Audit of the Suffolk County Sheriff’s Department—A Review of Healthcare and Inmate Deaths

During the period of July 1, 2019 through June 30, 2021 the audit found that SCSD did not always ensure that it received an annual statistical summary from its healthcare vendor. The audit recommends SCSD establish policies and procedures to ensure that it obtains the annual statistical summaries.

Executive Summary

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 the Suffolk County Sheriff’s Department (SCSD) for the period July 1, 2019 through June 30, 2021. The objectives of this audit were to determine the following:

• whether SCSD complied with the requirements of Section 932.17(2) of Title 103 of the Code of Massachusetts Regulations (CMR) and SCSD’s Policy S623 (Serious Illness, Injury or Death of Any Person on Site or on the Job) regarding the deaths of inmates in its custody[1]
• whether SCSD held quarterly meetings with its contracted healthcare vendor and reviewed the vendor’s quarterly reports in accordance with 103 CMR 932.01(3)
• whether SCSD provided receiving screenings[2] to its inmates upon arrival at SCSD’s jail or house of correction and initial health assessments in accordance with Sections 2 and 4 of its Policy S604 (Inmate Care and Treatment)
• whether inmates received all the healthcare required by Section 7 of SCSD’s Policy S604 (Inmate Care and Treatment), 103 CMR 932.18(2)(h), and 103 CMR 932.18(2)(k) when using SCSD’s sick call process.

Below is a summary of our findings and recommendations, with links to each page listed.

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Finding 1 Page 15	SCSD did not always ensure that it received an annual statistical summary from its healthcare vendor.
Recommendation Page 15	SCSD should establish policies and procedures to ensure that it obtains the annual statistical summaries.
Finding 2 Page 16	SCSD did not ensure that its healthcare vendor complied with all the requirements of SCSD’s sick call policy.
Recommendation Page 18	SCSD should establish monitoring controls (i.e., policies and procedures) over its sick call process to ensure that its healthcare vendor complies with all the requirements of SCSD’s healthcare policies.

 

Our audit of SCSD identified two other issues, but only one is disclosed in this public report (see Other Matters). The other issue has been omitted from this report in accordance with Exemption (n) of the Commonwealth’s public records law, Section 7(26)(n) of Chapter 4 of the General Laws, which allows for the withholding of certain records, such as confidential and sensitive information, if their disclosure is likely to jeopardize public safety.

In accordance with Paragraphs 7.61–7.62 of the Government Accountability Office’s Government Auditing Standards, as well as the policies of the Office of the State Auditor, for reporting confidential and sensitive information, we have given a separate, complete report to SCSD, which will be responsible for acting on our recommendations.

 

[1].     SCSD told us that if an inmate is in custody, it means that SCSD has the authorization from a court to incarcerate an inmate until the court orders their release. A death in custody is one that occurs during this period of incarceration.

[2].     A receiving screening is an assessment of an inmate’s health needs and/or medical conditions. It is conducted upon an inmate’s arrival at SCSD’s jail or house of correction.

Overview of Audited Entity

The Suffolk County Sheriff’s Department (SCSD) was established as an independent state agency on August 6, 2009, pursuant to Chapter 61 of the Acts of 2009. According to Section 4 of this chapter,

All functions, duties, and responsibilities of the office of a transferred sheriff pursuant to this act, including, but not limited to, the operation and management of the county jail and house of correction and any statutorily authorized functions of that office, are hereby transferred from the county to the commonwealth.

This transition was completed on January 1, 2010. The Sheriff became an employee of the Commonwealth but remained an elected official and retained administrative and operational control over SCSD. Under the Sheriff’s direction, superintendents administer SCSD operations at SCSD facilities, which include its house of correction (HOC) and jail. SCSD’s offices are in the HOC and jail.

According to SCSD’s internal control plan,

The primary Mission of SCSD . . . shall be: To enforce the laws of the Commonwealth and to serve and protect the citizens of Suffolk County; To Strengthen public safety through corrections and providing specialized support services to all criminal justice agencies; and to maintain the safe and secure custody and control of inmates and detainees while offering extensive rehabilitation opportunities to effectively reduce offender recidivism.

