Audit of the Worcester County Sheriff’s Office—A Review of Healthcare and Inmate Deaths Overview of Audited Entity

This section describes the makeup and responsibilities of the Worcester County Sheriff’s Office—A Review of Healthcare and Inmate Deaths.

Overview

The Worcester County Sheriff’s Office (WCSO) was established as an independent state agency on July 1, 1998, after Section 1 of Chapter 34B of the Massachusetts General Laws abolished Worcester County as a form of government. This law was then amended by Chapter 61 of the Acts of 2009. According to Section 4 of Chapter 34B of the General Laws,

All functions, duties, and responsibilities of the office of a transferred sheriff pursuant to [the Acts of 2009] 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.

The transaction 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 WCSO. Under the Sheriff’s direction, superintendents administer WCSO operations at WCSO’s facilities.

WCSO’s Policy 910.01 (Mission Statement: Philosophy and Goals) states,

The primary mission of the Worcester County Jail and House of Correction is to protect society from criminal offenders. The Worcester County Sheriff’s Office addresses this mission by pursuing the following goals:

A.   Safely and humanely housing inmates at the least restrictive security level as practical and still protect the public.

B.   Providing opportunities for inmates to rehabilitate and reintegrate themselves into the community.

C.   Providing prudent management over resources (human, financial and physical) allocated to the facility.

D.   Establishing and implementing policies, procedures and practices which are in compliance with applicable laws. . . .

E.   Identifying, evaluating and implementing creative and practical approaches (existing as well as new) to achieve the facility’s mission in a cost effective manner.

F.   Informing and educating the public as to Worcester County Jail and House of Correction’s mission, goals and role in the Criminal Justice System.

G.   Providing a safe, professional and rewarding work environment for staff.

As of December 31, 2022, WCSO had 530 employees who supervised and cared for the inmates in WCSO’s custody.¹ In fiscal years 2020 and 2021, WCSO’s annual state appropriation was approximately $53,472,100 each year; in fiscal year 2023, the annual state appropriation was approximately $57,215,100.

WCSO’s main administrative building and the Worcester County Jail and House of Correction (WCJHOC), which was constructed in 1973, are both located at 5 Paul X Tivnan Drive in West Boylston. As of December 31, 2022, WCJHOC had a population of 647 inmates in its custody, including 341 pretrial inmates, 293 sentenced inmates, and 13 regionally arrested individuals.²

According to its website, WCSO offers inmates the following programs and services:

• educational programs, including courses in topics such as computer literacy, financial literacy, and entrepreneurship;
• a substance use disorder treatment program that is six months long, available to 24 inmates at a time, and offers enrolled inmates physical, psychological, and emotional assistance;
• a work release program that lets certain inmates perform monitored work outside of WCJHOC during their shifts, thereby providing them with an opportunity to reintegrate back into the community; and
• general reentry/reintegration services, which include providing inmates with counselors to assist them throughout their sentences and referrals to community resources such as housing assistance and employment agencies.

Offender Management System

WCSO 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,³ booking numbers,⁴ booking dates, release dates, release types,⁵ and in-custody housing assignments.⁶ During the process of admitting an inmate, one of WCSO’s booking officers enters information from a mittimus⁷ into OMS.

Electronic Record Management Application

WCSO uses the Electronic Record Management Application (ERMA), a web-based medical record application administered by Wellpath, WCSO’s contracted general healthcare provider, to manage inmates’ medical records, appointment scheduling, and off-site healthcare.

Inmate Deaths

Section 932.17 of Title 103 of the Code of Massachusetts Regulations (CMR) requires agencies with county correctional facilities, such as WCSO, to establish guidelines for notifications, investigations, reports, and documentation regarding the deaths of inmates or facility employees. According to Section 4 of WCSO’s Policy 932.17 (Guidelines for Serious Illness, Injury or Death), in the event of an inmate’s serious illness, injury, or death while in WCSO’s custody, at least one of the officers on duty notifies the central control unit.⁸ The unit then notifies WCSO’s contracted general healthcare provider, WCSO’s emergency response team (which is made up of several WCSO officers), and MedStar (an ambulance service provider), to assist, administer medical care, and/or provide transportation to the hospital, if appropriate. This lifesaving assistance continues until either the inmate’s condition improves or a physician at the hospital calls the inmate’s time of death.

