Audit of the Plymouth 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 Plymouth County Sheriff’s Department.

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 Plymouth County Sheriff’s Department (PCSD) 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 and the conclusion we reached regarding each objective.

Objective	Conclusion
1.     Did PCSD comply with and implement the requirements of Section 932.17(2) of Title 103 of the Code of Massachusetts Regulations (CMR) and PCSD’s Policy 622 (Serious Illness, Injury & Death) regarding the deaths of inmates in its custody?	Yes
2.     Did PCSD hold quarterly meetings with its healthcare vendor and review quarterly reports for inmates’ healthcare services in accordance with 103 CMR 932.01(3)?	Yes
3.     Did PCSD provide medical receiving screenings to its inmates upon admission, and intake physical examinations, in accordance with Sections IV and VII of PCSD’s Policy 630 (Medical Services) and Sections IV and VII of PCSD’s Procedure 630 (Medical Services)?	Yes
4.     Did inmates at PCSD’s facility receive medical care after submission of a Sick Call Request Form in accordance with Section XII of PCSD’s Policy 630 and Section VII of PCSD’s Procedure 630?	Yes

 

To accomplish our objectives, we gained an understanding of PCSD’s internal control environment relevant to the objectives by reviewing PCSD’s internal control plan and applicable policies and procedures, as well as conducting site visits and interviews with PCSD’s management. We evaluated the design and implementation of the internal controls related to our audit objectives. We also tested the operating effectiveness of the supervisory controls on initial intake health assessments. To obtain sufficient, appropriate audit evidence to address our audit objectives, we conducted the following audit procedures.

We inspected the list of inmate deaths from PCSD management for the audit period, which reflected two inmates who died in PCSD custody on December 28, 2019 and March 16, 2021 and whose causes of death were reported as suicide and natural causes, respectively. To determine whether PCSD complied with 103 CMR 932.17(2) and PCSD’s Policy 622 regarding the deaths of inmates in its custody, we performed the following procedures.

• We inspected PCSD’s Policy 622 to determine whether PCSD has established guidelines that include the following, in accordance with the requirements of 103 CMR 932.17(2):

1. internal notification to include medical and administrative staff;
2. procedures when discovering the body;
3. disposition of the body;
4. notification of next of kin;
5. notification of [Criminal Offender Record Information] certified individuals as soon as practicable;
6. investigation of causes;
7. reporting and documentation procedures;
8. procedure for review of the incident by appropriate designated staff with a final report submitted to all appropriate parties

• To determine whether PCSD complied with and implemented the requirements of 103 CMR 932.17(2) and its in-custody death guidelines in Policy 622, we performed the following:
• We inspected the Final Death Packets, which include an interoffice memorandum,15 mortality review meeting minutes, and emails, to determine whether medical and administrative staff members were notified.
• We inspected the Final Death Packets, including the sections of incident reports by all PCSD officers who witnessed the inmate’s death, to ensure that the appropriate parties were notified when officers discovered the body.
• We inspected emails from PCSD to the Town of Plymouth, found in the Final Death Packets, that documented what happened to the bodies after they were autopsied to determine the disposition of the body.
• We inspected emails from PCSD’s assistant superintendent to the superintendent, found in the Final Death Packets, that recorded the notification of each inmate’s next of kin to determine whether the next of kin was notified.
• We inspected the Final Death Packets, specifically the mortality review meeting minutes and incident reports, to determine whether there was an investigation of causes for the deaths of the two inmates.
• We inspected the Final Death Packets to determine whether the officers completed the incident reports.
• We inspected the Final Death Packets, specifically the mortality review meeting minutes of the clinical review team, the incident reports, and the emails sent by the assistant superintendent to the superintendent, to determine whether appropriate, designated staff members reviewed the incident reports and whether the superintendent submitted final reports to the Sheriff.
• We verified that each inmate’s death was recorded in the Offender Management System (OMS) and inspected the date of when the mortality review was held with the involved officers. The date of death and date of review were compared to determine whether the mortality review was conducted within 30 days of the inmate’s death.

To determine whether quarterly meetings were held with the healthcare vendor, we inspected the minutes of all eight quarterly meetings held during the audit period. We then examined the list of people who attended each meeting to ensure that the meeting was held between PCSD and its healthcare vendor. In addition, we obtained the annual statistical summaries for 2020 and 2021 submitted by the healthcare vendor to determine whether PCSD complied with 103 CMR 932.

