Audit of the Norfolk County Sheriff’s Office - A Review of Healthcare and Inmate Deaths (July 26, 2024)
July 26, 2024 · Norfolk County Sheriff’s Office · Read the full official report on mass.gov ↗
Published July 26, 2024 Audit covers July 1, 2019 – June 30, 2021 Under Diana DiZoglio · 2023–present
source
“NSO did not complete an initial medical screening for one inmate upon their admission.”
Read the plain-English breakdown
This is a Massachusetts State Auditor performance audit of the Norfolk County Sheriff’s Office, focused on inmate healthcare processes and inmate deaths during a two-year period.
“In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has conducted a performance audit of the Norfolk County Sheriff’s Office (NSO) for the period July 1, 2019 through June 30, 2021.”
Auditors checked whether the sheriff’s office followed rules for inmate deaths, healthcare oversight meetings, medical intake screenings, and sick-call care.
“The purpose of our audit was to determine the following:”
Missing an intake medical screening can mean health problems are not caught early, which can put the inmate, other inmates, and staff at risk.
“Because NSO did not complete an initial medical screening for this inmate, there was a higher-than-acceptable risk that this inmate’s medical issues were not identified and treated, potentially affecting the health and safety of this inmate, other inmates, and NSO employees.”
For residents, this audit is about whether a taxpayer-funded county jail is meeting basic healthcare and safety rules for people in custody.
“In fiscal years 2020 and 2021, NSO’s state appropriations were $32,843,581 and $35,543,400, respectively.”
Most tested areas passed, but the office needs stronger controls and records to prove every inmate gets the required intake medical screening.
“We determined that, during the audit period, 1 inmate out of our sample of 60 did not receive the initial medical screening upon admission.”
The auditor recommended better monitoring and documentation, and said the office would be checked again after the audit.
“Our team will be conducting a post-audit review in roughly six months to follow up.”
The report is significant because it found a gap in a basic jail healthcare safeguard and also flagged a recordkeeping issue with how sick-call requests are tracked.
“Because NSO does not use the full functionality of the CorEMR system for sick calls, it cannot reliably use the designed reporting functions of this s to better track all sick call requests.”
“Initial medical screening” means a health check done when someone enters the jail, before they are placed with the general jail population.
“This occurs before an inmate is placed in NSO’s general population to ensure that each inmate’s health needs are identified and addressed.”
What the Auditor checked
- Complied Did NSO create and comply with a documented policy or procedure regarding the death of an inmate, as required by Section 932.17 of Title 103 of the Code of Massachusetts Regulations (CMR)?
- Complied Did NSO hold quarterly meetings with its in-house healthcare employees and review quarterly reports regarding healthcare services for inmates, as required by 103 CMR 932.01(3)?
- Did not comply Did NSO provide its inmates with initial medical screenings upon admission, as required by 103 CMR 932.06(1) and Section 601.13(1–2) (Receiving and Screening Procedures) of NSO’s Policy CSD 601 (Medical Services)?
- Complied Did NSO ensure that a qualified healthcare professional conducted a face-to-face meeting within 24 hours of receipt of a sick call request form, as required by Section 601.15(1)(b) (Sick Call) of NSO’s Policy CSD 601, and did NSO document the medical care it provided to its inmates after receipt of a sick call request form, as required by 103 CMR 932.18(2)(h) and (k)?
What the Auditor found
Why it matters: There was a higher-than-acceptable risk that the inmate’s medical issues were not identified and treated, potentially affecting health and safety.
Standard: 103 CMR 932.06(1) and Section 601.13(1–2) of NSO’s Policy CSD 601 require initial medical screenings upon admission. ( Section 932.06(1) of Title 103 of the Code of Massachusetts Regulations; Section 601.13(1–2) (Receiving and Screening Procedures) of NSO’s Policy CSD 601 (Medical Services) )
2 recommendations
- NSO should establish monitoring controls to ensure that it completes an initial medical screening upon each inmate’s admission.
- NSO should retain documentation confirming that it completed each inmate’s initial medical screening.
Agency response & Auditor reply
Agency: "At this time, we have no requested edits or notes for clarification on the report."
Auditor: "We appreciate the department’s cooperation with our audit team and encourage NSO to implement our recommendations regarding this matter."