Office of the Comptroller
Audit Services Division

�i{wauk.ge County
Jennifer L. Folliard

• Director of Audits

To the Honorable Chairman
of the Board of Supervisors
of the County of Milwaukee

August17,2018

We have completed an audit, Improved Staffing Levels from Armor, Assignment of a Contract Manager
with Clinical Expertise along with Contract Revisions Would Improve Inmate Medical Services.
Responses from the House of Correction (HOC) and the Office of the Sheriff are attached as Exhibits 4
and 5. Armor Correctional Services, Inc. was provided a copy of the report and given the opportunity to
submit a written response. We did not receive a response from Armor prior to our submission deadline.
We appreciate the cooperation extended by management and staff of the Milwaukee County House of
Correction and the Office of the Sheriff along with Armor Correctional Health Services, Inc. during the
course of this audit.
Our report describes how during a 22 month review period Armor never achieved the minimum overall
staffing level of 95% to avoid withholds from its payments from Milwaukee County. Staffing levels in five
areas including key positions of Registered Nurse and Psychiatric staffing were lower than the overall
average. We found that the contract contains at times unclear language and could be strengthened to
require additional requirements of Armor such as requiring a staffing plan,deployment information by facility
and additional information submitted with invoices. In addition, we found that having a contract manager
with clinical expertise would improve areas of medical service provision including: invoice review, peer
review,accreditation and various staffing issues. We made 18 recommendations that we believe will help
Milwaukee County improve its medical service provision to inmates housed at its facilities.
Please refer this report to the Committee on Finance and Audit.

��
Jennifer L. Folliard
Director of Audits

JLF/cah
Attachment
cc:

Scott B. Manske, CPA, Milwaukee County Comptroller
Milwaukee County Board of Supervisors
Chris Abele, Milwaukee County Executive
Teig Whaley-Smith, Director, Department of Administrative Services
Michael Hafemann, Superintendent, House of Correction
Acting Sheriff Richard Schmidt, Office of the Sheriff
Kelly Bablitch, Chief of Staff, Milwaukee County Board Staff
Steve Cady, Research & Policy Director, Office of the Comptroller
Janelle Jensen,Legislative Services Division Manager, Office of the Milwaukee County Clerk
Kerri Mitchell, Director, Department of Human Resources

633 W. Wisconsin Avenue, Suite 904
Milwaukee, Wisconsin 53203 • Telephone (414) 278-4206 • Fax (414) 223-1895

August 2018
Improved Staffing Levels from Armor,
Assignment of a Contract Manager with Clinical
Expertise along with Contract Revisions Would
Improve Inmate Medical Services

ASD

 The current contract does not require Armor to track deployment of staff by facility. Armor was
unable to provide this information and considers Milwaukee County one site. The facilities are
over 15 miles apart. Since 2013, the average Inmate population at the Jail increased by 44 inmates
while the HOC decreased by 288 inmates.
 Revisions to the contract and a contract manager with clinical expertise are needed to improve
the following areas of medical service provisions: the formulary, the grievance process, invoice
review, accreditation, staffing levels by facility, peer review, booking area staffing and processing
times, quality assurance and Wi-Fi issues in the Jail.
 Additional contract clarifications are needed to require Armor to submit segregated invoices that
include the reporting of time off and overtime. HOC staff does not currently perform spot checks
on Armor invoices versus Armor timesheets.

Staffing Levels for Armor Nov. of 2015 to Aug. of 2017

Jul-17

Aug-17

Jun-17

Apr-17

May-17

Feb-17

Mar-17

Jan-17

Dec-16

Nov-16

Oct-16

Sep-16

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

Aug-16

To report County government fraud, waste or
abuse call 414-933-7283 or visit
http://county.milwaukee.gov/Audit/FraudReporting-Form.htm

 Staffing levels in five areas including key positions of Registered Nurse and Psychiatric staff were
lower than the overall average.

Jul-16

For more information on this or any of our
reports visit
http://county.milwaukee.gov/Audit

 Armor failed to meet the minimum staffing level for all months reviewed and increased its reliance
on agency staffing. Armor had an overall staffing level of 89% during the review period of
November of 2015 to August of 2017. The graph below displays the monthly staffing levels.

Jun-16

• Suggested contract modifications include:
o Require staffing plans and deployment by
facility
o Clarify the Peer Review requirement
o Define Continuation of Care guidelines
o Standardize the audit clause
o Explore a required minimum staffing level
in the booking area
o Clarify the Formulary language
o Require Armor to report paid time off and
overtime on invoices
o Require Armor to submit segregated
invoices for Pharmacy and Specialty
Services
o HOC management should perform spot
checks on Armor invoices and periodically
review check signers and signatures.
authority.

WHAT WE FOUND

Apr-16

• The HOC should explore hiring a contract
manager with clinical expertise or contract
out for management of the contract to lead
to better enforcement of contract provisions
and medical expertise on staff at the HOC.

The objective of the audit was to assess the outside medical services provider’s compliance with
the contract to provide inmate health services at the two County facilities.

May-16

• HOC management should examine whether
existing contract penalties and withholds are
adequate due to Armor never achieving
minimum staffing levels during the review
period.

OVERALL OBJECTIVE

Mar-16

ASD made 18 recommendations that, if
implemented, will improve the contract and
compliance with contract provisions. HOC
management agreed to all of the concerns listed
in
our
recommendations.
Key
recommendations include:

It should be noted that the HOC is tasked with monitoring the contract which provides services at
two facilities, one of which is not under their control and to which HOC staff only have access at the
discretion of the Sheriff.

Jan-16

What We Recommended

In 2017, the total cost to run the Jail and the HOC was $80.9 million of which the County paid Armor
$16.0 million or 19.7% of the total cost for the facilities.

Feb-16

Under the direction of the Comptroller and in
response to a request from the Chairman of the
Milwaukee County Board of Supervisors, ASD
conducted an audit of Milwaukee County’s
contract with an outside vendor, Armor
Correctional Health Services, Inc. to assess
compliance with contract provisions related to
the quality of inmate health services. The audit
was primarily focused on compliance with the
2017 Armor contract with Milwaukee County.

Milwaukee County has a Jail operated by the Sheriff and a House of Correction operated by a
Superintendent which housed a combined average of 2,123 inmates in 2017. All housed inmates
are provided with medical care. In 2001, under court order, the County was to improve medical
services provided to inmates. The current responsibility for the provision of medical care is via a
contract with Armor Correctional Health Services, Inc. Armor begin providing inmate medical
services in May of 2013.

Dec-15

Why We Did This Audit

BACKGROUND

Nov-15

Highlights

Office of the Comptroller Audit Services Division – Milwaukee, WI
Scott B. Manske, CPA Milwaukee County Comptroller

Improved Staffing Levels from Armor, Assignment of a Contract
Manager with Clinical Expertise Along with Contract Revisions
Would Improve Inmate Medical Services
Table of Contents

Page

Summary

................................................................................................................................ 3

Background

................................................................................................................................ 9

Section 1:

Armor’s staffing levels continue to be under 95% of the staffing plan and the
contract does not require reporting of each facility’s staffing levels ......................... 12

Section 2:

The HOC should explore the retention of a contract manager with clinical
expertise to ensure compliance with all contract requirements and allow
for a detailed continuous review of the provision of care at both facilities ................ 26

Section 3:

The Medical Services Contract would benefit from revisions to clarify
responsibility and expectation of Armor and its provision of services ...................... 34

Section 4:

Requiring Armor to submit segregated invoices for pharmacy, specialty
services and general medical services would enhance tracking of services
rendered and payments. Additional review of invoices by a contract manager
with clinical expertise, along with spot checking of invoices, is recommended ........ 45

Exhibit 1:

Audit Scope ............................................................................................................ 49

Exhibit 2:

2017 Executed Armor Contract ............................................................................... 51

Exhibit 3:

Milwaukee County Jail and House of Corrections Health Assessment .................... 93

Exhibit 4:

Response from the House of Correction .............................................................. 104

Exhibit 5:

Response from Office of the Sheriff ..................................................................... 110

2

Summary
The Milwaukee County adult criminal justice system includes two facilities – the Jail with bed capacity
of 936 located in downtown Milwaukee, WI and the House of Correction (HOC) with bed capacity of
1,766 located in Franklin, WI. The facilities are over 15 miles apart. Currently the Jail is operated by
the Sheriff of Milwaukee County who is an independently elected constitutional officer while the HOC
is operated by the Superintendent who reports to the elected County Executive. Both facilities are
operated 24 hours a day, 7 days a week.

Every inmate while housed with Milwaukee County is to receive necessary medical care. In March
1996, Milton Christensen, who was then confined in the Milwaukee County Jail, filed a pro se,
handwritten petition for a writ of prohibition seeking relief from what he described as dangerous
conditions within the Jail.

Ultimately, the parties resolved their differences and in March 2001,

entered into a forty-eight page settlement agreement (referred to by the parties and the trial court as
a Consent Decree). The Consent Decree has a court appointed medical court monitor who typically
visits the Jail twice a year and issues a written report of findings including any recommendations for
improvements to the quality of medical care. The County continues to work to be in full compliance
with the Medical Services portion of the Consent Decree by continuing to implement
recommendations found in the Consent Decree Medical Monitor’s reports.

Currently, the responsibility for medical care is under the direction of the HOC for both facilities. The
HOC is tasked with monitoring a contract that provides services at two facilities, one of which is not
under their control and to which HOC staff only have access at the discretion of the Sheriff. The HOC
utilizes a contract with a private vendor, Armor Correctional Health Services, Inc. (Armor).

Armor

has been the medical contractor since May of 2013. The contract with Armor is to manage the
delivery of reasonable necessary health care including medical, dental and mental health services to
individuals once cleared for admittance by medical staff and physically booked into one of the
facilities. In 2017, the County paid Armor $16.0 million to provide medical services. That amount
was 19.7% of the total cost to run the Jail and the HOC in 2017.

Under the direction of the Milwaukee County Comptroller in response to a request from the Chairman
of the Milwaukee County Board of Supervisors, Audit Services Division conducted an audit of
Milwaukee County’s contract with an outside vendor, Armor Correctional Health Services, Inc. to
assess compliance with contract provisions related to the quality of inmate health services. The audit
3

was primarily focused on compliance with the 2017 Armor contract with Milwaukee County which is
attached as Exhibit 2.
Armor’s Staffing levels continue to be under 95% of the staffing plan and contract
requirements do not require reporting of each facility’s staffing levels.
Exhibit A of the 2017 Armor contract established minimum staffing levels by position with a total of
128.8 full time equivalent (FTE) staff positions required. Armor uses full time employees, agency
employees and Per Diem (pool) employees to meet the staffing threshold. Agency employees are
non-Armor employees who work for an outside agency that Armor hires to fulfill necessary hours.
Per Diem (pool) employees are hourly employees of Armor that are either part-time or not
permanently assigned to the HOC or the Jail. Per Section 3.2 of the contract Armor’s paid staffing
hours include paid time off for their employees.

Audit conducted a review of invoices from November 2015 through August 2017 and found that Armor
never met the 95% threshold for full payment for staffing according to Exhibit A during the review
period.

Audit’s review included full time Armor employee hours, pool employee hours, agency

employee hours and paid time off hours in its threshold hours calculation.

The Consent Decree Medical Monitor has expressed concerns with the use of both pool and agency
employees to obtain minimum staffing levels, and calculates vacancy rates in his reports based upon
full time Armor employees only. He has stated that there are negative impacts on quality when pool
and agency staff are utilized in large numbers. Audit did not conduct an analysis to determine the
impact on care while using pool or agency staff.

Armor’s total paid work hours increased from 19,342 hours in November of 2015 to 20,868 hours in
August of 2017. It was also noted that the use of agency hours increased from 518 hours or 2.7% of
total hours paid in November of 2015 to 3,700 hours or 17.7% of total hours paid in August of 2017.
Full-time Armor and pool staff hours actually decreased during that time period by 1,656 hours. In
addition in February of 2017, 83% of total paid hours for Licensed Practical Nurses were agency
hours.

While total Armor staffing levels averaged 89% over the time period of Audit’s review, there were
specific categories of positions that were consistently at a lower staffing level. Total staffing level
includes full-time, agency, pool and paid time off hours. There are five position titles that fall below
the average staffing level of 89% - Psychologist, Chief Psychiatrist/Psychiatrist, Advanced Registered
4

Nurse Practitioner (ARNP), Psychiatric ARNP and Registered Nurse (RN). RNs at 83% and the
Mental Health personnel at 85% had the lowest staffing levels from November of 2015 to August of
2017.

Section 10.1(a) of the contract calls for a base payment to Armor based upon an average daily inmate
population between 2,300 and 2,600. Exhibit A of the contract does not contain a staffing plan by
facility (Jail or HOC) nor by task which would allow for better monitoring of the service provision of
Armor by Milwaukee County. Audit was unable to obtain from Armor information on how they
deployed staff by facility. It is unclear based upon the invoices and staffing reports provided by Armor
to Milwaukee County, whether Armor’s staffing deployment is dynamic in response to inmate
population shifts both as an overall change to inmate population but also changes within each
facilities’ inmate population. Requiring a staffing plan by location and deployment and function would
allow for monitoring of Armor’s response to inmate population trends by facility.

The inmate

population has decreased by 244 inmates from 2013 to 2017. The number of inmates housed at the
Jail has increased 44 from 894 in 2013 to 938 in 2017, while the number of inmates housed at the
HOC has decreased 288 from 1,473 in 2013 to 1,185 in 2017.
The HOC should explore the retention of a contract manager with clinical expertise to ensure
compliance with all contract requirements and allow for a detailed continuous review of the
provision of care at both facilities.
Onsite visits by Audit conducted during two days of shadowing Armor personnel resulted in
observations that require additional review.

Audit staff followed the delivery of medications

(MedPass) once at the Jail and once at the HOC. MedPass at the Jail resulted in numerous
observations, however, an in-depth analysis is required to determine if the behavior was systemic to
the organization or limited to the Armor staff who was shadowed. A contract manager with clinical
expertise could perform this task. While the Audit staff who conducted the tours do not possess a
medical background, the observations noted were administrative and included:
•

Failure to speak to inmates who refused to appear to take their medicine as required by Armor
policies and procedures.

•

Failure to record the results of testing of blood pressure and blood glucose performed on nonscheduled inmates.

•

Signing of refusal of treatment forms without all information recorded by both Armor staff and
Correctional Officers.

•

Failure to perform checks on inmates to ensure they swallowed their medications.

5

Section 12.26 calls for an annual peer review to be conducted and paid for by Armor. During the
course of an interview with HOC management staff, it was stated that the lack of medical expertise
of HOC staff led to a reliance on the Consent Decree Medical Monitor’s reports and Jail Inspection
reports. The Superintendent also said that he considered the current Consent Decree Medical
Monitor’s reports to fulfill the peer review obligation of the contract. Milwaukee County has paid for
all of the Consent Decree Medical Monitor’s expenses during Armor’s contract period.
The Medical Services Contract would benefit from revisions to clarify responsibility and
expectation of Armor and its provision of services.
Milwaukee County contracts typically include an audit clause whereby contractors must allow the
Audit Services Division access to all records and employees who work in any capacity to support
services provided under the agreement for the duration of the contract and for a set time after the
contract has concluded. While the contract with Armor did include language allowing Audit to access
records, the standard audit clause was modified to say that such records would be produced “all at
cost to Milwaukee County, unless such request is unreasonable, in which case Armor shall provide a
cost to comply.” Going forward, we believe the County is best served when audit access is required,
without limitation, of all entities who choose to do business with the County and that the contract
should be modified to reflect this.

The inmate booking process at the Jail consists of two separate medical evaluations. A new process
was implemented in late 2017 to early 2018 by Armor to help alleviate delays in the intake process
along with a corrective action plan. Jail staff indicated as of January 2018 there has been no
noticeable improvement with the new Intake process. The Consent Decree limits the number of
inmates staying in “booking-open waiting” to 110 at the midnight count and to 30 hours to be
processed out of the Booking Area. This is an area of the contract that could be modified to require
a mandatory staffing level.

Grievance data collected by Milwaukee County and Armor do not reconcile, which results in a lack of
a reliable method to utilize grievances as a measurable indicator of the inmate’s satisfaction with
medical care. Audit also found there was inconsistent adherence to the procedure defined in the
contract for grievances. Audit requested data on the recorded or logged medical grievances and
complaints that are documented in the two systems (Armor and Milwaukee County). The most
common medical grievance based upon the data provided by Armor was inmates’ complaints
regarding co-pays for medical services at the facilities. While co-pays are charged by Milwaukee
County, Armor does not set the rate for the inmate. The Jail charges a fee of $20.00 per visit while
6

the HOC charges $7.50 per visit. Each facility sets the rates that they charge. Inmates are charged
via the inmate’s trust accounts which are managed by Milwaukee County. Armor is not involved in
the determination of the amount of co-pays.
Requiring Armor to submit segregated invoices for pharmacy, specialty services and general
medical services would enhance tracking of services rendered and payments. Additional
review of invoices by a contract manager with clinical expertise, along with spot checking of
invoices, is recommended.
Audit reviewed 22 months of invoices and the review showed that apart from a few minor calculation
errors, Average Daily Inmate population calculations and staffing withholds were appropriately
applied according to the contract. The HOC withheld $1,628,001 from Armor during the 22 month
period that Audit reviewed. However, at the time of the audit no system was being used by HOC
management to spot check the staffing and hours reported by Armor to be paid via the use of time
sheets or another source. The staffing matrix was not reviewed by a programmatic HOC staff
member who could provide a review based upon knowledge within the secure portion of the facility
of staffing levels. Some of the invoices submitted by Armor failed to display itemized paid time off by
individual or overtime which prevent the ability to verify that the invoices are accurate even if
timesheets had been requested and tested. The data submitted by Armor with the invoices was not
consistent over the review period.

According to the United States Governmental Accountability Office Standards for Internal Control,
segregation of duties is required so one individual does not control all key aspects of a transaction or
event to reduce the risk of error or fraud. During our review of HOC invoices, we noted an internal
control weakness over the authorization of payments to Armor due to a lack of segregation of duties.
The check request was prepared by the Manager who then had a subordinate sign as the “approval
signer” of the check request. Because the “preparer” oversees the work of the “approver” this process
does not adequately separate the duties. The HOC was notified during the course of the Audit and
made adjustments to rectify.
In addition, pharmacy and specialty services invoices were at times blended with the general invoice
for medical services. Section 1.11 and 1.5 of the contract establish dollar thresholds for the payments
of both pharmacy and specialty services and the blending of the invoices makes it difficult to track
expenses in these areas.

7

Conclusion
During the course of the audit there were a number of areas that raised the importance of having a
staff member at the HOC who has clinical expertise solely dedicated to the monitoring of the contract
and Armor’s performance. These items include:
•

The formulary

•

The grievance process

•

Invoice review

•

Staffing levels by facility and by task in addition to an overall staffing plan

•

Peer Review

•

Wi-Fi issues in the Jail

•

Accreditation from the National Commission on Correctional Health Care

•

Booking area staffing and processing times

•

Quality Assurance

Improved staffing levels from Armor, assignment of a contract manager with clinical expertise along
with contract revisions would improve inmate medical services at the Jail and HOC.

