Overview
During the audit period, BCSO should submit all of the eight required quarterly reports on its healthcare delivery system and health environment.
By not submitting quarterly reports regarding the healthcare environment during the audit period, BCSO may increase the risk of not identifying patterns in inmate illnesses or injuries and not receiving key information to make decisions regarding inmates’ healthcare.
Authoritative Guidance
According to 103 CMR 932.01(3)(a), Sheriff’s offices are required to submit “quarterly reports on the health care delivery system and health environment.”
BCSO’s “BCSO-095R” policy states,
4. Quarterly Reports and Meetings
A. The facility administrators responsible for healthcare, the Superintendent/designee, the responsible physician, the designated mental health director and Responsible Health Authority meet at least quarterly at which time the medical staff submits reports on the health care system for review, assessment and resolution. Minutes of the health administrator’s meeting are recorded, distributed and maintained. . . . A member of the staff summarizes the minutes of the meeting and retains a copy for future reference in the appropriate file.
B. A monthly statistical form is compiled which tallies the number of inmates seen by Health Services staff, categories of disease and services rendered or referred.
Reasons for Issue
When asked to provide the quarterly reports submitted by medical staff members for the audit period, BCSO officials stated that the meeting minutes they provided us were the reports being referenced in the policy and that no further reports could be found. In further correspondence, BCSOs officials stated that the previously provided monthly statistical forms serve as the reports. However, within BCSO’s policy, both the meeting minutes and statistical reports are separate and distinct requirements from each other and from the quarterly reports.
Recommendation
BCSO should establish policies and procedures, including monitoring controls, to ensure that all quarterly reports are generated and submitted in a timely manner.
Auditee’s Response
On Monday May 13, 2025, BCSO supplied the audit team with copies of reports on the health care system for the audit period of July 1, 2022 through June 30, 2024. These reports were sent via email and were regarding inmate injuries in the facility, and a detailed grievance review report, including a breakdown of type of grievance, intervention, analysis and recommendations.
Auditor’s Reply
We acknowledge that BCSO provided reports on inmate grievances and inmate injury reports for the audit period during our audit process. However, these do not constitute reports on the healthcare system as required by 103 CMR 932.01(3) and BCSO’s “BCSO-095R” policy.
We encourage BCSO to consider our recommendations to ensure that the issues identified in this finding do not reoccur. As part of our post-audit review process, we will follow up on this matter in approximately six months.
| Date published: | November 25, 2025 |
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