To determine whether PCSD provided the healthcare services in compliance with state regulations and its own policies, we examined the minutes of all eight quarterly meetings of PCSD and its healthcare vendor, as well as all the reports (such as risk management reports, infection control reports, continuous quality improvement monitoring reports, and annual reviews) that the vendor provided to PCSD during the audit period.

To determine whether PCSD provided its inmates with initial medical receiving screenings upon admission, and intake physical examinations within 14 days after admission, in accordance with Sections IV and VII of PCSD’s Policy 630, we selected a statistical, random sample with a 95% confidence level, 5% tolerable rate, and 0% expected error rate. Our sample consisted of 60 inmates out of a total of 6,434 admissions to PCSD during the audit period. We performed the following procedures:

• We examined each inmate’s Medical Intake Screening Form to document the date and time the form was completed and signed by a medical officer. For inmates who refused to receive the initial intake health assessment, we examined the signed Refusal of Medical Care Forms.
• According to PCSD Policy 630, inmates committed for more than 30 days are required to have intake physical examinations. We examined the Initial Physical Health Assessment Form to document the date and time it was completed and signed by a qualified healthcare professional. We then calculated the number of days after admission to determine whether inmates received intake physical examinations within 14 days as required by the policy.

To determine whether inmates received medical care after the submission of Sick Call Request Forms, in accordance with PCSD Policy 630, we selected a statistical, random sample with a 95% confidence level, 5% tolerable rate, and 0% expected error rate. Our sample consisted of 60 Sick Call Request Forms out of a total of 8,835 Sick Call Request Forms submitted by inmates during our audit period. To determine whether inmates received medical care after submission of Sick Call Request Forms in accordance with PCSD policy, we performed the following procedures:

• We examined the Sick Call Request Forms to ensure that a medical officer reviewed them and that the inmates were seen and treated.
• We calculated the number of days between the submission of the Sick Call Request Forms by inmates and the dates they were signed by a medical officer to ensure that all sick calls were reviewed within 24 hours after submission.

Data Reliability Assessment

OMS

To assess the reliability of the inmate data obtained from OMS, we interviewed head of the PCSD Information Technology (IT) Department, who is responsible for oversight of the system. We tested the general IT controls, including user access and account management controls. We selected a random sample of 20 inmates from the list of inmates in OMS and traced each full name and booking identification number to the original source document (the mittimus / United States Marshals Service Custody Form [USM 129 Individual Custody/Detention Report] / Immigration and Customs Enforcement Detainee Form [Order to Detain or Release Alien]). We also selected 20 random samples from hard copies of the mittimi and traced the same information from them to OMS. In addition, we tested the inmate data for duplicate records and matched the death-in-custody list from OMS to the list that Office of the Chief Medical Examiner provided to us.

Based on the results of these data reliability procedures, we determined that the OMS data were sufficiently reliable for the purposes of our audit.

Correctional Electronic Medical Records

To assess the reliability of the sick call data obtained from the Correctional Electronic Medical Records (CorEMR) System, we conducted interviews with PCSD personnel who had knowledge about the data. In addition, we matched the inmates’ patient identification numbers¹⁶ from CorEMR to the state identification numbers of inmates who were admitted during out audit period in OMS. We also tested general IT controls, including user access and account management controls.

To confirm the completeness and accuracy of the sick call data in CorEMR, we selected a random sample of 20 sick calls from the sick call list in CorEMR and agreed each patient name and patient identification number to hard copies of Sick Call Request Forms submitted by inmates. We also selected a random sample of 20 hard copies of Sick Call Request Forms and traced patient name and patient identification number back to the sick call list in CorEMR.

Based on the results of these data reliability procedures, we determined that the CorEMR data were sufficiently reliable for the purposes of our audit.

Conclusion

Our audit revealed no significant instances of noncompliance that must be reported under generally accepted government auditing standards.

15.    The interoffice memorandum includes a written summary of events to the superintendent and the Sheriff about an inmate’s death.

16.    Each inmate is assigned a patient identification number in CorEMR, which is the same as each inmate’s state identification number.

Date published:	March 15, 2023