Overview
The Massachusetts Department of Correction (DOC) did not always retain evidence of orientation forms (for general orientation and mental health orientation) and informed consent for healthcare services. Incarcerated individuals (I/Is) would receive and sign these forms during the admission process to a DOC intake facility. From the total population of 4,740 commitment identification numbers, we sampled 120 commitment identification numbers and noted the following issues:
- DOC was unable to provide 5 (4%) of the 120 signed general orientation forms in our sample acknowledging that I/Is received and understood the verbal and written information provided to them during orientation.
- DOC was unable to provide 8 (7%) of the 120 signed mental health orientation forms in our sample acknowledging that I/Is received and understood the verbal and written information provided during mental health orientation.
- DOC was unable to provide 2 (2%) of the 120 signed informed consent forms in our sample acknowledging that I/Is received and understood the verbal and written information provided before the initiation of any healthcare service.
- Additionally, there were the following two instances of incomplete forms:
- There was one instance of an I/I’s refusal to sign a mental health orientation form that did not have a DOC staff witness’s signature.
- There was one instance of a general orientation form signed by an I/I that was not dated.
If DOC management does not follow record retention requirements, which should include the establishment of internal policies and procedures requiring the retention of all healthcare forms and records, DOC cannot ensure that its I/Is received proper healthcare.
Authoritative Guidance
According to DOC’s Medical Services Policy
630.02 General Policy . . .
3. The Department, through the contractual medical provider, shall ensure that the delivery of all health care is to be preceded by an explanation of the nature of such treatment.
The Department and the contractual medical provider shall comply with all applicable statutes relating to informed consent procedures. The contractual medical provider shall have written guidelines for informed consent procedures. . . .
630.08 Inmate Health Orientation
Upon the arrival of an inmate at an institution, following commitment, return, or transfer, the institution shall provide the inmate with both verbal and written instructions that explain the procedures for gaining access to health care when needed.
According to Section 650.03(a) of DOC’s Mental Health Services Policy,
In non-emergency situations, inmates shall be provided information necessary to give informed consent prior to the initiation of mental health treatment services, including treatment with psychotropic medication.
According to Section 607.02 of DOC’s Inmate Medical Records Policy,
The medical record shall be maintained from the time of commitment to release or discharge of the inmate from the custody of the DOC. Following the release or discharge of the inmate, the DOC shall retain inmate medical records for a period of thirty years. . . .
5. The content of the medical portion of the inmate medical record shall include, but not be limited to the following identifying information . . . consent to treat forms.
Reasons for Issue
DOC did not have documented internal procedures in place for processing and retaining orientation forms (for general orientation and mental health orientation) and informed consent for healthcare services signed by I/Is.
Recommendations
- DOC management should establish record retention requirements by developing and documenting internal procedures, or modifying existing policies, regarding the processing and retention of informed consent and orientation forms (for general orientation and mental health orientation). For example, DOC could modify its health orientation policy to require that DOC collect signed acknowledgement forms from I/Is and maintain these records as evidence that I/Is understood the admission policies.
- DOC management should monitor the record retention process it establishes by periodically reviewing healthcare records to ensure that employees adhere to the record retention procedure. Further, DOC should reevaluate the record retention procedure as changes to the process become necessary.
- DOC management should provide training for its staff members and vendor employees on newly created record retention requirements to ensure that all employees adhere to these requirements.
Auditee’s Response
The Massachusetts Department of Correction (DOC) appreciates the Office of the State Auditor’s findings of:
- 96% of reviewed records demonstrated evidence of signed general orientation forms.
- 93% of reviewed records demonstrated evidence of signed mental health orientation forms.
- 98% of reviewed records demonstrated evidence of signed informed consent forms.
103 DOC 607: Inmate Medical Records establishes retention requirements for health records including (by reference or inference) orientation and consent forms. Pertinent excerpts from this policy include, but are not limited to:
607.01: General Policy: “The contractual clinical provider at each facility shall maintain a uniform medical record which shall include, but not be limited to, documentation of all medical, dental, and mental health encounters, visits, diagnoses and treatment.”
607.02: Department of Correction Inmate Medical Records: “The inmate medical record shall include documentation of all inmate visits or contacts with medical, mental health, or dental treatment staff. The inmate medical record shall also contain all reports, records, entries, orders, and written documentation concerning the inmate’s medical, mental health, dental, and substance use disorder care. The record shall be maintained from the time of commitment to release or discharge the inmate from the custody of the DOC. Following the release or discharge of the inmate, the DOC shall retain inmate medical records for a period of thirty years.” and 103 DOC 607.02(5): “The content of the medical portion of the inmate medical record shall include, but not be limited to the following identifying information: . . . consent to treat forms . . . .”
Discussions during the audit process identified areas in which existing DOC and vendor policies may be modified to more explicitly reference retention obligations. Training in existing and updated policies will support staff and vendor employees in sustaining and extending the high level of compliance identified in the audit report.
Auditor’s Reply
Based on its response, DOC is taking measures to address our concerns regarding this matter. As part of our post-audit review process, we will follow up on this matter in approximately six months.
| Date published: | December 19, 2025 |
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