MICHIGAN
OFFICE OF THE AUDITOR GENERAL

AUDIT REPORT

PERFORMANCE AUDIT
OF

PRISONER MEDICAL AND DENTAL SERVICES
DEPARTMENT OF CORRECTIONS

March 2008

THOMAS H. MCTAVISH, C.P.A.
AUDITOR GENERAL

471-0300-06

The auditor general shall conduct post audits of financial
transactions and accounts of the state and of all branches,
departments, offices, boards, commissions, agencies,
authorities and institutions of the state established by this
constitution or by law, and performance post audits thereof.
– Article IV, Section 53 of the Michigan Constitution

Audit report information can be accessed at:
http://audgen.michigan.gov

Michigan

Off ice of the Auditor General
REPORT SUMMARY
Performance Audit
Prisoner Medical and Dental Services
Department of Corrections

Report Number:
471-0300-06

Released:
March 2008

The Bureau of Health Care Services (BHCS), Department of Corrections (DOC), is
responsible for coordinating medical and dental services. These services are
provided through a network of outpatient clinics operated at correctional facilities
and through a managed health care system for off-site specialty services.

Audit Objective:
To assess the effectiveness of DOC's
efforts to comply with selected policies
and procedures related to the delivery of
medical and dental services.
Audit Conclusion:
We concluded that DOC's efforts to
comply with selected policies and
procedures related to the delivery of
medical services were not effective. We
also concluded that DOC's efforts to
comply with selected policies and
procedures related to the delivery of dental
services were effective. We noted one
material condition (Finding 1) and one
reportable condition (Finding 2).
Material Condition:
BHCS did not conduct all required chronic
condition medical evaluations, routine
annual health care screenings, and clinic
visits resulting from prisoner requests for
health care services. Also, BHCS did not
ensure that it provided these evaluations,
screenings, and clinic visits within time
frames established in its policies and
procedures. (Finding 1)

Reportable Condition:
BHCS did not consistently charge prisoner
copayments (Finding 2).

~~~~~~~~~~
Audit Objective:
To assess the effectiveness of DOC's
utilization of the electronic prisoner medical
record system.
Audit Conclusion:
We concluded that DOC's utilization of the
electronic prisoner medical record system
was moderately effective. We noted one
material condition (Finding 3).
Material Condition:
BHCS did not ensure that its electronic
medical record system (Serapis) contained
complete and accurate data and provided
for sufficient collection, analysis, and
reporting of data (Finding 3).

~~~~~~~~~~

Audit Objective:
To assess the effectiveness of DOC's
efforts to manage prisoner medications.
Audit Conclusion:
We concluded that DOC's efforts to
manage prisoner medications were
moderately effective. We noted three
reportable conditions (Findings 4 through
6).
Reportable Conditions:
DOC should improve controls related to
maintaining and distributing restricted
medications (Finding 4).
DOC did not effectively monitor the
disposal of unused or expired medications
or medications returned to the pharmacy
contractor (Finding 5).
BHCS did not document the justification
for the use of a brand name or
nonformulary drug rather than a generic or
formulary drug. In addition, BHCS did not
document the regional medical officer's
approval for brand name and nonformulary
drugs
prescribed
by
health
care
professionals. (Finding 6)

~~~~~~~~~~
Audit Objective:
To assess the effectiveness of DOC's
efforts to manage health care staffing.

moderately effective.
We noted one
material condition related to the delivery of
health care services (Finding 1), which is
reported under the delivery of services
objective.

~~~~~~~~~~
Audit Objective:
To assess the effectiveness of DOC's
efforts to monitor the managed health care
and pharmaceutical contracts.
Audit Conclusion:
We concluded that DOC's efforts to
monitor the managed health care and
pharmaceutical contracts were moderately
effective.
We noted one reportable
condition (Finding 7).
Reportable Condition:
BHCS should improve its monitoring of the
managed health care and pharmaceutical
contracts.

~~~~~~~~~~
Agency Response:
Our audit report includes 7 findings and 9
corresponding recommendations. DOC's
preliminary response indicates that it
agrees with all of the recommendations
and has complied or will comply with
them.

~~~~~~~~~~

Audit Conclusion:
We concluded that DOC's efforts to
manage health care staffing were

A copy of the full report can be
obtained by calling 517.334.8050
or by visiting our Web site at:
http://audgen.michigan.gov

Michigan Office of the Auditor General
201 N. Washington Square
Lansing, Michigan 48913
Thomas H. McTavish, C.P.A.
Auditor General
Scott M. Strong, C.P.A., C.I.A.
Deputy Auditor General

STATE OF MICHIGAN

OFFICE OF THE AUDITOR GENERAL
201 N. WASHINGTON SQUARE
LANSING, MICHIGAN 48913
(517) 334-8050
FAX (517) 334-8079

THOMAS H. MCTAVISH, C.P.A.
AUDITOR GENERAL

March 25, 2008

Ms. Patricia L. Caruso, Director
Department of Corrections
Grandview Plaza Building
Lansing, Michigan
Dear Ms. Caruso:
This is our report on the performance audit of Prisoner Medical and Dental Services,
Department of Corrections.
This report contains our report summary; description; audit objectives, scope, and
methodology and agency responses and prior audit follow-up; comments, findings,
recommendations, and agency preliminary responses; six exhibits, presented as
supplemental information; and a glossary of acronyms and terms.
Our comments, findings, and recommendations are organized by audit objective. The
agency preliminary responses were taken from the agency's responses subsequent to
our audit fieldwork. The Michigan Compiled Laws and administrative procedures
require that the audited agency develop a formal response within 60 days after release
of the audit report.
We appreciate the courtesy and cooperation extended to us during this audit.
Sincerely,

Thomas H. McTavish, C.P.A.
Auditor General

471-0300-06

This Page Left Intentionally Blank

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TABLE OF CONTENTS

PRISONER MEDICAL AND DENTAL SERVICES
DEPARTMENT OF CORRECTIONS

Page
INTRODUCTION

Report Summary

1

Report Letter

3

Description

7

Audit Objectives, Scope, and Methodology and Agency Responses
and Prior Audit Follow-Up

10

COMMENTS, FINDINGS, RECOMMENDATIONS,
AND AGENCY PRELIMINARY RESPONSES

Effectiveness of Efforts to Comply With Selected Policies and Procedures
Related to Delivery of Services

15

1.

Delivery of Health Care Services

15

2.

Prisoner Copayments

20

Effectiveness of Utilization of the Electronic Prisoner Medical Record System
3.

Electronic Prisoner Medical Record System

Effectiveness of Efforts to Manage Prisoner Medications

21
21
25

4.

Restricted Medications

25

5.

Disposal of Medications

27

6.

Brand Name and Nonformulary Prescriptions

30

Effectiveness of Efforts to Manage Health Care Staffing

32

Effectiveness of Efforts to Monitor Contracts

33

7.

Contract Monitoring

33

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SUPPLEMENTAL INFORMATION

Description of Exhibits

38

Exhibit 1 - Average Annual Health Care Expenditures Per Prisoner

40

Exhibit 2 - Cumulative Percentage Change in Health Care Expenditures
Per Prisoner and Medical Care Consumer Price Index

41

Exhibit 3 - Results of Timeliness of Health Care Services Testing - Chronic
Care Visits

42

Exhibit 4 - Results of Timeliness of Health Care Services Testing - Annual
Health Care Screenings

44

Exhibit 5 - Results of Timeliness of Health Care Services Testing - PrisonerInitiated Health Care Visits

45

Exhibit 6 - Comparison of Prisoner Health Care Services and Benefits
Available Through Other Programs

46

GLOSSARY

Glossary of Acronyms and Terms

51

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Description

The Bureau of Health Care Services (BHCS), Department of Corrections (DOC), is
responsible for coordinating medical and dental services. These services are provided
through a network of outpatient clinics operated at correctional facilities and through a
managed health care system* for off-site specialty services. In-patient care is provided
at local hospitals, at the Duane L. Waters Hospital, and at a DOC-operated secure unit
at Foote Hospital in Jackson.
Medical and dental services are provided to prisoners using a standard of care imposed
by court decisions, legislation, accepted correctional and health care standards, and
DOC policies and procedures (see Exhibit 6, presented as supplemental information).
Through February 5, 1999, DOC operated under a 1984 consent decree with the U.S.
Department of Justice. Under this consent decree, DOC agreed to improve health care
services. Federal court-appointed experts monitored DOC's compliance with the
consent decree. As a result of DOC's compliance, the U.S. Department of Justice
terminated the consent decree in 2002. DOC is still operating under a 1985 consent
decree (the Hadix consent decree) created to resolve complaints by prisoners housed
at the former Central Complex of the State Prison of Southern Michigan, including the
Reception and Guidance Center. Under the Hadix consent decree, DOC also agreed to
improve health care services.
Federal court-appointed experts monitor DOC's
compliance with the consent decree. The plaintiffs, DOC, the independent monitors,
and the court are attempting to resolve issues regarding what is necessary to show
compliance with the consent decree.
DOC spent $213.7 million for selected prisoner health care services* in fiscal year
2005-06, including $140.8 million for on-site health care services and central office staff
and $72.9 million for off-site specialty health care services. The average prisoner
population for fiscal year 2005-06 was 50,595 prisoners, resulting in an average annual
cost per prisoner of $4,223 for health care services (see Exhibit 1, presented as
supplemental information).
Effective April 1, 1997, BHCS entered into a contract to provide a Statewide managed
health care system for off-site specialty services. DOC reimburses the contractor for
* See glossary at end of report for definition.

