Audit of the Worcester County Sheriff’s Office—A Review of Healthcare and Inmate Deaths Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Worcester County Sheriff’s Office—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 Worcester County Sheriff’s Office (WCSO) for the period July 1, 2020 through December 31, 2022.

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
Did WCSO comply with and implement the requirements of Section 932.17(2) of Title 103 of the Code of Massachusetts Regulations (CMR) and WCSO’s Policy 932.17 (Guidelines for Serious Illness, Injury or Death) regarding the deaths of inmates in its custody?	Yes
Did WCSO hold quarterly meetings with its contracted healthcare providers and review quarterly reports regarding healthcare services for inmates in accordance with 103 CMR 932.01(3)?	Yes
Did WCSO provide its inmates with medical screenings upon admission and physical examinations within 14 days after admission, in accordance with its Policy 932.06 (Admission Medical Screening) and its Policy 932.07 (Health Appraisal/Physical Examination)?	Yes
Did inmates at WCSO receive medical care after submission of sick call requests in accordance with Wellpath’s “Nonemergency Health Care Requests and Services” Policy (HCD-100_E-07) for WCSO?	Yes
Did WCSO provide initial mental health assessments to all inmates in its custody, in accordance with 103 CMR 932.13 and its Policy 932.13 (Mental Health Services and Suicide Prevention)?	Yes

To accomplish our audit objectives, we gained an understanding of the aspects of WCSO’s internal control environment relevant to our objectives by reviewing WCSO’s internal control plan and applicable policies and procedures and by conducting site visits and interviews with WCSO management. We evaluated the design and implementation of the internal controls relevant to our audit objectives.

To obtain sufficient, appropriate evidence to address our audit objectives, we performed the procedures described below.

Inmate Deaths

We inspected the list of inmate deaths that occurred during the audit period, which WCSO management provided to us. The list included two inmates who died in WCSO’s custody. To determine whether WCSO complied with and implemented the requirements of Title 103 CMR 932.17(2) and WCSO’s Policy 932.17 regarding the deaths of inmates in its custody, we took the following actions:

• We inspected WCSO’s Policy 932.17 to determine whether WCSO had guidelines that include the following requirements listed in 103 CMR 932.17(2):
  • (a)  internal notification to include medical and administrative staff;
  • (b)  procedures when discovering body;
  • (c)  disposition of [i.e., the possession of] the body;
  • (d)  notification of next of kin;
  • (e)  [Criminal Offender Record Information] notification [sent to victim(s) of an inmate] as soon as practicable [when such notification is necessary];
  • (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 WCSO complied with and implemented the requirements of 103 CMR 932.17(2) and its Policy 932.17 regarding the two in-custody deaths that occurred during the audit period, we took the following actions for each of these deaths:

• We examined the incident reports, prepared by the assistant superintendent, for both deaths to ensure that the required medical and administrative staff members were notified about the deaths. We also examined the incident reports to determine whether there was any possible staff member misconduct leading up to the discovery of the deaths.
• We examined the incident report summaries to determine the following:
• that the responding staff member(s) provided lifesaving measures and notified the appropriate parties about the inmates’ unresponsiveness;
• that the disposition/possession of the bodies were moved to the appropriate authority (e.g., the hospital or the medical examiner);
• that the superintendent (or their designee) notified the next of kin of the inmates’ deaths; and
• that any victims of the inmates were notified of the inmates’ deaths as soon as was practicable. (This action was not applicable for the two deaths in question.)
• We inspected the Offender Management System (OMS) records corresponding to each deceased inmate to determine whether the release types were properly classified as deaths.
• We inspected the incident reports to determine whether WCSO ensured that staff members followed the required reporting and documentation procedures.
• We inspected each Critical Incident Overview report, prepared by the assistant superintendent whenever a critical clinical event occurs, to determine whether they were completed within 30 days of each death.

We noted no exceptions in our testing. Therefore, we determined that, during the audit period, WCSO complied with and implemented the requirements regarding the deaths of inmates in its custody.

Quarterly Meetings

To determine whether WCSO held quarterly meetings with its contracted healthcare providers and reviewed quarterly reports regarding healthcare services for inmates in accordance with 103 CMR 932.01(3), we took the following actions. We examined the minutes and attendance sheets (which were signed by meeting attendees) of all 10 (100%) of the quarterly meetings that took place during the audit period between WCSO and its contracted healthcare providers. In addition, we inspected all 10 (100%) of the quarterly reports discussed in each of the quarterly meetings and all three (100%) annual statistical summaries that the contracted healthcare providers submitted to WCSO during the audit period.

We noted no exceptions in our testing. Therefore, we determined that, during the audit period, WCSO held quarterly meetings with its contracted healthcare providers and reviewed quarterly reports regarding healthcare services for inmates.