8

Background
The Milwaukee County adult criminal justice system includes two facilities – the Jail located in
downtown Milwaukee, WI and the House of Correction (HOC) located in Franklin, WI which are over
15 miles apart.

Currently the Jail is operated by the Sheriff of Milwaukee County who is an

independently elected constitutional officer while the HOC is operated by the Superintendent who
reports to the elected County Executive. Both facilities are operated 24 hours a day, 7 days a week.

The Jail is a secure detention facility with a rated bed capacity of 936. The Jail holds accused felons
and misdemeanants until they are released on a pretrial basis or are adjudicated and a small number
of sentenced offenders awaiting transfer or hearings on new charges. The HOC receives and
maintains custody of all sentenced inmates in Milwaukee County committed by authorized courts for
periods not exceeding one year per conviction and from other jurisdictions as authorized by
Milwaukee County Ordinance 20.02. The HOC has a rated bed capacity of 1,766. Under Section
302.315 of the Wisconsin State Statutes, the HOC is permitted, but not required, to receive and
maintain custody of pretrial prisoners from the Jail at the request of the Sheriff.

Every inmate while housed with Milwaukee County is to receive necessary medical care per State
Statute 302.336(2) and the Wisconsin Department of Corrections (DOC) Administrative Code,
Chapter 350 including an initial medical screening of all inmates. The responsibility for the provision
of medical care currently falls to the HOC for both facilities under a contract with Armor Correctional
Health Services, Inc. (Armor). Armor has been the medical contractor since May of 2013. The HOC
is responsible for the entire cost of the contract for inmate medical and mental health services and
per County Board File No. 12-987, does not charge the Sheriff for the Jail portion of inmate medical
costs. The HOC staff has access to the Jail at the discretion of the Sheriff even though the HOC has
oversight of all medical care provided at the Jail.

In 2017, the County paid Armor $16.0 million to

provide medical services. That amount was 19.7% of the total cost to run the Jail and the HOC as
shown in Table 1. The total 2017 cost for the Jail and the HOC was $80.9 million.

9

Table 1
2017 Actual Expenses for Jail & HOC (Includes Transportation)
Cost Area

Amount

Staffing
Medical Contract with Armor
Internal Service Charges such as Risk, IT & Fleet
Laundry, Printshop, Law Enforcement Supplies & Other Costs
Facility Costs – HOC1
Food Services
Transportation
Total Costs

$46,039,339
15,967,021
6,150,476
4,116,016
3,166,299
3,020,303
2,409,738
$80,869,192

Percentage
56.9%
19.7%
7.6%
5.1%
4.0%
3.7%
3.0%
100.0%

1

The Jail is a part of the Courthouse Complex whose facility costs are budgeted centrally in the Facilities
Management’s budget.
Source:

Audit created table based upon data from Advantage (Milwaukee County’s Financial System).

Medical Unit Background
In March 1996, Milton Christensen, who was then confined in the Milwaukee County Jail, filed a pro
se, handwritten petition for a writ of prohibition seeking relief from what he described as dangerous
conditions within the Jail.

Shortly thereafter, the Legal Aid Society of Milwaukee, Inc. began

representing Christensen, and in July 1996, filed a class action complaint on behalf of “all persons
who are now or in the future will be confined in the Milwaukee County Jail,” alleging constitutional
violations by the defendants based upon the conditions maintained in the Jail.

Ultimately, the parties

resolved their differences and in March 2001, entered into a forty-eight page settlement agreement
(referred to by the parties and the trial court as a Consent Decree). The Consent Decree was
approved by the trial court in May 2001, and became an order of the court. The Consent Decree is
divided into two parts. One part deals with the medical services provided to inmates and the other
deals with population management at the Jail. This report pertains only to the medical services
portion of the Consent Decree.

The Consent Decree has a court appointed medical court monitor who typically visits the Jail twice a
year and issues a written report of findings including any recommendations for improvements to the
quality of medical care. The County continues to work to be in full compliance with the Medical
Services portion of the Consent Decree by continuing to implement recommendations found in the
Consent Decree Medical Monitor’s reports.

Since 2013, oversight for medical care is provided by HOC administrative staff for services at both
facilities and on May 11, 2013, a contract was entered into with Armor pursuant to an order of the
10

Milwaukee County Circuit Court. The contract with Armor is to manage the delivery of reasonable
necessary health care including medical, dental and mental health services to individuals once
cleared for admittance by medical staff and physically booked into one of the facilities. The contract
excludes individuals not housed at the facility such as home detention inmates that are electronically
monitored. Armor has continued to hold the contract since 2013.
Under the direction of the Milwaukee County Comptroller in response to a request from the Chairman
of the Milwaukee County Board of Supervisors, Audit Services Division conducted an audit of
Milwaukee County’s contract with an outside vendor to assess compliance with contract provisions
related to the quality of inmate health services. The audit is primarily focused on compliance with the
2017 Armor contract with Milwaukee County.

The ability to audit clause contained in the 2017 contract is not consistent with standard County policy
for auditing of records. However, Armor, Jail and HOC management staff were very cooperative with
Audit staff during the course of the audit.

It should be noted that the HOC is tasked with monitoring a contract that provides services at two
facilities, one of which is not under their control and to which HOC staff only have access at the
discretion of the Sheriff.

11

Section 1: Armor’s staffing levels continue to be under 95% of
the staffing plan and the contract does not require
reporting of each facility’s staffing levels.
Armor showed some improvement in staffing levels during the
review period, however, Armor never achieved the 95%
minimum staffing threshold for full payment and a review of
staffing hours revealed an increase in reliance on agency
staffing.
Exhibit A of the 2017 Armor contract established minimum staffing
levels by position and Section 3.2 allows for payment withholds
when Armor falls below 95% of the staffing requirement. Exhibit A
is listed in Table 2. There is a total of 128.8 full time equivalents
(FTE) staff positions required. Armor uses full time employees,
agency employees and Per Diem (pool) employees to meet the
staffing threshold. Agency employees are non-Armor employees
who work for an outside agency that Armor hires to fulfill necessary
hours. Per Diem (pool) employees are hourly employees of Armor
that are either part-time or not permanently assigned to the HOC or
the Jail. Per Section 3.2 of the contract Armor’s paid staffing hours
include paid time off for its employees.
Table 2
Exhibit A Staffing List from Armor’s 2017 Contract
Position
Health Services Administrator
Medical Director
Physician
Advanced Registered Nurse Practitioner (ARNP)
Director of Nursing
Assistant Director of Nursing
Registered Nurse (RN) - Quality Assurance
RN-Infection Control
RN-Staff Development
RN-Supervisor
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Certified Medical Assistant (CMA)
Unit Clerk

Armor FTE’s
1.0
1.0
1.5
10.0
2.0
0.0
1.0
1.0
2.0
6.5
31.0
26.0
6.0
5.0

Position

Administrative Assistant
Medical Records Supervisor
Medical Records Clerk
Chief Psychiatrist
Psychiatrist
Psych ARNP
Director of Mental Health
Psychologist
PSW-Supervisor
Psychiatric Social Worker (PSW)
Case Management
RN-Mental Health
Dentist
Dental Assistant
Total

Source: Armor’s 2017 contract.

12

Armor FTE’s
2.0
1.0
5.6
1.0
0.2
4.0
1.0
1.0
2.0
10.0
3.0
2.0
1.0
1.0
128.8

Audit conducted a review of invoices from November 2015 through
Armor never met the
95% threshold for full
payment for staffing
according to Exhibit A
during the review
period.

August 2017 and found that Armor never met the 95% threshold for
full payment for staffing according to Exhibit A during the review
period.

Audit’s review included full time Armor employee hours,

pool employee hours, agency employee hours and paid time off
hours in its threshold hours calculation. In addition, hours were
included where an employee of a higher classification, such as a
Psychiatric Social Worker Supervisor, performed work at a lower
classification as a Psychiatric Social Worker, to fill a vacancy. Table
3 and Chart 1 detail the staffing level attained by month during the
review period. Nationally there is a shortage of health care workers
especially RNs and working in a correctional field as an RN has a
very low level of retention.

Table 3
Armor Total Staffing Levels for the Months of
November 2015 ─ August 2017
Month
November 2015
December 2015
January 2016
February 2016
March 2016
April 2016
May 2016

Staff %
90.4%
87.7%
90.1%
85.7%
84.3%
82.7%
85.4%

Month

Staff %

June 2016
July 2016
August 2016
September 2016
October 2016
November 2016
December 2016

Source: Audit calculations based upon Armor’s invoices.

13

84.3%
80.0%
91.1%
90.2%
93.2%
90.2%
88.9%

Month
January 2017
February 2017
March 2017
April 2017
May 2017
June 2017
July 2017
August 2017

Staff %
93.6%
94.0%
94.7%
93.4%
92.3%
88.9%
92.1%
89.8%

Audit Services Division recommends the following:
1. Since Armor never achieved minimum staffing levels during the
22 month period reviewed by Audit, HOC management should
examine whether or not additional staffing withholds and
penalties should be included in future contracts.
Armor increased its reliance on agency staffing over the 22
month period that was reviewed.
The Consent Decree Medical Monitor has expressed concerns with
the use of both pool and agency employees to obtain minimum
staffing levels and calculates vacancy rates based upon full time
Armor employees only. The magnitude of the impact upon the
vacancy rate can be illustrated in the October 2017 report where
the Consent Decree Medical Monitor includes the Registered Nurse
(RN) vacancy levels in his reviews based upon full time permanent
Armor employees which is 50.0%. The monitor does discuss that
14

with the inclusion of agency and pool hours the vacancy rate would
be only 5.0%. However, he also reiterates that he has previously
noted that there are negative impacts on quality when pool and
agency staff are utilized in large numbers. Audit did not conduct an
analysis to determine the impact on care while using pool or agency
staff.

Armor’s total paid work hours increased from 19,342 hours in
November of 2015 to 20,868 hours in August of 2017. It was also
The use of agency hours
increased from 518 hours
or 2.7% of total hours paid
in November of 2015 to
3,700 hours or 17.7% of
total hours paid in August
of 2017.

noted that the use of agency hours increased from 518 hours or
2.7% of total hours paid in November of 2015 to 3,700 hours or
17.7% of total hours paid in August of 2017. Table 4 displays this
data and demonstrates that full-time Armor and pool staff hours
actually decreased during that time period by 1,656 hours.

In

addition, in February of 2017 out of total Licensed Practical Nurses
paid hours of 4,160, 83% or 3,441 were agency hours. Section 3.2
of Armor’s contract does not contain language prohibiting or
allowing pool and agency hours.

Chart 2 contains the monthly detail of the split of the hours paid by
full time and pool staff versus agency staff for the 22 months
reviewed by Audit staff.

15

Table 4
Change in Percentage of Hours Paid by Agency Staff for
November 2015 and August 2017

Month

Total Hours
Paid

November 2015
August 2017
Change

19,342
20,868
1,526

Full Time &
Pool Hours

Agency
Hours

18,824
17,168
(1,656)

Agency Hours % of
Total Hours Paid

518
3,700
3,182

2.7%
17.7%
15.0%

Source: Audit created table based upon Armor’s invoices.

Chart 2
Split of Hours Paid by Full-Time & Pool and Agency
For the Period of November 2015 to August 2017
25,000

20,000

15,000

10,000

5,000

-

Hours Paid FT and Pool

Hours Paid Agency

Exhibit A staffing level

Source: Audit created table based upon Armor invoices. Monthly required hours vary based upon days within
a month, weekends in a month and holidays.

Audit Services Division recommends the following:
2. An analysis should be conducted to assess the impact, if any,
on quality of care while using pool or agency staff. If needed,
HOC management should add language to future contracts to
limit the use of agency and pool staffing to provide a higher
quality of care for inmates as asserted by the Consent Decree
Medical Monitor.
16

Armor’s overall staffing level average was 89% while RN
staffing levels were 83% and Psychiatric staffing levels were
85%. Armor has shown success with recruitment of new staff
however, retention issues remain.
While total Armor’s staffing levels averaged 89% over the time
period of Audit’s review, there were specific categories of positions
that were consistently at a lower staffing level. Total staffing level
includes full-time, agency, pool and paid time off hours. Armor
never achieved 100% of the Exhibit A staffing plan even with
agency and pool staff. Armor has made good faith efforts to recruit
staff including salary adjustments and other benefits in an attempt
to attract new employees in a competitive market. Armor continues
to have retention issues while finding some success in hiring and
adding agency and pool hours as noted above. Table 5 details, by
While total Armor’s
staffing levels
averaged 89% over the
time period of Audit’s
review, there were
specific categories of
positions that were
consistently at a lower
staffing level.

position grouping, the staffing levels from November 2015 to August
2017. The table is included to isolate positions that had lower
staffing levels that may be masked by the contract-wide average.

There are five position titles that fall below the average staffing level
of 89% - Psychologist, Chief Psychiatrist/Psychiatrist, Advanced
Registered Nurse Practitioner, Psychiatric ARNP and RN. RNs and
the Mental Health personnel had the lowest staffing levels from
November of 2015 to August of 2017.

RNs comprise the largest

group of staff positions with 37.0 FTEs required in the Exhibit A
staffing plan. A staffing rate of 83% leads to an average of six
vacant RN positions over the duration of the period analyzed.

17

Table 5
Total Hours Paid (FT, Pool, Agency & Paid Time Off) by
Position from November 2015 ─ August 2017
Position
Title

FTEs

Psychologist
1.0
Chief Psychiatrist/Psychiatrist
1.2
Advanced Registered Nurse Practitioner (ARNP)
10.0
Psych ARNP
4.0
Registered Nurse (RN)
37.0
Physician
1.5
RN-Supervisor
12.0
Psychiatric Social Worker (PSW)/PSW Supervisor
6.5
Director of Nursing
2.0
Director of Mental Health Services
1.0
Medical Director
1.0
Unit Clerk
5.0
Administrative Assistant
2.0
Dentist/Dental Assistant
2.0
Health Services Administrator
1.0
Licensed Practical Nurse
26.0
Certified Medical Assistant
6.0
Case Management
3.0
Medical Records
6.6
Total
128.8

Hours
Required
3,816
4,582
38,164
15,328
141,824
5,742
45,984
24,728
7,632
3,816
3,816
19,160
7,632
7,632
3,816
99,494
22,992
11,496
25,204
492,858

Hours
Paid
2,047
2,892
25,806
11,800
118,210
5,103
42,118
22,831
7,188
3,627
3,651
18,519
7,385
7,473
3,742
98,136
22,684
11,375
25,184
439,771

Percent
Paid*
54%
63%
68%
77%
83%
89%
92%
92%
94%
95%
96%
97%
97%
98%
98%
99%
99%
99%
100%
89%

* Footnote: Rounded to the nearest percentage.
Source: Audit created table based upon Armor staffing reports.

Audit staff found Armor blended title codes with similar pay rates
into one line on invoices submitted to the HOC. For example, while
Exhibit A calls for 1.0 FTE Chief Psychiatrist and 0.2 FTE
Psychiatrist, the August 2016 invoice on staffing hours lists the
Chief Psychiatrist as 0.00 FTE and the Psychiatrist as 1.20 FTE. In
addition, RN positions on Exhibit A that are specialized were
grouped together on the invoice. As a result, our findings contain
blended staffing levels for these positions since true vacancies by
position based on Exhibit A could not be determined.

The

documentation provided at Audit’s request from HOC management
indicated these positions were blended on invoices due to an
identical rate of pay. The HOC did provide emails from the Consent
Decree Medical Monitor approving other staffing deviations from
Exhibit A at times but did not provide documentation approving this
18

blending. While HOC management indicated a systematic process
of review of monthly invoices for staffing deviations there were no
written policies and procedures provided.

Audit Services Division recommends the following:

3. The HOC should formalize in writing policies and procedures for
Armor to follow to document when it is acceptable to substitute
positions for Exhibit A in invoicing and what notifications and
approvals from the HOC are required in order to do so.
Chart 3 displays the five positions with the lowest staffing levels.

Chart 3
Positions with Lowest Staffing Levels

100%
90%

77%

80%
68%

70%
60%

83%

63%
54%

50%
40%
30%
20%
10%
0%
Psychologist -

1.0 FTE

Chief Psychiatrist &
Psychiatrist - 1.2 FTE

Advanced RN
Psychiatric Advanced RN
Practitioner - 10.0 FTE Practitioner - 4.0 FTE

RN - 37.0 FTE

Source: Audit created chart base upon Armor's invoices.

Section 3.2 of the contract establishes that when the overall staffing
level for a month falls below 95% of the required staffing level,
Milwaukee County can withhold a portion of the payment to Armor.
The withholds are calculated for each FTE category below the 95%
19

of Exhibit A and the average hourly rate is multiplied by the hours
below 95%. Effectively the withhold for Armor is equivalent to
salary costs that were avoided. The HOC withheld $1,628,001 from
Armor during the 22 month period that Audit reviewed.

The 2017 contract added language to Section 3.2 that stated if
Armor staffing levels fall below 95% for three consecutive months,
then there will be an additional penalty enhancer of $10,000 per
month inclusive of those three months for a total maximum annual
penalty of $120,000. Invoices from the end of the first and second
quarters of 2017 showed that the additional penalty was charged to
Armor. Audit’s review of invoices concluded prior to the end of the
third quarter of 2017.

Audit Services Division recommends the following:
4. A cost analysis should be conducted by HOC Management of
the cost of filling positions versus the penalties allowed in the
current contract and if needed additional penalties should be
added to the contract to encourage Armor to attain staffing
levels in excess of 95% on a consistent basis.

Section 3.2 of Armor’s contract does not contain language
prohibiting or allowing pool and agency hours, but does state, “it is
not the intent of this provision for Armor to consistently have fewer
employees working over 100% of a position’s full time hours in order
to get to a staffing equivalency of at least 95% FTE hours overall.”
The clause appears to speak to not consistently using excessive
overtime to achieve the staffing levels.

Audit selected four months of invoices to review for potential use of
excessive overtime. The Armor invoices for December 2015 and
August 2017 included overtime hours. The Armor invoices for
August 2016 and November 2016 did not include overtime hours as
a separate category. Audit derived the overtime hours for those
months by calculating the amount of hours required by FTE for each
20

position. Any hours paid to staff in excess of the hours required
were calculated as overtime hours in Table 6 below.
Table 6
Overtime (OT) Hours Data for Staff who Worked OT in
December of 2015, August & November of 2016 & August 2017
OT Hours as
Percent of
Hours Paid

OT
Hours

Month
December 2015
August 2016
November 2016
August 2017

1,063
879
1,208
1,288

5%
4%
6%
6%

Number of
Staff who
Worked OT

Monthly
Average of
OT Hours/Staff

59
51
62
69

18.0
17.2
19.5
18.7

Source: Audit table created based on Armor invoices.

Chart 4 shows the breakdown of the percentage of staff who worked
various categories of overtime hours in our sample. Just under half
Staff working in
excess of 40 hours in
a month was 9% of all
staff who worked
overtime.

of all overtime hours worked by staff were 10 hours or less per
month for the months reviewed. Staff working in excess of 40 hours
in a month was 9% of all staff who worked overtime. The largest
overtime reported was 136 hours by one RN in the month of August
2017.

Chart 4
Split of Overtime Hours for Staffing for the months of December
of 2015, August and November of 2016 and August of 2017
9%
Less than 10 OT hours

9%

11 - 20 OT Hours
21 - 30 OT Hours

44%
17%

31 - 40 OT Hours
21%

More than 40 OT Hours

Source: Audit chart created based on Armor invoices.

