Commonwealth of Massachusetts Office of the State Auditor, 2020
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Official Audit Report – Issued January 9, 2020 Massachusetts Department of Correction For the period July 1, 2016 through June 30, 2018 State House Room 230 Boston, MA 02133 firstname.lastname@example.org www.mass.gov/auditor January 9, 2020 Ms. Carol Mici, Commissioner Massachusetts Department of Correction 50 Maple Street Milford, MA 01757 Dear Ms. Mici: I am pleased to provide this performance audit of the Department of Correction. This report details the audit objectives, scope, methodology, findings, and recommendations for the audit period, July 1, 2016 through June 30, 2018. My audit staff discussed the contents of this report with management of the agency, whose comments are reflected in this report. I would also like to express my appreciation to the Department of Correction for the cooperation and assistance provided to my staff during the audit. Sincerely, Suzanne M. Bump Auditor of the Commonwealth cc: Thomas A. Turco III, Secretary, Executive Office of Public Safety and Security Audit No. 2019-0145-3J Table of Contents Department of Correction TABLE OF CONTENTS EXECUTIVE SUMMARY ........................................................................................................................................... 1 OVERVIEW OF AUDITED ENTITY ............................................................................................................................. 2 AUDIT OBJECTIVES, SCOPE, AND METHODOLOGY ................................................................................................. 6 DETAILED AUDIT FINDINGS WITH AUDITEE’S RESPONSE ...................................................................................... 11 1. The Department of Correction did not adhere to sick call standards. ....................................................... 11 2. DOC did not always maintain documentation showing that reentry services were provided to inmates. . 14 APPENDIX A ......................................................................................................................................................... 16 APPENDIX B ......................................................................................................................................................... 17 i Audit No. 2019-0145-3J List of Abbreviations Department of Correction LIST OF ABBREVIATIONS ACL ARMR CMR DOC IMS IRP MCI MMIS QHP RFR SCRF Audit Command Language Authorization for Release of Medical Records Code of Massachusetts Regulations Department of Correction Inmate Management System Individual Reentry Plan Massachusetts Correctional Institution Medicaid Management Information System qualified healthcare professional Request for Response Sick Call Request Form ii Audit No. 2019-0145-3J Executive Summary Department of Correction EXECUTIVE SUMMARY In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has conducted a performance audit of the Department of Correction (DOC) for the period July 1, 2016 through June 30, 2018. In this performance audit, we examined inmate access to healthcare, including sick call requests, reentry healthcare services, and women’s specific healthcare services related to pregnancy and annual preventive examinations. Below is a summary of our findings and recommendations, with links to each page listed. Finding 1 Page 11 During the audit period, Sick Call Request Forms (SCRFs) were not processed or triaged within 24 hours (72 on weekends) and/or were not completely filled out by nurses and/or physicians, and inmates were not always seen by a qualified healthcare professional within seven days after they submitted SCRFs. Recommendation Page 12 DOC should ensure that there are internal controls and monitoring in place to ensure compliance with DOC policies and procedures. Finding 2 Page 14 DOC did not always maintain documentation to support the following: that Individual Reentry Plans were reviewed with the inmates, signed by the inmates, and provided to the inmates before release; that physical and mental health appointments for post-release services were scheduled with external medical providers when necessary; and that DOC obtained signed Authorizations for Release of Medical Records from inmates. Recommendations Page 15 1. DOC should ensure that its staff is properly trained in reentry service standards and provide job aids for all aspects of the reentry process. 2. DOC should evaluate whether it would be useful to have employees work solely in reentry rather than doing multiple jobs, thereby ensuring that these employees can focus on reentry and the applicable standards and timelines. 