The Dukes County Sheriff’s Office Did Not Retain Copies of Sick Call Request Forms.

If DCSO does not retain copies of sick call request forms, which contain all information that supports that the sick calls were triaged on time, then there is a higher-than-acceptable risk that some inmates may not have their healthcare issues properly resolved in a timely manner or at all.

Overview

DCSO did not retain copies of any sick call request forms in inmates’ medical records during the audit period. As a result, we were unable to identify whether DCSO had triaged, and/or met with inmates who submitted, sick call requests. DCSO’s in-house healthcare employee immediately shredded the sick call request forms after reviewing them, without scanning the forms and saving them in the Correctional Electronic Medical Records (CorEMR) system.

If DCSO does not retain copies of sick call request forms, which contain all information that supports that the sick calls were triaged on time, then there is a higher-than-acceptable risk that some inmates may not have their healthcare issues properly resolved in a timely manner or at all.

Authoritative Guidance

According to 103 CMR 932.18(2),

The medical record file shall contain, but not be limited to, the following items . . .

(h)  place, date and time of health encounters; . . .

(j)   health service reports (e.g., dental, psychiatric, and other consultations); and

(k)  all findings, diagnoses, treatments, dispositions.

Section J10-09 of the Massachusetts Statewide Records Retention Schedule states that all sheriffs must “retain [health records] 5 years after release or termination of parole. This series is used to record physical exams of inmates.”

Reasons for Noncompliance

DCSO management stated that, during the audit period, the in-house healthcare employee did not have authorization to access to the section labeled “sick calls” to document and retain sick call request forms in the CorEMR system. Upon our discussion with DCSO, management immediately provided the in-house healthcare employee with access to the sick call tab in the CorEMR system.

In addition, DCSO has not implemented monitoring controls over its sick call process to ensure that all sick calls are documented and retained.

Recommendations

1. DCSO should ensure that sick call request forms are scanned into the appropriate inmates’ medical files in the CorEMR system.
2. DCSO should implement effective monitoring controls over its sick call process to ensure that all sick calls are documented and retained.

Auditee’s Response

The goal of the Dukes County Sheriff’s Office is always to be in complete compliance. At the time of the implementation of CorEMR, the vendor never provided permissions for the approved administrative staff to see the sick call tab. During the initial contact with the State Auditor’s Office regarding this matter on February 13, 2023, the in-house healthcare staff were unaware of the requested information. While implementing a corrective action plan, the agency determined that the newly hired in-house healthcare staff did not have access to the requested sick call tab. Accordingly, permissions to the sick call tab were provided on February 21, 2023 and the in-house healthcare staff have since ensured that all sick call forms are scanned into the appropriate inmates’ medical files in the CorEMR system.

Auditor’s Reply

Based on its response, DCSO has taken measures to address our concerns on this matter.

Date published:	March 4, 2024