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these services based on a fixed per prisoner per month rate, adjusted quarterly to
reflect actual costs, plus a management fee to cover administration costs. DOC
reduces the management fee as actual costs for services increase, to provide incentive
for the contractor to control costs. This undertaking resulted in one managed health
care contract replacing several hundred contracts with individual health care providers.
Effective May 28, 2000, BHCS expanded the managed health care contract to include
medical service providers*, which include physicians, physician assistants, and nurse
practitioners. The cost for these services is based on a fixed hourly rate. In fiscal year
2005-06, DOC paid the managed health care contractor $84.6 million for off-site
specialty services and on-site medical service providers.
Effective April 1, 2004, BHCS entered into a contract with a pharmaceutical company.
Initially, 21 correctional facilities participated in the contract and DOC later added
9 more correctional facilities. As of July 1, 2006, the contract was expanded to include
all correctional facilities Statewide. The cost for these services is based on a fixed per
prisoner per month rate plus the cost of pharmaceuticals. In fiscal year 2005-06, DOC
paid $27.1 million for pharmaceuticals, excluding psychotropic medications for mental
health prisoners under the care of the Department of Community Health.
Effective November 6, 2001, DOC entered into a contract with the managed health care
contractor to provide an electronic prisoner medical record system (Serapis) for
$2.9 million. DOC began implementing Serapis at correctional facilities in October
2002.
Effective October 7, 2003, DOC and the Department of Information Technology entered
into a contract with the managed health care contractor for $1.0 million to provide
maintenance and support for Serapis. In addition, BHCS informed us that it had spent
$2.0 million to equip correctional facilities for Serapis.

* See glossary at end of report for definition.

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DOC's fiscal year 2005-06 costs for prisoner medical, dental, and vision services are
summarized as follows:

Services Provided
Directly by DOC
On-site services
Off-site services
Total

Services Provided
Under Managed
Health Care Contract

Pharmacy
Contracts

Total

$ 101,921,338

$ 11,740,083
72,893,548

$ 27,127,051

$ 140,788,472
72,893,548

$ 101,921,338

$ 84,633,631

$ 27,127,051

$ 213,682,020

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Audit Objectives, Scope, and Methodology
and Agency Responses and Prior Audit Follow-Up

Audit Objectives
Our performance audit* of Prisoner Medical and Dental Services, Department of
Corrections (DOC), had the following objectives:
1.

To assess the effectiveness* of DOC's efforts to comply with selected policies and
procedures related to the delivery of medical and dental services.

2.

To assess the effectiveness of DOC's utilization of the electronic prisoner medical
record system.

3.

To assess the effectiveness of DOC's efforts to manage prisoner medications.

4.

To assess the effectiveness of DOC's efforts to manage health care staffing.

5.

To assess the effectiveness of DOC's efforts to monitor the managed health care
and pharmaceutical contracts.

Audit Scope
Our audit scope was to examine the health care and other records of the Bureau of
Health Care Services (BHCS) related to the delivery of prisoner medical and dental
services. Our audit was conducted in accordance with Government Auditing Standards
issued by the Comptroller General of the United States and, accordingly, included such
tests of the records and such other auditing procedures as we considered necessary in
the circumstances. Our audit procedures, conducted from April through September
2006, included examining BHCS's records from October 1, 2003 through July 31, 2006.
Although BHCS is also responsible for mental health services, substance abuse
services, and routine vision examinations, these were not included in the scope of this
audit. In addition, DOC informed us that it is in the process of working with a consultant
to revamp the delivery of health care services in a manner it believes will be more cost
effective. Therefore, we did not evaluate the cost-effectiveness of the current system
because our findings may not be applicable to the new system. Furthermore, the new
* See glossary at end of report for definition.

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system was not implemented at the time of our audit fieldwork; consequently, we did not
have sufficient data to evaluate its potential cost-effectiveness. Also, we did not include
a review of prisoner transportation for medical reasons or the pharmacy contractor's
performance in the scope of this audit because we plan to include these areas in the
scope of future audits.
Our audit was not directed toward examining medical decisions made by health care
professionals, including contracted health care professionals, concerning patient
treatment or expressing conclusions on those medical decisions; accordingly, we
express no conclusion on those medical decisions.
We obtained information from DOC, the U.S. Department of Labor, the U.S. Department
of Health and Human Services, the State of Michigan Medicaid State Plan, and the
State of Michigan Employee Benefits Summary & Enrollment Information (see
Exhibits 1, 2, and 6). We did not audit this information and, accordingly, we express no
conclusion on this information.
Audit Methodology
To establish our audit objectives, we conducted a preliminary review of prisoner health
care services. This included discussions with key central office staff and on-site
interviews with regional and facility health care staff regarding their functions and
responsibilities. Also, we reviewed prisoner health care policies and procedures.
To assess the effectiveness of DOC's efforts to comply with selected policies and
procedures related to the delivery of medical and dental services, we reviewed DOC's
policies, procedures, and chronic care guidelines that establish time frames for delivery
of services. We then reviewed prisoner health care files to assess DOC's compliance
with these time frames for chronic care visits, annual health care screenings, and clinic
visits resulting from prisoner requests for medical and dental services. Also, we
interviewed health care staff at the DOC central office and selected facilities and
reviewed prisoner copayments.
In addition, we reviewed DOC central office's
procedures for conducting reviews of prisoner deaths and observed procedures for
emergency runs and administration of medications at selected facilities.
To assess the effectiveness of DOC's utilization of the electronic prisoner medical
record system, we interviewed personnel from BHCS and DOC's Bureau of Fiscal
Management and health care staff at selected facilities, reviewed selected prisoner
health care files, and reviewed reports and other information related to the system.
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To assess the effectiveness of DOC's efforts to manage prisoner medications, we
reviewed controls over restricted medications, disposal of medications, the use of
over-the-counter medications, and approvals for the use of nonformulary drugs*.
To assess the effectiveness of DOC's efforts to manage health care staffing, we
interviewed BHCS personnel, obtained and analyzed staffing data for health care
positions, reviewed overtime, and researched pay rates for nursing staff.
To assess the effectiveness of DOC's efforts to monitor the managed health care and
pharmaceutical contracts, we interviewed personnel from BHCS and the Bureau of
Fiscal Management, reviewed the managed health care and pharmaceutical contracts,
reviewed the billing process and tested a sample of billings, and tested the licensure of
the health care professionals. Also, we analyzed the volume and monetary amount of
health care lawsuit settlements per year and analyzed health care costs per prisoner in
relation to the medical care consumer price index (see Exhibit 2). In addition, we
discussed with management the reports and information that were available and used to
manage selected prisoner health care services and compared basic prisoner health
care services to benefits available through other programs (see Exhibit 6).
We use a risk and opportunity based approach when selecting activities or programs to
be audited. Accordingly, our audit efforts are focused on activities or programs having
the greatest probability for needing improvement as identified through a preliminary
review. By design, our limited audit resources are used to identify where and how
improvements can be made. Consequently, our performance audit reports are
prepared on an exception basis.
Agency Responses and Prior Audit Follow-Up
Our audit report includes 7 findings and 9 corresponding recommendations. DOC's
preliminary response indicates that it agrees with all of the recommendations and has
complied or will comply with them.
The agency preliminary response that follows each recommendation in our report was
taken from the agency's written comments and oral discussion subsequent to our audit
fieldwork. Section 18.1462 of the Michigan Compiled Laws and the State of Michigan
Financial Management Guide (Part VII, Chapter 4, Section 100) require DOC to develop

* See glossary at end of report for definition.

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a formal response to our audit findings and recommendations within 60 days after
release of the audit report.
Within the scope of this audit, we followed up 9 of the 10 prior audit recommendations
from our February 2000 performance audit of the Bureau of Health Care Services,
Department of Corrections (47-300-98). BHCS complied with 4 of the prior audit
recommendations, 3 recommendations were no longer applicable, and 2 were rewritten
for inclusion in this report. We also followed up the 1 prior audit recommendation from
our September 2002 financial related audit of Vendor Payments for the Health Care of
Prisoners, Department of Corrections (47-305-00). DOC complied with the prior audit
recommendation.