1 Audit No. 2019-0145-3J Overview of Audited Entity Department of Correction OVERVIEW OF AUDITED ENTITY The Department of Correction (DOC) was established under Section 1 of Chapter 350 of the Acts of 1919 and Section 1 of Chapter 27 of the Massachusetts General Laws. DOC is responsible for operating the Commonwealth’s prison system. According to its intranet site, DOC’s vision is “to effect positive behavioral change in order to eliminate violence, victimization and recidivism” and its mission is “to promote public safety by managing offenders while providing care and appropriate programming in preparation for successful reentry into the community.” As of June 2018, DOC was responsible for 8,741 inmates housed in 16 correctional facilities (see Appendix A) across the Commonwealth and had approximately 4,600 employees. DOC’s state appropriations for fiscal years 2017 and 2018 were $593,413,000 and $645,035,000, respectively. DOC obtains accreditation through the American Correctional Association, the National Commission on Correctional Health Care, the state Department of Public Health, and the state Department of Mental Health to confirm compliance with applicable regulations. In our audit, we reviewed inmate access to healthcare, including sick call requests, reentry healthcare services, and women’s specific healthcare services related to pregnancy and annual preventive examinations. During the audit period, healthcare at DOC facilities was provided by a third-party vendor (Massachusetts Partnership for Correctional Healthcare, LLC) through a Commonwealth of Massachusetts Standard Contract. This contractor was selected through the competitive bid process using the state’s online procurement management system.1 The contract term was for five years (July 1, 2013 through June 30, 2018), with two options to renew the contract for up to two years each. The role and obligations of the contractor are outlined in the Request for Response (RFR) “Comprehensive Health Services to Massachusetts Prison Population (RFR 14-DOC 9004—Prison Health Services)” and include but are not limited to the following: The Contractor shall provide a comprehensive program of medical, dental and mental health services to all inmates and civilly committed persons, male and female, adult and minor, residing at all Facilities or otherwise committed to the care and custody of [DOC]. . . . The Contractor shall provide Inmates with humane health care in accordance with Community Standards [see Appendix B] throughout the term of Contract. 1. The system was called COMM-PASS when the bidding process began; it is now called COMMBUYS. 2 Audit No. 2019-0145-3J Overview of Audited Entity Department of Correction The Contractor shall operate the Program based on a contractual staffing plan using only licensed, registered, certified and professionally trained Personnel, or other Personnel whom [DOC’s Assistant Deputy Commissioner for Clinical Services] deems qualified on a case-by-case basis to provide Services under this Contract. . . . The Contractor shall maintain complete and accurate records of care in accordance with applicable standards, and . . . collect and analyze health care statistics on a regular basis for provision to the Health Services Division [of DOC] in accordance with reporting requirements set forth herein. . . . The contractor, or the respective Medical Contractor and Mental Health Contractor, shall be solely responsible for making all decisions with respect to the type, timing and level of Services needed by Inmates covered by the Program. This includes, without limitation, the determination of whether an Inmate is in need of clinical care, inpatient hospitalization, and/or referral to an outside specialist or otherwise needs specialized care. . . . The Contractor . . . shall have the sole authority and responsibility for the implementation, modification and continuation of any and all health care for Inmates. DOC monitors the contractor’s compliance with contract requirements by conducting internal audits of medical and mental health records. During these internal audits, DOC officials review areas that include, but are not limited to, intake/transfer (accuracy of notes related to inmate problems), timeliness (frequency of contact with inmates), existence and accuracy of treatment plans, and documented need for specific medications. DOC conducted 131 internal audits during the audit period. According to the RFR, a minimum of 90% compliance is necessary for a contractor to be considered compliant with the contract requirements. If there are areas of noncompliance, the contractor must submit a corrective action plan to DOC, which schedules a follow-up audit within 90 days. If there are still areas of noncompliance after this audit, DOC may impose a financial penalty. DOC did not take the option to renew this healthcare contract; as of July 1, 2018, DOC began a new contract with Correct Care Solutions, LLC. Sick Call Requests According to Section 10 of DOC policy “103 DOC 630—Medical Services,” “access to daily sick call is an inmate’s right and not a privilege.” Each of the 16 DOC facilities has written sick call procedures for processing inmate sick call requests, and all inmates at each facility (including inmates in restricted housing) have access to the Sick Call Request Form (SCRF). To request access to healthcare, an inmate completes an SCRF, selecting a type of service requested (medical, dental, or mental health); stating the nature of the problem or request; and adding his/her name, inmate commitment number, and signature, as well as the date. S/he then submits the SCRF in a designated drop box located in the 3 Audit No. 2019-0145-3J Overview of Audited Entity Department of Correction facility. It is DOC’s responsibility to process the SCRFs daily and to schedule appointments as necessary. DOC maintains SCRFs in inmates’ individual medical files. According to Section 491.07(2) of Title 103 of the Code of Massachusetts Regulations, DOC must give inmates unimpeded equal access to the grievance process to address their complaints. An inmate can file a grievance for any reason using the designated form; all inmates, regardless of housing unit, must have access to grievance and appeal forms. DOC must provide a response to an inmate’s grievance, and the inmate may appeal the response by filing a designated appeal form to the appellate authority.2 The appellate authority must respond to the appeal and make a final determination on the matter. For both the grievance process and the sick call request process, non-English-speaking inmates can request translation in up to 140 different languages. If an inmate cannot complete a form because of language/literacy barriers, the inmate can request assistance through his/her assigned correctional program officer. Reentry Services DOC is responsible for providing reentry services to all inmates to ensure successful transition from the inmate population into the community. For each inmate, DOC creates an Individual Reentry Plan that addresses post-release housing; eligibility for the state Medicaid program (MassHealth); employment opportunities; community resources; and physical or mental health services, which include providing medications and scheduling physical and mental health appointments upon release. Women’s Healthcare There are certain healthcare services that are specific to female inmates, such as certain preventive exams and prenatal and postnatal care. The preventive exams include pelvic and breast exams and mammograms. Generally, these appointments are scheduled when an inmate arrives at a DOC facility, but the inmate can refuse the services. The purposes of the preventive exams are overall health and early detection of cancer. Pregnant inmates are given necessary medical services, tests, and periodic health monitoring and evaluations (unless the inmate has refused them). DOC must provide pregnant inmates with appropriate clothing, sanitary materials, and nutrients necessary to maintain a healthy pregnancy. Postpartum inmates must receive a postpartum depression screening upon return to DOC 2. The appellate authority for grievance appeals is the superintendent of the institution where the grievance occurs. 4 Audit No. 2019-0145-3J Overview of Audited Entity Department of Correction custody; they are also eligible for mental health services related to postpartum depression if the issue presents itself after that screening. Additionally, the use of restraints is not allowable without due cause during the second and third trimesters of a pregnancy or during post-delivery recuperation. 5 Audit No. 2019-0145-3J Audit Objectives, Scope, and Methodology Department of Correction AUDIT OBJECTIVES, SCOPE, AND METHODOLOGY In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has conducted a performance audit of certain activities of the Department of Correction (DOC) for the period July 1, 2016 through June 30, 2018. We conducted this performance audit in accordance with generally accepted government auditing standards, except Sections 6.56–6.59 of Chapter 6 of the US Government Accountability Office’s Government Auditing Standards, pertaining to obtaining sufficient, appropriate evidence to meet the audit objectives. See “Scope Limitation” below for details regarding the issue we encountered with access to medical files. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Below is a list of our audit objectives, indicating each question we intended our audit to answer; the conclusion we reached regarding each objective; and, if applicable, where each objective is discussed in the audit findings. Objective 1. Conclusion Does DOC comply with authoritative guidance (see below) for inmate healthcare related to the following? a. sick call requests No; see Finding 1 b. doctors’ appointments, health insurance coverage, and medications during reentry preparation No; see Finding 2 c. Yes; see Scope Limitation women’s health Our substantive testing for each objective was based on certain sections of the following authoritative guidance: For objective 1a: DOC policy “103 DOC 630—Medical Services” Section 761.07(7) of Title 103 of the Code of Massachusetts Regulations (CMR) National Commission on Correctional Health Care publication Standards for Health Services in Prisons 6 Audit No. 2019-0145-3J Audit Objectives, Scope, and Methodology Department of Correction 103 CMR 491 For objective 1b: DOC policy “103 DOC 493—Reentry Policy” DOC policy “103 DOC 630—Medical