Massachusetts Department of Correction - Finding 3

The Massachusetts Department of Correction did not always retain evidence of annual hardcopy personalized program plans in incarcerated individuals’ six-part folders, as required by Section 155.00 of Title 103 of the Code of Massachusetts Regulations.

Overview

DOC did not always retain evidence of hardcopy personalized program plans (PPPs) related to annual program review meetings with I/Is. From the total population of 2,445 commitment identification numbers, we sampled 104 commitment identification numbers and noted the following issues:

• DOC was unable to provide all of the annual PPPs for 24 (23%) commitment identification numbers for I/Is out of our sample of 104.¹²
• There was one instance of a PPP that was signed and dated by the I/I on March 12, 2024, but the correctional program officer (CPO) signed and dated the same PPP on July 9, 2024.

If DOC management does not ensure that existing record retention policies are being adhered to or does not establish new policies or procedures regarding the proper filing of records in a timely manner to ensure compliance with record retention policies, DOC cannot ensure that its I/Is are receiving proper educational, vocational, or behavioral program recommendations.

Authoritative Guidance

According to Section 155.06(3) of Title 103 of the Code of Massachusetts Regulations (CMR),

The specific material described in 103 CMR 155.00 shall be filed in the six-part folder, ordered according to the six-position format, and the material shall include the following: . . .

Position III.

(c)  Classification. 103 CMR 155.06(3)(c) shall contain the inmate’s signed personal program plan, inactive visiting card(s), handbook/orientation receipts and general population waivers.

Additionally, DOC adheres to the Prison Rape Elimination Act (PREA) Standards, Section 115.33(e) of which states, “The agency shall maintain documentation of inmate participation in these education sessions.”

Reasons for Issue

DOC stated that hardcopy annual PPPs submitted by CPOs to the records department at each facility are being misfiled or not filed in the I/Is’ six-part folders in a timely manner.

Recommendations

1. DOC management should establish record retention requirements by developing and documenting internal procedures, or modifying existing policies, regarding the processing and retention of PPPs in I/Is’ six-part folders. Furthermore, DOC should consider implementing the review, signing, and filing of PPPs electronically rather than as hardcopy files in I/Is’ six-part folders and should consider updating 103 CMR 155.00 accordingly.
2. DOC management should monitor the record retention process it establishes by periodically reviewing I/Is’ six-part folders 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.
3. DOC should provide training for its staff members on the newly created record retention requirements to ensure that all employees adhere to these requirements.

Auditee’s Response

DOC Corrective Action:

1. DOC is in the process of developing a Standard Operating Procedure to 103 CMR 155: Case Records to better clarify in section 155.06(3)(c) that a signed copy of every personalized program plan generated in conjunction with every classification review shall be filed in the six-part folder. Current language lacks clarity as to whether all personalized program plans need to be filed/maintained in the six-part folder or just the most recent.
2. DOC has initiated plans to increase audits of six-part-folders to ensure that personalized program plans are filed in conjunction with annual classification reviews. Oversight will be provided at the Central Office Level by the Program Services Division staff.
3. DOC has already provided directives to Institutional Directors of Classification and Treatment, Institutional Records Managers, and Deputy Superintendents of Reentry to develop sound internal processes to ensure that personalized program plans are filed promptly in order to avoid being misplaced or not being filed in an individual’s six-part folder prior to them being transferred to another facility (as the six-part folder transfers with them).
4. Case Plan training and Classification Chairperson training have been updated to include language regarding the requirement pursuant to 103 CMR 155: Case Records, section 155.06(3)(c), to file an individual’s signed personalized program plan in accordance with their classification reviews.
5. The DOC is currently in the process of developing a new [data management system] which includes automating the electronic signatures of both staff and incarcerated individuals on the personalized program plan, thereby creating a more efficiently managed and accessible record.

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.

12.    Each I/I associated with these commitment identification numbers could have up to three annual PPPs during the audit period, one for each year included within the audit period.

Date published:	December 19, 2025