As of June 30, 2021, SCSD had 977 employees, including 761 full-time correction officers working at either the Suffolk County Jail or SCSD’s HOC. In fiscal years 2020 and 2021, SCSD’s annual state appropriations were approximately $117.6 million and $116.6 million, respectively. In addition to its state appropriations, SCSD received the following federal funding to support its programs for these fiscal years.

Program	Fiscal Year 2020	Fiscal Year 2021	Total
Adult Basic Education	$ 152,462	$ 160,526	$ 312,988
Substance Abuse Grant	86,277	81,232	167,509
Human Immunodeficiency Virus Grant	0	76,595	76,595
State Opioid Response Grant	0	225,000	225,000
Total	$ 238,739	$ 543,353	$ 782,092

 

SCSD operates its HOC at 20 Bradston Street in Boston, which was opened in 1991 and is used for the care and custody of pretrial and sentenced inmates. Inmates can only be housed at the HOC if their sentences are less than two and a half years. As of June 30, 2021, there were 708 inmates, 184 of whom were female and 524 of whom were male.

SCSD also operates the Suffolk County Jail at 200 Nashua Street in Boston. The jail houses pretrial male detainees.³ As of June 30, 2021, there were 357 male detainees housed there.

According to its website, SCSD inmates and detainees at both facilities are offered the following programs and services:

• Education, which includes career counseling, literacy courses, and English courses (for English-language learners)
• Vocational education in areas such as graphic arts, carpentry, and computer literacy
• Religious services, including visits from clergy and masses in various languages
• Social services, including yoga, meditation, and parenting classes as well as training from substance use disorder counselors
• Community work programs, which allow inmates to work in the community through various state agencies, such as the Massachusetts Department of Transportation
• A women’s program, which includes workshops for women on topics such as reentry (life skills and job skills for inmates being released from an HOC or jail), anger management, and substance use disorder recovery
• Reentry services, which include providing case managers to male offenders (specifically those who are at high risk to reoffend) to assist them throughout their sentences; help them transition back into the community; and make referrals to community resources, such as housing assistance and job opportunities.

Offender Management System

SCSD uses a system called the Offender Management System (OMS) to track and manage information on inmates in its custody. The information maintained in the system includes inmates’ names, genders, ethnicities, dates of birth, Social Security numbers, state identification numbers,⁴ booking numbers,⁵ booking dates, release dates, release types,⁶ and in-custody housing assignments.⁷ During an inmate’s admission process, SCSD’s booking officer enters information from a mittimus⁸ into OMS.

Electronic Record Management Application

SCSD uses the Electronic Record Management Application (ERMA), a Web-based application administered by WellPath (its healthcare vendor), to manage inmates’ medical records, appointment scheduling, and offsite healthcare.

Inmate Deaths

Section 932.17 of Title 103 of the Code of Massachusetts Regulations (CMR) requires county correctional facilities such as SCSD’s to establish guidelines for notifications, investigations, reports, and documentation regarding the deaths of inmates or facility employees. In the case of an inmate’s serious illness or injury while in SCSD’s custody, the central control unit⁹ notifies healthcare staff members—including an onsite physician (who is an employee of SCSD’s healthcare vendor), an emergency medical service provider (which is a third party), and SCSD’s special emergency response team—to report to the scene to provide emergency medical aid. Only the physician or emergency medical service provider can determine whether the inmate has died and order the cessation of this emergency medical aid.

If an inmate dies, the central control unit notifies the superintendent of the facility and SCSD’s Sheriff’s Investigative Division. The Sheriff’s Investigative Division then notifies the Boston Police Department (BPD), the Suffolk County District Attorney, the Massachusetts Office of the Chief Medical Examiner (OCME), and the deceased inmate’s next of kin. If the inmate is held in custody for another jurisdiction (because of inmate overflow), that jurisdiction will be notified as well.

Upon arrival at the facility, BPD secures the scene and conducts an investigation, which the SCSD Sheriff’s Investigative Division facilitates, to determine the cause and manner of death. Once the investigation is completed, OCME retrieves the body and conducts a postmortem exam.¹⁰ OCME then completes and signs the death certificate, and the body is released to the next of kin. The health services administrator (HSA)¹¹ conducts a mortality review¹² within 30 days after an inmate’s death.