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COMMENTS, FINDINGS, RECOMMENDATIONS,
AND AGENCY PRELIMINARY RESPONSES

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EFFECTIVENESS OF EFFORTS TO COMPLY WITH SELECTED
POLICIES AND PROCEDURES RELATED TO DELIVERY OF SERVICES
COMMENT
Audit Objective: To assess the effectiveness of the Department of Corrections'
(DOC's) efforts to comply with selected policies and procedures related to the delivery
of medical and dental services.
Audit Conclusion: We concluded that DOC's efforts to comply with selected
policies and procedures related to the delivery of medical services were not
effective. We also concluded that DOC's efforts to comply with selected policies
and procedures related to the delivery of dental services were effective. We noted
one material condition*. The Bureau of Health Care Services (BHCS) did not conduct
all required chronic condition medical evaluations, routine annual health care
screenings, and clinic visits resulting from prisoner requests for health care services.
Also, BHCS did not ensure that it provided these evaluations, screenings, and clinic
visits within time frames established in its policies and procedures. (Finding 1)
We also noted one reportable condition* related to prisoner copayments (Finding 2).

FINDING
1.

Delivery of Health Care Services
BHCS did not conduct all required chronic condition medical evaluations, routine
annual health care screenings, and clinic visits resulting from prisoner requests for
health care services. Also, BHCS did not ensure that it provided these evaluations,
screenings, and clinic visits within time frames established in its policies and
procedures. As a result, BHCS may have jeopardized its ability to identify,
manage, and treat potentially serious medical conditions before they became more
severe and costly to treat or before they became a threat to the prison population
and staff.

* See glossary at end of report for definition.

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We reviewed prisoners' medical files and requests for health care services and
noted:
a.

Of 120 prisoners identified as having chronic conditions, 61 (51%) were not
seen for their chronic care visits or were not seen as often as required by
DOC's chronic care guidelines (see Exhibit 3, presented as supplemental
information). We reviewed 373 required visits for the 120 prisoners and
determined that 44 (12%) of the visits were missed and 42 (11%) were late.
The average number of days between the missed chronic care visit and the
prisoner's next chronic care visit was 237 days. Also, the late chronic care
visits were an average of 105 days later than the guideline requirements.
DOC's chronic care guidelines state that, at a minimum, any prisoner enrolled
in a chronic care clinic* must be seen every six months if their condition is well
controlled or good, every three months if their condition is fair, and every
month if their condition is poor.
BHCS indicated that health care professional staffing vacancies at some of the
facilities resulted in the untimely chronic care visits. In other cases, BHCS
indicated that the prisoners were simply overlooked and had not been included
in the schedule for chronic care appointments.
We noted similar conditions in our prior audit. DOC disagreed with our prior
audit recommendation and indicated that, in the cases we cited, the prisoners
had been seen by medical staff in between chronic care clinics and their
chronic conditions were stable. During the current audit, we considered other
health care visits with medical staff in addition to chronic care clinic visits. For
the 23% of visits that were missed or late, we found no documentation in the
prisoners' medical records that medical staff addressed the prisoners' chronic
conditions during these other visits.

b.

Of 307 prisoners reviewed, 6 (2%) did not receive their most recent annual
health care screening (see Exhibit 4, presented as supplemental information).
The annual health care screenings for the 6 prisoners were an average of
594 days overdue. In addition, BHCS did not complete the annual health care
screening for 69 (22%) of the 307 prisoners within 30 days after the prisoner's

* See glossary at end of report for definition.

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birthday as required by policy. The annual health care screenings for the
69 prisoners were an average of 103 days late.
DOC policy directive 03.04.100 requires that prisoners have an annual health
care screening within 30 days before or after their birthday.
The annual health care screening is an important health care visit as it may be
the only time prisoners are seen by medical staff during the year. The annual
health care screening allows BHCS to assess prisoners' disabilities and
necessary accommodations, review their hepatitis B vaccination status, and
provide health education and disease prevention information. In addition, the
annual health care screening is the only health care visit during which
prisoners are screened for tuberculosis. Both tuberculosis and hepatitis B can
be contagious and, if left undetected, could be spread to other prisoners or
staff.
BHCS indicated that the facility health care clinics' failure to comply with
annual health care screening policy requirements was the result of nursing
staff vacancies at the health care clinics. We noted that there was an 18%
vacancy rate for nursing staff as of June 2006 (see background section for
fourth objective). In other cases, BHCS indicated that the prisoners were
simply overlooked and had not been included in the schedule for annual
health care screenings.
c.

Of 130 prisoners initiating requests that necessitated a visit from a health care
professional, 4 (3%) prisoners initiating requests had not been seen by a
health care professional for that request and 55 (42%) were not seen by a
health care professional within the required time frames (see Exhibit 5,
presented as supplemental information). The 4 prisoners who had requested
health care visits, but had not been seen, had been waiting for an average of
128 business days. Of the 55 late appointments, we noted that prisoners who
needed appointments were seen by a health care professional an average of
12 business days late.
DOC policy directive 03.04.100 requires health care staff to collect prisoners'
requests for health care and nursing staff either to respond in writing to the
prisoners' requests or to see the prisoners within one business day after
receipt of their requests. In addition, if nursing staff believe that an
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appointment is needed, the prisoner is required to be seen by an appropriate
health care professional within 2 or 7 business days after the written response,
depending on the type of health care professional.
BHCS indicated that health care professional staffing vacancies resulted in
some of the delays in response to the prisoner health care requests.

RECOMMENDATIONS
We recommend that BHCS conduct all required chronic condition medical
evaluations, routine annual health care screenings, and clinic visits resulting from
prisoner requests for health care services.
We also recommend that BHCS ensure that it provides these evaluations,
screenings, and clinic visits within time frames established by its policies and
procedures.

AGENCY PRELIMINARY RESPONSE
BHCS agrees and informed us that it will comply. BHCS indicated that although
this has been a problem in the past, there are several efforts underway that will
improve scheduling and the timeliness of health services delivery. BHCS informed
us that prisoners have been assigned an acuity index that will allow staff to better
track prisoners with chronic medical conditions. DOC has appointed a Health Care
Improvement Team (HCIT) which has conducted a critical assessment of the
administration and management of health care operations and developed a
strategic plan to guide BHCS in the redesign of the health care delivery system.
BHCS indicated that in the systemic redesign of the health care delivery system,
HCIT identified the following areas for improvement: BHCS management,
infrastructure, health services contracts, quality assurance, communications, and
independent reviews.
BHCS stated that progress steps on those HCIT activities that are aligned
substantially to correct this finding include the following:
•

The management infrastructure work group has developed a new
management structure for the BHCS central office staff to enhance the
strategic planning, quality assurance, and performance monitoring of the
health care delivery system.

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•

A request for proposal (RFP) for an updated and robust electronic medical
record (EMR) had been posted and is currently in process through
collaboration with the Department of Management and Budget and the
Department of Information Technology. The initiative will result in improved
productivity of medical practitioner staff of all disciplines. This new EMR will
also give DOC the capacity to run exception reports.

•

BHCS is reviewing its medical practitioner and nursing staffing plan to ensure
that sufficient human resources exist to provide timely routine health care
services and to investigate and resolve exceptions. In addition, although
BHCS will continue annual screenings for tuberculosis, BHCS is considering
reducing the frequency of routine health care screenings for some age groups
to be more consistent with the Centers for Disease Control and Prevention
and correctional industry practices.

•

As part of the recent extension of the Correctional Medical Services (CMS)
contract, provisions were negotiated to increase accountability in the areas of
provider staffing and productivity.

•

An RFP for managed care health services was posted in July 2007 and
subsequently withdrawn to strengthen the RFP and improve competitive
bidding. Subsequently, a request for information (RFI) in advance of the
second RFP was posted in November 2007. DOC hosted a successful RFI
conference attended by over 50 participants from the community of potential
vendors.

•

In collaboration with the Department of Management and Budget, HCIT is now
reviewing the RFI responses in preparation for a new RFP for managed care
services that will be more responsive to DOC needs.

•

The new position of an assistant chief medical officer has been added to
central office staff to strengthen the clinical oversight by BHCS for
performance monitoring of the health service contract providers.

•

The development of a quality assurance administrator position with support
staff is currently in process to monitor clinical performance by both contract
providers and DOC health staff.

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•

The development of an independent review contract to assist in the utilization
practices of the health care delivery system for implementation in fiscal year
2008-09.

FINDING
2.