21

The existing provisions of the contract do not contain staffing
plans by location or function which results in the staffing level
at each facility remaining unknown under current contract
provisions.
Exhibit A of the contract does not contain a staffing plan by facility
(Jail or HOC) nor by task which would allow for better monitoring of
service provision by Milwaukee County. Audit was unable to obtain
from Armor information on how they deployed staff by facility. At
the time the Consent Decree was executed, a schedule of potential
The contract does
not contain a
staffing plan by
facility (Jail or
HOC).

staffing was included in the attachments to the court documents as
Exhibit D that listed not only the staff required at each facility
(including a shift relief factor) but also which task it was intended for
the staff to be assigned.

Audit recreated Exhibit D as Table 7

detailing the envisioned staff by task and by facility. The listing from
the attachments to the Consent Decree did not include the following
staffing: Psychiatric, Dental or high level Administrative positions.
While the 2017 contract calls for a staffing of 128.8 FTEs including
the previously noted positions, the Consent Decree called for 112.2
FTEs.

22

Table 7
Exhibit D from the Christensen Consent Decree
Title
Supervisor
Nurse Practitioner

RN II

RN I

LPN
Medical Assistants
Administrative Assistant

Location

Task

FTE by Task

Jail

6.52

HOC

6.52

Jail

Booking

6.52

Jail

Women's Health

1.16

Jail

Family practice

1.16

HOC

Women's Health

0.50

HOC

Family practice

3.26

Jail

Charge

4.89

Jail

Mental Health

1.63

Jail

Nurse Educator

1.00

HOC

Charge

4.89

HOC

Mental Health

1.63

HOC

Nurse Educator

1.00

Jail

Booking

9.78

Jail

Triage/sick call

3.26

Jail

Infirmary

4.89

Jail

Chronic Care

1.16

Jail

Physicals

1.16

HOC

Triage/sick call

6.52

HOC

Infirmary

4.89

HOC

Chronic Care

1.16

HOC

Physicals

2.79

Jail

Medications

9.78

HOC

Medications

13.04

Jail

TB program

3.26

HOC

TB program

3.26

Jail

FTE by Title
13.04

12.6

15.04

35.61
22.82
6.52

3.26

HOC
TOTAL

3.26

6.52

112.15

112.15

Source: Audit created based on Christensen Consent Decree Court File Documents.

Section 10.1(a) of the contract calls for a base payment to Armor
The total inmate
population housed at
the Jail has increased
44 from 894 in 2013 to
938 in 2017 while the
total inmate population
housed at the HOC has
decreased 288 from
1,473 to 2013 to 1,185
in 2017.

based upon an average daily inmate population between 2,300
and 2,600. Table 8 shows that the system inmate population has
decreased by 244 from 2,367 inmates in 2013 to 2,123 in 2017.
Perhaps of more importance, however, it also shows that the total
inmate population housed at the Jail has increased 44 from 894 in
2013 to 938 in 2017 while the total inmate population housed at
the HOC has decreased 288 from 1,473 in 2013 to 1,185 in 2017.
23

Section 10.1(a) notes that increased payments will result when the
inmate population exceeds 2,700 which does not match the inmate
population band listed earlier in that section. The 2018 contract
established a not to exceed inmate population number of 2,400
inmates which corrected this discrepancy.
Table 8
Total Average Daily Housed Inmate Population (ADP)
For the Years 2013 ─ 2017
Facility
Jail ADP
HOC ADP
Total Housed Inmate ADP
Percent at Jail of Total ADP
Source:

2013

2014

2015

2016

2017

Change
’13-17’

894
1,473
2,367
37.8%

945
1,176
2,121
44.6%

950
1,272
2,222
42.8%

938
1,206
2,144
43.8%

938
1,185
2,123
44.2%

44
(288)
(244)
6.4%

Audit created table based upon information provided from the Milwaukee County’s Sheriff’s
Office Special Projects Team and the HOC management staff.

It is unclear based upon the invoices and staffing reports provided
by Armor to Milwaukee County whether Armor’s staffing
deployment is dynamic to inmate population shifts both as an
overall change to inmate population but also changes within each
facilities’ inmate population.

Again, requiring a staffing plan and

deployment by location and function would allow for monitoring of
Armor’s response to inmate population trends by facility. The HOC
and the Jail are 15 miles apart from one another. Providing invoices
with staffing hours at each facility would enhance monitoring by the
HOC of medical staff deployment.

According to Armor personnel, Armor considers Milwaukee County
as one facility and does not distinguish location of actual staff hours
paid between the two facilities but Armor indicated they do deploy
staff as needed.

The HOC should explore requiring future

contractors to use a labor distribution system to track deployment
of staff. The lack of data from the facilities also denies Milwaukee
County the information regarding if increased vacancies are
occurring at one facility versus the other.
24

Anecdotally, Armor

personnel interviewed stated that the HOC is a more desirable
place to work and that it is easier to find staff to hire for placement
at the HOC. Due to the lack of information provided, Audit was
unable to quantitatively verify this assertion.

Section 3.1 of the contract does allow for the HOC to renegotiate
the contract if inmate population numbers are outside the range in
the contract, however, this clause is based upon the total inmate
population in the system and not the inmate population within each
facility. HOC management indicated in an interview that they had
not sought to renegotiate the contract with Armor even though the
inmate population had declined since 2013. Chart 5 displays the
change in inmate population since 2013.

Chart 5
Average Daily Population of Inmates Housed at HOC and Jail
from 2013 to 2017

3,000
2,500
2,000
1,500
1,000

1,473
1,176
894

1,272
950

945

1,206
938

1,185

938

500
2013

2014
HOC

2015
Jail

2016

2017

Total Inmate Population

Source: Audit created chart based upon information provided from the Milwaukee County's Sheriff's Office
Special Projects Team and the HOC management staff.

Audit Services Division recommends the following:
5. The HOC should explore including in future contracts a staffing
plan by facility and task to assist in the monitoring of the
provision of medical services at each facility. The inmate
population threshold provided in the Contract should be
examined for possible delineation by facility of minimum staffing
which allows for additional monitoring and dynamic staffing
decisions by both Armor and the HOC. Having the staffing
levels of each position and task and the staffing levels for each
facility would assist in the monitoring.
25

Section 2: The HOC should explore the retention of a contract
manager with clinical expertise to ensure
compliance with all contract requirements and allow
for a detailed continuous review of the provision of
care at both facilities.
A record review conducted of Armor by an independent health
care consultant found the records documented were in
compliance with the contract requirements. During our onsite
visits we observed situations that require additional review
and monitoring which could be accomplished by the hiring of
a contract manager with clinical expertise.
Audit contracted with an independent health care consultant to
conduct a review of the provision of medical care based upon a
statistical random sample.

The independent health care

consultant’s report was limited to a retrospective review of
electronic medical records of services provided to inmates, and did
A record review
conducted of Armor by
an independent health
care consultant found
the electronic medical
records documented
were in compliance
with the contract
requirements.

not include any direct observations or interviews with inmates,
Armor employees or County employees beyond an initial tour and
introductory meeting. All findings and conclusions are based solely
on the information recorded in the health records.

The report

concluded:
Based on the foregoing, it appears that inmates are receiving
appropriate care in compliance with the Requirements. Due
to the limitations of the methodology, this conclusion may be
drawn only at the highest level and, for that reason, abstracts
are often followed by a sample case review. In this instance,
however, there is no evidence to suggest that such a case
review is necessary but, as with assessments, there are
opportunities for improvement and those have been included
throughout this report.
In addition to a review of medical records, the independent health
care consultant reviewed Armor’s Policies and Procedures in
comparison to the National Commission on Correctional Health
Care (NCCHC) standards and found Armor’s Policies and
Procedures conform to standards of the NCCHC. A copy of the
consultant’s full report is attached as Exhibit 3.
26

It should be noted that, the Milwaukee County District Attorney’s
Office has filed a criminal complaint alleging the intentional
falsification of health care records by Armor Correctional Health
Services, Inc. The independent health care consultant’s review of
medical records is based upon the assumption that the information
in the medical record accurately reflects the provision of medical
care. The independent health care consultant did find that, “100%
of records reviewed indicated appropriate and timely medications
were offered or received. When inmates refused medication, the
most frequent deficiencies in documentation were illegibility and
missing information.”
Onsite visits by Audit
conducted during two
days of shadowing
Armor personnel
resulted in observations
that require additional
review and monitoring.

Onsite visits by Audit conducted during two days of shadowing
Armor personnel resulted in observations that require additional
review and monitoring.

Audit staff followed the delivery of

medications (MedPass) once at the Jail and once at the HOC.
Medications are distributed via a portable medical cart with a laptop
attached as shown in Image 1. The MedPass at the HOC did not
result in a need for additional review.

MedPass at the Jail resulted in numerous observations, however,
an in-depth analysis is required to determine if the behavior was
systemic to the organization or limited to the Armor staff who was
shadowed. While the Audit staff who conducted the tours do not
possess a medical background the observations noted were
administrative and related in part to the processing of the refusal of
treatment form which is shown in Image 2. The observations led
Audit to conclude that a contract manager with clinical expertise
could perform spot checks to attempt to determine if the behavior
was systemic.

27

Image 1
Picture of Med Cart used for MedPass

Source: Stock photo provided by Jail Management Staff.

Image 2 is a copy of the refusal form used by Armor during MedPass.

Source: Armor form provided by LPN to Audit during Med Pass tour.

28

Image 3
Photo of a Pod at Milwaukee County Jail

Source: Stock photo provided by Jail Management Staff.

During MedPass at the Jail two inmates refused to leave their cells
on the second floor of the pod to come to the med cart for their
medications. (Image 3 is a photo of the two floor style of pod within
the Jail.) The MedPass Licensed Practical Nurse (LPN) did not
leave the cart to speak with either inmate. Armor staff is required,
as noted in its Employee Orientation Guide, to request the reason
for and consequences of refusal to an inmate and indicate on the
refusal of treatment form that this occurred.

The refusal of

treatment form contains a signature line for the inmate
acknowledging receipt of information from Armor staff. The LPN
did not attempt to obtain the inmates’ signatures.

Audit staff were shown refusal of treatment forms by the LPN which
did not document which medications were refused nor why. In
addition inmate names were also missing from some of the refusal
of treatment forms. The LPN indicated that the missing information
would be added during charting. Audit did not observe the charting
process. If an inmate refuses to sign the refusal of treatment form
a Correctional Officer may sign instead at the time of refusal. The

29

LPN showed audit staff refusal of treatment forms that were signed
by Correctional Officers without all information being filled out.

Out of 25 inmates that were scheduled to receive medication during
the Med Pass, five inmates were not checked by Armor staff or
Correctional Officers for the cheeking of medicine. Checking for
cheeking of medicine is visualization of the oral cavity after the
patient has taken a dose of medication to verify that it has been
swallowed. Armor’s policies and procedures direct MedPass staff
to perform a cheeking check when distributing medicine. Audit staff
observed the LPN preparing the next inmate’s medicine while the
inmate attempted to have the Auditor check for cheeking instead of
the nurse.

During the course of the MedPass there were four inmates who
requested to have tests run such as blood pressure and blood
glucose levels. The LPN performed the tests but did not write down
the results nor record them in the computer system.

When

questioned by the Auditor, the LPN indicated she would add the
results during the charting process.

Audit did not observe the

charting process and is therefore unable to confirm if the test
readings were ultimately documented in the inmates’ medical
records.

Armor management was informed of the observations made by
Audit staff. Armor management told Audit that the LPN who was
shadowed during MedPass at the Jail was found to have
photocopied her signature onto the refusal of treatment forms prior
to entry into the pods for MedPass. The LPN was disciplined for the
photocopying and provided additional training on following proper
cheeking review procedures, according to Armor management.

Audit was also told that the morning MedPass was not provided to
inmates in the Jail’s Mental Health Unit the morning of Audit’s
observations. In addition, Audit staff was shown in the Electronic
30

Medical Records system (EMR) two examples of inmates who
missed medication.

After contacting Armor for additional

information, Armor provided Audit with a Corrective Action Plan
regarding medication refusals in the Mental Health Unit.

Audit Services Division recommends:
6. The Jail and the HOC should review what training is provided to
all Correctional Officers to ensure they are aware of the
information required on medical forms prior to signing any forms
and to provide clarity as needed.
A National Institute of Corrections (NIC) – Milwaukee County
Jail Operational Assessment released in March of 2018
included references to many of the items identified by Audit
including staffing shortages, booking room operations, and
further supports the Audit recommendation for a contract
manager with clinical expertise.
An assessment of the Milwaukee County Jail by the National
Institute of Correction (NIC) was conducted at the request of the
Interim Sheriff in early 2018 and was released on March 29, 2018.
The goal of the assessment for the Office of the Sheriff was “to
determine if the agency is doing the right things and further what
The findings of the
NIC assessment were
consistent with those
of Audit.

can be done differently and finally, are there any best practices that
might assist them.”

The findings of the NIC assessment were

consistent with those of Audit.
The first of the current challenges listed in the assessment was the
nursing shortages and the impact upon the booking area. The
report noted that two medical screenings occur and that according
to Jail staff, the secondary medical screening creates the largest
delay of the booking process and that the agency’s goal is to have
the booking process completed within four hours. This is consistent
with the data reviewed and observations made by Audit which are
discussed further below. The NIC observations of booking also
noted some issues including the wrong inmate being provided for
assessment, an inmate sent to housing without a second health
screening and the inmate’s inability to see a consent form online
31

that they are requested to sign. NIC found the medical area of
booking generally disorganized and in need of cleaning.
Finally, the NIC report discussed the inability of Armor to fill a
number of vacancies within the contract, most importantly the
Psychiatrist vacancy.
The establishment of a contract manager with clinical
expertise and clarification of peer review requirements
contained in the contract should lead to stronger management
oversight and improvements in the provision of inmate
medical care.
During the course of an interview with HOC management, it was
stated that the lack of medical expertise of HOC staff led to a
reliance on the Consent Decree Medical Monitor’s reports and Jail
Inspection reports. In addition, the HOC access to the Jail is at the
discretion of the Sheriff. This has made the monitoring of Armor’s
The establishment of a
contract manager with
clinical expertise and
clarification of peer
review requirements
contained in the
contract should lead to
stronger management
oversight and
improvements in the
provision of inmate
medical care.

services at the Jail problematic for HOC staff, although under new
Jail management this issue appears to have been resolved.

In addition, Section 12.26 of the contract which outlines Quality
Improvement requirements calls for an annual peer review by one
or more outside detention health care consultant(s) on an annual
basis. The results are to be shared with the County and available
for NCCHC review accreditation.

Armor is to bear all costs

associated with the outside consultants. An annual peer review
paid for by Armor has not occurred. Section 12.16 of the contract
allows for the County to designate a Correctional Health Care
Monitor (should the Christensen Consent Decree cease) who will
be its representative and who shall require Armor to meet all
contract requirements. The Superintendent of the HOC indicated
that Section 12.16 was included should the Consent Decree be
lifted and the reports from the Consent Decree Medical Monitor
were no longer being provided. The Superintendent also said that
he considered the current Consent Decree Medical Monitor’s
reports to fulfill the peer review obligation. Milwaukee County has
paid for the Consent Decree Medical Monitor’s expenses.
32

Audit Services Division recommends the following:
7. The HOC should explore hiring a contract manager with clinical
expertise or contracting with an outside entity which would solve
the lack of medical expertise and lead to better enforcement of
the contract provisions. A contract manager with clinical
expertise could also provide easier access to the Jail and
provide a point person for Jail personnel on medical issues.
8. The HOC should revise the contract language in Section 12.26
to reflect the use of the Consent Decree Medical Monitor’s
reports as the required peer review report or establish policies
and procedures to ensure that Armor conducts an annual peer
review at Armor’s expense.
The independent health care consultant found that
documentation of comprehensive discharge planning was
lacking in the electronic medical records reviewed.
It was found by the independent health care consultant that
comprehensive discharge plans were lacking from the electronic
medical records for inmates upon release.

Section 2.01 of the

contract requires Armor to facilitate continuation of care and
facilitate placement in the community upon release for inmates with
diagnosed mental health issues, when the Jail or HOC provides
reasonable advance notice of release. Reasonable is not defined
within the contract. Armor personnel indicated in interviews that
these plans are taking place. It is unknown if Armor is not in
compliance on this issue, not updating records or if reasonable
notification is not being provided by the HOC or Jail.
Audit Services Division recommends the following:
9. The HOC should define what is required from the HOC and the
Jail in order for Armor to properly fulfill their obligation and
establish a timeline for provision of release of information to
Armor. The HOC should also ensure that Armor is providing
documentation of comprehensive discharge plans in inmates’
medical records.

33

Section 3: The Medical Services Contract would benefit from
revisions to clarify responsibility and expectation of
Armor and its provision of services.
The ability to audit clause contained in the 2017 contract is not
consistent with standard county policy for auditing of records.
Armor and Jail and HOC management staff were very
cooperative with Audit staff during the course of the audit.
Milwaukee County contracts typically include an audit clause
whereby contractors must allow the Audit Services Division to have
access to all records and employees who work in any capacity to
support services provided under the agreement for the duration of
the contract and for a set time after the contract has concluded.
While the contract with Armor did include language allowing Audit
to access records, the standard audit clause was modified to say
that such records would be produced “all at cost to Milwaukee
County, unless such request is unreasonable, in which case Armor
The ability to audit
clause contained in the
2017 contract is not
consistent with standard
county policy.

shall provide a cost to comply.”

When we began our audit, Armor indicated that they had requested
that language be added to the contract and suggested they may
need to bill the County for audit’s retrieval of records and access to
Armor employees. The Audit Services Division was able to work
with the Office of Corporation Counsel and Armor to come to
agreement whereby Audit staff was able to receive records from the
vendor and interview Armor personnel at no cost to the County as
long as the Audit Services Division made good faith efforts to do so
in a manner that minimized both direct cost to the vendor for
producing paper and electronic records and indirect costs
associated with interviewing staff. We acknowledge and appreciate
Armor’s cooperation with our work. However, best practice,
supported by Government Auditing Standards, states that reliability
of audit results is enhanced in environments where access to
records and people is unrestricted. Going forward, we believe the
County is best served when audit access is required, without
34

limitation, in contracts with all entities who choose to do business
with the County.
Audit Services Divisions recommends:
10.

Future inmate medical contracts include the following audit
clause: The Contractor shall permit the authorized
representatives of the Director of Audits, after reasonable
notice, the right to inspect and audit all data and records of
the Contractor related to carrying out this Agreement for a
period of up to three (3) years after completion of the contract.

The Inmate booking process at the Jail continues to suffer
from delays in required medical screenings which possibly
could be improved by a change in contract provisions
regarding the staffing of the area by Armor.
The inmate booking process at the Jail consists of two separate
medical evaluations.

The first is the inmate screening that is

required by Department of Corrections (DOC) Chapter 350.13, that
upon arrival of inmates at the Jail, and after the completion of prebooking medical screening documents, a receiving screening
(intake screening) is initiated and performed by an Armor RN using
The inmate booking
process at the Jail
continues to suffer from
delays in required
medical screenings.

the “Patient-Intake Health Screening” form. Section 10.4(I)(c) of the
2017 contract includes a penalty provision should Armor fail to
initiate the first inmate medical screening within 60 minutes.
Receiving Screening is defined by the NCCHC as: A process of
structured inquiry and observation intended to identify potential
emergency situations among new arrivals and to ensure that
patients with known illnesses and those on medications are
identified for further assessment and continued treatment.