In the event of an inmate’s death, the central control unit notifies the following parties of the inmate’s death: the Sheriff, the superintendent (or their designee) of the facility where the inmate was held in custody, the Security Investigations Unit, and the health services administrator.⁹ The superintendent (or their designee) notifies the following parties of the inmate’s death: the Massachusetts State Police, the Worcester County District Attorney’s Office, the Office of the Chief Medical Examiner, and the inmate’s next of kin.

Once members from the Massachusetts State Police arrive at WCJHOC, they, alongside the Security Investigations Unit, secure the scene of the incident and conduct an investigation to determine the cause and manner of death. The Office of the Chief Medical Examiner conducts a postmortem exam.¹⁰ After this, the Office of the Chief Medical Examiner completes and signs the death certificate, then releases the body to the inmate’s next of kin.

Following the death of an inmate, each involved staff member must submit an incident report to WCSO’s superintendent (or their designee) by the end of their shift on the day of the incident. Any treatments and/or lifesaving measures that were taken are documented in the inmate’s medical record. A designated officer collects the deceased inmate’s medical record, mental health record, medication record, guest visitation information, and any other pertinent documentation. The superintendent retains all of this documentation for the investigation. The Security Investigations Unit may also conduct an investigation while assisting with the Massachusetts State Police’s investigation. The assistant director of the Security Investigations Unit submits a written investigative report (which contains any documents that correspond to an incident, such as incident reports, external agency reports, medical records, and photographs) to the director of security at the conclusion of an internal investigation.

After the death of an inmate, the health services administrator convenes a mortality review¹¹ within 30 days. If the mortality review results in recommendations, then the health services administrator is responsible for ensuring that all affected parties implement these recommendations immediately.

Healthcare Services

During the audit period, healthcare at WCJHOC was contractually provided by two external vendors, Wellpath and Advocates.

Wellpath administers general healthcare services and related administrative services at WCJHOC. These general healthcare services include, but are not limited to, admission medical screenings, scheduled sick calls, annual health assessments, dental appointments, and ambulance services.

Advocates provides mental healthcare services for inmates at WCJHOC. These mental healthcare services include, but are not limited to, initial mental health assessments, ongoing evaluations and treatments, suicide assessments, prevention of and treatment for concerns like self-harm, and community reentry preparation.

Quarterly Meetings

According to 103 CMR 932.01(3),

The county correctional facility [in this case, WCSO] shall require that the health authority [in this case, the contracted healthcare provider] meet with the Sheriff/facility administrator or designee at least quarterly and submit the following:

(a)  quarterly reports on the health care delivery system and health environment; and

(b)  annual statistical summaries.

Quarterly reports, as referenced in the above regulation, cover topics such as risk management, infection control, inmate grievances, critical clinical events (e.g., instances of death or physical assault while providing healthcare), and medications that the contracted healthcare providers currently administer to inmates. Statistical summaries, also referenced in the above regulation, contain data related to inmate health records and provide a comprehensive overview of medical services delivered to inmates during the year.

The contracted healthcare providers document and maintain meeting minutes. These meetings cover quality improvement, emergency drills, mortality review findings, and other statistical reports used to monitor trends in the delivery of healthcare at WCSO.

Admission Medical Screening

According to Section 4 of WCSO’s Policy 932.06 (Admission Medical Screening), an admission medical screening is performed by a qualified healthcare professional (QHP)¹² on each inmate upon admission to WCJHOC to ensure that their health needs are identified and addressed. The admission medical screening consists of a questionnaire and observation to identify potential emergencies and to ensure that newly admitted inmates’ illnesses, health needs, and medications are identified for further assessment and continued treatment while in custody.

A QHP records all findings of the admission medical screening electronically in ERMA, specifically on the Admission Medical Screening Form, which is then approved by a higher-level QHP. If an inmate refuses the admission medical screening, QHPs counsel the inmate on the benefits of the screening to encourage them to complete it.

Upon each inmate’s admission to WCSO, a QHP communicates (both verbally and in writing) to the inmate how they can access healthcare services. This communication can include special accommodations, such as the use of a translation service, to ensure that any inmate who may have difficulty communicating with staff members understands how to access healthcare services.