Services” For objective 1c: DOC policy “103 DOC 630—Medical Services” DOC policy “103 DOC 620—Special Health Care Practices” Section 118 of Chapter 127 of the General Laws We gained an understanding of the internal control environment related to our audit objectives by reviewing applicable DOC policies and procedures, reviewing laws and regulations, and making inquiries and observations. In addition, we performed the following procedures to obtain sufficient, appropriate evidence to address our audit objectives. Scope Limitation We encountered a scope limitation with regard to objectives 1a and 1c. Because of a mold infestation, some female inmates’ medical files that were stored at Massachusetts Correctional Institution (MCI)— Framingham were quarantined and could not be obtained for review. Further, the affected medical files could not be identified or excluded from the population; this affected our sick call request test and women’s health tests. If these medical files had been available, it is possible that our audit procedures might have identified further issues. Sick Call Requests We obtained a list of inmates incarcerated at all DOC facilities during the audit period from the Inmate Management System (IMS), the program DOC uses to track and process inmates. Because all inmates have initial health assessments upon arrival at DOC facilities and any identified issues should be addressed at that time, we filtered the list to include inmates who were incarcerated for more than 30 days to identify a population of inmates who might have submitted Sick Call Request Forms (SCRFs). The filtered list of inmates who were incarcerated for more than 30 days totaled 18,394. Using a statistical sampling method and Audit Command Language (ACL) software, with a confidence level of 7 Audit No. 2019-0145-3J Audit Objectives, Scope, and Methodology Department of Correction 95% and a tolerable error rate of 5%, we selected a random sample of 60 of the 18,394 inmates. We obtained and reviewed each inmate’s hardcopy medical file/s, which contained paperwork related to the inmate’s health-related services provided by DOC, including any SCRFs. In each inmate’s medical file/s, we reviewed all SCRFs where the inmate had indicated a date that fell during our audit period. We reviewed these forms to confirm compliance with certain requirements of “103 DOC 630—Medical Services,” which is DOC’s internal policy for healthcare provided to inmates; 103 CMR 761.07(7); and the National Commission on Correctional Health Care publication Standards for Health Services in Prisons. Specifically, we reviewed each SCRF to determine the following: the date the inmate submitted it, the date it was triaged, whether it was triaged in an appropriate amount of time, the provider to which the inmate was referred, the nurse triage determination,3 the inmate’s institution (i.e., the facility where the inmate was held), the date the inmate saw a qualified healthcare professional (QHP), and whether the inmate was seen by a QHP in an appropriate amount of time. Additionally, DOC officials gave us a list of all 24 grievances related to inmates’ access to healthcare that were filed during the audit period. We obtained and reviewed all hardcopy paperwork and electronic forms related to each grievance. The grievance information provided by DOC included the Informal Complaint Form, the Formal Grievance Form, the Grievance Appeal Form, any Grievance Extension Forms, and any case notes in IMS. We reviewed the grievance documentation to confirm compliance with certain sections of 103 CMR 491. Specifically, we confirmed compliance with the following requirements: inmates filing informal complaints before submitting formal grievances; formal grievances being submitted within 10 days of incidents; DOC documenting formal grievances in IMS; DOC responding to formal grievances in 10 days; DOC filing extensions when it could not respond to grievances within 10 days; inmates submitting appeals within 10 days of receiving their formal grievance responses; DOC documenting the appeals in IMS; and DOC responding to the appeals in 30 days unless an extension was filed. Reentry Services From the list of inmates mentioned above, we identified a total of 4,800 who were paroled or released and had a Criminal designation in IMS (indicating that they had been sentenced) as opposed to a PreTrial or Out of State designation. Using a statistical sampling method and ACL, with a confidence level of 3. This triage determination is made when a nurse reviews the health issue reported by the inmate and determines the urgency of the inmate’s need to be seen by a medical professional. 