Prisoner Copayments
BHCS did not consistently charge prisoner copayments. Failure to charge the
copayment could result in an increase in the number of requests for health care
services and could result in additional work for health care staff.
Section 791.267a of the Michigan Compiled Laws states that a prisoner who
receives nonemergency medical or dental services at his or her request is
responsible for a copayment fee to DOC for those services, as determined by
DOC.
DOC policy directive 03.04.101 states that the prisoner shall be charged a $5.00
copayment for each medical and dental visit, except for under certain
circumstances, such as when a health care professional initiates a health care visit.
The policy further states that a prisoner shall be offered necessary health care
services (i.e., medical and dental services) regardless of ability to pay but shall be
charged a fee for health care services.
DOC implemented prisoner copayment requirements in 1997 in an attempt to
reduce frivolous health care requests and to allow health care staff to focus their
efforts on more significant health care issues.
BHCS claimed that the
implementation of the copayment fee reduced the number of prisoner requests for
health care services by approximately 10,000 per month.
BHCS provided additional information to the health care clinics in January 2005
(appended in March 2005) in an attempt to clarify the policy directive. However,
health care staff misinterpreted the additional guidance. We noted that 5 of the 6
facilities we visited rarely charged copayments for medical or dental services. We
also noted that, since the policy clarification was issued in January 2005, the
average number of prisoner requests for health care services increased by 20%,
even though the prisoner population had increased by only 2%. Although several
factors could impact an increase in requests, health care staff at the facilities

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attributed a significant portion of the increase in requests to reductions in
copayment charges. If BHCS had charged prisoner copayments during this time
period, it may have reduced the number of frivolous requests, allowing health care
staff more time to provide medically necessary services in a timely manner. In
addition, BHCS's collection of prisoner copayments decreased by approximately
$55,000 (29.5%).

RECOMMENDATION
We recommend that BHCS consistently charge prisoner copayments in
accordance with DOC policy.

AGENCY PRELIMINARY RESPONSE
BHCS agrees and informed us that it complied in 2006 by providing additional
information to health care staff to clarify the DOC policy. In addition, BHCS
indicated that, as a result of increased oversight by the Bureau of Fiscal
Management, the new BHCS central office structure, and increased performance
monitoring and quality assurance activities called for in the strategic plan, BHCS
will demand better compliance with its copayment policy at the facility level.

EFFECTIVENESS OF UTILIZATION OF
THE ELECTRONIC PRISONER MEDICAL RECORD SYSTEM
COMMENT
Audit Objective: To assess the effectiveness of DOC's utilization of the electronic
prisoner medical record system.
Audit Conclusion: We concluded that DOC's utilization of the electronic prisoner
medical record system was moderately effective. We noted one material condition.
BHCS did not ensure that its electronic prisoner medical record system (Serapis)
contained complete and accurate data and provided for sufficient collection, analysis,
and reporting of data (Finding 3).

FINDING
3.

Electronic Prisoner Medical Record System
BHCS did not ensure that its electronic prisoner medical record system (Serapis)
contained complete and accurate data and provided for sufficient collection,
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analysis, and reporting of data. This limited DOC's ability to efficiently analyze
individual medical records; to summarize those records; and to evaluate trends and
develop summary data on health care services, conditions, and costs by age
group, condition, or treatment of prisoners. These types of analyses would assist
BHCS in allocating resources to better manage health care services and could also
be used to evaluate the success of the services in comparison with health care
trends within other prisons, the State, or the nation.
DOC purchased Serapis in 2001 as the electronic health record for the prison
population. Although some records such as x-rays, outside consult papers, and
some diagnostic testing results are retained in a hard copy format, DOC plans to
rely on Serapis as the primary record of health care services rendered to prisoners.
As of May 2006, 39 of the 42 facilities had implemented Serapis. The cost for
Serapis software, equipment, servers, maintenance, and support as of May 2006
was $5.9 million.
We noted:
a.

BHCS's electronic prisoner medical records were not complete and accurate.
For example:
(1) BHCS did not have an accurate electronic record of prisoners enrolled in
chronic care clinics. Our review of 120 prisoners enrolled in chronic care
clinics disclosed that 5 (4%) should not have been labeled as chronic
care patients. Furthermore, we noted that 39 (33%) of 120 chronic care
patients were listed under only one chronic care clinic when the paper
medical record indicated that they were enrolled in more than one clinic.
Because these chronic care patients were labeled as chronic care
patients when they should not be or were listed under only one chronic
care clinic, BHCS could not electronically summarize the true population
for any given clinic. To analyze data related to a specific clinic, BHCS
would have to review individual electronic records and hard copy files of
all prisoners.
(2) BHCS did not have a complete electronic record of prisoner visits with
health care staff. Our review of 187 prisoner medical files disclosed that
67 (36%) did not contain all medical information in Serapis, even though
the facilities had implemented Serapis prior to the period of our testing.
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For example, BHCS did not enter all health care visits in Serapis;
therefore, it could not easily summarize and evaluate the number of
prisoner visits with health care staff. Analysis of this type of information
would assist in identifying staffing needs and monitoring the timeliness of
health care visits.
We were informed that Serapis's response time was slow and that it was
frequently not in operation. When Serapis was not responding, health
care staff recorded medical information manually rather than
electronically, preventing BHCS from creating a comprehensive electronic
medical record. During our two- to three-day visits to the health care
clinics at 6 facilities, Serapis was not in operation for some period of time
during our visit at 3 facilities.
(3) BHCS did not have an accurate electronic record of prisoner-initiated
requests for health care services processed by health care staff. The
facilities we visited did not use consistent criteria when entering a
prisoner request for health care on Serapis. For example, at some
facilities, a prisoner inquiry regarding a prescription refill or an
appointment time would not be entered as a request whereas, at other
facilities, all requests, regardless of the nature of the request, would be
entered into Serapis. As a result, BHCS could not analyze the number
and types of requests by facility to help evaluate the medical staff work
loads and the needs of the prison population.
b.

BHCS did not ensure that Serapis provided sufficient collection, analysis, and
reporting capabilities. For example:
(1) Serapis did not have search capabilities to summarize aggregate prisoner
data by diagnosis, test, or treatment or to identify prior treatment of health
care issues by individual prisoner. For individual prisoner records, health
care staff had to scroll through and review every entry in the electronic file
in order to find specific information. Also, BHCS could not perform other
analyses of aggregate prisoner data, such as comparing condition
occurrences within the prison system to occurrences outside the prison
population.

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(2) Serapis did not produce useful Statewide reports. Although BHCS began
implementing Serapis in 2002, it informed us that it had just begun the
process of developing the reports it believed would help in management
of health care services. At the time of our audit, BHCS could obtain
reports by prisoner or facility but could not obtain summary level
Statewide reports from Serapis.
Developing summary reports of
Statewide data would assist BHCS in monitoring health care activities and
allocating resources among facilities based on health care needs.
(3) Serapis did not include templates or data collection methods to collect
medical information related to hepatitis C. In addition, Serapis did not
have an effective means of gathering information for prisoners enrolled in
multiple chronic care clinics. As a result, health care staff did not fully
utilize Serapis to maintain prisoner health care records. Documenting this
information electronically would assist BHCS in monitoring prisoners
enrolled in the hepatitis C chronic care clinic and the needs of prisoners
with multiple chronic conditions.

RECOMMENDATION
We recommend that BHCS ensure that its electronic prisoner medical record
system (Serapis) contains complete and accurate data and provides for sufficient
collection, analysis, and reporting of data.

AGENCY PRELIMINARY RESPONSE
BHCS agrees and informed us that it is taking steps to comply. BHCS indicated
that progress steps to date on those HCIT activities related to EMR include the
following:
•

BHCS has established a form to record medical information when the system
is nonoperational. Staff have been instructed to enter information recorded on
the form when the system returns to operation. In addition, staff have been
instructed to record all prisoner-initiated requests and all health care
encounters into the EMR system.

•

In the recently negotiated extension of the CMS contract, provisions were
added to allow for penalties if the medical practitioners fail to use EMR.

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•

DOC has conducted an exhaustive review of several national software
products for correctional health electronic medical records. This included a
weeklong series of product presentations as part of DOC's RFI process. As a
result of this process, the Department of Management and Budget has posted
an RFP to replace the Serapis EMR.

•

The Joint Evaluation Committee is currently in the RFP evaluation process for
a new EMR. The improvement of the fully integrated EMR will greatly
enhance the efficiency of staff and provide additional reporting capabilities.
The new EMR will also incorporate the dental and mental health records.

BHCS will also address enrollment of prisoners in multiple chronic care clinics in
the EMR system. The new EMR will also enhance the retrieval of information
already in the record.

EFFECTIVENESS OF EFFORTS TO
MANAGE PRISONER MEDICATIONS
COMMENT
Audit Objective: To assess the effectiveness of DOC's efforts to manage prisoner
medications.
Audit Conclusion: We concluded that DOC's efforts to manage prisoner
medications were moderately effective. We noted three reportable conditions related
to restricted medications, disposal of medications, and brand name and nonformulary
prescriptions (Findings 4 through 6).

FINDING
4.

Restricted Medications
DOC should improve controls related to maintaining and distributing restricted
medications. Failure to ensure that medications are properly controlled and
distributed increases the cost of restricted medications and the risk that restricted
medications could be subject to loss, theft, or abuse.

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Restricted medications are defined in the BHCS formulary* and include
psychotropic medications, scheduled medications, injectable medications, and
medications that health care staff identify as having a potential for abuse. Nursing
staff keep restricted medications in the health care clinic and distribute the
medications to prisoners.
Our review of restricted medications disclosed:
a.