Section 10.4(I)(b) of the contract allows the HOC to assess a
penalty when the second medical evaluation, the Inmate History
and Physical Examination, is not completed within the required
fourteen days after the day of booking as is required in DOC
Chapter 350.13(5). The second assessment is a more thorough
medical history and is conducted as part of the booking process at
the Jail. The exam was developed in conjunction with health care
professionals and is used at booking with each inmate to record
35

information about medical, mental health, and dental conditions,
physical and developmental disabilities, alcohol or other drug abuse
problems, and suicide risk.

The evaluation may contain referrals

to medical, mental health, or supervisory staff in a timely manner in
response to identified concerns. If urgent concerns are identified,
the referral shall be immediate. The second evaluation performed
by Armor in the booking area fulfills the 14 day requirement.

Neither penalty is to be assessed if Armor’s staff does not have
reasonable access to any inmate in order to complete the history or
examination. According to the DOC State Inspector, the intake
screening process conducted by Armor in the booking area fulfills
both DOC Chapter 350 requirements.

Despite a contractual time frame of 60 minutes for the first
screening, in July of 2017 based upon a mutual agreement that 60
minutes was an unrealistic time requirement, a new requirement of
four hours for both evaluations was implemented. However, no
contract amendment was processed and this was not formally
documented in writing. Audit reviewed two months of data provided
by the Jail and calculated that 17.5% of the intake screenings were
delayed as a result of Armor’s staff for over four hours resulting in
potential penalties of $120,600. Jail administrative staff indicated
that tracking the process was not cost-effective as the amount of
overtime required to calculate the time could exceed the penalties
assessed. This coupled with lack of application of the penalties by
HOC staff to Armor led to the discontinuation of tracking in the fall
of 2017.

The 2018 contract eliminated all references to both

evaluation penalties and time requirements for medical screening
in Inmate Booking.

A new process was implemented in late 2017 to early 2018 by
Armor to help alleviate delays in the intake process along with a
corrective action plan. Jail staff indicated as of January 2018 there
has been no noticeable improvement with the new Intake process.
36

The Consent Decree limits the number of inmates staying in
“booking-open waiting” to 110 at the midnight count and to 30 hours
to be processed out of the Booking Area.

Interviews conducted with both Milwaukee County and Armor staff
indicated that often booking medical staff are required to assist for
medical emergencies in other areas of the jail or medically clearing
inmates after a fight which results in an understaffing in the booking
area at least on a temporary basis.

The Consent Decree also

contained information on staffing within the intake area as it noted
that:
Two nurses shall be available 24 hours a day to conduct
intake screening of all incoming inmates. The key to
effective screening is to identify and separate those who
may need immediate referral for medical and mental
health problems from those who do not. The screening
shall include, but not be limited to a medical history re:
acute and/or chronic problems, mental health issues,
medications, allergies, etc. The nurses should also take
base line vital signs.

Audit Services Division recommends the following:
11.

The HOC should explore whether future contracts should
require a minimum staffing level in the Booking area such as
two RNs per shift as noted above in the language from the
Consent Decree and establish policies and procedures on
when Armor is allowed to pull staff from booking to deal with
issues in other areas.

The language regarding the formulary should be clarified to
indicate who should be conducting the quarterly review.
Section 1.11 of the 2017 contract states, “The formulary schedule
will be reviewed on a quarterly basis.” This language is unclear if
the review should be by the HOC or by Armor. Audit staff was
shown documentation confirming that Armor reviews and made
changes to the formulary from December 2016 to January 2017
with their contracted vendor for pharmacy, but it does not appear
that the HOC is monitoring the formulary. The language regarding
37

The language regarding
the formulary should be
clarified to indicate who
should be conducting
the quarterly review.

the formulary should be clarified to indicate who should be
conducting the quarterly review.

Armor currently employs a

national formulary with its selected vendor, Diamond Pharmacy. It
is unclear if Milwaukee County should have any input in the
development of the formulary. Based upon interviews with Armor
personnel, a selection of Armor physicians on a national basis work
with Diamond on the formulary.

Audit Services Division recommends the following:
12. The HOC should clarify the language in Section 1.11 to indicate
who is responsible for the quarterly review of the formulary and
indicate whether or not Armor is allowed to use its national
formulary at the Jail and the HOC. If the conclusion is that the
HOC should be conducting a quarterly review, the HOC should
establish policies and procedures for how it will complete the
task.
Grievance data from Milwaukee County and Armor do not
reconcile resulting in a lack of a reliable method to utilize
grievances as a measurable indicator of the inmate’s
satisfaction with medical care along with inconsistent
adherence to the procedure defined in the contract for
grievances.
Section 12.24 of the contract states:
Inmate complaints or grievances regarding services under
this Agreement shall be forwarded to the Armor’s Health
Services Administrator or designee who shall in writing
confirm receipt of the compliant or grievance, and promptly
review the compliant or grievance, gather all information
concerning the complaint or grievance, and take
appropriate action in accordance with the Sheriff’s or
Superintendent’s grievance procedures. Armor shall
respond to all Inmate complaints or grievances concerning
services under this Agreement within seventy-two (72)
hours of Armor’s receipt of such compliant or grievance
and provide written notice to the Captain (or their
designee) in charge of grievances at the County Jail and
HOC at the time of the response, confirming compliance
with this provision.
Chart 6 shows the grievance process found in Armor’s policies and
procedures and based upon interviews with County staff.
38

Chart 6

Based upon interviews
with County staff and
the data provided to
Audit it does not
appear that the
grievance process
consistently follows
the process in the
contract.

According to Jail staff, medical grievances are forwarded to Armor.
The HOC indicated they also forward grievances to Armor but
expect Armor to respond back to HOC staff. The data provided to
Audit showed several medical grievances submitted to Armor from
the HOC a month after the inmate had written the medical
grievance. As a part of the grievance process, Armor has the ability
to access the Milwaukee County grievance system and was able to
enter data into the Milwaukee County system. This access limits
the County’s ability to independently monitor how grievances are
resolved. Based upon interviews with County staff and the data

39

provided to Audit it does not appear that the grievance process
consistently follows the process displayed above.

In addition, Audit requested data on the recorded or logged medical
Even though
grievances are
provided to Armor from
Milwaukee County, the
grievance data
provided showed the
County data does not
reconcile with the data
provided by Armor.

grievances and complaints that are documented in the two systems
(Armor and Milwaukee County).

Even though grievances are

provided to Armor from Milwaukee County, the grievance data
provided showed the County data does not reconcile with the data
provided by Armor as shown in Table 9.

Table 9
Total Medical Inmate Grievances Filed for the
Years 2016 and 2017
Milwaukee County
Data
2016
2017
Source:

1,178
1,281

Armor
Data
914
1,194

Audit created table based on data from Milwaukee County
Management & Armor Management.

Table 10 lists grievance complaint categories. The most common
medical grievance based upon the data provided by Armor was
inmates’ complaints regarding co-pays for medical services at the
facility. While co-pays are charged by Milwaukee County, Armor
does not set the rate for the inmate. The Jail charges a fee of
$20.00 per visit while the HOC charges $7.50 per visit. Each facility
sets the rates that they charge.

Inmates are charged via the

inmate’s trust accounts which are managed by Milwaukee County.
Armor is not involved in the determination of the amount of co-pays.

40

Table 10
Complaint Categories According to Armor Data for the
Years 2016 and 2017
2016
Category
Problems with Co-Pay
Dissatisfied with Quality of Medical Care
Problems with Medication
Other (Conduct of Health Staff, Work Status)
Total
Source:

Count
319
244
164
187
914

2017
Percent
35%
27%
18%
20%
100%

Count
474
255
223
242
1,194

Percent
40%
21%
19%
20%
100%

Audit created table based on data from Armor Management, via the Grievanator which is
Armor’s grievance database.

The Operational Assessment by the NIC issued in March of 2018
listed a number of concerns under the grievance section including
grievances labeled as unfounded however, there is no evidence in
the record that they were actually investigated. The concerns cited
are listed below:
•

NIC found 43 medical grievances logged for 2018 and all were
listed as forwarded, corrected or unfounded.
A common
response to any grievance was “per our medical records.”

•

NIC randomly reviewed 18 grievances and in 17 out of the 18,
NIC did not find evidence that indicated anyone had done
anything other than look at the computer record. There was no
evidence of anyone talking to an inmate or a staff member
regarding the complaint.

•

NIC noted an inmate who was charged twice for a medical
encounter and attempted to resolve the issue through the
grievance process but has been unsuccessful.

•

NIC noted that current practices for grievances are not
consistent with policies.

If the County has a properly functioning grievance process, it would
provide an additional measure of the inmate’s view of the quality of
their medical services. It would also allow for the analysis of the
impact of inmate population decreases since a lower number of
inmates to care for should result in increased levels of care if
staffing remains consistent. The lack of reliable data does not
41

provide the County with the opportunity to measure this theory. On
a similar note, grievances could also be tracked and analyzed to
assess the impact of staffing vacancies on the inmate’s perception
of the quality of their care.

If grievances also contained staff

member’s name it could assist in the evaluation of staff.

Audit Services Divisions recommends the following:
13.

The HOC and Jail staff should work with Armor to ensure that
all entities are following the contractual guidelines for
grievances and that the data systems contain an accurate
reflection of inmates’ grievances. Once this is achieved, data
should be reviewed to see if grievances are linked to shifts in
inmate population or staffing vacancies.

14.

The HOC should work with IMSD to ensure that Armor no
longer has access to the County’s grievance system for the
purpose of processing grievances.

At the Jail there is a lack of consistent Wi-Fi Service and no
established workaround to account for times when Wi-Fi is not
available. This has impacted the medical service provision
and the parties should work to find resolutions to minimize the
impact upon inmates when Wi-Fi service is unavailable.
Armor staff that is conducting MedPass in the Jail rely upon a WiFi connection to save inmate medical information to the Electronic
Medical Records at the time the service occurs. However, at the
Jail Wi-Fi is not available in every pod. Lack of consistent Wi-Fi
service in the Jail can result in the time stamp in the EMR for
medical services being incorrectly recorded as the time of backing
up of data versus actual time of service. This occurs when there is
no Wi-Fi service and the date stamp is generated once connectivity
is reestablished. This resulted in an instance of double medication
due to MedPass being conducted by an Armor staff member who
typically works at the HOC. The first MedPass had been conducted
but the data was not saved and another MedPass occurred prior to
the updating of the information in the EMR resulting in double
medication for inmates. This was in part due to the staff member
not realizing the data was not posted in real time as it is at the HOC.
As a result, the permanent record of the inmates does not
42

accurately reflect the time at which the provision of services
occurred due to the delay in saving of data when access to Wi-Fi is
not occurring. According to a screen shot found in a criminal
complaint against Armor, the EMR has a “date/time if different”
stamp that could be explored as a solution.

As of May 24, 2018, Milwaukee County’s Information Management
Services Division (IMSD) is in the final stages at the Jail of providing
and activating MiFi devices, a wireless router that acts as mobile
Wi-Fi hotspot, for each MedCart which should provide internet
access in all pods.

It should be noted that the HOC is tasked with monitoring the
contract that provides services at a facility to which HOC staff only
have access at the discretion of the Sheriff. The Wi-Fi issues at the
Jail involve facility needs which are under the Sheriff’s jurisdiction.
These issues, however, impact the provisions of medical services
which fall under the HOC’s jurisdiction.

Audit Services Division recommends:
15.

The HOC should continue to work with the Jail, IMSD and
Armor to ensure that the lack of Wi-Fi or inconsistent Wi-Fi
connectivity does not impact the quality of care for inmates by
working to enhance the Wi-Fi system in the Jail and
establishing policies and procedures at both facilities to
establish a workaround when Wi-Fi is unavailable such as the
possible use of the “date/time if different” tab in the EMR.
Both facilities currently have a plan in place if the entire Wi-Fi
system is unavailable.

Armor is currently in compliance with contract requirements
for accreditation and staff licenses.
Accreditation
The National Commission on Correctional Health Care (NCCHC) is
the only organization dedicated solely to improving health care in
jails, prisons and juvenile confinement facilities. Accreditation for
inmate medical services is governed by NCCHC. Section 4.1 of the
43

contract provisions, as seen in Table 11 has varied since the initial
contract.

Table 11
Contract Language Regarding NCCHC Accreditation
Year
2013
2014
2015
2016
2017
2018

Source:

Contract Language
Required Armor to seek and obtain NCCHC accreditation – this was not achieved.
2013 contract was extended through 2015.
2013 contract was extended through 2015.
Armor’s services shall be designed to meet NCCHC’s standards.
Armor will fully cooperate with Milwaukee County in all efforts to attain and maintain
formal accreditation.
Armor will fully cooperate with Milwaukee County in all efforts to attain and maintain
formal accreditation except where modified by the Consent Decree Medical Monitor.
Audit created table based on Armor contracts for the years 2013─2018.

Per the Armor Health Services Administrator, the tentative time
frame for submitting the HOC NCCHC accreditation application was
May 2018.

Licenses and Training
Section 3.3 requires all Armor personnel to be licensed, certified or
registered, as appropriate and as required by applicable Wisconsin
Law. Based upon the Wisconsin Circuit Court Access Program
(CCAP) and the Department of Safety and Professional Services
review in June of 2017 Audit found no violations in terms of Staff
Medical Licensure Requirements.

We requested Armor provide its Policies and Procures Manual and
New Employee Training Manual to view training provisions. In
addition,

we

spot

checked

selected

documentation that training occurred.

training

areas

for

Armor provided training

documents and sign in sheets or evaluation forms by attendees for
those selected trainings.

Based on our review of this

documentation, it appears that Armor conducted training in the
areas we selected.

44

Section 4: Requiring Armor to submit segregated invoices for
pharmacy, specialty services and general medical
services would enhance tracking of services
rendered and payments.
Additional review of
invoices by a contract manager with clinical
expertise, along with spot checking of invoices, is
recommended.
A review of invoicing revealed compliance with most contract
provisions. However, blended invoices from Armor and
internal control weaknesses should be rectified.
The review conducted by Audit showed that apart from a few minor
calculation errors, average daily inmate population calculations and
staffing withholds were appropriately applied according to the
Appropriate penalties
based upon contract
provisions have been
charged to Armor
except for intake
screening.

contract. Appropriate penalties based upon contract provisions
have been charged to Armor based upon invoice review by HOC
and verified by Audit except for intake screening issues as
discussed earlier.

The HOC withheld $1,628,001 from Armor

during the 22 month period that Audit reviewed.

Section 3.2 of the contract requires that Armor submit a monthly
contract staffing compliance report showing all contract positions
relative to the staffing matrix and include all positions and the name
of the individual providing the service and hours paid to the
individual. However, at the time of the audit no system was being
used by HOC management to spot check the staffing and hours
reported by Armor to be paid via the use of time sheets or another
source. The staffing matrix was not reviewed by a programmatic
HOC staff member who could provide a review based upon
knowledge within the secure portion of the facility of staffing levels.
Some of the invoices submitted by Armor failed to display itemized
paid time off by individual or overtime which prevent the ability to
verify that the invoices are accurate even if timesheets had been
requested and tested for accuracy. The data submitted by Armor
with the invoices was not consistent over the review period.
45

According to the United States Governmental Accountability Office
Standards for Internal Control, segregation of duties is required so
one individual does not control all key aspects of a transaction or
event to reduce the risk of error or fraud. During our review of HOC
invoices, we noted an internal control weakness over the
authorization of payments to Armor due to a lack of segregation of
duties. The check request was prepared by the Manager who then
had a subordinate sign as the “approval signer” of the check
request.

Because the “preparer” oversees the work of the

“approver” this process does not adequately separate the duties.
The HOC was notified during the course of the Audit and made
adjustments to rectify.

Pharmacy and
specialty service
invoices were at times
blended with the
general invoice for
medical services.

In addition, pharmacy and specialty service invoices were at times
blended with the general invoice for medical services. Section 1.11
and 1.5 of the contract establish dollar thresholds for the payments
of both pharmacy and specialty services and the blending of the
invoices makes it difficult to track expenses in these areas.

Audit Services Division recommends the following:
16.

The HOC should require Armor to report paid time off in the
detailed staffing report that is submitted with its invoices. The
HOC should establish policies and procedures to ensure that
the staffing invoices submitted to the HOC Superintendent are
reviewed and verified by a programmatic staff member who
can verify or at a minimum spot check Armor staffing levels.

17.

The HOC should require Armor to submit segregated invoices
for both pharmacy and specialty services to enhance tracking
of the payments of these services and verification of accuracy
of invoices.

18.

HOC management should periodically review check signers
and signature authority to ensure that the internal control
weakness identified by Audit staff during its review continues
to be rectified by the HOC.

46

Conclusion
During the course of the audit there were a number of areas that
raised the importance of having a staff member at the HOC who
has clinical expertise solely dedicated to the monitoring of the
contract and Armor’s performance. These items include:
•

The formulary

•

The grievance process

•

Invoice review

•

Staffing levels by facility and by task in addition to an overall
staffing plan

•

Peer Review

•

Wi-Fi issues in the Jail

•

Accreditation from the NCCHC

•

Booking area staffing and processing times

•

Quality Assurance

Improved staffing levels from Armor, assignment of a contract
manager with clinical expertise along with contract revisions would
improve inmate medical services at the Jail and HOC.

47

This Page Intentionally Left Blank

48

Exhibit 1

Audit Scope
The objectives of this audit were to:
•

Determine if Armor Correctional Health Care Services, Inc. (Armor) is providing Health Care
Services to Milwaukee County inmates in accordance with the Milwaukee County contract
provisions and NCHHC standards.

•

Determine if Milwaukee County is receiving the medical services that are invoiced by Armor for
services rendered.

•

Determine if Armor is following the staffing model requirements as described in their contract with
Milwaukee County (as prescribed by the Christensen Consent Decree).

The primary focus was on the Armor contract with Milwaukee County for the contractual period of,
but not limited to, 2017. Additional contractual years were reviewed as needed to fully address issues
identified during our audit work.

The Audit Services Division (Audit) conducted this performance audit in accordance with generally
accepted government auditing standards. Those standards require that we plan and perform the
audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based on our audit objectives.
During the course of the audit, Audit:
•

Reviewed Milwaukee County Board and committee minutes to identify issues, concerns,
recommendations, and County Board resolutions.

•

Reviewed relevant audit contractual documents for compliance.

•

Reviewed legal documents relevant to the audit.

•

Reviewed Milwaukee County Financial Databases for relevant departmental 2017 actual
expenses.

•

Reviewed applicable County Ordinances and Administrative Manual sections, State Statutes and
Administrative Code, and Federal regulations and rules sections to ensure compliance with
federal, state, and local laws.

•

Obtained and reviewed applicable policies and procedures and internal forms, reports,
correspondence, etc. relating to the audit objectives.

•

Interviewed and corresponded with Armor, Milwaukee County Jail (Jail) and House of Corrections
(HOC) departmental staff to obtain a clear understanding of how operations/medical services
provided are performed.
49

•

Corresponded with other County department and State department staff that perform functions
directly related to auditee operations to obtain additional perspectives on how well operations are
performed.