SCSD Policy S623 (Serious Illness, Injury or Death of Any Person on Site or on the Job) states that in the event of an inmate’s suicide, SCSD’s Clinical Review Committee, which includes the HSA, as well as the medical director and the director of mental health of SCSD’s healthcare vendor, “conducts an in-depth clinical review [which is different than the mortality review] to determine whether changes in the [inmate’s] clinical psychiatric management could have prevented the result.”

All staff members and witnesses to a death must submit incident reports to SCSD’s Sheriff’s Investigative Division. SCSD’s Sheriff’s Investigative Division provides copies of these incident reports, along with OCME’s report, BPD’s investigation report, and other relevant reports surrounding the death in jail or the HOC, to the Suffolk County Sheriff, superintendent, and general counsel.

Healthcare

During the audit period, healthcare at SCSD facilities was contractually provided by third-party vendors (NaphCare, Inc. from July 1, 2019 through February 28, 2021, and WellPath, from March 1, 2021 through June 30, 2021). SCSD’s “Request for Responses: Comprehensive Health Services to Suffolk County Sheriff’s Department Offenders (BD-21-1098-HOC-SD02-53116),” dated August 17, 2020, outlines the following responsibilities of its healthcare vendor:

3.2 Role of the Contractor

The Contractor shall provide services to all inmates/detainees in the custody of SCSD.

The Contractor shall be solely responsible for making all decisions with respect to the type, timing and level of services needed by offenders. This includes, without limitation, the determination of whether an inmate/detainee is in need of clinical care, inpatient hospitalization, and/or referral to an outside specialist or otherwise needs specialized care. Except as herein otherwise provided, the Contractor shall be the sole supplier and/or coordinator of all medical, mental health, and dental services under this Contract, and, as such, shall have the sole authority and responsibility for the implementation, modification, and continuation of any and all health care for offenders.

The Contractor shall provide all means of addressing the serious medical, dental and mental health needs of the inmate/detainee population based upon clinical assessments of the individual inmates/detainees in a manner that is cost effective and consistent with community standards of care.

According to the request for responses, SCSD is required to monitor the contractor’s compliance by conducting a process performance audit of the services at each facility. This audit consists of reviewing performance measures of various health records regarding medical, dental, mental, or other health services, to ensure that the contractor is accountable for the quality and timeliness of the services provided. The request for responses does not include a required frequency for the audits. (For our audit testing, we used 103 CMR 932.01(3), which requires that healthcare vendors submit quarterly and annual reports.) SCSD is also required to monitor and review vendor staffing levels by conducting a formal staffing analysis. Staffing level changes are determined by a written agreement between the contractor and SCSD, and adjustments to compensation are based solely on the direct costs of rates and benefits.

Administrative Oversight of Healthcare

According to 103 CMR 932.01(3), county correctional healthcare vendors must meet with the Sheriff, facility administrator, or a designee selected by SCSD at least quarterly and submit quarterly reports on the healthcare delivery system and health environment, as well as annual statistical summaries.¹³ The healthcare vendor documents and maintains meeting minutes. The meetings cover quality improvement, emergency drills, mortality review findings, and other statistical reports used to monitor trends in the delivery of healthcare at SCSD.

Receiving Screenings

Upon arrival at the jail or HOC, if an inmate is determined to be in an emergency condition, they are referred to SCSD’s medical clinic for evaluation and treatment. After medical clearance¹⁴ is completed, a healthcare staff member performs a receiving screening to ensure that the inmate’s needs are met within 24 hours after an inmate’s arrival to the facility. According to Section 2 of SCSD Policy S604 (Inmate Care and Treatment), all SCSD inmates are required to have a receiving screening by healthcare staff members upon admission. The purpose of this screening is to determine whether the inmate has any medical needs that must be immediately addressed. The screening consists of a structured inquiry and observation to determine potential emergencies and to ensure that patients with known illnesses, medication prescriptions, or other health needs are identified for further assessment and continued treatment while they are in custody.

A healthcare staff member documents the receiving screening in the Receiving Screening Form held in the inmate’s medical record in ERMA. The Receiving Screening Form is then approved by a qualified healthcare professional (QHP).¹⁵ According to SCSD management, inmates have the right to waive the receiving screening by signing an Inmate Refused Receiving Screening Form.

