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Prison Medical Treatment Has a Ways to Go

April 5, 2010

Maryland taxpayers spend about $150 million each year providing medical services to its prisoners—about $500 each month for each of the 23,000 inmates. Yet the state does not have enough medical expertise even to review the 100 or more inmate deaths that occur each year.

These are some of the findings of a state auditor’s report released today (April 5) after a review of ongoing progress in the state Department of Public Safety and Correctional Services’ (DPSCS) effort to improve medical care for inmates.

Most of the problems found in previous audits have not been fully solved and, in one case, problems the department thinks are “corrected” have been rated as “minimal progress” by auditors:

OIHS [Office of Inmate Health Services] had initiated at least some corrective action on all 7 findings and had established a corrective action plan, which included timelines and processes to monitor the implementation of the plan for all the findings in the audit report. Nevertheless, full resolution of most of the 7 findings reviewed had not yet been achieved.

In response to the auditor’s report, which is not a new audit but a “review” and status report from previous audits, DPSCS officials emphasized improvements made to the system, including implementation of a methadone maintenance program for heroin addicts. They also disagreed with several of the auditors’ findings, pointing out that health outcomes and disease management for inmates was, in many cases, better than that in other prison systems and even better than in the general population. For findings that involved record keeping or database deficiencies, corrections officials claimed that other records showed treatment was being received. The auditors noted in footnotes that these other records did not give a clear or complete picture of the medical situation.

For example, the auditors suggested that the department put a process in place “to ensure that inmates with chronic medical conditions receive appropriate treatment as required.”

The department had made “minimal progress” on this, auditors found, but the department agreed in part, disagreed in part:

The chronic care database does not capture all inmates who are designated as having a chronic illness. However, we believe inmates with chronic conditions are receiving care substantial enough to alter the course of complications associated with their disease. . . . When compared to the community and other state correctional systems, Maryland inmates with chronic conditions, on average, have good outcomes.

In their response, auditors noted that “The chronic care database was created to monitor this segment of the inmate population. As the chronic care database is not comprehensive, OIHS had limited assurance that all inmates with chronic conditions were fully receiving appropriate treatment.”

Most inmate care is done by private contractors, and making sure those contractors are doing what they’re supposed to is the job of some 30 DPSCS employees, plus 10 other contract employees. But, state auditors found, the DPSCS does not require its contractors to file an official “corrective action plan” to address problems that are found. Worse, it did not appear that the department was requiring the contractors to perform the internal audits that would find problems:

Specifically, our review of eight OIHS audits completed between September 2007 and November 2009 identified six audits where OIHS should have required corrective action plans from the medical contractor to address certain service delivery deficiencies identified by the audits (such as failure to provide required services to inmates who were diabetic or had HIV). However, as of January 2010, OIHS had only obtained three corrective action plans from the medical contractor for these six audits. Furthermore, one of these three corrective action plans did not address the weaknesses discussed in the related audit findings. OIHS also did not have a process to ensure all contractor performed audits were submitted as required. These audits were self assessments to monitor compliance with contract requirements. Specifically, the medical contractor was required to complete 66 audits during calendar year 2009 according to OIHS records, but OIHS had not determined how many of these audits were actually completed, and did not have any of the audits on hand. As a result, OIHS could not determine how many contractor audits required corrective action plans based on service delivery deficiencies identified.

Even after inmates’ deaths, the state auditors found, Maryland prison officials do little to assess what, if anything, went wrong or correct deficiencies in care. The department has made progress in this area, the auditors found. But the problem seems to be that the department has only one MD on staff. As the DPSCS acknowledged in its response:

A physician reviewer is an essential component of the death review process. However, given that the Department only has one physician provider for an inmate population of 23,000 inmates, some additional steps were taken to alert the DPSCS Medical Director of those incidents of death that required a more urgent review. In the current process, the site level’s master’s degree nurses review the case to participate in the 72 hour death review on site. They have served to alert the DPSCS Medical Director about deviations from standards of care and have also achieved a more timely review.

That line bears repeating: the Department only has one physician provider for an inmate population of 23,000 inmates.