•

Conducted on site tours of the HOC and the Jail to become oriented with facility layout, staff,
population served & facility processes (operational and medical) and shadowed staff performing
job duties related to contract provisions to assess compliance with contract requirements.

•

Hired an independent medical consultant to assess Armor’s performance in delivering services
to inmates via a record review of a sample of medical records.

•

Conducted an assessment of monthly invoices submitted, adjustments, and payments related to
Armor contracts covering 2015 through 2017.

•

Interviewed and corresponded with Armor, HOC and Jail staff responsible for the administration
and payment of Armor invoices to obtain a better understanding of how the payment process
works.

•

Analyzed Armor staffing level reports to determine if contract requirements are being met.

•

Interviewed and corresponded with Armor staff to obtain a better understanding of the hiring and
recruiting practices.

•

Reviewed Armor staff training, licensure & certification records.

•

Reviewed and analyzed inmate medical grievances filed at HOC and the MCJ.

•

Conducted an assessment of potential contractual penalties due to delays in Jail Intake
Screening times.

•

Met with Armor staff regarding the Pharmacy Services management of formulary schedules.

50

DocuSign Envelope ID: AB40274A-7C4C-4D87-930B-4C0D9DE8B957

Exhibit 2

Contract for Inmate Health Services for

Milwaukee County

THIS HEALTH SERVICES AGREEMENT (“Agreement”) between Milwaukee County
(hereinafter referred to as the "County'”), and Armor Correctional Health Services, Inc., a Florida
corporation, (hereinafter referred to as “Armor” or “Contractor”), is dated for reference purposes
as of the 1st day of January 2017. Services under this Agreement shall commence on the 1st day
of January 2017.
WITNESSETH
WHEREAS, pursuant to the Order of the Milwaukee County Circuit Court in the case of
Christensen v. Milwaukee County et al., the County is required to enter into this contract to
obtain reasonably necessary health care (including medical, dental and mental health services)
for detainees and inmates in the physical care, custody and control of the Sheriff at Milwaukee
County Jail (hereinafter “Jail”) and of the Superintendent at the Milwaukee County House of
Correction (hereinafter “HOC”), collectively herein known as the “Facilities”; and
WHEREAS, the Sheriff has responsibility to provide medical care for Inmates in his
physical care, custody and control at the Jail and the Superintendent has responsibility to provide
medical care for Inmates in his physical care, custody and control at the HOC; and
WHEREAS, references in this Agreement to “Sheriff” or “Superintendent” are
understood to constitute a reference to each individual in their responsibility for the provision of
medical care to Inmates in the respective Facility identified previously; and
WHEREAS, Armor is in the business of providing correctional health care services and
agrees to provide such services for the County under the terms and conditions of this Agreement
relative to detainees and inmates in the physical care, custody and control of the Sheriff and
Superintendent and housed at the Facilities.
NOW, THEREFORE, in consideration of the premises and the covenants and promises
hereinafter made, the parties hereto agree as follows:
ARTICLE I: HEALTH CARE SERVICES
1.1.

General Engagement; Appointment. The County hereby engages and appoints Armor
to manage and pay for the delivery of reasonably necessary health care, including
medical, dental and mental health services, to individuals cleared by medical and
physically booked into one of the Facilities for housing (such individuals being
hereinafter referred to in this Agreement as “Inmate,” singular or “Inmates,” plural),
which excludes individuals not housed at the Facilities. Armor accepts such appointment
to perform such services in accordance with the terms and conditions of this Agreement.
Armor will provide preliminary screening and assessing of an individual's medical
condition at the time the individual is being presented for booking into the Facilities,
even prior to the completion of the booking process, to determine whether the
individual’s physical condition is reasonably able to be accommodated within the
Facility. An individual shall be medically cleared for booking into the Facilities when
medically stabilized and the individual's medical condition no longer requires immediate
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emergency medical care or outside hospitalization so that the individual can be
reasonably housed in the Facilities.
1.2.

Scope of General Services. The responsibility of Armor for providing health care
commences once an individual becomes an Inmate, as defined in Section l.l above.
Armor has no responsibility and shall not be liable for any health care or costs associated
with any individual prior to becoming an Inmate. While Armor has no financial
obligation for individuals booked offsite, if the Sheriff or Superintendent notifies a duly
appointed member of the on-site Armor staff of any booking performed outside the
Facilities, Armor will use reasonable efforts to manage offsite care and reduce offsite
costs by providing utilization management for those individuals booked offsite and
receiving inpatient care prior to becoming an Inmate.
While an Inmate, Armor shall provide or arrange for on a regular basis, all professional
medical, dental, mental health, and related health care and administrative services for
each Inmate, including: a comprehensive health evaluation of each Inmate following
booking into the Facilities in accordance with NCCHC Standards, booking/intake health
screenings, regularly scheduled sick call, nursing care, general physician and dentist
visits, hospitalization, medical specialty services as outlined below, emergency medical
care, emergency ambulance services when medically necessary, medical records
management, pharmacy services, including HIV medications, medical clearances for intra
and inter-agency transfers, food handling and work clearances, continuing care of
identified health problems, detoxification, discharge planning, health education and
training services, a quality assurance program, administrative support services, and other
services, all as more specifically described herein.

1.3.

Specialty Services. In addition to providing the general services described above, Armor
will obtain for Inmates housed at the Facilities special medical services including basic
radiology services and laboratory services. Armor will also evaluate the need for and
feasibility of providing select onsite specialty services (e.g., Orthopedics) to reduce
offsite transports. Specialty services Armor determines to be feasible will be provided
onsite. When non-emergency specialty care is required and not provided onsite, Armor
will make appropriate off-site arrangements for the rendering of such care, and shall
coordinate with the Sheriff for Inmates in the physical care, custody and control of the
Sheriff in the Jail and with the Superintendent for Inmates in the physical care, custody
and control of the Superintendent in the HOC to provide non-emergency transportation of
an Inmate to and from offsite care.

1.4.

Emergency Services. Armor shall provide emergency first aid to correctional staff and
visitors to Inmates at the Facilities upon request of the Sheriff or Superintendent or their
employees or agents, except when doing so would jeopardize Armor's care to an Inmate.
Armor shall not be responsible for payment of emergency and follow-up services and
transportation provided to correctional staff or visitors in the event of an emergency.

1.5.

Limitations on Medical Services. Armor will arrange for the admission of any Inmate
who, in the opinion of the Armor Medical Director, requires hospitalization. Subject to
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the limits set forth herein, Armor will be responsible for all Inmate costs associated with
hospitalization, off-site and on-site specialty services, inclusive of diagnostic procedures,
and emergency transportation services incurred subsequent to becoming an Inmate.
(a)

"Hospitalization” refers to those services, which will be rendered in a hospital or
medical center. Such services include but are not limited to inpatient
hospitalization, physician fees associated with inpatient and/or outpatient care,
ambulatory surgery, emergency ambulatory care, diagnostic and therapeutic
radiology, pharmacy, laboratory and pathological capabilities, and physical
therapy capabilities. Armor will pursue preferred provider contracts/discount
agreements with local hospitals to meet the needs of the Sheriff’s inmate health
care program at the Jail and the Superintendent’s inmate health care program at
the HOC.

(b)

"Offsite and specialty medical care” refers to those services rendered by a
medical provider outside the Facilities or by a licensed independent (non-Armor
employee) medical specialist coming onsite to provide specialty services.

(c)

For each twelve (12) month period of the Agreement, Armor's total financial
liability for costs associated with health care for Inmates relating to
hospitalization, emergency transportation, off-site and specialty medical care (as
defined above) will be capped as follows:
(1)
Armor’s total liability for hospitalization, emergency transportation, offsite and specialty medical costs will be capped at $800,000.00 for each
twelve (12) month contract period under this Agreement.
(2)
Any hospitalization, emergency transportation, off-site and specialty
medical care costs in excess of $800,000.00 during any twelve (12) month
contract period shall be managed and paid by Armor and reimbursed by
the County, as set forth in 1.5 (d) below.
(3)
Should the total hospitalization, emergency transportation, and off-site and
specialty medical care costs for any twelve (12) month contract period fall
below $800,000.00 after a full reconciliation, Armor will credit 100% of
the difference back to the County.
(4)
Armor will account for all "specialty medical care" provided onsite, which
may include, but is not limited to OB/GYN, dialysis, and physical therapy
in the Aggregate Cap in accordance with the contract.

(d)

Aggregate Reconciliation - Following the completion of each 12 month contract
period (running from the date Armor commences provision of healthcare services
at the Facilities), Armor shall submit documentation showing the amount Armor
has paid for hospitalization, emergency transportation, and off-site and specialty
medical care during the past 12 month contract period. Any amount under/over
the $800,000.00 shall be invoiced/credited as set forth below. Armor will provide
supporting documentation along with an invoice/credit. Because Armor cannot
always control when third party providers bill for services, once this initial
documentation has been provided, Armor shall thereafter submit quarterly
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additional documentation showing any additional amounts paid for the ended 12
month period, along with an invoice/credit to be paid/credited as set forth below.
If under the cap, Armor shall credit the County on the next monthly invoice (if the
contract is still active), or submit a check to the County for the amount below the
cap. If over the cap, Armor shall provide any additional supporting documentation
and will, as requested by the County, discuss reasons for the overage. The
County shall pay the excess amount within 45 days of receipt of invoice. Armor
will provide to the County any requested supporting cost information in Armor's
possession.
(e)

1.6.

1.7.

In the event this Agreement is terminated early, this $800,000.00 annual
aggregate cap will be prorated.

Exceptions to Treatment. Armor shall not be financially responsible for the cost of any
health care services provided to any individual prior to becoming an Inmate as defined in
Section 1.1, above.
(a)

Should any new diagnostic test be mandated and approved in relation to
community health care standards for treatment and/or required by Armor's
Medical Director as necessary for the treatment of Inmates housed at the
Facilities, and the cost of such treatment, in total aggregate, would exceed 1% of
the annual base compensation for the then current twelve (12) month period under
the term of this Agreement, then the County and Armor shall negotiate for
additional compensation due Armor for all actual expenses incurred from newly
mandated changes in treatment standards.

(b)

Armor shall provide prenatal, delivery and postpartum health care services to
pregnant Inmates, infants born in custody at the County jail or HOC, but
healthcare services provided to an infant once transferred to a medical facility
from the County jail or HOC will not be the responsibility of Armor. Armor shall
not be responsible for the costs of or furnishing of any abortions, unless medically
necessary.

(c)

Pursuant to Wisconsin statute, 343.305(5)(b)(c) and The Wisconsin Department
of Transportation, Division of State Patrol, Chemical Test Section, the County of
Milwaukee requires Armor to do blood draws as requested by the
Facilities. Otherwise, to comply with NCCHC standards, Armor shall not
perform any forensic testing. Armor shall not be penalized or otherwise
negatively impacted should adherence to this section hinder efforts to obtain
NCCHC accreditation.

Inmates Outside the Facilities. Health care services are only for Inmates. Inmates on
any sort of temporary release (authorized or unauthorized) from the Facilities, including,
but not limited to, Inmates temporarily released for the purpose of attending funerals or
other family emergencies, Inmates on escape status, Inmates on pass, parole or
supervised custody who do not sleep in the Facilities at night, will not be included in the
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daily population count, and will not be the financial responsibility of Armor with respect
to any claim, liability, cost or expense for the payment or furnishing of health care
services required while not in the Facilities. Armor is responsible to provide reasonably
necessary care to Inmates while in the Facilities, but the cost of medical services
provided to Inmates who become ill or are injured while on temporary release will not be
the financial responsibility of Armor after their return to the Facilities. This relates solely
to the costs associated with the particular illness or injury incurred while on such
temporary release. The cost of medical services for other illnesses and injuries will be
the responsibility of Armor.
(a)

Once Inmates from the Facilities are transferred to the custody of other police or
other penal jurisdictions, these Inmates are likewise excluded from the population
count and are not the responsibility of Armor for the furnishing or payment of
health care services.

1.8.

Elective Medical Care. Armor will not be responsible for providing elective medical
care to Inmates. For purposes of this Agreement, “elective medical care” means medical
care, which, if not provided, would not, in the opinion of Armor's Medical Director,
cause the Inmate's health to deteriorate or cause definite harm to the Inmate's well-being.
Such decisions concerning medical care shall be consistent with applicable laws and
general NCCHC standards. In the event of a dispute between Armor's Medical Director
and the Sheriff or Superintendent regarding elective medical care, Armor will state in
writing to the Sheriff or Superintendent reasons why the medical care is being denied.

1.9.

Transportation Services. Armor shall promptly notify the HOC or Jail staff and work
together to arrange for emergency transportation.

1.10. HIV and Other Illnesses; Testing. Armor will administer Inmate testing in accordance
with NCCHC standards and as otherwise deemed medically necessary by Armor's
Medical Director.
1.11. Pharmacy. Armor shall provide pharmacy services management, including providing
and administering medicines, including prescribed drugs to the Inmates. Armor shall use
best efforts to utilize the current formulary schedule to dispense pharmaceuticals to
Inmates within a reasonable time period, not to exceed 24 hours from the time the
prescription or order was written to start. Armor shall pay the cost for all pharmacy,
subject to the total annual pharmacy limit set forth below.

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(a)

Armor’s total liability for pharmacy costs will be limited to $850,000.00 for each
twelve (12) month period under this Agreement. Should the total pharmacy cost
be less than $850,000, Armor shall credit the County the difference. Should the
total pharmacy cost exceed $850,000, the County shall reimburse Armor the
excess. On a monthly basis, Armor shall submit an itemized report showing
actual pharmacy paid by Armor. Any credit to the County shall be reflected on an
invoice within 30 days, and any excess shall be discussed and reimbursed by the
County to Armor within 45 days.

(b)

The formulary schedule will be reviewed on a quarterly basis.

ARTICLE II: MENTAL HEALTH SERVICES
2.01. Continuation of Care. Armor will use reasonable and best practice efforts to facilitate
continuation of care and facilitate placement in the community upon release for inmates
with diagnosed mental health issues, when security provides reasonable advance notice of
release.
ARTICLE III: PERSONNEL
3.1.

Staffing. Armor shall provide all medical, dental, mental health, technical and support
personnel for the rendering of health care services to Inmates at the Facilities as described
in this Agreement. The chart attached as Exhibit A includes the agreed-upon staffing
matrix showing the staffing Armor will use to provide the health care and support
services required by the Facilities for an average daily inmate population up to 2600
Inmates.
(a)

Armor agrees to provide all staff in Exhibit A

(b)

Should the inmate population exceed 2600, or fall below 2400, for three
consecutive monthly averages, then both parties agree to review staffing. If
staffing changes are required to properly care for the changed population, the
County and Armor shall agree upon revised compensation required to provide the
revised staffing.

(c)

In the event the Facilities operations or processes change impacting Armor's
delivery of medical care and performance under this Agreement, Armor reserves
the right to and may provide for additional health care staffing beyond the
positions noted in the attached Exhibit A, incorporated herein, in order to perform
the necessary health care services as required under this Agreement. Should
additional health care staffing be required, Armor also reserves the right to review
the base compensation and, with the County’s participation and approval, which
shall not be unreasonably withheld, make necessary adjustments in base
compensation in order to accommodate any additional staff positions which may
be needed.
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3.2.

Staffing Withholds. The intent of section 3 is for Armor to provide 100% of the
specified number of FTE employees in Exhibit A. It is not the intent of this provision for
Armor to consistently have fewer employees working over 100% of a position’s full time
hours in order to get to a staffing equivalency of at least 95% FTE hours overall.
Armor will provide the County or its representative with a monthly contract staffing
compliance report showing all contract positions relative to the staffing matrix. The
report shall list all contract positions and the individual by name providing the service,
hours each individual worked, to include paid time off, in relation to the total contract
FTE’s required for that period. The staffing compliance report will be due no later than
fifteen days following each monthly pay period.
If total paid monthly full time equivalents (FTE’s) falls below 95% of total FTE’s in
Exhibit A, the County may apply staffing withholds as follows: once total paid FTE’s in
any month fall below 95% of total monthly FTE’s in the staffing set forth in Exhibit A,
for each FTE category below 95% of total contract FTE’s, the County may deduct from
its monthly payment to Armor at 100% of the average hourly rate for the
position. Notwithstanding the preceding provisions, in some instances, a shift of hours
from positions at over 100% to cover positions under 95%, will not be approved by the
County. If Armor falls below 95% total paid FTEs for three (3) consecutive months, then
there will be an additional penalty enhancer of $10,000 per month inclusive of those three
(3) months.

3.3.

Licensure, Certification and Registration of Personnel. All personnel provided or
made available by Armor to render services hereunder shall be licensed, certified or
registered, as appropriate, in their respective areas of expertise as required by applicable
Wisconsin law. Each license or certification shall be on file at a central location as
mutually agreed upon.

3.4.

Sheriff’s and Superintendent’s Satisfaction with Health Care Personnel. Sheriff and
Superintendent reserve the right to approve or reject in writing, for any lawful reason, any
and all Armor personnel or any independent contractor, subcontractors or assignee of
Armor assigned to this contract. Additionally, Sheriff or Superintendent may deny access
or admission to Facilities at any time for such personnel. Such access will not
unreasonably be withheld by Sheriff or Superintendent. Sheriff and Superintendent will
require and be responsible for criminal background checks and initial drug testing of all
Armor personnel, at County’s expense, prior to any such personnel’s initiation of
recurring services.
If the Sheriff or Superintendent becomes dissatisfied with any personnel provided by
Armor hereunder, or by any independent contractor, subcontractors or assignee of Armor,
Armor, in recognition of the sensitive nature of correctional services, shall, following
receipt of written notice from the Sheriff or Superintendent of the grounds for such
dissatisfaction, exercise its best efforts to resolve the problem. If the problem is not
resolved to the Sheriff’s or Superintendent’s reasonable satisfaction, Armor shall remove
or shall cause to be removed any employee, agent, independent contractor, subcontractor,
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or assignee about whom the Sheriff or Superintendent has expressed dissatisfaction.
Should removal of an individual become necessary, Armor will be allowed a reasonable
time from date of removal to find an acceptable replacement, without penalty or prejudice
to the interests of Armor.
3.5.

Use of Inmates in the Provision of Health Care Services. Inmates shall not be
employed or otherwise engaged by either Armor or the Sheriff or Superintendent in the
direct rendering of any health care services. Upon prior written approval of the Sheriff or
Superintendent, Inmates may be used in positions not involving the rendering of health
care services directly to Inmates.

3.6.

Subcontracting and Delegation. In order to discharge its obligations hereunder, Armor
will engage certain health care professionals as independent contractors rather than as
employees. The Sheriff or Superintendent may request to approve such professionals, but
approval will not be unreasonably withheld. Subject to the approval described above, the
Sheriff and Superintendent consent to such subcontracting or delegation. As the
relationship between Armor and these health care professionals will be that of
independent contractor, Armor will not be considered or deemed to be engaged in the
practice of medicine or other professions practiced by these professionals. Armor will
not exercise control over the manner or means by which these independent contractors
perform their professional medical duties. However, Armor shall exercise administrative
supervision and clinical oversight over such professionals necessary to ensure the strict
fulfillment of the obligations contained in this Agreement. For each agent and
subcontractor, including all medical professionals, physicians, dentists and nurses
performing duties as agents or independent contractors of Armor under this Agreement,
Armor shall obtain proof that there is in effect a professional liability or medical
malpractice insurance policy, as applicable coverage for each health care professional
identified herein, in an amount of at least one million dollars per occurrence/three million
dollars annual aggregate limit. As requested by the Sheriff or Superintendent, Armor will
make available copies of subcontractor agreements providing service under the
Agreement. Armor agrees that all Armor subcontractors shall be subject to a background
check by the Sheriff or Superintendent, as the Sheriff or Superintendent shall direct.