8 Audit No. 2019-0145-3J Audit Objectives, Scope, and Methodology Department of Correction 95% and a tolerable error rate of 5%, we selected a random sample of 60 of the 4,800 inmates. We obtained and reviewed reentry screenshots from IMS to confirm compliance with certain requirements of “103 DOC 493—Reentry Policy” and “103 DOC 630—Medical Services.” Specifically, we determined whether each inmate was given an Individual Reentry Plan; each inmate signed an Authorization for Release of Medical Records; medical appointments were arranged, if necessary; each inmate was given enough medication to last until his/her post-release appointment, if necessary; a Medicaid Management Information System (MMIS) check was conducted 30 days before each inmate’s release; a secondary MMIS check was conducted within 5 days of each inmate’s release; and each inmate was given a MassHealth card (if eligible) or instructions on how to follow up with MassHealth upon release. Women’s Health From the list of inmates mentioned above, we identified a total of 4,629 female inmates at the MCI— Framingham or South Middlesex Correctional Center facilities. Using a statistical sampling method and ACL, with a confidence level of 95% and a tolerable error rate of 5%, we selected a random sample of 60 of these 4,629 inmates. To conduct our testing of medical services provided specifically to the female inmates, we obtained and reviewed the hardcopy medical files for the selected inmates. These files contained hardcopy paperwork related to services requested, and provided to the inmate, during incarceration. We reviewed the medical files to determine whether DOC had complied with certain requirements of “103 DOC 630—Medical Services,” including providing annual pelvic and breast examinations to inmates, providing mammograms every two years to inmates aged 40 through 49, and providing annual mammograms to inmates aged 50 and above. We obtained a list from DOC officials of 67 female inmates who had a pregnancy designation in IMS at any point during the audit period. Using a nonstatistical sampling method and ACL, we selected a random sample of 20 of the 67 inmates. Because our sampling methodology is nonstatistical, we cannot project the results of our testing to the entire population. To conduct our testing of health services for pregnant inmates, confirming compliance with certain portions of Section 118 of Chapter 127 of the General Laws and “103 DOC 620—Special Health Care Practices,” we obtained the medical files for the inmates selected. These contained hardcopy documentation of medical services requested and provided during the inmates’ incarceration. Specifically, we determined whether each inmate was given information about pregnancy options and DOC facility policies regarding care and labor; a Treatment Plan; specialty care if necessary; a postpartum evaluation by a mental health clinician within two 9 Audit No. 2019-0145-3J Audit Objectives, Scope, and Methodology Department of Correction business days of return to DOC custody; and mental healthcare if suffering from postpartum depression, as well as whether there was a documented need for restraint if the inmate was restrained. Data Reliability Assessment We reviewed certain general information technology controls, including access controls, security training, personnel screening, and account management, over IMS to determine the reliability of the data therein. In addition, for the list of inmates extracted from IMS, we ran data integrity tests to identify any missing data or data outside our audit period and traced inmate data to and from inmate medical files to confirm the accuracy and completeness of the inmate list. For the list of pregnant inmates extracted from IMS, we selected a sample of 10 inmates and reviewed the medical files for evidence indicating that they were pregnant during the audit period. There could be inmates on the list who were not pregnant during the audit period because re-incarcerated inmates with a pregnancy designation in IMS could have had their information copied to their new inmate files. Therefore, this list is of undetermined reliability. However, the list is relevant and the sole source available to identify the population of pregnant inmates during the audit period to conduct our audit. Despite these uncertainties, we believe the list of pregnant inmates sufficiently captures all pregnant inmates during the audit period for the purpose of identifying our population for audit testing. We determined that the data were sufficiently reliable for the purposes of our audit work. 10 Audit No. 2019-0145-3J Detailed Audit Findings with Auditee’s Response Department of Correction DETAILED AUDIT FINDINGS WITH AUDITEE’S RESPONSE 1. The Department of Correction did not adhere to sick call standards. During the audit period, Sick Call Request Forms (SCRFs) were not processed or triaged within 24 hours (72 on weekends)4 and/or were not completely filled out by nurses and/or physicians, and inmates were not always seen by a qualified healthcare professional (QHP) within seven days after they submitted SCRFs. Without timely treatment for physical and mental health issues, an inmate’s condition could worsen. Additionally, the Department of Correction (DOC) puts itself at risk of legal action by not documenting that SCRFs are triaged and inmates are seen promptly. Although we found that all 60 inmates in our sample were seen by a QHP, DOC did not process and triage the