BHCS did not periodically inventory restricted medications with the most
potential for theft or abuse. As a result, BHCS increased its risk that these
medications could be lost or stolen without being detected in a timely manner.
BHCS only requires restricted medications to be inventoried if they are located
in the physician's dispensing box or classified as a controlled substance.
BHCS should consider expanding its procedures to periodically inventory
additional restricted medications with the most potential for theft or abuse.

b.

Nursing staff did not always ensure that prisoners had swallowed their
restricted medications as required by operating procedures. As a result, staff
were not assured that the prisoners had taken the prescribed medications,
thereby increasing the risk that prisoners could introduce the medications as
contraband in the facility.
DOC operating procedure 03.04.100C requires that nurses observe each
prisoner taking restricted medication, ask the prisoner to repeat his or her
name and number to ensure that the medication was swallowed, and perform
a mouth check, if necessary.
We observed the distribution of medications at four facilities and noted that
nurses at two facilities did not perform mouth checks to ensure that the
prisoners had swallowed their medications prior to leaving the health care
area. Health care staff and corrections officers from one facility where staff
had not performed mouth checks informed us that they had found medications
in the prison yard. Both staff and officers thought that prisoners were
discarding medications after leaving the health care area.

* See glossary at end of report for definition.

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RECOMMENDATION
We recommend that DOC improve controls related to maintaining and distributing
restricted medications.

AGENCY PRELIMINARY RESPONSE
BHCS agrees and informed us that it will comply. BHCS indicated that the HCIT
Strategic Plan for health care has several initiatives that will address this issue,
including:
•

The pharmaceutical RFP will include an electronic medication administration
record that will electronically record the receiving, dispensing, and disposing of
medications. This will make reconciliation of inventories of restricted
medications with the potential for theft or abuse more feasible.

•

BHCS has reminded staff to ensure that prisoners have swallowed their
restricted medication as required by policy.

•

The development of a quality assurance administrator position with support
staff will increase clinical performance monitoring and lead to continuous
quality improvement activity in this area as appropriate.

•

The new RFPs for managed care service and pharmacy service will allow
DOC to incorporate further controls over restricted medications.

FINDING
5.

Disposal of Medications
DOC did not effectively monitor the disposal of unused or expired medications or
medications returned to the pharmacy contractor. As a result, BHCS was unable to
control the cost and quantity of disposed medications. In addition, this increased
the risk of loss, theft, or abuse of medications.
Health care clinics disposed of medications if they were expired, they were
discontinued by the physician, the prisoner was paroled or discharged, or the

27
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medication was prepared in advance but not taken by the prisoner. During our
review, we noted:
a.

DOC operating procedures did not address the standard information that
should be documented when medications are destroyed or returned to the
pharmacy contractor. As a result, facilities did not use a standardized log to
document destroyed and returned medications.
We reviewed logs of
destroyed and returned medication from 12 facilities and noted that some of
the logs did not include the prisoner's name, the name of the medication, or
whether the medication was destroyed or returned. Only 3 (25%) of 12 logs
included the standard information to document what medications had been
destroyed or returned to the pharmacy contractor.
Without detailed
information, BHCS cannot ensure that medications were properly disposed of
and that the facility received the proper credit for returned medications.

b.

Destroyed medication logs at 3 (25%) of 12 facilities did not contain two
required signatures. We noted:
(1) Of 100 log sheets we reviewed at the first facility, 55 (55%) did not
contain any signatures and 45 (45%) contained only one signature.
(2) Of 3 log sheets we reviewed at the second facility, 2 (67%) did not
contain any signatures.
(3) Of 41 log sheets we reviewed at the third facility, 2 (5%) contained only
one signature.
DOC operating procedure 03.04.100C requires that two nurses dispose of
unused medications and that both must sign the destroyed medication log.

c.

DOC operating procedures did not address the return of medications to the
pharmacy contractor for credit and/or disposal. As a result, health care clinics
were not aware that DOC could receive credit for the return of some
medications to the pharmacy contractor. Without policies and procedures on
when and how to return medications to the pharmacy contractor, BHCS
cannot ensure that it has properly received credit for returned medications and
has controls in place to reduce the risk of loss, theft, or abuse.

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d.

DOC operating procedures did not address what to do with a prisoner's
excess medications when the prisoner is paroled or discharged. As a result,
the health care facilities were handling these medications inconsistently and
medications purchased by DOC may have been destroyed unnecessarily.
DOC operating procedure 03.04.100C requires that the health care clinic
provide a 30-day supply of prescribed medications in safety containers for
prisoners being paroled or discharged upon the prisoners' departure. To
comply with this procedure, health care staff order a new 30-day supply of all
medications just prior to discharge even if the prisoner has a supply of
medications available.
Health care staff from 4 of 6 facilities informed us that they allowed prisoners
to take any unused nonrestricted medications in addition to the 30-day supply.
Staff from the 2 other facilities informed us that they did not allow prisoners to
take nonrestricted medications already in the prisoners' possession. Instead,
nonrestricted medications were returned to the health care clinic for disposal
and prisoners were provided a new 30-day supply of the same medication.
Standardizing procedures for handling prisoner medications upon parole or
discharge of prisoners may help BHCS control the cost of medication.

RECOMMENDATION
We recommend that DOC effectively monitor the disposal of unused or expired
medications or medications returned to the pharmacy contractor.

AGENCY PRELIMINARY RESPONSE
BHCS agrees and informed us that it is taking steps to comply. BHCS indicated
that the following are initiatives in the HCIT Strategic Plan for health care that
address this issue:
•

The pharmaceutical RFP will include an electronic medication administration
record that will electronically record the receiving, dispensing, and disposal of
medications. This will improve BHCS's ability to monitor the disposal of
medications and returns to the pharmacy vendor for credit.

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•

The development of a quality assurance administrator position with support
staff will increase performance monitoring and lead to continuous quality
improvement activity in this area as appropriate.

•

The Bureau of Fiscal Management is assisting BHCS with monitoring the
contractor's credits for returned medications.

•

BHCS will also strengthen future pharmacy contracts to ensure that
contractors are required to disclose the reason when credits are not issued for
returns.

In addition, BHCS indicated that it has sent direction to staff and is in the process
of updating the operating procedure to allow prisoners to take unused nonrestricted
medications with them upon parole or discharge in addition to a 30-day supply
when it is not cost effective to have the pharmacy contractor fill prescriptions for
less than 30 days.

FINDING
6.

Brand Name and Nonformulary Prescriptions
BHCS did not document the justification for the use of a brand name or
nonformulary drug rather than a generic or formulary drug. In addition, BHCS did
not document the regional medical officer's approval for brand name and
nonformulary drugs prescribed by health care professionals. As a result, BHCS
was unable to ensure that medications were being prescribed at the lowest cost to
the State while maintaining prisoner health care. BHCS purchased approximately
$641,000 in brand name drugs that had generic equivalents between October
2003 and April 2006.
DOC operating procedure 03.04.100C states that generic drugs are to be
substituted for brand name drugs whenever a generic equivalent is available.
When a brand name or nonformulary drug must be used because of medical
necessity, the regional medical officer is required to approve the request.
Typically, generic drugs are less expensive than brand name drugs; therefore,
requiring the use of generic drugs whenever possible provides a cost savings to
DOC.

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We reviewed 30 prescriptions written for brand name or nonformulary drugs
prescribed between January 2004 and April 2006 and noted:
a.

BHCS did not document the justification for 19 (63%) prescriptions written for
a brand name or nonformulary drug rather than a generic or formulary drug.

b.

BHCS did not document the regional medical officer's approval for 26 (87%)
prescriptions.

RECOMMENDATIONS
We recommend that BHCS document the justification for the use of a brand name
or nonformulary drug rather than a generic or formulary drug.
We also recommend that BHCS document the regional medical officer's approval
for brand name and nonformulary drugs prescribed by health care professionals.

AGENCY PRELIMINARY RESPONSE
BHCS agrees and informed us that it has complied. BHCS indicated that the
pharmacy contractor and State pharmacists have been instructed to ensure that
brand name and nonformulary drugs are only provided when the prescription for
such has been approved by the regional medical officer or when the prescription is
for a 10-day supply or less. The regional medical officers have been instructed to
ensure that justification for prescriptions for brand name and nonformulary drugs
are documented prior to their approval. In addition, the HCIT Strategic Plan calls
for additional initiatives that will address this issue, including:
•

Redesign of the health care infrastructure at both central office and regional
office levels will result in increased administrative control and monitoring of
pharmaceutical usage.

•

The new pharmacy RFP will contain more control over acquisition and
dispensing of pharmaceuticals.

•

The new RFP for managed care services will contain more control over the
prescriptive practices and patterns of prescribing medical practitioners.

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•

The development of a quality assurance administrator position with support
staff will increase performance monitoring and lead to continuous quality
improvement activity in this area as appropriate.