Physical Examinations

According to Section 3(A and B) of WCSO’s Policy 932.07 (Health Appraisal/Physical Examination), each inmate committed to the facility receives a thorough physical examination within 14 days after admission, unless there is documented evidence of an examination within the previous 90 days. The physical examination is completed by a QHP and includes, but is not limited to, reviewing the inmate’s medical record, examining the inmate for any signs of trauma or disease, conducting laboratory and/or diagnostic tests, and reviewing findings and any follow-up services with inmates who require further treatment. The QHP records the inmate’s physical examination data in the inmate’s electronic medical record in ERMA, specifically on the physical examination form, which is then reviewed and approved by a higher-level QHP.

Initial Mental Health Assessments

According to Sections 3 and 4 of WCSO Policy 932.13 (Mental Health Services and Suicide Prevention), an initial mental health assessment is performed by a qualified mental health professional¹³ on each inmate upon admission to WCJHOC to ensure that their mental health needs are identified and addressed. The screening consists of a questionnaire on suicidal ideation and acts of self-harm. In addition, the qualified mental health professional observes the inmate to identify potential emergencies and to ensure that newly admitted inmates’ mental health needs and medications are identified for further assessment and continued treatment while in custody.

During the initial mental health assessment, if the qualified mental health professional realizes that an inmate has a potential mental health risk, then this qualified mental health professional refers the inmate to a higher-level qualified mental health professional for a comprehensive mental health evaluation. This higher-level qualified mental health professional completes the comprehensive mental health evaluation within 14 business days of the initial mental health assessment. The qualified mental health professional records the inmate’s evaluation data in the inmate’s electronic medical record in ERMA.

Sick Call Requests

According to Sections 3 and 7 of Wellpath’s “Nonemergency Health Care Requests and Services” Policy (HCD-100_E-07) for WCSO, to request access to healthcare, an inmate completes a Health Services Request Form (HSRF) with the following information: the type of service requested (medical, dental, or mental health); the nature of the problem or request; their personal information, including their name, patient identification number,¹⁴ date of birth, and housing unit; and their signature and the date. The inmate then submits the HSRF by putting it in a designated, secure lockbox (one of which is located in each housing unit). A QHP picks up HSRFs daily to evaluate and triage each request. QHPs provide treatment according to clinical priorities and schedule follow-up appointments as needed. A face-to-face meeting with a QHP is required within 24 hours upon receipt of an HSRF. All HSRFs that are triaged as emergent are responded to immediately; health concerns that are beyond the responding QHP’s expertise are then referred to the most appropriate healthcare provider external to WCSO’s contracted healthcare providers. Throughout this process, each inmate’s individual medical file (including medical notes)¹⁵ is maintained in ERMA.

1.   For an inmate to be in WCSO’s custody means that WCSO 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 regionally arrested individual is a person who has been arrested by a local law enforcement department. WCSO’s facility holds the individual before they appear in court.

3.   A state identification number is a unique number assigned to each inmate in the criminal justice system.

4.   A booking number is a unique number assigned by WCSO to an inmate upon their admission to WCJHOC. A new booking number is generated upon every unique admission to the facility.

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

6.   A housing assignment is an inmate’s specific unit, cell, and bed within WCJHOC.

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

8.   The central control unit is a booth, operated by WCSO employees, in the center of WCJHOC. It is the central site of control for radio communication devices and physical access throughout all of WCSO’s facilities. All communication into and out of WCSO’s facilities goes through the central control unit.

9.   According to WCSO’s Policy 932.01 (Health Policy and Authority), the health services administrators is “a contracted medical administrator who supervises the administration of the medical and dental services at the WCSO.”

10.   A postmortem exam is an examination of the deceased’s body to determine the cause of death.

11.   A mortality review is an assessment of the clinical care provided to an inmate and the circumstances leading up to an inmate’s death.

12.   According to Wellpath’s “Nonemergency Health Care Requests and Services” Policy (HCD-100_E-07) for WCSO, QHPs “include 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.”

13.   According to WCSO’s Policy 932.13, a qualified mental health professional is “a treatment provider who is a psychiatrist, psychologist, psychiatric social worker, psychiatric nurse, or others, who by virtue of education, credentials and experience, are permitted by law to evaluate and care for mental health needs of patients.”

14.   Each inmate is assigned a patient identification number. The patient identification number, which is used in ERMA, is the same as each inmate’s state identification number, which is used in OMS.

15.   Medical notes are records of the encounters that occur between the contracted healthcare providers and an inmate.

Date published:	November 21, 2024