Overview
Three inmate deaths occurred during the audit period and the clinical mortality reviews for these deaths had completion dates ranging from 112 days to 184 days after the death of the inmate. While clinical mortality reviews can be granted extensions beyond the 30 days permitted in MSO policy, MSO was unable to provide written evidence that the special sheriff approved these extensions.
Without properly documenting extension approvals for clinical mortality reviews, MSO cannot substantiate that extensions were granted for these reviews. While we recognize the need for extensions to complete some clinical mortality reviews, extension requests should be properly documented to ensure that MSO can demonstrate to others, including external auditors, that it complied with its own policies.
Authoritative Guidance
Section .09(7) of MSO’s “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate” states,
A Clinical Mortality Review shall be conducted and completed within thirty-(30) days by the responsible physician or designee. The review shall be documented, and a copy of the report shall be provided to the Special Sheriff or designee and the Chief Legal Counsel. The Special Sheriff may approve additional time as needed.
As a best practice, written evidence of the special sheriff’s approval of the extension request of the clinical mortality review should be maintained.
Reasons for Issue
MSO stated that the special sheriff gave their approval for the extension, but that there was no documentation for this approval because it was likely communicated in person or through a telephone call. MSO further stated that it adhered to its policy and that additional time was provided for the extended clinical mortality review.
Also, during our audit, we noted that MSO does not have documentation requirements for the extension of approvals for clinical mortality reviews.
Recommendations
- MSO should document, in writing, and maintain extension approvals for, clinical mortality reviews.
- MSO should update Section .09(7) of its “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate” to include written documentation requirements for extension approvals for clinical mortality reviews.
Auditee’s Response
The MSO objects to the [Office of the State Auditor’s (OSA’S)] Finding 1 being categorized as a “finding.” Per the OSA’s own language in the [draft audit report], the MSO clearly meets the criteria set forth in the first audit objective. The recommendation of the OSA, while appreciated, should be listed as a recommendation to further the MSO’s already extensive efforts in this area. The OSA acknowledges that the MSO has fully complied with and implemented all provisions set forth in [Section 932.17(2) of Title 103 of the Code of Massachusetts Regulations (CMR)] Guidelines for Serious Illness, Injury, or Death (“CMRs”) through the implementation of MSO Policy and Procedure 617 – Procedures in the Event of Death or Serious Illness of an Inmate (“MSO PP 617”). The MSO voluntarily holds itself to a higher standard than what is required by the CMRs by adhering to the more rigorous standards promulgated by the National Commission on Correctional Health Care (“NCCHC”) which are reflected in MSO PP 617. Among the NCCHC’s recommended compliance indicators is, “a clinical mortality review is conducted within 30 days.” However, this thirty (30) day window is only a guideline, not a binding requirement. This is a recommended guideline from a voluntary accreditation for which the MSO has been deemed in full compliance; it should not be categorized into a finding of non-compliance with this audit objective as the OSA admittedly has no documented standard to make this finding. Despite the MSO’s voluntary adherence to the higher standards set by the NCCHC, it is important to note that neither 103 CMR 932.17(2) nor any applicable regulation or accrediting body requires documentation as described in the finding.
For the aforementioned reasons, Finding 1 does not rise to the level of a finding and should be revised to a recommendation in the final audit report.
Auditor’s Reply
We acknowledge that MSO implemented the requirements of Section 932.17(2) of Title 103 of the Code of Massachusetts Regulations (CMR) by maintaining written policies and procedures that include all of the CMR’s listed requirements. However, during our testing of MSO’s “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate” (listed in MSO’s response as MSO PP 617), we found that MSO did not maintain documentation to support Section .09(7) of said policy. As cited in the “Authoritative Guidance” section of this finding, Section .09(7) of MSO’s “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate” states,
A Clinical Mortality Review shall be conducted and completed [emphasis added] within thirty-(30) days by the responsible physician or designee. The review shall be documented, and a copy of the report shall be provided to the Special Sheriff or designee and the Chief Legal Counsel. The Special Sheriff may approve additional time as needed.
In its response, MSO describes how the 30-day requirement for the clinical mortality reviews in MSO’s “Policy and Procedure 617—Procedures in the Event of Death or Serious Illness of an Inmate” is a recommended guideline, not a binding requirement, from the National Commission of Correctional Health Care, and that MSO voluntarily adheres to these standards. However, once MSO chose to adopt these standards and add them to its policy, these standards became MSO’s official requirements.
This policy does allow the special sheriff to approve additional time as needed, but MSO was unable to demonstrate that the approval for these extensions was granted. Without requiring evidence of the special sheriff’s approval, MSO cannot prove that it is in compliance with its own policy when clinical mortality reviews are not completed within 30 days.
In summary, we appreciate MSO’s response but note that it refers to standards to which we did not audit. Instead, we audited MSO’s own policies and performance standards, those of which that are referenced in this finding MSO did not meet. This constitutes a valid and appropriate audit finding, consistent with generally accepted government auditing standards.
| Date published: | December 19, 2025 |
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