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

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 Suffolk County Sheriff’s Department (SCSD) 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; the conclusion we reached regarding each objective; and, if applicable, where each objective is discussed in the audit findings.

Objective	Conclusion
Did SCSD comply with and implement 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?	See Other Matters
Did SCSD hold quarterly meetings with its healthcare vendor and review quarterly reports in accordance with 103 CMR 932.01(3) for inmates’ healthcare?	No; see Finding 1
Did SCSD provide receiving screenings to its inmates upon admission, and an initial health assessment within 14 days after admission, in accordance with Sections 2 and 4 of its Policy S604 (Inmate Care and Treatment)?	Yes
Did inmates at SCSD receive medical care after submission of Health Service Request Forms (HSRFs) in accordance with Section 7 of its Policy S604, 103 CMR 932.18(2)(h), and 103 CMR 932.18(2)(k)?	No; see Finding 2

To accomplish our objectives, we gained an understanding of SCSD’s internal control environment relevant to the objectives by reviewing SCSD’s internal control plan and applicable policies and procedures, as well as conducting site visits and interviews with SCSD’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 receiving screenings. 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 SCSD management for the audit period, which reflected one inmate who died in SCSD custody on November 27, 2020 and whose cause of death was reported as suicide. To determine whether SCSD complied with 103 CMR 932.17(2) and SCSD’s Policy S623 regarding the deaths of inmates in its custody, we performed the following procedures.

• We inspected SCSD’s Policy S623 to determine whether SCSD has established guidelines that include the following, in accordance with the requirements of 103 CMR 932.17(2):

(a)  internal notification to include medical and administrative staff;

(b)  procedures when discovering body;

(c)  disposition of the body;

(d)  notification of next of kin;

(e)  notification of [Criminal Offender Record Information] certified individuals as soon as practicable;

(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.

• To determine whether SCSD complied with and implemented the requirements of 103 CMR 932.17(2) and its in-custody death guidelines in Policy S623, we performed the following:
• We examined the SCSD incident reports submitted by all SCSD responding staff members and witnesses to the inmate’s death to ensure that the superintendent notified the inmate’s next of kin.
• We examined SCSD’s logbook entries to ensure that the healthcare staff members and administrative staff members were notified.
• We examined SCSD daily shift events,¹⁷ incident reports, and logbook entries to ensure that the responding staff members documented activities, provided lifesaving measures, and notified the appropriate parties when they discovered the body.
• We examined the Boston Police Department’s investigation report, the Boston Emergency Medical Service’s incident history, the Boston Fire Department’s incident history, and the Massachusetts Office of the Chief Medical Examiner’s (OCME’s) report to ensure that an investigation of causes was performed by these parties.
• We examined OCME’s report to ensure that SCSD notified OCME to retrieve the body.
• We examined the SCSD Sheriff’s Investigative Division’s Summary, which is its incident investigation report, to ensure that SCSD followed its policies and procedures to ensure that appropriate staff members review the incident surrounding the inmate’s death. In addition, we requested the reports covering the mortality and clinical reviews from SCSD that were required by SCSD Policy S623. In response, SCSD management told us that they had met with NaphCare, the previous healthcare vendor, to discuss the reports that were completed for the one death that occurred during the audit period. However, NaphCare did not provide SCSD with a copy of these reports (see Other Matters).

To determine whether SCSD provided the healthcare services in compliance with state regulations and its own policies, we examined the minutes of all six quarterly meetings of SCSD 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 SCSD during the audit period.

