtained a list for these four expenditures, totaling approximately $131,000, from OCME.
• We checked all four COVID-19-related invoices identified for the audit period against a Massachusetts Management Accounting and Reporting System (MMARS) query to verify that a separate appropriation was created for these COVID-19 fund expenses.
• We checked that a major program and program code was created in MMARS for these four COVID-19-related expenses.
• We verified that necessary documentation, such as purchase requisition, purchase orders, and MMARS payment request forms, and internal controls were in place to support these four COVID‑19-related expenses.
• We also confirmed that overall COVID-19 expenditures did not exceed the awarded amount.

Data Reliability Assessment

CMTS

To assess the reliability of the data, we took the following actions.

We tested selected information system controls (security management, access controls, configuration management, segregation of duties, and contingency planning), interviewed knowledgeable staff members at OCME about this list, and tested for hidden records, duplicate values, and values outside of the audit period. We filtered all reported cases during the audit period from OCME’s CMTS in order to identify cases for which OCME had accepted jurisdiction. OCME accepts jurisdiction of a case when it is of the opinion that the death was because of violence, unnatural means, or natural causes that require further investigation. For those cases for which OCME accepted jurisdiction, we identified the four subgroups that make up the accepted case population for which a death certificate is issued. Those groups are autopsies, external views, chart reviews, and district medical examiner views. To verify that the list of these accepted cases was complete, we randomly selected 20 decedent case charts and traced these back to CMTS. To verify that the list of these accepted cases was accurate, we randomly selected 20 case records from CMTS and traced them back to source documents.

MMARS

In 2018 and 2022, the Office of the State Auditor performed a data reliability assessment of MMARS that focused on testing selected system controls (access, security awareness, audit and accountability, configuration management, identification and authentication, and personnel security). We traced two out of the four MMARS COVID-19-related expense postings for the audit period to and from source documentation, such as vendor invoices, and compared the total overall expenses to financial reports. Finally, we compared COVID-19 funds received by OCME as posted to MMARS to the COVID-19 Funds Award Letter to confirm the source of the COVID-19 funds.

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

5.   These cases included only autopsy and external views, as these are the only types of cases where OCME takes custody of the deceased person's body.

Date published:	December 19, 2024