3.7.

Affirmative Action Armor will undertake an affirmative action program at Facilities as
required by 14 CFR Part 152, Subpart E, to insure that no person shall on the grounds of
race, creed, color, national origin, or sex be excluded from participating in any
employment activities covered in 14 CFR Part 152, Subpart E. Armor assures that no
person shall be excluded on these grounds from participating in or receiving the services
or benefits of any program or activity covered by this subpart. Armor will require that its
covered suborganizations provide assurances that they similarly will undertake
affirmative action programs and that they will require assurances from their
suborganizations, as created by 14 CFR Part 152, Subpart E, to the same effect.

3.8

Non-Discrimination, Equal Employment Opportunity and Affirmative Action
Programs In the performance of work under this Contract, Armor shall not discriminate
against any employee or applicant for employment because of race, color, national origin,

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age, sex, sexual orientation, gender identity or handicap, which shall include, but not be
limited to, the following:
(a)

Employment, upgrading, demotion or transfer; recruitment or recruitment
advertising; layoff or termination; rates of pay or other forms of compensation;
and selection for training, including apprenticeships. Armor will post in
conspicuous places, available for employees and applicants for employment,
notices to be provided by County, setting forth the provisions of the nondiscriminatory clause.

(b)

Armor agrees to strive to implement the principles of equal employment
opportunity through an effective Affirmative Action program, and made a part of
this Contract. The program shall have as its primary objective to staff the very
best qualified person for each position, and then, when and where possible
without negatively impacting this first objective, to increase the utilization of
women, minorities and handicapped persons, and other protected groups, at all
levels of employment, in all divisions of Armor’s Milwaukee County work force,
where these groups may have been previously under-utilized and underrepresented. Armor also agrees that in the event of any dispute as to compliance
with the aforestated requirements, it shall be the disputing party’s responsibility to
show that Armor has not met all such requirements.

(c)

When a violation of the non-discrimination, equal opportunity or Affirmative
Action provisions of this section has been determined by a court of competent
jurisdiction, Armor shall immediately be informed of the violation and directed to
take all action necessary to halt the violation, as well as such action as may be
necessary to correct, if possible, any injustice to any person adversely affected by
the violation, and immediately take steps to prevent further violations.

(d)

If, after notice of a violation to Armor, further violations of this section are proven
in a court of competent jurisdiction during the term of the Contract, County may
terminate the Contract without liability for the uncompleted portion or any
materials or services purchased or paid for by Armor for use in completing the
Contract, or it may permit Armor to complete the Contract, but, in either event,
Armor shall be ineligible to bid on any future contracts let by County.
ARTICLE IV: ACCREDITATION

4.1.

Obligation of Armor. Armor's services shall be designed to meet the National
Commission on Correctional Health Care for Jails (NCCHC) standards in place at the
commencement of this Agreement. While Armor will design their care to comply with
NCCHC standard, if there is a material change in NCCHC standards resulting in
additional costs to Armor, the County agrees to pay such documented additional costs.
Armor will cooperate fully with the County in all efforts to attain and maintain formal
accreditation of the Facilities’ health care program. Armor will be responsible for the
payment of the fees for maintaining or renewing NCCHC accreditation, except any fees
incurred due to non-Armor failures.
Any deficiency in Armor's performance of health care services under this Agreement
resulting in notice from any regulatory or accrediting organization shall be rectified
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immediately, provided that such a breach is directly attributed to Armor’s acts or
omissions, including Armor's employees, agents (County employees shall not be deemed
agents of Armor under the terms of this Agreement) and subcontractors. Failure to
rectify any such deficiency within a thirty (30) day cure period may result in the County,
in its sole discretion, terminating this Agreement. Armor shall, in conjunction with the
HOC and Jail, continue to expeditiously prepare for and pursue NCCHC accreditation.
Once accreditation is obtained, Armor shall maintain accreditation during any subsequent
term of this Agreement. If Armor’s acts or omissions, and not those of County
employees, fails to so maintain accreditation, and such is solely due to Armor's failure to
comply with NCCHC standards, then Armor will pay a penalty of Twenty-five Thousand
Dollars ($25,000.00) to the County as liquidated damages.

ARTICLE V: EDUCATION
5.1.

Inmate and Staff Education. Armor shall conduct an ongoing health education
program for Inmates at the Facilities with the objective of raising the level of Inmate
health and health care. Armor staff will provide relevant training to the Sheriff’s and
Superintendent’s staff as required by accrediting bodies. Armor will also work with the
Sheriff and Superintendent to provide correctional staff with health care training as
desired by the Sheriff or Superintendent and as Armor is able to accommodate without
jeopardizing the quality of Inmate care.

5.2.

Medical Services Staff Education. Armor will require that its medical, professional and
para-professional staff receive all necessary and requisite legal and statutorily mandated
in-service, annual or proficiency training and other such professional or para-professional
education and training programs needed to provide current proficiency in the
professional's or para-professional's particular medical discipline or specialty. County
shall ensure the same for County employees. County employees shall be invited to attend
any Armor training provided onsite at the Facilities and Armor employees shall be
invited to any training provided onsite at the Facilities for County employees. Armor
shall have no obligations for costs associated with CME, licensing, certification,
recertification or training for County employees.
ARTICLE VI: REPORTS AND RECORDS

6.1.

Medical Records. Armor shall cause and require to be maintained a complete and
accurate medical record for each Inmate receiving health care services from Armor. Each
medical record will be the property of the County and such records shall be maintained
by Armor in accordance with applicable laws, NCCHC standards. The medical records
shall be kept separate from the Inmate's confinement record. A complete legible copy of
the applicable medical record shall be available, within a reasonable time, to the Sheriff
or Superintendent and will, with reasonable notice, be available to accompany each
Inmate who is transferred from the Facilities to another location for offsite services or
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transferred to another institution. Medical records shall be kept confidential. Subject to
applicable law regarding confidentiality of such records, Armor shall comply with
Wisconsin law and the Sheriff’s or Superintendent’s policy with regard to access by
Inmates and Facilities staff to medical records. No information contained in the medical
records shall be released by Armor except as directed by the Sheriff’s or Superintendent’s
policy, by a court order, or otherwise in accordance with applicable law. Armor shall
provide all medical records, forms, jackets, and other materials necessary to maintain the
medical records. Armor will provide customized EMR software of Armor’s choosing that
incorporates Armor’s policies in use at the Facilities, server, terminals, printers, scanners
and interfaces. County will provide the cabling, routers and connections needed in the
Facilities to connect the EMR. Upon the expiration or termination of this Agreement, the
functional EMR and all medical records shall become the property of the County, and the
County shall assume payment of the monthly per inmate fee for the EMR, currently $1.50
per Inmate per month, if County desires to retain the EMR. Armor will use reasonable
effort to allow the County to continue to utilize such EMR on the same terms and
conditions applicable to Armor. The EMR will be customized with Armor forms, policies
and procedures. The County may continue to use such forms, policies and procedures,
but hereby acknowledges such are proprietary; therefore, the County shall keep such
forms, policies and procedures exclusively within the Sheriff’s and Superintendent’s
Offices and associated County departments that have a need to know. If however, the
County finds the EMR software chosen by Armor to be inadequate or inappropriate for
the County’s operational needs, then the parties shall meet and determine whether to
pursue a new system and/or enhancements to the EMR system.
6.2.

Regular Reports by Armor to the Sheriff and Superintendent. Armor shall make
available to the Sheriff and Superintendent, on a date and in a form mutually acceptable
to Armor and the Sheriff and Superintendent, monthly and annual reports relating to
services rendered under this Agreement.

6.3.

Third Party Reimbursement. Armor will seek and obtain from Inmates information
concerning any health insurance the Inmate might have that would cover offsite services
managed by Armor. Armor will instruct offsite providers to bill third party insurance
first. After seeking payment from available third party insurance, Armor will process the
remaining claim for payment consideration. Armor shall provide the County with
periodic reports when such credits are applied. Armor and the County specifically
understand that Medicaid and Medicare may not be available third party sources, and, to
the extent required by law, Armor's policies strictly forbid asking about
Medicaid/Medicare and providing any Medicaid/Medicare information to any provider
where such coverage is not allowed. Armor shall follow the patient Protection and
Affordable Care Act (PPACA) as it develops. As it becomes applicable to Inmates,
Armor will cooperate with County to obtain any costs savings available under the
PPACA.

6.4.

Inmate Information. Subject to the applicable Wisconsin law, in order to assist Armor
in providing the best possible health care services to Inmates, the Sheriff and
Superintendent will provide Armor with information pertaining to Inmates that Armor
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and the Sheriff and Superintendent mutually identify as reasonable and necessary for
Armor to adequately perform its obligations hereunder.
6.5.

Armor Records Available to the Sheriff or Superintendent with Limitations on
Disclosure. With reasonable notice, Armor shall make available to the Sheriff or
Superintendent, at the Sheriff’s or Superintendent’s request, all records, documents and
other papers relating to the direct delivery of health care services to Inmates hereunder.
The Sheriff and Superintendent understand that many of the systems, methods,
procedures, written materials and other controls employed by Armor in the performance
of its obligations hereunder are proprietary in nature and will remain the property of
Armor. Information concerning such may not, at any time, be used, distributed, copied or
otherwise utilized by the Sheriff or Superintendent, except in connection with the
delivery of health care services hereunder, and as permitted or required by law, unless
such disclosure is approved in advance in writing by Armor.

6.6.

Sheriff’s and Superintendent’s Records Available to Armor with Limitations on
Disclosure. During the term of this Agreement and for a three years thereafter, the
Sheriff and Superintendent shall provide Armor, at Armor's request, Sheriff’s and
Superintendent’s records relating to the provision of health care services to Inmates as
may be reasonably requested by Armor or as are pertinent to the investigation or defense
of any claim related to Armor's conduct. Consistent with applicable law, the Sheriff and
Superintendent will make available to Armor such records as are maintained by the
Sheriff or Superintendent, hospitals and other outside health care providers involved in
the care or treatment of Inmates (to the extent the Sheriff or Superintendent has access to
those records) as Armor may reasonably request. Any such information provided by the
Sheriff or Superintendent to Armor that the Sheriff or Superintendent considers
confidential and clearly labeled confidential shall be kept confidential by Armor and shall
not, except as may be required by law, be distributed to any third party without the prior
written approval of the Sheriff or Superintendent.

6.7.

Public Record Law. In the event that Armor should assert any proprietary or
confidential status to any of its systems, methods, procedures or written materials and
other controls employed by Armor in the performance of its obligation pursuant to this
Agreement, then Armor shall assess such claim on its own, and shall defend and hold
harmless the County, the County’s employees, officers, appointees and agents against all
liabilities for Armor's failure to comply with the requirements of the law with regard to
the release of records.

6.8.

HIPAA Compliance. To the extent HIPAA applies to Armor, Armor shall comply with
those requirements of the Health Insurance Portability and Accountability Act of 1996
(HIPAA) and amendments relating to Armor's responsibilities pursuant to this
Agreement.

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ARTICLE VII: SECURITY
7.1.

General. Armor, the Sheriff and the Superintendent understand that adequate security
services are necessary for the safety of the agents, employees and subcontractors of
Armor as well as for the security of the Inmates and the Sheriff’s and Superintendent’s
staff, consistent with the correctional setting. The Sheriff and Superintendent will take all
reasonable measures to provide sufficient security to enable Armor, County and their
personnel, to safely and adequately provide the health care services described in this
Agreement. Armor, County and their staff and personnel, understand that the Facilities in
which services will be rendered are detention Facilities and that working in such
Facilities involves inherent dangers. Armor, County and their staff and personnel further
understand that the Sheriff and Superintendent cannot guarantee anyone's safety in the
Facilities and nothing herein shall be construed to make the Sheriff and Superintendent,
their officers or employees a guarantor of the safety of Armor or County employees,
agents or subcontractors.
(a)

In the event that any recommendation by Armor for particular health services for
any Inmate or transfers to a medical facility should not be implemented and
carried out due to acts or omissions of the Sheriff or Superintendent, Armor will
be released from professional liability for any damages resulting from any such
decision on the part of the Sheriff or Superintendent, as long as the
recommendation was made in writing.

7.2.

Loss of Equipment and Supplies. The County shall not be liable for loss of or damage
to equipment and supplies of Armor, its agents, employees or subcontractors unless such
loss or damage was caused by the negligence of the County or its employees.

7.3.

Security During Transportation Off-Site. The Sheriff or Superintendent will provide
security as necessary and appropriate in connection with the transportation of any Inmate
between the Facilities and any other location for off-site services as contemplated herein.
ARTICLE VIII: OFFICE SPACE, EQUIPMENT, INVENTORY AND SUPPLIES

8.1.

General. The Sheriff and Superintendent agree to provide Armor with office space at the
Facilities, the use of the equipment (including office furniture) currently being used at the
Facilities to provide health care services to Inmates, and utilities (such as electricity, local
phone and water) sufficient to enable Armor to perform its obligations hereunder. Armor
will supply and be responsible for payment of long distance telephone carrier services
and minor equipment (less than $3,500 purchase price) within the Facilities for use of its
personnel. The County will provide necessary maintenance and housekeeping of the
office space at the Facilities. Armor agrees it has inspected the Facilities and medical
office space at the Facilities and that such space and the Facilities can be utilized to
perform the obligations required under this Agreement.

8.2.

Delivery of Possession. The Sheriff and Superintendent will provide to Armor,
beginning on the date of commencement of this Agreement, possession and control of all
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medical and office equipment and supplies that are the County’s property, in place at the
Facilities health care units. At the termination of this or any subsequent Agreement,
Armor will return to the County possession and control of all County owned equipment,
in working order, reasonable wear and tear excepted, which were in place at the Facilities'
health care unit prior to the commencement of services by Armor under this Agreement.
8.3.

Maintenance and Replenishment of Equipment. Armor will maintain all Armor owned
equipment in working order and County shall maintain all County owned equipment in
working order during the term of this Agreement. The County shall provide all
reasonably required medical equipment with a value of $3,501 or greater, necessary to
provide health care services in the Facilities. Armor shall at its sole expense purchase all
required medical and office equipment not provided by County to perform services
pursuant to this agreement with a per item cost of $3,500 or less. At the conclusion of the
initial term and any renewal terms of this Agreement all equipment purchased by Armor
may be purchase by the County for the then current market price less 10%. If the
Agreement with Armor is terminated prior to the initial contract term and extensions, the
County will be provided the opportunity to purchase the equipment at the current market
price. Prior to the start of the initial contract period, the County shall provide Armor with
a complete listing of all equipment within the medical units that will be available for
Armor to use.

8.4.

General Maintenance Services. The Sheriff and Superintendent will provide for each
Inmate receiving health care services at the Facilities the same services provided by the
Sheriff and Superintendent to all other Inmates at the Facilities including, but not limited
to, daily housekeeping services, dietary services, building maintenance services, personal
hygiene supplies and services, and linen supplies.

8.5.

Supplies. Armor warrants and represents that the quality and quantity of supplies on hand
during this Agreement will be sufficient to enable Armor to perform its obligations
hereunder, barring a significant deviation from standard usage (e.g., riot, natural disaster).
Armor shall be responsible, at its sole expense, to purchase any and all additional office
supplies needed, from time to time, to provide health services to the Inmates pursuant to
the provisions of this Agreement.

8.6.

Biohazardous Waste. Armor shall be responsible, at its sole cost, for the proper disposal
of all biohazardous medically generated waste occurring at the Facilities during the term
of this Agreement.

8.7.

Software and Electronic Information. All software programs and other information
technology purchased or developed by Armor and used in its performance of this
Agreement are proprietary to and/or the property of Armor. The County shall not have
any right, title or interest, in or to such property, except as otherwise provided in this
paragraph. At the expiration or termination of this Agreement, Armor will allow the
County to continue using Armor’s EMR as long as the County pays the EMR provider’s
monthly per inmate fee, assuming the EMR provider agrees. If the County does not wish
to continue utilizing Armor’s EMR software, Armor shall provide the County with all
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Milwaukee County

Inmate data that has been stored electronically, in a relational database utilizing Sequel or
Oracle and a PDF electronic copy of Inmates medical records and shall ensure that all
paper Inmate medical records and electronic documents are complete and accurate.

ARTICLE IX: TERM AND TERMINATION OF AGREEMENT
9.1.

Term. This Agreement will be effective at 12:01 a.m. on January 1, 2017, as to the
providing of services hereunder. The initial term of this Agreement shall be one (1) year.
This Agreement may also only be revised and extended as mutually agreed upon by the
parties.

9.2.

Termination. This Agreement may be terminated as provided in this Agreement or as
follows:
(a)
Termination by Agreement. In the event that County and Armor mutually agree in
writing, this Agreement may be terminated on the terms and date stipulated
therein.

9.3.

(b)

Termination for Default. In the event the County or Armor shall give notice to the
other that such other party has materially defaulted in the performance of any of
its material obligations hereunder and such default shall not have been cured
within thirty (30) days following the giving of such notice in writing, the party
giving the notice shall have the right immediately to terminate this Agreement.

(c)

Unrestricted right of termination. The County further reserves the right to
terminate this Contract at any time for any reason by giving Armor thirty (30)
days' written notice by Certified Mail of such termination. In the event of said
termination, Armor shall reduce its activities hereunder as mutually agreed to,
upon receipt of said notice. Upon said termination, Armor shall be paid for all
services rendered through the date of termination.

(d)

Annual Appropriations and Funding. Both parties acknowledge that the
performance of this Agreement and payment for medical services to Armor
pursuant to this Agreement is predicated on the continued annual appropriations
by the Board of Supervisors of Milwaukee County to meet the medical needs of
the Inmates in the facilities and the Sheriff’s and Superintendent’s ability to
perform under this Agreement.

(e)

Armor may terminate if the County falls more than 45 days behind on timely
payment to Armor. Armor may also terminate without cause by providing the
County with no less than 180 days advance written notice.

Responsibility for Inmate Health Care. Upon termination of this Agreement, all of
Armor's responsibility for providing health care services to all Inmates, including Inmates
receiving health care services at sites outside the Facilities, will terminate.
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9.4.

Owner of Documents Upon Early Termination. Upon early termination of this
Agreement prior to its expiration, copies of all finished or unfinished documents, studies,
correspondence, reports or other products prepared by Armor for County shall be
provided to the County.