To determine whether SCSD provided its inmates with receiving screenings upon admission, and initial health assessments within 14 days after admission, in accordance with Sections 2 and 4 of its Policy S604, we selected a statistical, random sample with a 95% confidence level, 5% tolerable rate, and 0% expected error rate. Our sample consisted of 60 new inmates out of a total population of 13,261 who were admitted to SCSD’s jail or house of correction (HOC) during the audit period. We reviewed the evidence and performed the following tests:

• We examined each inmate’s Receiving Screening Form to document the date and time it was completed and signed by a healthcare staff member. For inmates who refused the receiving screening upon intake, we examined the signed Inmate Refused Receiving Screening Forms.
• We calculated the number of days each inmate was committed at the SCSD jail or HOC by comparing the booking and release dates. According to SCSD policy, inmates committed for more than 30 days are required to have initial health assessments. For each inmate committed for 30 days or more, we examined the Initial Health History and Physical Assessment Form to document the date and time it was completed and signed by a qualified healthcare professional (QHP). We then calculated the number of days after arrival that the initial health assessment was completed to determine whether inmates received initial health assessments within 14 days as required by policy.

Paragraph 9.12 of the United States Government Accountability Office’s Government Auditing Standards states, “Auditors should . . . report any significant constraints imposed on the audit approach by information limitations or scope impairments.” During our audit of SCSD, we experienced a scope limitation / constraints regarding our ability to obtain the information necessary to achieve our sick-call-related objective. Specifically, we asked SCSD management to provide us with a list of inmates who used the department’s sick call process during the audit period. SCSD management told us that they could not provide us with the sick call data for the period July 1, 2019 through February 28, 2021 because of ongoing litigation with NaphCare, its former healthcare vendor. SCSD management told us that all NaphCare’s data had been transferred to its new vendor’s electronic medical record system; however, the records and charts were saved as attachments to each inmate’s records in this system. Therefore, SCSD could not extract the full population of sick calls from the Electronic Record Management Application (ERMA) in a format that would be useful to us. As a result, we had to limit the scope of our review for our fourth objective to the period March 1, 2021 through June 30, 2021.

• To determine whether inmates received medical care after submission of HSRFs in accordance with SCSD policy, we selected a statistical, random sample with a 95% confidence level, 5% tolerable rate, and 0% expected error rate. Our sample consisted of 60 HSRFs out of a total population of 5,664 HSRFs submitted by inmates during the period March 1, 2021 through June 30, 2021. We performed the following procedures:
• We examined the HSRFs to ensure that a QHP documented the immediacy of need and required intervention on the HSRF.
• We calculated triage time by comparing the date of triage and the date the healthcare staff member received each HSRF to ensure that all sick calls were evaluated and triaged within 24 hours.
• We compared the date a healthcare staff member received each sick call to the date of each face-to-face interaction to ensure that a QHP met with each inmate within 48 hours during the week and 72 hours on weekends upon receipt of a sick call.
• We examined all HSRFs to ensure that a QHP documented the suggested treatment and referred problems beyond their scope to the appropriate provider.

Due to the scope limitation, we did not project the results of these tests to the entire audit period.

Data Reliability Assessment

Offender Management System

To assess the reliability of the inmate data obtained from the Offender Management System (OMS), we interviewed employees of SCSD’s IT department who were responsible for oversight of the system. We tested the general IT controls, including access and account management controls. We selected a random sample of 20 inmates from the list of inmates in OMS and agreed each full name, date of birth, booking date, sex, age, race, and facility to the original source document (the mittimus). We also selected 20 random samples from hard copies of the mittimi and traced the inmates’ same information (full name, date of birth, booking date, sex, age, and race) from them to OMS. In addition, we tested the inmate data population for duplicate records and matched the death-in-custody list from OMS with a list OCME 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.

ERMA

We assessed the reliability of the sick call data obtained from ERMA by conducting interviews with WellPath officials who had knowledge about the data. In addition, we matched the patient identification number from ERMA to the state identification number of newly admitted inmates in OMS during the period March 1, 2021 through June 30, 2021. Further, we reviewed System and Organization Controls reports¹⁸ that covered the period November 1, 2020 through October 31, 2021 and ensured that certain information system control tests had been performed.

To confirm the completeness and accuracy of the sick call data in ERMA, we selected a random sample of 20 sick calls from the sick call list in ERMA and agreed each patient name, patient number, date of request, and date of service by the QHP to hard copies of HSRFs filed by inmates. We also selected a random sample of 20 hard copies of HSRFs and traced the information from them back to the sick call list in ERMA.

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

Date published:	December 7, 2022