EFFECTIVENESS OF EFFORTS TO
MANAGE HEALTH CARE STAFFING
COMMENT
Background: BHCS had a vacancy rate for nurses in health care clinics of 18% as of
June 2006. This rate included the following vacancies by position:

Position
Licensed practical nurse
Registered nurse
Registered nurse manager
Total

Total Full-Time
Equated Positions

Vacant Full-Time
Equated Positions

Rate

92.0
411.5
110.0

21
70
21

23%
17%
19%

613.5

112

18%

BHCS informed us that it had worked with the Office of the State Employer to obtain
rate increases and signing bonuses for nursing staff and had attended several
recruitment fairs in an attempt to attract nurses. Our review of the Department of Labor
and Economic Growth's Labor Market Initiative related to nursing salaries Statewide
compared with the Civil Service Commission Compensation Plan disclosed that
registered nurses and licensed practical nurses Statewide annually earned about
$55,380 and $36,920, respectively. DOC's registered nurses annually earned from
$37,481 to $51,480 and DOC's licensed practical nurses annually earned from $32,656
to $43,867. It should be noted that DOC's nurses have additional custody type
responsibilities and are required to work in an inherently dangerous environment.
Audit Objective: To assess the effectiveness of DOC's efforts to manage health care
staffing.
Audit Conclusion: We concluded that DOC's efforts to manage health care
staffing were moderately effective. We noted one material condition related to the
delivery of health care services (Finding 1), which is reported under the delivery of
services objective.
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EFFECTIVENESS OF EFFORTS TO
MONITOR CONTRACTS
COMMENT
Audit Objective: To assess the effectiveness of DOC's efforts to monitor the managed
health care and pharmaceutical contracts.
Audit Conclusion: We concluded that DOC's efforts to monitor the managed
health care and pharmaceutical contracts were moderately effective. We noted
one reportable condition related to contract monitoring (Finding 7).

FINDING
7.

Contract Monitoring
BHCS should improve its monitoring of the managed health care and
pharmaceutical contracts. Monitoring this type of information could assist BHCS in
controlling costs, delivering health care services, and identifying future health care
needs. DOC expended $180.5 million and $213.7 million on selected prisoner
health care services, which included $57.7 million and $72.9 million for contracted
specialty services and $29.1 million and $27.1 million for pharmaceuticals in fiscal
years 2004-05 and 2005-06, respectively.
DOC is required by the United States Constitution, federal court cases, and its
policies and procedures to provide health care services to prisoners. Although
DOC contracts for health care and pharmaceutical services, contracting does not
relieve DOC of its responsibilities to ensure that it meets its legal mandate.
DOC has assigned the responsibility for monitoring the financial aspects of the
contracts to the Bureau of Fiscal Management and the responsibility for monitoring
the service delivery aspects to BHCS. We noted that the Bureau of Fiscal
Management has implemented controls to monitor and reconcile billings, to monitor
cost fluctuations, and to ensure timely payments to the contractor. We also noted
that BHCS could improve its monitoring of the health care and pharmaceutical
services. For example:
a.

BHCS did not obtain data on the number and types of off-site specialty
services provided under the managed health care contract in a format that
could be easily summarized and used for analytical purposes. As a result,
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BHCS could not determine whether off-site specialty services were being
provided in the most efficient manner. Also, analyzing this data could help to
facilitate an understanding of current prisoner health care status and help to
project future contract costs. For example, contract costs for the contract year
covering April 1, 2005 through March 31, 2006 unexpectedly increased by
$10.4 million, or more than three times the rate of the consumer price index
annual increase for health care costs for the Midwest region. BHCS was
unable to determine specific reasons for the increase in costs because it did
not obtain useful data to analyze fluctuations in services provided from its
contractor.
b.

BHCS did not work with the Bureau of Fiscal Management or the contractor to
identify the cause of inaccuracies in quarterly pharmacy reports. As a result,
the reports were not useful in monitoring prescription activity. Analysis of
prescription activity could be used to control costs and better manage health
care services.
The Bureau of Fiscal Management obtained data from the contractor on the
volume and type of prescriptions written by health care professionals and
compiled quarterly reports for BHCS's use in managing the contract. BHCS
informed us that the reports were cumbersome and inaccurate and, therefore,
BHCS did not utilize the reports. Based on our review of the report for the
period June 1, 2006 through June 15, 2006, we identified items that BHCS
should have followed up with the contractor. For example:
(1)

The report showed that prescriptions were written by one health care
professional who was no longer assigned in a capacity to write
prescriptions and one health care professional who had retired. After
pursuing these issues with the contractor, it was determined that these
items were errors on the report and that the actual prescriptions were
written by authorized individuals.
Although we found that these
prescriptions were proper, BHCS should review the report and follow up
these types of discrepancies to reduce the risk that a prescription could
be written by an unauthorized individual and not be detected in a timely
manner.

(2)

The names of several health care professionals who wrote prescriptions
could not be located on the Licensing Database of the Bureau of Health
34

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Professions, Department of Community Health. After follow-up with the
contractor, we determined that these names were incorrectly spelled in
the contractor's database or that the names had changed because of a
change in marital status. Although we were able to verify licensure for all
the health care professionals, BHCS should be reviewing the report and
bringing these types of discrepancies to the contractor's attention so that
they can be corrected.
(3)

c.

Medications were ordered by a health care professional identified as
"practitioner" on the report. Through follow-up with the contractor, we
determined that these orders were used to fill a physician's box that
health care professionals could access to fill prescriptions for urgent
medical care. BHCS should review this practice and ensure that controls
are in place over the ordering of this medication.

BHCS did not obtain the information necessary to identify and monitor the use
of nonformulary drugs from one of the pharmacy contractors it used during our
audit period. As a result, BHCS could not determine the cost and volume of
nonformulary drugs purchased from this contractor. BHCS attempted to obtain
the information; however, the contractor did not identify whether DOC
purchased the generic or brand name drug.

RECOMMENDATION
We recommend that BHCS improve its monitoring of the managed health care and
pharmaceutical contracts.

AGENCY PRELIMINARY RESPONSE
BHCS agrees and informed us that it has taken steps to comply. BHCS indicated
that it continues to work with the present off-site specialty services contractor to
obtain reports and information to assist in monitoring prisoner health care services
under the present contract.
BHCS also indicated that the recently negotiated contract extension with CMS
added several provisions that allow DOC to hold CMS more accountable in several
areas.

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BHCS informed us that the HCIT Strategic Plan for health care calls for the
following initiatives in this area, which will improve contract monitoring:
•

A new improved robust EMR will allow for additional electronic monitoring
capabilities.

•

A new managed care contract will greatly improve accountability, employ
global managed care principles, and provide incentives for greater fiscal
responsibility.

•

A new management structure will enhance contract performance monitoring,
including:
o

A health services administrator who is accountable together with the
Bureau of Fiscal Management for developing new business processes
that will require enhanced accountability and oversight of the managed
care vendor.

o

The new position of an assistant chief medical officer to strengthen the
clinical oversight by BHCS for performance monitoring of the health
service contract providers.

o

The development of a quality assurance administrator position with
support staff to monitor clinical performance by both contract providers
and DOC health care staff.

•

The development and implementation of a comprehensive continuous quality
improvement program within a "Culture of Quality."

•

The development of an independent review contract to assist in the utilization
practices of the health care delivery system for implementation in fiscal year
2008-09.

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SUPPLEMENTAL INFORMATION

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Description of Exhibits

Exhibit 1 - Average Annual Health Care Expenditures Per Prisoner
This exhibit shows the trend in health care expenditures per prisoner for fiscal years
1996-97 through 2005-06.
Exhibit 2 - Cumulative Percentage Change in Health Care Expenditures Per Prisoner
and Medical Care Consumer Price Index
This exhibit shows the cumulative percentage increase or decrease in the Department
of Corrections' health care expenditures per prisoner compared to the percentage
increase in the consumer price index for medical care from fiscal year 1996-97 through
fiscal year 2005-06.
Exhibit 3 - Results of Timeliness of Health Care Services Testing - Chronic Care Visits
This exhibit displays two tables. The top table summarizes, by facility, the number of
prisoner medical files reviewed for chronic care treatment, the number of prisoners with
late or missed chronic care visits, the number of required chronic care visits reviewed,
the number of late or missed chronic care visits, the average number of days that late
chronic care visits were late, and the average number of days between the missed
chronic care visit and the subsequent chronic care visit. The bottom table summarizes,
by control status, the number of required chronic care visits reviewed, the number of
late or missed chronic care visits, the average number of days that late chronic care
visits were late, and the average number of days between the missed chronic care visit
and the subsequent chronic care visit.
Exhibit 4 - Results of Timeliness of Health Care Services Testing - Annual Health Care
Screenings
This exhibit summarizes, by facility, the number of prisoner medical files reviewed for
annual health care screenings, the number of prisoners with late annual health care
screenings, the average number of days that late annual health care screenings were
late, the number of prisoners whose most recent annual health care screening was
more than one year late, and the average number of days that annual health care
screenings were overdue for prisoners whose most recent annual health care screening
was more than one year late.