ARTICLE X: COMPENSATION
10.1. Base Compensation. For each one year term of this Agreement, the base monthly
compensation shall be invoiced in advance of the month in which services are provided.
The County shall pay the base monthly compensation invoice within 45 days of receipt of
said invoice. All monthly adjustments (e.g., withholds, per diems) shall be invoiced or
credited, as the case may be, the following month. In the event this Agreement should
terminate or be amended on a date other than the end of any calendar month,
compensation to Armor will be prorated accordingly based on the fractional portion of
the month during which Armor actually provided services. Any properly submitted
invoice not paid within 45 days from receipt shall accrue interest at 1.5% per month until
paid in full.
(a)

For the one year term (1/1/17 thru 12/31/17) of this Agreement, the County shall
pay to Armor the base price sum of $16,158,442 for an average daily inmate
resident population up to 2600, payable in twelve (12) equal monthly
installments. Furthermore, if funding is available and the contract is renewed,
effective on January 1, 2018, Armor compensation will increase by an amount
mutually agreed upon by the parties. For each Inmate in excess of 2700 average
daily inmate resident population, the County shall pay Armor a per diem of $1.69.
For each Inmate below 2300 average daily inmate resident population, Armor
shall credit County a per diem of $1.69.

(b)

The Parties hereto acknowledge there may be legal and/or public challenges to the
implementation of Armor services called for under this Agreement. Should Armor
be required to suspend, in whole or in part, or terminate services due to such
challenge, or otherwise at the request of the County, the County shall pay Armor
on a pro rata basis for services incurred up to the date services are suspended or
terminated. Should Armor recommence services (in whole or in part) after
services have been suspended (in whole or in part) or terminated, the County shall
pay Armor’s actual startup costs incurred to resume provision of services. Armor
shall invoice County for such actual costs together with reasonable supporting
documentation.

10.2. Inmate Population. The average daily inmate resident population shall be based upon
the midnight count taken each day. The average daily inmate resident population counts
are added for each day of the month and divided by the number of days in the month to
determine the average monthly inmate population. The excess, if any, over the inmate
population caps will be multiplied by the per diem rate and the number of days in the
month to arrive at the increase in compensation payable to Armor for the month.
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(a)

10.3

Should the Sheriff or Superintendent designate any other facility requiring the
provision of health care services by Armor, the parties agree to negotiate the
additional staff and compensation prior to Armor commencing services at the
newly designated facility.

Failure to Perform/Reimbursement. For any services required to be performed by
Armor under this Agreement, but that are performed by the County due to Armor's failure
to perform, Armor shall reimburse County for those expenses and, to the extent possible,
such expenses shall be credited to the County on the monthly payment due Armor under
this Agreement.

10.4. Penalties.
I.
Penalties to which Armor is subject are as follows:
(a)

(b)

(c).

(d).

(e)

Armor shall not be liable for a penalty when Armor's failure arises as a result of
any reason beyond its control, including but not limited to physical facility
limitations, lockdowns, strikes or labor disputes, inmate disturbances, acts of God,
failure of County to fulfill County responsibilities under this Agreement, or any
other similar causes beyond the reasonable control of Armor.
The County may assess Armor, on a monthly basis, a fine of One Hundred Fifty
and 00/100 Dollars ($150.00) for each Inmate History and Physical Examination
not completed within the required fourteen (14) days after the day of booking.
This fine will not be assessed if Armor's staff does not have reasonable access to
any inmate in order to complete the history or examination.
The County may assess Armor, on a monthly basis, a fine of One Hundred Fifty
and 00/100 Dollars ($150.00) for each booking intake screening not initiated
within 60 minutes of notification and reasonable opportunity to complete. In
situations involving a mass arrest resulting in a large influx of new prisoners (ten
(10) people or more) being processed in the booking area, the sixty (60) minute
booking requirement will be reasonably extended to no more than an additional
sixty (60) minutes.
The County may assess Armor, on a monthly basis, a fine of One Hundred Fifty
and 00/100 Dollars ($150.00) for each hospital readmission during the previous
month deemed not to be medically necessary by a competent correctional
healthcare physician.
The County may assess Armor, on a monthly basis, a fine of One Hundred Fifty
and 00/100 Dollars ($150.00) for each Armor subcontractor invoice not paid
within 45 days of receipt of a clean invoice, unless the County has failed to timely
pay Armor as set forth herein.

10.6. Inmates from Other Jurisdictions. Medical care rendered within the Facilities to
Inmates from other jurisdictions housed in the Facilities pursuant to contracts between the
Sheriff or Superintendent and such other jurisdictions will be the responsibility of Armor.
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Armor will arrange medical care that cannot be rendered in the Facilities, but Armor shall
have no financial responsibility for such offsite services.
10.7. Responsibility for Work Release Inmates. Notwithstanding any other provisions of this
Agreement to the contrary, both parties agree that Inmates assigned to the work release
program who are not housed at the Jail are personally responsible for the costs of any
medical services provided to them. Armor may assist with arranging the necessary
medical transportation for Inmates participating in the work release program who are not
housed at the Jail to obtain medical care.
10.8. Changes in the Law. If any statute, rule or regulation is passed or any order, legal
mandate or decree issued or any statute or guideline adopted which materially increases
the cost to Armor of providing health care services pursuant to this Agreement, Armor
and the County will mutually agree on additional compensation to be paid by the County
to Armor as a result of such changes.
ARTICLE XI: LIABILITY AND RISK MANAGEMENT
Armor agrees to evidence and maintain proof of financial responsibility to cover costs as
may arise from claims of tort, statutes and benefits under Workers’ Compensation laws
and/or vicarious liability arising from employees, board, or volunteers. Such evidence
shall include insurance coverage for Worker’s Compensation claims as required by the
State of Wisconsin, Commercial General Liability (which includes board, staff, and
volunteers), Automobile Liability and Professional Liability in the minimum amounts
listed below.
Automobile insurance that meets the minimum limits as described in the Agreement is
required for all vehicles (owned, non-owned, and/or hired). In addition, if any employees
of Armor use their personal vehicles to transport County employees, representatives or
clients, or for any other purpose related to the Agreement, those employees shall have
Automobile Liability Insurance providing the same liability limits as required herein
through any combination of employee Automobile Liability and employer Automobile or
General Liability Insurance which in the aggregate provides liability coverage, while
employee is acting as agent of employer, on the employee’s vehicle in the same amount
as required of Armor.
Armor shall maintain Professional Liability coverage as listed below.
It being further understood that failure to comply with insurance requirements might
result in suspension or termination of the Agreement.
Type of Coverage
Wisconsin Workers’ Compensation
or Proof of all States Coverage

Minimum Limits
Statutory
Waiver of Subrogation

Employers’ Liability

$100,000/$500,000/$100,000
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Commercial General Liability
Bodily Injury & Property Damage
Incl. Personal Injury, Fire, Legal
Contractual & Products/Completed
Operations

$1,000,000 – Per Occurrence
$2,000,000 – General Aggregate

Automobile Liability
Bodily Injury & Property Damage
All Autos – Owned, Non-Owned
and/or Hired

$1,000,000 Per Accident

Uninsured Motorists

Per Wisconsin Requirements

Professional Liability
To include Certified/Licensed Mental
Health and Licensed Physician or
any other qualified healthcare provider
as required by State Statute

$1,000,000 Per Occurrence
$5,000,000 Annual Aggregate

Cyber Liability

$1,000,000 Per Occurrence
$2,000,000 Annual Aggregate

Milwaukee County shall be named as an “additional insured” on Armor’s Certificate of
Insurance for general liability, and automobile insurance. Milwaukee County must be
afforded a thirty day (30) written notice of cancellation or non-renewal. Disclosure must
be made of any non-standard or restrictive additional insured endorsement. Certificates
indicating the above coverages shall be submitted to the County. A waiver of subrogation
is required on the Workers’ Compensation policy, excluding negligent acts and
omissions of the County.
Professional Liability insurance shall include coverage for errors, omissions, and
negligent acts related to the rendering of said professional services with limits not less
than $1,000,000 per claim and $5,000,000 in the aggregate with separate limits for the
entity..
If Armor’s Professional Liability insurance is underwritten on a Claims-Made basis, the
Retroactive date shall be prior to or coincide with the date of this Agreement, the
Certificate of Insurance shall state that professional malpractice or errors and omissions
coverage, if the services being provided are professional services coverage is ClaimsMade and indicate the Retroactive Date. Armor shall maintain coverage for the duration
of this agreement and for five (5) years following the completion of this agreement.

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It is also agreed that on Claims-Made Professional Liability policies, either Armor or
County may invoke the tail option on behalf of the other party and that the Extended
Reporting Period premium shall be paid by the County.
Binders are acceptable preliminarily during the provider application process to evidence
compliance with the insurance requirements.
All coverages shall be placed with an insurance company approved by the State of Wisconsin
and rated “A” per Best’s Key Rating Guide. Additional information as to policy form,
retroactive date, discovery provisions and applicable retentions, shall be submitted to County,
if requested, to obtain approval of insurance requirements. Any deviations, including use of
purchasing groups, risk retention groups, etc., or requests for waiver from the above
requirements shall be submitted in writing to the Milwaukee County Risk Manager for
approval prior to the commencement of activities under the contract.

Milwaukee County Risk Manager
Milwaukee County Courthouse – Room 302
901 N. 9th St.
Milwaukee, WI 53233
The insurance requirements contained within this agreement are subject to periodic
review and adjustment by the County Risk Manager. Increased or additional requirements
at the request of Milwaukee County made during the contract term resulting in a change
in cost to Armor shall be reimbursed by the County within 45 days of receipt of invoice
for requested insurance changes.
ARTICLE XII: MISCELLANEOUS
12.1. Independent Contractor Status. The parties acknowledge that Armor is an independent
contractor and that all medical care decisions will be the sole responsibility of Armor.
Nothing in this Agreement is intended, nor shall they be construed to create an agency
relationship, an employer/employee relationship, a joint venture relationship, joint
employer or any other relationship allowing the County to exercise control or direction
over the manner or method by which Armor, its employees, agents, assignees or its
subcontractors perform hereunder. If Armor is held to be a joint employer of County
employees for any reason, the County shall defend, indemnify and hold harmless Armor
for any and all costs and damages resulting there from, except for costs and damages
directly arising from Armor’s direct negligence or intentional wrongful acts.
12.2. Badges and/or Visitor Passes. All Armor employees will wear identification badges at
all times in a visible manner. Armor shall return identification badges and/or visitor
passes immediately after an employee's, subcontractor's, independent contractor's or per
diem employee's resignation, removal, termination, or reassignment.

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12.3. Subcontracting. Any subcontract shall include the obligations contained in this
Agreement, and shall not relieve Armor of its obligation to provide the services and be
bound by the requirements of this Agreement. The County and Armor each binds itself,
its successors, assigns and legal representatives to the other party hereto and to the
successors, assigns and legal representatives of such other party in respect to all
covenants, agreements and obligations contained herein.
12.4. Notice. Unless otherwise provided herein, all notices or other communications required
or permitted to be given under this Agreement shall be in writing and shall be deemed to
have been duly given when delivered according to this section. Delivery shall be by
overnight courier or certified or registered mail, return receipt requested postage prepaid,
and addressed to the appropriate party at the following address:
Notice to Sheriff

Notice to Armor

Richard Schmidt
Inspector
Milwaukee County Jail
949 North 9th Street
Milwaukee, WI 53233

Bruce Teal, CEO and
Kenneth Palombo, COO
Armor Correctional Health Svcs. Inc.
4960 S.W. 72nd Ave, Suite 400

Notice to Superintendent

Notice to Milwaukee County

Michael Hafemann
Superintendent, HOC
8885 S. 68th St.
Franklin, WI. 53132

Teig Whaley-Smith
Director, DAS
901 N. 9th St. Room 308
Milwaukee, WI. 53233

Miami, Florida 33155

Or to such other respective addresses as the parties may designate to each other in writing
from time to time.
12.5. Entire Agreement. This Agreement and exhibits attached specifically incorporated
herein constitute the entire agreement of the parties and is intended as a complete and
exclusive statement of the promises, representations, negotiations, discussions and
agreements that have been made in connection with the subject matter hereof. No
modifications or amendments to this Agreement shall be binding upon the parties unless
the same is in writing and signed by the respective parties hereto. All prior negotiations,
requests for proposal, proposals, agreements and understandings with respect to the
subject matter of this Agreement are superseded hereby.
12.6. Amendment. This Agreement may be amended or revised only in writing and signed by
all parties.
12.7. Mediation of Disputes. Prior to bringing any lawsuit under this Agreement, the parties
hereto agree to submit any and all disputes to pre-suit mediation under the Wisconsin
Rules for Certified and Court-Appointed Mediators and the Wisconsin Rules of Civil
Procedure, together with the rules of the American Arbitration Association or the
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Foundation for Dispute Resolution. The parties agree to share equally the cost of the
mediation.
12.8. Waiver of Breach. The waiver by either party of a breach or violation of any provision
of this Agreement shall not operate as, or be construed to be, a waiver of any subsequent
breach of the same or other provision hereof.

12.9. Other Contracts and Third-Party Beneficiaries. The parties agree that they have not
entered into this Agreement for the benefit of any third person or persons, and it is their
express intention that the Agreement is intended to be for their respective benefit only
and not for the benefit of others who might otherwise be deemed to constitute third party
beneficiaries hereof.
12.10. Severability. In the event any provision of this Agreement is held to be unenforceable for
any reason, the unenforceability thereof shall not affect the remainder of the Agreement,
which shall remain in full force and effect and enforceable in accordance with its terms.
12.11. Force Majeure. Neither party shall be held responsible for any delay or failure in
performance (other than payment obligations) to the extent that such delay or failure is
caused by, without limitation, acts of nature, acts of public enemy, fire, explosion,
government regulation, civil or military authority, acts or omissions of carriers or other
similar causes beyond its control.
12.12. Default. Unless Armor's performance is specifically exempted by this Agreement,
County shall be entitled to a credit or reimbursement for any reasonable cost the County
incurs for any medical services required to be performed by Armor when and to the
extent that Armor shall fail to perform (excluding failures caused by County employees)
and a thirty (30) day cure period has passed. The credit or reimbursement provided for in
this section shall not be deemed to be the sole remedy of the County and the County is
otherwise entitled to seek all other lawful remedies the County is entitled to under this
Agreement, including any and all damages stemming from the failure of Armor to pay as
is required under this Agreement.
12.13. Permits and License. Armor acknowledges that it will maintain all relevant permits and
licenses required for Armor to perform the services required by this Agreement, except
those required and held by the County (e.g., pharmacy) or required of County employees.
This will include, but not be limited to licenses and permits for radiology (as allowed by
law). Armor shall ensure that all individuals or entities performing the services required
under this Agreement, excluding County employees but including Armor employees,
agents, assignees, subcontractors or independent contractors shall be appropriately
licensed, registered or certified as required by applicable law. Armor and the County
shall notify the other party of any revocation, suspension, termination, expiration,
restrictions, etc., of any required license, registration or certification of any individual or
entity to perform the services herein specified.

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12.14. Liaison. The Sheriff or Superintendent or their designees (so designated in writing by the
Sheriff and Superintendent) shall be the liaison with Armor for each Facility.
12.15. Authority. Each party hereto expressly represents and warrants that the person executing
this Agreement is the legal, valid and binding representative of each party.
12.16. County’s Correctional Healthcare Advocate. The County may, if deemed necessary by
the Sheriff or Superintendent, designate a Correctional Health Care Monitor (should the
Christensen Decree cease) who will be its representative and who shall require Armor to
meet all contract requirements; monitor Armor's compliance and any corrective action to
resolve areas of non-compliance or deficiencies; recommend liquidated
damages/penalties based on non-compliance and as set forth within this Agreement; and
facilitate any dispute resolution.
If Milwaukee County is no longer under a court ordered consent decree that provides
minimum service levels for the inmate medical and mental health programs at the County
Jail and House of Correction, the County will, at its own expense, hire a qualified
medical professional to review service levels one (1) time each calendar year. This
review will be conducted to determine whether or not the inmate medical and mental
health service levels are being maintained at a level that reflects industry best practices as
provided in the medical and mental health standards promulgated by the National
Commission on Correctional Health Care (NCCHC). The vendor must fully participate
in this once a year review and at all times work in cooperation with the County retained
medical professional. Following each medical/mental health service levels review, if any
deficiencies in service levels are identified the applicable party (County, vendor or both)
will initiate corrective action to eliminate said deficiencies as expeditiously as possible.
12.17. Appearances. Armor's representatives shall cooperate with the County as necessary for
required court appearances related to medical services at the Facilities, which Armor staff
time shall be counted toward hours worked.
12.18. Civic Groups. Upon mutual agreement of the County and Armor, Armor shall discuss
the services provided under this Agreement with local civic groups or visiting officials.
12.19. Facilities. The Sheriff and Superintendent may prohibit entry to any Facilities or remove
from Facilities any of Armor's subcontractors, independent contractors or employees who
do not perform their duties in a professional manner, who violate the security regulations
and procedures of the Sheriff or Superintendent, or who present a security risk or threat
as determined in the sole discretion of the Sheriff or Superintendent. The Sheriff and
Superintendent reserve the right to search any person, property or article entering any
Facilities. Armor's employees, independent contractors, and subcontractors, their desks,
lockers, personal effects, and vehicles parked in the premises are subject to search at any
time. Sheriff and Superintendent reserve the right to require drug and alcohol testing of
independent contractors or employees for due cause at the expense of the Sheriff or
Superintendent.