SCRFs promptly. For 18 of 60 inmate medical files tested, SCRFs were processed and triaged 1 to 31 days late. We identified 55 SCRFs with this issue out of 297 SCRFs maintained in the 18 inmate medical files. Of the 55 SCRFs, 28 did not have a date from the triage nurse or the inmate, so we could not determine whether the inmate was seen by a triage nurse within the required time. There were portions of the SCRFs that were not filled out in their entirety, by nurses and/or physicians, for 23 of 60 inmate medical files tested. Within the 23 files were a total of 363 SCRFs, 163 of which were missing information: 33 did not have a referral to a medical professional, 102 did not have a nurse triage determination, and 28 did not indicate the institution where the inmate was housed. Finally, for 19 of 60 inmate medical files tested, there was no evidence that the inmates were seen by QHPs within seven days after they submitted SCRFs. We identified 72 SCRFs with issues out of 302 SCRFs in the 19 files. Of the 72 SCRFs, 33 did not have a date from a QHP or the inmate, so we could not determine whether the inmates were seen within seven days by a QHP. Additionally, 38 SCRFs had instances where an inmate was seen more than seven days after submission of the SCRF, and in 1 case, the date recorded by the QHP was one day before the date recorded by the inmate. Authoritative Guidance In regard to SCRFs being processed and triaged and the inmates being seen by QHPs promptly, Section 10(4) of DOC policy “103 DOC 630—Medical Services” states, 4. Medical services are available for inmates 24 hours a day, seven days a week. There may not always be a physician on site, but physicians are on call and other medical personnel are on site to assist inmates with their medical needs. 11 Audit No. 2019-0145-3J Detailed Audit Findings with Auditee’s Response Department of Correction All requests must be processed and triaged by a qualified healthcare professional within twentyfour (24) hours or seventy-two (72) on week-ends. All inmates who submit a sick call request shall be seen by a qualified healthcare professional on a priority basis that will not exceed seven (7) calendar days from the day of submission of the request. In regard to SCRFs being filled out entirely and signed by DOC representation, Section 761.07(7) of Title 103 of the Code of Massachusetts Regulations states, Requests for medical attention shall be assessed and processed in accordance with guidelines established by the National Commission on Correctional Health Care and according to American Correctional Association standards and Department guidelines. The National Commission on Correctional Health Care publication Standards for Health Services in Prisons recommends that “all aspects of the health care request process, from review and prioritization to subsequent encounter, [be] documented, dated, and timed.” Reasons for Issues DOC officials could not provide us with a reason for these issues at the time of our audit. However, we did note that controls over the administration of these activities appeared to be deficient. Recommendation DOC should ensure that there are internal controls and monitoring in place to ensure compliance with DOC policies and procedures. Auditee’s Response The Department of Correction (DOC) received and reviewed the list of examples of concern raised by the Auditor’s findings. The Health Services Division (HSD) pulled each inmate medical file and identified the issues corresponding to the Auditor’s findings. The DOC HSD appreciates the external review and feedback for the Sick Call process and policy. As a result of your findings, the DOC has identified an opportunity for improvement which is addressed here. We recognize this is a collaborative and constructive process which affords the DOC an opportunity to improve on existing process and policies to more effectively deliver equitable access to quality healthcare for every inmate. SCRF not processed or triaged within 24 hours (72 on weekends) In a subsequent review of the files, HSD found discrepancies between the date of submission as written by the inmate and the date the SCRF was received in the Health Services Unit (HSU) at the site. The standard practice for the DOC is to use the date of receipt by the HSU. When the SCRF is retrieved, the QHP is required to stamp or indicate on the form when it was received. 