Admission Medical Screenings and Physical Examinations

To determine whether WCSO provided its inmates with medical screenings upon admission and physical examinations within 14 days after admission, in accordance with its Policies 932.06 and 932.07, we took the following actions. Using a 95% confidence level,¹⁶ a 0% expected error rate,¹⁷ and a 5% tolerable error rate,¹⁸ we selected a random, statistical¹⁹ sample of 60 inmates out of a total population of 7,278 inmates who were admitted to the Worcester County Jail and House of Correction (WCJHOC) during the audit period. Using our sample, we took the following actions:

• We examined each inmate’s Admission Medical Screening Form to determine the date and time it was completed and signed by a qualified healthcare professional (QHP). We then compared the date the admission medical screening was completed to the date and time of each inmate’s admission to WCJHOC to determine whether WCSO completed each admission medical screening within 24 hours of an inmate’s admission to WCJHOC.
• We examined the physical examination form to calculate the number of days between each inmate’s admission date and the date their physical examination was completed to determine whether WCSO completed each physical examination within 14 days of an inmate’s admission to WCJHOC.

We noted no exceptions in our testing. Therefore, we determined that, during the audit period, WCSO provided its inmates with medical screenings upon admission and physical examinations within 14 days after admission.

Initial Mental Health Assessments

To determine whether WCSO provided initial mental health assessments to all inmates in its custody, in accordance with 103 CMR 932.13 and its Policy 932.13, we took the following actions. Using a 95% confidence level, a 0% expected error rate, and a 5% tolerable error rate, we selected a random, statistical sample of 60 inmates out of a total population of 7,278 inmates who were admitted to WCJHOC during the audit period. Using our sample, we took the following actions:

• We examined each inmate’s Mental Health Intake Form (which is completed by the qualified mental health professional during the initial mental health assessment) to determine the date a qualified mental health professional completed it. We then compared the date of each inmate’s admission to the date the initial mental health assessment was completed to determine whether WCSO completed each mental health assessment within 24 hours of an inmate’s admission to WCJHOC.
• We examined the Mental Health Evaluation form (which is completed by the qualified mental health professional during a comprehensive mental health evaluation) to calculate the number of days between each inmate’s admission date and the date their comprehensive mental health evaluation was completed (for those referred) to determine whether WCSO completed each comprehensive mental health evaluation within 14 days of an inmate’s referral.

We noted no exceptions in our testing. Therefore, we determined that, during the audit period, WCSO provided initial mental health assessments to all inmates in its custody.

Data Reliability Assessment

OMS

To assess the reliability of the OMS data, including the OMS inmate list and the OMS in-custody death list, we took the following actions. We interviewed WCSO information technology who were knowledgeable about OMS. We tested general information technology controls (e.g., access, segregation of duties, configuration management, and security management controls).

In addition, we selected a random sample of 20 inmates from the OMS inmate list and traced the inmates’ information from this list (i.e., full name, date of birth, booking date, sex, and race) to the information in the original source documents (i.e., the mittimuses) for agreement. We also selected 20 random samples of hard copies of the mittimuses and traced the inmates’ information from these mittimuses (i.e., full name, date of birth, booking date, sex, and race) to the OMS inmate list. In addition, we tested the OMS inmate list to ensure that it did not contain any duplicate records. We also reconciled the OMS in-custody death list with a separate list of WCSO in-custody deaths that the Office of the Chief Medical Examiner provided to us.

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

ERMA

To assess the reliability of the ERMA data in the sick call list, we took the following actions. We interviewed Wellpath information technology employees who were knowledgeable about ERMA. We reviewed the System and Organization Control²⁰ reports for the audit period; our review included, but was not limited to, testing all access and account management controls.

In addition, we selected a random sample of 20 inmates from the ERMA sick call list and traced the inmates’ information from this list (i.e., patient identification number, date of birth, date of sick call request, and date of scheduled face-to-face meeting with a QHP) to the information in the HSRFs that were scanned and stored in ERMA for agreement. We also selected 20 random samples from the scanned HSRFs and traced the inmate’s information from these HSFRs (i.e., patient identification number, date of birth, and date of sick call request) to the ERMA sick call list for agreement. In addition, we tested the ERMA sick call data to ensure that it did not contain any spreadsheet issues (i.e., hidden objects such as rows or headers).

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

Conclusion

Our audit revealed no significant issues that must be reported under generally accepted government auditing standards. Therefore, this report contains no findings.

16.   Confidence level is a mathematically based measure of the auditor’s assurance that the sample results (statistic) are representative of the population (parameter), expressed as a percentage. A 95% confidence level means that 95 out of 100 times, the statistics accurately represent the larger population.

17.   Expected error rate is the number of errors that are expected in the population, expressed as a percentage. It is based on the auditor’s knowledge of factors such as prior audit results, the understanding of controls gained in planning, or a probe sample. In this case, we are assuming there are no errors in the data provided to us by the auditee.

18.   The tolerable error rate (which is expressed as a percentage) is the maximum error in the population that is acceptable while still using the sample to conclude that the results from the sample have achieved the objective.

19.   Auditors use statistical sampling to select items for audit testing when a population is large (usually over 1,000) and contains similar items. Auditors generally use a statistics software program to choose a random sample when statistical sampling is used. The results of testing using statistical sampling, unlike those from judgmental sampling, can usually be used to make conclusions or projections about entire populations.

20.   A System and Organization Control report is a report, issued by an independent contractor, on controls about a service organization’s systems relevant to security, availability, processing integrity, confidentiality, or privacy. 

 

Date published:	November 21, 2024