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Contract for Inmate Health Services for

Milwaukee County

12.20. Computer Security. Armor shall use its best efforts to ensure that any of its actions do
not corrupt or infect any of County’s computer equipment, computer software, data files,
or databases. Any costs to the County for corruption and infection due to Armor
employees’ use thereof will be borne by Armor.
12.21. Media Requests. If media requests are received, Armor may be responsible for
responding to the media after coordinating its response with Sheriff’s or Superintendent’s
Public Information Office.
12.22. Emergency Notification. Armor shall promptly notify the Sheriff or Superintendent of
any unusual illnesses, any emergency care, any Inmate death, and any potential media
concern.
12.23. Infection Control. Armor shall implement an infection control program which includes
but is not limited to concurrent surveillance of staff and Inmates, prevention techniques,
treatment, and reporting of infections in accordance with local, state and federal laws,
OSHA and Governing Standards.
12.24. Inmate Grievances, Complaints. Inmate complaints or grievances regarding services
under this Agreement shall be forwarded to the Armor's Health Services Administrator or
designee who shall in writing confirm receipt of the complaint or grievance, and
promptly review the complaint or grievance, gather all information concerning the
complaint or grievance, and take appropriate action in accordance with the Sheriff’s or
Superintendent’s grievance procedures. Armor shall respond to all Inmate complaints or
grievances concerning services under this Agreement within seventy-two (72) hours of
Armor's receipt of such complaint or grievance and provide written notice to the Captain
(or their designee) in charge of grievances at the County jail and HOC at the time of the
response, confirming compliance with this provision.
12.25. Utilization Review. Armor shall implement and operate a Utilization Review Program
for the County.
12.26. Comprehensive Quality Improvement. Armor shall develop a comprehensive quality
improvement program of regularly scheduled audits of all Inmate health care services
provided under the Agreement, documentation of deficiencies, and plans for correction of
deficiencies. The quality improvement plan shall include a provision for program and
contract monitoring (peer review) by one or more "outside" detention health care
consultant(s) on an annual basis. The results of the outside consultant's review(s) shall be
shared with the County and available for NCCHC review accreditation. Armor shall bear
all costs associated with the outside consultants.
12.27. Emergency Medical Disaster Plan. Subject to the approval of the Sheriff and
Superintendent, Armor shall maintain procedures from the start date of this Agreement
for the delivery of medical services in the event of a disaster, including but not limited to,
fire, tornado, hurricane, epidemic, riot, strike or mass arrests. Such procedures shall be

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Contract for Inmate Health Services for

Milwaukee County

maintained and/or modified by Armor's Medical Director working closely with the
Sheriff’s and Superintendent’s staff and may include:
(a)
Communications system;
(b)
Recall of key staff;
(c)
Assignment of health care staff;
(d)
Establishment of command post;
(e)
Safety and security of the patient and staff areas;
(f)
Use of emergency equipment and supplies to include automatic external
defibrillators (AED's);
(g)
Establishment of a triage area;
(h)
Triage procedures;
(i)
Medical records-Identification of injured
12.28 Indemnity. Each party agrees to indemnify, defend and hold harmless, the other (the
indemnified party), and their agents, officers and employees, from and against all loss or
expense including costs and attorney's fees (for attorneys provided by or approved by
Armor), by reason of liability for damages including suits at law or in equity, caused by
the indemnifying party’s wrongful, intentional, or negligent act or omission, or its (their)
agents which may arise out of or are connected with the activities covered by this
Agreement.
12.29 County ownership of Data. Upon completion of the work or upon termination of the
contract, it is understood that any reports, information and data, given to or prepared or
assembled by Armor under this Contract shall not be made available to any individual or
organization by Armor without the prior written approval of the County. No reports or
documents produced in whole or in part under this Contract shall be the subject of an
application for copyright by or on behalf of the Armor.
12.30 Records and Audits Pursuant to §56.30(6)(d) of the Milwaukee County Code of
Ordinances, Armor shall allow Milwaukee County, the Milwaukee County Department of
Audit, or any other party the Milwaukee County may name, when and as they demand, to
audit, examine and make copies of records in any form and format, meaning any medium
on which written, drawn, printed, spoken, visual or electromagnetic information is
recorded or preserved, regardless of physical form or characteristics, which has been
created or is being kept by Armor, including not limited to, handwritten, typed or printed
pages, maps, charts, photographs, films, recordings, tapes (including computer tapes),
computer files, computer printouts and optical disks, and excerpts or transcripts from any
such records or other information directly relating to matters under this Agreement, all at
cost to Milwaukee County, unless such request is unreasonable, in which case Armor
shall provide a cost to comply. Any subcontracting by Armor in performing the duties
described under this contract shall subject the subcontractor and/or associates to the same
audit terms and conditions as Armor. Armor (or any subcontractor) shall maintain and
make available to Milwaukee County the aforementioned audit information for no less
than five years after the conclusion of each contract term.
12.31 Assignment This Contract shall be binding upon and inure to the benefit of the parties
and their successors and assigns; provided, however, that neither party shall assign its
obligations hereunder without the prior written consent of the other, which consent shall
not be unreasonably withheld
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Contract for Inmate Health Services for

Milwaukee County

12.32 Prohibited practices Armor hereby attests that it is familiar with Milwaukee County's
Code of Ethics which states, an officer, or employee or his immediate family, may not
solicit or receive anything of value pursuant to an understanding that such officer's or
employee's vote, official actions or judgment would be influenced thereby."
12.33 Christensen Decree The parties agree that, unless otherwise addressed in this Agreement
(e.g., section 10.8), all terms and conditions of the Christensen Decree (Christensen v.
Milwaukee County, Case No. 96-CV-1835) existing at the time this original contract
commenced must be met or exceeded and maintained through the entire term of the
contract and subsequent extensions, unless such Decree is terminated earlier.
12.34 Authority This Agreement shall be interpreted and enforced under the laws and
jurisdiction of the State of Wisconsin. This Agreement constitutes the entire
understanding between the parties and is not subject to amendment unless agreed upon in
writing by all parties hereto. Armor acknowledges and agrees that it will perform its
obligations hereunder in compliance with all applicable state, local or federal law, rules,
regulations and orders.
12.35 Authorization The County has executed this Contract pursuant to the Order of the
Milwaukee County Circuit Court.

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Contract for Inmate Health Services for

Milwaukee County

IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the day,
month and year first above written.
Approved for execution:
By:

Reviewed:
Date:

1/13/2017

By:

Corporation Counsel

Approved:
Date: 1/17/2017

1/20/2017

By:

Community Business Development Partners

Approved as to Sec.59.255(2)(e), Wis. Stats.:
Date: 1/23/2017

By:

County Executive

1/23/2017

Approved as to Wis. Stats. §59.41:
Date:

1/18/2017

Superintendent

1/24/2017

By:

Date:
Corporation Counsel

Approved:

By:

Date:
Comptroller

Approved:
By:

Date:
Kenneth Palombo, Armor

Approved:
By:

1/17/2017

Risk Management

Approved:
By:

Date:

Date:
Office of the Sheriff

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Contract for Inmate Health Services for

Milwaukee County

Exhibit A
The Positions identified below are included in Armor’s Base Compensation
set forth in section 10.1(a).
Position

Armor FTEs
Effective 1/1/16

Health Service Administrator

1.00

Medical Director

1.00

Physician

1.50

ARNP

10.00

Director of Nursing

2.00

Assistant Director of Nursing

0.00

RN-Quality Assurance

1.00

RN-Infection Control

1.00

RN-Staff Development

2.00

RN-Supervisor

6.50

RN

31.00

LPN

26.00

CMA

6.00

Unit Clerk

5.00

Administrative Assistant

2.00

Medical Records Supervisor

1.00

Medical Records Clerk

5.60

Chief Psychiatrist

1.00

Psychiatrist

0.20

Psych ARNP

4.00

Director of Mental Health

1.00

Psychologist
Psychiatric Social Worker
Supervisor

1.00

Psychiatric Social Worker

10.00

Case Management

3.00

RN-MH

2.00

Dentist

1.00

Dental Assistant

1.00

Total Hours/FTE

128.80

78

2.00

Exhibit 3

Milwaukee County
Office of the Comptroller, Audit Services Division
Jail and House of Corrections Health Assessment
Prepared by: Jeanette May, Ph. D., MPH
March 9, 2018

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Table of Contents
Topic

Page

1. Introduction

3

2. Methodology

3

3. General Findings and Conclusions

4

4. Section Detail

5

Part A – Basic Record/Inmate Information

5

Part B – Overall

5

Part C – Physical Assessment

6

Part D – Mental Health Services

7

Part E – Dental Services

8

Part F – Chronic Care

8

Part G – Women’s Health Services

9

Part H – Requests for Healthcare/Grievances

9

5. Electronic Medical Records

10

6. Conclusion

11

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1. INTRODUCTION
As the U.S. population ages, so does the inmate population. The Urban Institute projects that persons over 50
years of age will comprise 28% of the U.S. inmate population by 2019,1 and aging inmates will require increased
healthcare services. Many correctional facility operators, including Milwaukee County, contract for inmates’
healthcare services. Milwaukee County operates two correctional facilities - the jail (Jail) and the House of
Corrections (HOC) - and inmates’ healthcare services (Services) are provided or coordinated by Armor
Correctional Health Services (Armor) pursuant to a contract (Contract) with Milwaukee County. This report
assesses Armor’s performance in delivering Services to inmates. The goals of the assessment were to:
1. Determine whether inmates and the County are, in fact, receiving the Services invoiced by Armor;
2. Determine whether the Services rendered by Armor comply with the terms and conditions of the
Contract, and with standards (Standards) established by the National Commission on Correctional
Health Care; and
3. Provide a cursory assessment of electronic health records (EMR) generally, and of Armor’s EMR
specifically.
The Contract terms and the Standards are referred to collectively as the Requirements.
2. METHODOLOGY
The assessment was limited to a retrospective review of health records of services provided to inmates, and did
not include any direct observations or any interviews with inmates, Armor employees or County employees.
Hence, all findings and conclusions are based solely on the information recorded in the health records. The Jail
and HOC were assessed in the aggregate, and were not assessed for difference that may exist between the two.
Selected data was abstracted from the health records of 116 inmates with one or more identified health
conditions. Records included all periods of incarceration (aka multiple bookings) for each inmate; the 116
inmates represented 173 bookings and 139 incarcerations. Incarceration for inmates whose records are
represented in the sample began on or between the dates of January 1, 2015 and December 31, 2017.

1

Kim and Peterson, “Aging Behind Bars: Trends and Implications of Graying Prisoners in the Federal Prison System,”
(September 2014).

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The data was analyzed to determine if the Services complied with the Requirements. The population was then
stratified by the number of health conditions: one condition, two or three conditions, or four or more
conditions. The sample size for each stratum provides a 90% confidence interval with a 19% error band.2
Jail

HOC

1 Health Condition

25

25

2-3 Health Conditions

23

24

4 or more Health Conditions

20

22

Total Incarcerations

68

71

3. GENERAL FINDINGS AND CONCLUSIONS
The following are general findings and conclusions. Detailed findings and conclusions are listed in item 4,
SECTION DETAIL.


100% of records reviewed documented care in compliance with the Requirements.



Electronic documentation in the health record was generally timely and appropriate and offered insight
into care, health requests and the process followed to offer care to inmates but paper documents
scanned into the health record were less clear and, at times, illegible.3




The mental health care tab was inconsistently used.
Dental services generally met the Requirements but were less timely as needs grew more urgent.



A new health screener form offers more comprehensive level assessment for the initial heath
assessment.



Levels assigned at initial health assessments were generally appropriate, and the timeliness of follow-up
care met the Requirements.



Comprehensive discharge planning was lacking, possibly due to the staff’s lack of awareness of
upcoming releases.

2

A confidence interval is a range of values so defined that there is a specified probability that the value of a single
parameter lies within it. An error band depicts the upper and lower confidence bounds for all data points on a fitted line
within the range.
3
An electronic medical record is used at the Jail and HOC. Most information is entered electronically into the EMR but
paper documents are sometimes scanned into the EMR.

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4. SECTION DETAIL
Note that references in this section to inmates pertain only to inmates included in the sample, as evinced by the
data abstracted from their health records.
Part A – Basic Record/Inmate Information
Elements abstracted included:


ID;



Facility (Jail or HOC);



Location;



Number of conditions; and



Condition type(s).

Attributes of the Sample Population:


82% are male and 18% are female;



69% were discharged prior to the abstract, while 31% were in the facility at the time of the abstract;




31% received specialty care4 during their incarceration;
58% of the records included summaries of care rendered offsite, most commonly lists of medications;



Though conditions were not tracked, it seemed that, anecdotally, the most common health conditions
were asthma, hypertension and mental illness such as depression.

Part B – Overall
Elements abstracted included:



Access to care (JA01);
Staffing (JC01 – Is access not met due to potential lack of staff);



Medication (JD02 – Medications are delivered timely and current medications upon admission are
continued effectively);




Hospital and Specialty Care (JD05 – Hospital and specialty care offered and available when needed);
Emergency services provided (JE08);



Summary of offsite care (JD05); and



Discharge planning completed.

4

Specialty care means medical care provided by medical specialists that is more complex that is commonly provided by
primary care physicians.

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Findings and Conclusions:


100% of records reviewed indicated the level or process of care appropriate for the identified
conditions.



There was no evidence of insufficient staffing levels (though a record review is not the optimal way to
make this determination).



100% of records reviewed indicated appropriate and timely medications were offered or received.
When inmates refused medication, the most frequent deficiencies in documentation were illegibility
and missing information.



31% of records reviewed indicated that the inmate received specialty care, most frequently emergency
department care and referral to specialists.




Off-site care and medication lists were well documented.
There was a noticeable absence of documented discharge planning education for Inmates with serious
health needs who were discharged from the facility, possibly due to the staff’s lack of awareness of
upcoming releases.5

Part C – Physical Assessment (JE02 – identify urgent needs, identify known needs, isolate contagious inmates,
obtain medical clearance to admit)
Elements abstracted included:


Intake physical assessment completed;



Assigned level and justification;



Appointment completed and guideline met;



Laboratory tests ordered;



Assessment for alcohol or other drug abuse (JE08);



Detoxification, assessment and management (JG06).

Findings and Conclusions:


100% of records reviewed indicated that the inmate received an initial physical assessment (the
assessment was pending for two inmates).



The sample by level:
o Level 0 – 21
o Level 1 – 37
o Level 2 – 36
o Level 3 – 22
o Total
116

5

Standard JE-13 requires that discharge planning be provided to inmates with serious health needs whose release is
imminent.

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

89% of records reviewed at levels 1-3 contained justification for the level, while 11% did not.6



100% of records reviewed met the Requirements for assessing patients in a timely manner (Level 1
within one day, Level 2 within three days, and Level 3 within seven days).



Laboratory tests were ordered during the first appointment for infectious disease assessment and/or
chronic condition baseline. Tests were not ordered if the Inmate refused or recently results were and
available.



100% of records reviewed indicated that inmates were assessed for addiction, and 28 (24%) were
started on treatment with an initial flow sheet.

Part D - Mental Health Services
Elements abstracted included:


Mental health assessment completed;




Alert/reason;
Suicide watch (JG05 acute 24/7 observation, non-acute <15 min apart);



Follow-up; and



Basic mental health services (JG04).

Findings and Conclusions:


100% of records reviewed indicated that inmates were assessed for mental health;



9% (11/116) of records reviewed indicated that inmates were put on alert for opiate use or suicide
watch;



8 % (9/116) of records reviewed indicated that inmates were put on suicide watch and at the time of
abstraction all but two were cleared;



The Requirements for basic mental health services were met for all Inmates but the following items
were noted:
o
o
o
o

6

Several inmates expressed interest in support groups and were put on a waiting list;
The Mental Health Record component of the EMR was rarely utilized; notes regarding mental
health assessments and appointments were recorded in the Notes section of the EMR;
3% (4/116) of records reviewed contained behavioral health treatment plans;
Mental health-related requests are common, with inmates often repeating the request.

A more detailed and comprehensive assessment section has been added to the initial screening tool.

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Part E – Dental Services
Elements abstracted included:


Completed/guideline met (JE06 within 14 days); and



Completed /guideline met (Within twelve months).

Findings and Conclusions:


100% of records reviewed indicated that inmates were screened for dental conditions during the initial
health assessment;



The Standards require that an oral screening be conducted within 14 days of admission by a dentist or a
trained qualified professional but there is no assurance that the intake screeners are trained in this area
(JE06 #2);



100% of records reviewed indicated that inmates are examined by a dentist within twelve months of
incarceration, as required;



Standards require that Inmates have timely and immediate access to dental care for urgent or painful
conditions but there were three instances where dental related pain went untreated for more than 48
hours.

Part F – Chronic Care
Elements abstracted included:



Chronic care evidence based orders (JE12);
Chronic care review of test (JE12);



Chronic care treatment plans up to date (JE12);



Chronic care treatment plan shared with inmate (JE12);



Chronic disease identified and on problem list (JG01);



Chronic disease plan implemented (JG01);



Medical diet documented by licensed professional; and



Healthy lifestyle promoted.

Findings and Conclusions:


100% of records reviewed indication that inmates with identified chronic conditions received
appropriate care/tests/orders. The Armor EMR has specific tabs for chronic conditions, and note
sections that support comprehensive and simple tracking of orders, medications, etc. In addition, each
inmate diagnosed with a chronic condition was enrolled in the chronic care clinic and follows a specific
protocol.



Standards require that Inmates receive individual health education and instruction in self-care for their
condition. 100% of records reviewed indicated that inmates received basic standardized education, so

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the Standard was arguably met, but education was not individualized to the patient’s specific conditions.
Visit notes in the EMR often recorded more detailed and individualized educational efforts by the
provider but on a less consistent basis than the basic education delivered through the health assessment.

Part G – Women’s Health Services
Elements abstracted included:


Contraception offered (JG08);




Continuity and coordination of care for pregnant inmates (JG09);
Counseling for pregnant inmates (JG09);



Prenatal care; and



Postpartum care.

Findings and Conclusions:


21 Inmates included in the abstract sample were female.



Requirements mandate that women be offered nondirective counseling about pregnancy prevention
including access to emergency contraception, and that continuation of contraception be considered for
women who are on a method of contraception at intake. There is little evidence that nondirective
counseling was offered but all women were queried about current form of birth control and interest in
continuing this form.



Two of the 21 female Inmates (10%) were pregnant. One was quickly transferred and the other received
appropriate care based on the Standards, including a special diet, vitamins etc.

Part H – Requests for Healthcare, Grievances
Elements abstracted included:


Healthcare requests documented (JE07);




Clinical addressed within 48 hours (JE07);
Grievances documented;



Summary of grievances; and



Actions taken.

Summary:


91 inmates (78%) had documented healthcare related requests.



Requirements mandate that clinically related requests be addressed within 48 hours. Of the 91
requests, 86 (95%) were clinically related and, of those, 83 (97%) were addressed within 48 hours.



One grievance, regarding alleged excessive force and neglect, resulted in a court case.

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5. ELECTRONIC MEDICAL RECORDS
An electronic medical record (EMR) is a digital version of a patient’s health record. Like the traditional paper
chart, EMRs contain the patient’s medical history, and is used primarily by healthcare practitioners for diagnosis
and treatment. EMRs can improve quality of care by enhancing the practitioner’s ability to track data over time,
and identifying patients who are due for visits and screenings. Eight key functions of an EMR include:7
1.
2.
3.
4.
5.
6.
7.
8.

Access to patient information such as diagnosis, allergies, lab results and medications;
Access to new and past test results among providers in multiple care settings;
Computerized order entry;
Computerized decision-support systems to prevent drug interactions and improve compliance with best
practices;
Secure electronic communication among providers and with patients;
Patient access to health records, disease management tools, and health information resources;
Computerized administration processes such as scheduling; and
Standards-based electronic data storage and reporting for patient safety and disease surveillance
efforts.

Correctional EMRs are important for several reasons:
1. Timely sharing of information is essential for the inmate population;
2. Inmate populations are aging and, as a result, is sicker with high rates of health problems, mental health
issues and substance use disorders;
3. Inmate populations are transient and continuity of care back into the community is essential given the
profile of this population. For example, inmates released represent 17% of the total AIDS population,
13-19% of the population infected with HIV, 12-16% of the population infected with hepatitis B, 20-32%
of those with hepatitis C and 35% of the population with tuberculosis.
While correctional facility use of EMRs is rare,8 there are many advantages to using health information
technology to store and use inmate heath information. Overall, correctional-focused EMRs should be:

7



Simple to use;



Unified;



Uniform;



Easily accessible by authorized personnel;




Able to produce hard copies upon request;
Able to give medical staff quick access to previous booking records; and

Institute of Medicine, “Key Capabilities of an Electronic Health Record System,” P. Tang, M. Coye, et al., (2003).

8

Damberg, et al., “A Review of Quality Measures used by State and Federal Prisons,” in Journal of Correctional Health Care,
Vol. 17(2), (April 2011).

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

Designed to reduce human error and enhance clinical outcomes.

Armor’s EMR meets healthcare providers’ needs for information capture and retrieval.
6. CONCLUSION
Based on the foregoing, it appears that Inmates are receiving appropriate care in compliance with the
Requirements. Due to the limitations of the methodology, this conclusion may be drawn only at the highest level
and, for that reason, abstracts are often followed by a sample case review. In this instance, however, there is
no evidence to suggest that such a case review is necessary but, as with assessments, there are opportunities
for improvement and those have been included throughout this report.

103

Exhibit 4

104

105

106

107

108

109

Exhibit 5

110

111

112

113