Initial Health Assessment

According to Section 4 of SCSD Policy S604, each inmate committed to the facility for 30 days or more must receive an initial health assessment within 14 days of admission, unless there is documented evidence of an examination within the previous 90 days. A healthcare staff member completes the health assessment, which includes, but is not limited to, reviewing the inmate’s medical record, examining the inmate for any signs of trauma or disease, conducting medically indicated tests, and reviewing findings and any follow-up services with inmates who require further treatment. A healthcare staff member completes the Initial Health History and Physical Assessment Form and documents the initial health assessment in the inmate’s medical record for the initial health assessment in ERMA. The Initial Health History and Physical Assessment Form is then approved by a QHP.

Sick Call Requests

According to Section VII(A) of SCSD Policy S604,

All inmates shall have the opportunity, through the daily sick call process, to confidentially request medical assistance or health care services for non-emergent illnesses or injury.

During our audit period, the sick call process was administered by SCSD’s healthcare vendor.

To request access to healthcare, an inmate completes a sick call form, called the Health Service Request Form (HSRF), and states the type of service requested (medical, dental, or mental health); the date the form is completed; and the nature of the problem or request. They also add their name, patient identification number,¹⁶ booking number, date of birth, in-custody housing assignment, and signature. They submit the HSRF by putting it in a secure lockbox in their housing unit or handing it directly to a healthcare staff member during a medication pass, which occurs at least twice a day. Healthcare staff members pick up the HSRFs daily to evaluate and triage each request within 24 hours. QHPs provide treatment and schedule follow-up appointments according to clinical priorities. A face-to-face encounter with a QHP is required within 48 hours after the receipt of the HSRF from an inmate during the week and within 72 hours of the receipt on weekends. All requests that are triaged as emergencies are responded to immediately, and problems beyond the QHP’s scope are referred to appropriate healthcare providers. The inmates’ medical files are maintained in ERMA.

[3]     A detainee is a person held in custody before their trial.

[4]     A state identification number is a unique number assigned to an inmate from a court system.

[5]     A booking number is a unique number assigned by SCSD to an inmate upon their arrival to SCSD’s jail or HOC.

[6]     The release type is the way in which an inmate is discharged from a facility, such as bail, death, parole, or completion of their sentence.

[7]     A housing assignment is an inmate’s specific unit, cell, and bed within the HOC or jail.

[8]     A mittimus is a written court-issued document that follows an inmate through their time in the criminal justice system.

[9]    The central control unit is a booth, staffed by employees, in the center of its jail or HOC that contains radio communication devices and access to controls at SCSD. All communication in and out of the facility goes through the central control unit.

[10]     The postmortem exam is an examination of the deceased’s body in order to determine the cause of death.

 

[11]     According to WellPath’s Policy HCD-100_A-02 (Responsible Health Authority), the HSA is the designated WellPath employee who “maintains a coordinated system for health care delivery.”

[12]            According to WellPath’s Policy HCD-100_A-09 (Procedure in the Event of a Patient Death), a mortality review “consists of both an administrative and clinical mortality review, as well as a psychological autopsy, if death is by suicide. . . . The clinical mortality review is an assessment of the clinical care provided and the circumstances leading up to a death. Its purpose is to identify areas of patient care or system policies and procedures that can be improved. . . . The administrative mortality review is an assessment of correctional and emergency response actions surrounding a patient’s death, regardless of the availability of autopsy results, and is conducted in conjunction with custody staff. . . . The psychological autopsy is a written reconstruction of an individual’s life. It is usually conducted by a psychologist or another qualified mental health professional.”

 

[13]     The statistical summary contains data related to inmate health records and provides a comprehensive overview of medical services delivered to inmates during the year.

[14]     According to WellPath’s Policy HCD-100_E-02 (Receiving Screening), medical clearance is “a clinical assessment of physical and mental status before an individual is admitted into the facility. The medical clearance may come from the on-site health care staff or may require sending the individual to the hospital emergency room. The medical clearance is to be documented in writing.”

[15]            According to Wellpath’s Policy HCD-100_A-02, QHPs include the following: “Physicians, physician assistants, nurses, nurse practitioners, dentists, . . . mental health professionals, and others who by virtue of education, credentials, and experience are permitted by law to evaluate and care for patients.”

[16]           A patient identification number is assigned in ERMA for each inmate, which is the same as each inmate’s state identification number.

Date published:	December 7, 2022