12 Audit No. 2019-0145-3J Detailed Audit Findings with Auditee’s Response Department of Correction This is the date used to document the timeliness of service. In several cases, the auditors identified the date that the inmate denoted on the form. However, this date is not always the date the SCRF is actually submitted. In some instances, the inmate may inadvertently use the incorrect date. In some instances, the inmate incorrectly post-dates the SCRF. In some instances, the inmate may not submit the form on the same day that the inmate fills it out. Therefore, to ensure more consistency with dates, the HSD has opted to use the date the SCRF is received by HSU. SCRF not completely filled out by nurses or physicians HSD reviewed the forms and agrees with the Auditor’s findings. The forms have several check boxes to provide basic information regarding the SCRF request including, but not limited to: date/time triaged, acuity of request, facility, and specialty. HSD did review the medical record of those individuals and did not find any instance where an incomplete SCRF resulted in untimely response to urgent or emergent issues. HSD recognizes the importance of fully completing all required fields on the SCRF. HSD will work with its contracted healthcare vendor to reinforce the requirement that all fields must be completed. Inmates were not always seen by a qualified health professional within 7 days after SCRF submission HSD identified several SCRFs which were administrative in nature. For example, there were requests for replacement hearing aid batteries, repair to eyeglasses, or asking for HIV/Hepatitis C testing. These are examples of administrative requests which would not require the inmate to see a QHP for care. Instead, these issues were responded to by providing the requested supplies or repairs, or referring the SCRF to a counselor for the requested testing. The sick call process is the most common avenue inmates have to bring these issues to the attention of the medical provider. However, the SCRF policy language does not account for these types of administrative requests. Therefore, the DOC will review the policy and revise the language to differentiate between the services which may, or may not, require clinical assessment within the current policy timeframes. Auditor’s Reply Regarding the processing of SCRFs, for our analysis we used the date of submission indicated on the SCRF to conduct our analysis because this form is the official record used by the agency to document the need for medical services requested by an inmate in accordance with DOC policy. We recognize that inmates may sometimes enter erroneous dates on SCRFs. However, since the extent to which errors like this may have occurred in our sample could not be reasonably determined by us or by DOC, it was necessary and reasonable for us to rely on the accuracy of the submission dates on the SCRFs to assess DOC’s compliance with its requirements in this area. It should be noted that, even using the date stamp 13 Audit No. 2019-0145-3J Detailed Audit Findings with Auditee’s Response Department of Correction as the official date of receipt as DOC suggests, our analysis still showed a significant number of instances where DOC did not meet its processing timelines. Based on its response, DOC is taking measures to clarify existing policies and ensure that they are consistently applied throughout all its facilities. 2. DOC did not always maintain documentation showing that reentry services were provided to inmates. DOC did not always maintain documentation to support the following: that Individual Reentry Plans (IRPs) were reviewed with the inmates, signed by the inmates, and provided to the inmates before release; that physical and mental health appointments for post-release services were scheduled with external medical providers when necessary; and that DOC obtained signed Authorizations for Release of Medical Records (ARMRs) from inmates. Without an IRP, an inmate may be unaware of, and/or may miss, a needed appointment; may run out of necessary medications; and may be unaware of his/her current status with regard to health insurance coverage. In addition, inmates may lose continuity of care when appointments for known physical or mental health issues are not scheduled with medical service providers in the inmates’ areas of release. DOC also puts itself at legal risk by not maintaining copies of IRPs and signed ARMRs, since these provide evidence that inmates have received information and allow DOC to release medical records. Of the 60 inmate files tested, 22 did not have evidence that the IRP was reviewed with the inmate, signed by the inmate, and given to the inmate before release from DOC custody. The IRP documents physical and mental health appointments for needed services provided in an inmate’s area; medication provided upon release and any prescriptions for refills; and MassHealth coverage, if the inmate is eligible. For 5 of the 60 inmates tested, there was a request for a medical appointment or documented physical or mental health issue, meaning an appointment was necessary, but there was no evidence in DOC’s Inmate Management System (IMS) that appointments had been made for post-release services with external medical providers. Finally, for 23 of the 60 inmates tested, there was an indication of a physical or mental health appointment needed or scheduled, but there was no evidence that an ARMR was obtained and signed. 