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  auditor@sao.state.ma.us  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

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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

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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.

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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.

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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

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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.

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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.

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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

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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

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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.

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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

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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.

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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.

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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.

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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

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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.

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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.

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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

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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).”

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