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Exhibit 5 - Results of Timeliness of Health Care Services Testing - Prisoner-Initiated
Health Care Visits
This exhibit summarizes, by facility, the number of health care requests reviewed, the
number of health care requests requiring a visit with a health care professional, the
number of late visits with health care professionals, the average number of business
days late when policy required a visit within 2 days, the average number of business
days late when the policy required a visit within 7 days, the number of health care
requests requiring a visit for which the prisoner had not been seen at the time of our
testing, and the average number of business days late for requests requiring visits for
which the prisoner had not been seen at the time of our testing.
Exhibit 6 - Comparison of Prisoner Health Care Services and Benefits Available
Through Other Programs
This exhibit shows a comparison of basic prisoner health care services and benefits
available through other programs. This is not an all-inclusive list of services provided to
prisoners or of benefits available through the other programs.

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UNAUDITED
Exhibit 1

PRISONER MEDICAL AND DENTAL SERVICES
Department of Corrections
Average Annual Health Care Expenditures Per Prisoner
For Fiscal Years 1996-97 Through 2005-06

Health Care Expenditures Per Prisoner

$4,500

$4,223

$4,000

$3,690
$3,322

$3,500
$3,101

$3,197

$3,250

2001-02

2002-03

$2,839

$3,000
$2,573

$2,515

$2,614

$2,500
$2,000
$1,500
$1,000
$500
$0
1996-97

1997-98

1998-99 1999-2000 2000-01

2003-04

2004-05

2005-06

Fiscal Year

This graph shows that the Department of Corrections' health care expenditures per prisoner have steadily
increased since fiscal year 1997-98.
Source: Bureau of Fiscal Management, Department of Corrections.

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UNAUDITED
Exhibit 2

PRISONER MEDICAL AND DENTAL SERVICES
Department of Corrections
Cumulative Percentage Change in Health Care Expenditures Per Prisoner
and Medical Care Consumer Price Index
For Fiscal Years 1997-98 Through 2005-06

Percentage Increase Since Fiscal Year 1996-97

70.0%

Percentage change in average annual health care expenditures per prisoner

60.0%

Percentage increase in medical care consumer price index

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%
1996-97

1997-98

1998-99

1999-2000

2000-01

2001-02

2002-03

2003-04

2004-05

2005-06

-10.0%

Fiscal Year
This graph shows the cumulative percentage change in the Department of Corrections' health care expenditures per
prisoner and the medical care consumer price index from fiscal year 1996-97 through fiscal year 2005-06.
Source: Bureau of Fiscal Management, Department of Corrections, and Bureau of Labor Statistics, U.S. Department
of Labor.

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PRISONER MEDICAL AND DENTAL SERVICES
Department of Corrections
Results of Timeliness of Health Care Services Testing - Chronic Care Visits

By Facility

Facility

Number of
Prisoner Medical
Files Reviewed
for Chronic Care
Treatment

Facility A
Facility B
Facility C
Facility D
Facility E
Facility F
Total

20
20
20
20
20
20
120

Number of
Prisoners With
Late or Missed
Chronic Care Visits

Percentage of
Prisoners with
Late or Missed
Chronic Care Visits

10
14
10
7
5
15
61

50%
70%
50%
35%
25%
75%
51%

Number of
Required
Chronic Care
Visits Reviewed
79
53
66
53
73
49
373

Number of
Late or Missed
Chronic Care Visits
Included in Review
17
19
13
8
8
21
86

Late or Missed
Visits as a
Percentage of
Chronic Care
Visits Reviewed
22%
36%
20%
15%
11%
43%
23%

This table summarizes the results of our review of the timeliness of chronic care visits by facility. We used DOC's chronic care guidelines that establish
requirements for chronic care visits to assess timeliness.
The percentage of prisoners with late or missed chronic care visits ranged from 25% (Facility E) to 75% (Facility F).
The average number of days that the prisoners' chronic care visits were late ranged from 84 (Facility A) to 130 (Facility E). For missed visits, the average
number of days between the missed chronic care visit and the subsequent chronic care visit ranged from 179 (Facility E) to 328 (Facility D). See Finding 1.a.

By Control Status

Control
Status for
Chronic Care
Condition
Good
Fair
Poor
Total

Number of
Months Between
Chronic Care Visits
6
3
1

Number of
Required
Chronic Care
Visits Reviewed
271
82
20
373

Number of
Late or Missed
Chronic Care Visits
53
27
6
86

Number of
Late or Missed
Visits as a
Percentage of
Chronic Care
Visits Reviewed
20%
33%
30%
23%

This table summarizes the results of our review of the timeliness of chronic care visits by control status for the chronic care condition.
For chronic care conditions in "Good" status, 35 of the visits reviewed were late an average of 112 days and 18 visits had been missed.
For chronic care conditions in "Fair" status, 7 of the visits reviewed were late an average of 71 days and 20 visits had been missed.
For chronic care conditions in "Poor" status, 6 visits had been missed.

42
471-0300-06

Exhibit 3

Number of Late
Chronic Care Visits

Late Visits as a
Percentage of All
Late or Missed
Chronic Care Visits

7
14
7
5
2
7
42

41%
74%
54%
63%
25%
33%
49%

Number of Late
Chronic Care Visits
35
7
0
42

Late Visits as a
Percentage of All
Late or Missed
Chronic Care Visits
66%
26%
0%
49%

For Late
Chronic Care Visits,
Average Number
of Days Late

Number of Missed
Chronic Care Visits

84
113
86
110
130
120
105

For Late
Chronic Care Visits,
Average Number
of Days Late

10
5
6
3
6
14
44

Number of Missed
Chronic Care Visits

112
71
0
105

18
20
6
44

Missed Visits
as a Percentage of
All Late or Missed
Chronic Care Visits
59%
26%
46%
38%
75%
67%
51%

Missed Visits
as a Percentage of
All Late or Missed
Chronic Care Visits
34%
74%
100%
51%

For Missed
Chronic Care Visits,
Average Number
of Days Between
Missed Visit and
Subsequent Visit
234
192
187
328
179
283
237

For Missed
Chronic Care Visits,
Average Number
of Days Between
Missed Visit and
Subsequent Visit
283
224
145
237

43
471-0300-06

Exhibit 4
PRISONER MEDICAL AND DENTAL SERVICES
Department of Corrections
Results of Timeliness of Health Care Services Testing - Annual Health Care Screenings

Facility
Facility A
Facility B
Facility C
Facility D
Facility E
Facility F
Total

Number of
Prisoner Medical
Files Reviewed
for Annual Health
Care Screenings
50
52
50
54
50
51
307

Number of
Prisoners With
Late Annual
Health Care
Screenings
2
0
28
14
4
21
69

Average Number
of Days That Late
Annual Health
Care Screenings
Were Late

Percentage of
Prisoners With
Late Annual
Health Care
Screenings
4%
0%
56%
26%
8%
41%
22%

187
0
136
75
64
77
103

Number of
Prisoners Whose
Most Recent
Annual Health
Care Screening
Was More Than
One Year Late
0
0
3
1
0
2
6

Average Number of Days
That Annual Health Care
Screenings Were Overdue
for Prisoners Whose
Most Recent Annual
Health Care Screening Was
More Than One Year Late
0
0
620
513
0
594
594

This table summarizes the results of our review of the timeliness of annual health care screenings by facility. We used DOC's policies and procedures
that establish requirements for annual health care screenings to assess timeliness.
The number of late screenings ranged from 0 (Facility B) to 28 (Facility C).
The average number of days that the visits were late ranged from 0 (Facility B) to 187 (Facility A). In addition, 6 prisoners at three facilities (Facilities C,
D, and F) had missed their annual health care screenings. See Finding 1.b.

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Exhibit 5
PRISONER MEDICAL AND DENTAL SERVICES
Department of Corrections
Results of Timeliness of Health Care Services Testing - Prisoner-Initiated Health Care Visits

Facility

Number of
Health Care
Requests
Reviewed

Number of
Health Care
Requests
Requiring
Visit With Health
Care Professional

Facility A
Facility B
Facility C
Facility D
Facility E
Facility F
Total

25
24
25
29
25
26
154

14
16
24
29
23
24
130

Number of
Late Visits With
Health Care
Professional
12
6
13
4
9
11
55

Percentage of
Late Visits With
Health Care
Professional

For Late Visits,
Average Number of
Business Days
Late When Policy
Required Visit
Within 2 Days

86%
38%
54%
14%
39%
46%
42%

18
3
9
3
7
30
12

For Late Visits,
Average Number of
Business Days
Late When Policy
Required Visit
Within 7 Days
10
22
0
13
5
13
12

Number of Health
Care Requests
Requiring a Visit
for Which
Prisoner Had
Not Been Seen
at Time of Testing
0
0
1
0
0
3
4

Average Number of
Business Days
Late for Requests
Requiring Visits for
Which Prisoner
Had Not Been Seen
at Time of Testing
0
0
162
0
0
116
128

This exhibit summarizes the results of our review of the timeliness of prisoner-initiated health care visits by facility. We used DOC's policies and procedures that establish
requirements for prisoner-initiated health care visits to assess timeliness.
The percentage of late visits ranged from 14% (Facility D) to 86% (Facility A).
The average number of business days late when policy required a visit within 2 days ranged from 3 (Facilities B and D) to 30 (Facility F). The average number of business
days late when policy required a visit within 7 days ranged from 0 (Facility C) to 22 (Facility B). In addition, 4 prisoners were not seen by a health care professional at two
facilities (Facilities C and F). See Finding 1.c.