14 Audit No. 2019-0145-3J Detailed Audit Findings with Auditee’s Response Department of Correction Authoritative Guidance In regard to IRPs, DOC officials told us that DOC provides an IRP to each inmate. The information on the IRP is also reflected in IMS with a note identifying when DOC had the conversation with the inmate. In addition, the DOC Reentry Services Operations Manual states that each inmate must sign a copy of the IRP and DOC must provide a copy to each inmate for his/her release. In regard to physical or mental health appointments with external medical providers, Section 8(B) of “103 DOC 493—Reentry Policy” states, The medical/mental health discharge planner shall schedule appointments with community providers and document the appointments in IMS. In regard to ARMRs, Section 21 of “103 DOC 630—Medical Services” states, When an inmate is being referred to an outside designated health care provider, the inmate should sign an authorization for release of medical records. Reasons for Issue DOC officials told us that some employees did not have appropriate reentry training and DOC did not provide enough job aids to properly assist them when they were not aware of reentry standards. DOC officials further explained that employees might work in reentry inconsistently and therefore might not be as knowledgeable about the standards. Recommendations 1. DOC should ensure that its staff is properly trained in reentry service standards and provide job aids for all aspects of the reentry process. 2. DOC should evaluate whether it would be useful to have employees work solely in reentry rather than doing multiple jobs, thereby ensuring that these employees can focus on reentry and the applicable standards and timelines. Auditee’s Response Taking into account the Auditor’s findings, the DOC will review its current policies and staff training procedures for inmate reentry. DOC will also provide staff with accurate job aids required to complete the reentry process. DOC will also review reentry staffing caseloads to ensure that staff can complete reentry tasks as required by DOC policy and procedures. 15 Audit No. 2019-0145-3J Appendix A Department of Correction APPENDIX A Department of Correction Facilities and Locations Facility Name Location Boston Pre-Release Center 430 Canterbury Street, Roslindale, MA 02131 Bridgewater State Hospital 20 Administration Road, Bridgewater, MA 02324 Lemuel Shattuck Hospital Correctional Unit 180 Morton Street, Jamaica Plain, MA 02130 Massachusetts Alcohol and Substance Abuse Center 1 Bump Pond Road, Plymouth, MA 02360 Massachusetts Correctional Institution (MCI)—Cedar Junction 2405 Main Street, South Walpole, MA 02071 MCI—Concord 965 Elm Street, Concord, MA 01742 MCI—Framingham 99 Loring Drive, Framingham, MA 01701 MCI—Norfolk 2 Clark Street, Norfolk, MA 02056 MCI—Shirley Harvard Road, Shirley, MA 01464 Massachusetts Treatment Center 30 Administration Road, Bridgewater, MA 02324 North Central Correctional Institution 500 Colony Road, Gardner, MA 01440 Northeastern Correctional Center 1 Barretts Mill Road, West Concord, MA 01742 Old Colony Correctional Center 1 Administration Road, Bridgewater, MA 02324 Pondville Correctional Center 1 Industries Drive, Norfolk, MA 02056 South Middlesex Correctional Center 135 Western Avenue, Framingham, MA 01701 Souza-Baranowski Correctional Center 1 Harvard Road, Shirley, MA 01464 16 Audit No. 2019-0145-3J Appendix B Department of Correction APPENDIX B Request for Response Definitions5 Best Practices Practices that are based on the collective experience and wisdom of the field. Community Standard The “Community Standard” for medical, dental and mental health Services shall mean the scope and quality of Services, including diagnostic testing, preventive Services, and after care considered appropriate, in terms of type, amount, frequency, level, setting and duration which is appropriate to the patient’s diagnosis or condition. The care must be medically necessary and consistent with generally accepted practice parameters as recognized by health care providers in the same or similar general specialty who typically treat or manage the diagnosis or condition, help restore or maintain the patient’s health, prevent the deterioration or palliate the patient’s condition, prevent the reasonably likely onset of a health problem, or detect an incipient problem. The “Community Standard” shall be interpreted in light of a prison system environment, taking into consideration the unique nature of the delivery of health care to an Inmate population within a prison system, and taking into account the Inmate’s individual history of incarceration and present circumstances. Accordingly, Services should be Evidence Based and should incorporate Best Practices utilized by health care professionals in prison systems. Evidence Based Services that are founded upon published literature that demonstrates the efficacy of services provided in prison systems, and are capable of being audited against established standards. “Evidence-based” practices mean that (1) there is a definable outcome(s); (2) it is measurable; and (3) it is defined according to practical realities. 5. These definitions are quoted from the Department of Correction’s Request for Response “Comprehensive Health Services to Massachusetts Prison Population (RFR 14-DOC 9004—Prison Health Services).” 17