45
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UNAUDITED
Exhibit 6
PRISONER MEDICAL AND DENTAL SERVICES
Department of Corrections (DOC)
Comparison of Prisoner Health Care Services and Benefits Available Through Other Programs
As of August 2006

Service
PREVENTIVE CARE:
Health maintenance examination

Prisoner Health
Care Services

Medicare

Medicaid

State Health Maintenance
Organization (HMO) and
Dental Maintenance
Organization (DMO)

State Health,
Preferred Provider
Organization (PPO),
Dental, and Vision Plans

Covered for comprehensive
history and physical
examination upon intake and
annual health care screening

Covered once

Covered

Covered after $10 office
visit copayment

Covered once per year

Annual gynecological examination

Covered (included in annual
health care screening)

Covered, one every 24
months or one every 12
months for high risk

Potentially covered as
part of annual health
maintenance
examination

Covered after $10 office
visit copayment

Covered once per year

Pap smear

Covered (included in annual
health care screening)

Covered

Covered

Covered after $10 office
visit copayment

Covered once per year

Immunizations

Covered

Pneumococcal vaccine
and hepatitis B vaccine
for those at high or
medium risk

Recommended
preventative
immunizations are
covered

Covered after $10 office
visit copayment

Covered

Annual flu shot

Covered for prisoners at risk
for influenza-related
complications

Covered

Not specifically
addressed

Covered after $10 office
visit copayment

Covered

Dietary services

Covered

Covered for diabetics,
kidney disease

Not specifically
addressed

Not specifically
addressed

Not specifically
addressed

Health education

Covered

Not covered

Not specifically
addressed

Not specifically
addressed

Not specifically
addressed

Covered (included in annual
health care screening)

Covered

Covered

Covered

Covered, not subject to
preventative maximum

Covered, with $5 copayment
if not emergent

Covered

Covered if to diagnose
or treat a disease or
serious medical
condition

Covered, with $10
copayment

Covered, with $10
copayment, deductible
not applicable

Covered, with $5 copayment
if not emergent

Covered

Not specifically
addressed

Covered, with $10
copayment

Covered, with $10
copayment, deductible
not applicable

Covered

Covered

Covered

Covered, with $50
copayment if not
admitted

Covered

Covered

Covered

Covered

Covered

Covered after deductible

MAMMOGRAPHY:
Annual standard film mammography

PHYSICIAN OFFICE SERVICES:
Office visits/consultations

Urgent care visits

EMERGENCY MEDICAL CARE:
Hospital emergency room for
medical emergency or accidental
injury

Ambulance services - medically
necessary

This comparison continued on next page.

46
471-0300-06

UNAUDITED
Exhibit 6
PRISONER MEDICAL AND DENTAL SERVICES
Department of Corrections (DOC)
Comparison of Prisoner Health Care Services and Benefits Available Through Other Programs
As of August 2006
Continued

Service

DIAGNOSTIC SERVICES:
Laboratory and pathology tests

Prisoner Health
Care Services

Medicare

Medicaid

State Health Maintenance
Organization (HMO) and
Dental Maintenance
Organization (DMO)

State Health,
Preferred Provider
Organization (PPO),
Dental, and Vision Plans

Covered if ordered by a
medical service provider

Covered if medically
necessary

Covered when
ordered by a physician

Covered

Covered after deductible

Covered if ordered by a
medical service provider

Covered if medically
necessary

Covered when
ordered by a physician

Covered

Covered 100% after
deductible

Covered when medically
appropriate

Covered

Covered

Covered for unlimited
days

Covered after deductible
for unlimited days

Covered when medically
appropriate

Covered

Covered

Covered

Covered 100% after
deductible

SURGICAL SERVICES:
Surgery (including related surgical
services)

Covered if ordered by a
medical service provider

Covered

Covered

Covered

Covered 100% after
deductible

ORGAN AND TISSUE TRANSPLANTS:
Liver, heart, lung, pancreas, and
other specified organ transplants

Covered when medically
appropriate

Covered

Reviewed on a caseby-case basis for
coverage

Covered in designated
facilities

Covered in designated
facilities only; up to $1
million lifetime maximum
for each organ transplant

Bone marrow - specific criteria apply

Covered when medically
appropriate

Covered

Reviewed on a caseby-case basis for
coverage

Covered in designated
facilities

Covered after deductible
in designated facilities

Kidney, cornea, and skin

Covered when medically
appropriate

Covered

Not specifically
addressed

Covered subject to
medical criteria

Covered after deductible
in designated facilities

Covered

Covered

Covered

Covered

Covered

Prosthetic and orthotic appliances

Covered

Covered

Covered if directed by
physician

Covered

Covered

Hearing care (hearing tests,
hearing aids, etc.)

Covered, as needed

Not covered

Covered

Varies by HMO

Covered after medical
clearance examination
by physician

Diagnostic tests and x-rays

HOSPITAL CARE:
Semi-private room, inpatient
care, general nursing care, hospital
services, and supplies
Inpatient consultations

OTHER MEDICAL SERVICES:
Durable medical equipment

This comparison continued on next page.

47
471-0300-06

UNAUDITED
Exhibit 6
PRISONER MEDICAL AND DENTAL SERVICES
Department of Corrections (DOC)
Comparison of Prisoner Health Care Services and Benefits Available Through Other Programs
As of August 2006
Continued

Service
PRESCRIPTION DRUGS:
Generic

Prisoner Health
Care Services

Medicare

Medicaid

State Health Maintenance
Organization (HMO) and
Dental Maintenance
Organization (DMO)

State Health,
Preferred Provider
Organization (PPO),
Dental, and Vision Plans

Covered

Other Medicare
programs available for
prescription coverage.

Covered, with
limitations

Varies by HMO

Covered after $7
copayment

Brand-name (preferred)

Covered if approved by a
medical service provider and
a regional medical officer

Other Medicare
programs available for
prescription coverage.

Covered, with
limitations

Varies by HMO

Covered after $15
copayment

Brand-name (nonpreferred)

Covered if approved by a
medical service provider and
a regional medical officer

Other Medicare
programs available for
prescription coverage.

Covered, with
limitations

Varies by HMO

Covered after $30
copayment

Covered

Not covered

Covered, with $10
copayment

Covered after deductible

Covered if ordered by a
medical service provider

Covered

Not covered

Covered, with $10
copayment

Covered after deductible

Covered once a year and on
intake

Not covered

Covered if to diagnose
and treat conditions
related to a specific
medical problem

Covered, two per year

Covered, two per year

Preventive services (teeth cleaning)

Covered when determined
necessary by the examining
dentist

Not covered

Not specifically
addressed

Covered

Covered

Radiographs

Covered

Not covered

Not specifically
addressed

Covered

Covered 90%

Oral surgery

Covered

Not covered

Covered if to diagnose
and treat conditions
related to a specific
medical problem

Covered

Covered 90%

Extractions

Covered

Not covered

Covered if to diagnose
and treat conditions
related to a specific
medical problem

Covered

Covered 90%

Restoratives

Covered

Not covered

Not specifically
addressed

Covered

Covered 90%

Endodontics

Covered

Not covered

Not specifically
addressed

Covered

Covered 90%

OUTPATIENT PHYSICAL, SPEECH AND OCCUPATIONAL THERAPY:
Outpatient physical, speech, and
Covered if ordered by a
medical service provider
occupational therapy - facility and
clinic services
Outpatient physical therapy physician's office

DENTAL CARE OPTIONS:
Diagnostic examinations and
consultations

This comparison continued on next page.

48
471-0300-06

UNAUDITED
Exhibit 6
PRISONER MEDICAL AND DENTAL SERVICES
Department of Corrections (DOC)
Comparison of Prisoner Health Care Services and Benefits Available Through Other Programs
As of August 2006
Continued

Service

Prisoner Health
Care Services

Medicare

Medicaid

State Health Maintenance
Organization (HMO) and
Dental Maintenance
Organization (DMO)

State Health,
Preferred Provider
Organization (PPO),
Dental, and Vision Plans

Periodontics

Not covered

Not covered

Not specifically
addressed

Covered

Covered 90%

Prosthodontics

Covered if recommended by
dentist

Not covered

Covered if to correct
deficiencies likely to
impair general health

Covered

Covered 50%

Prosthodontics repair

Covered if recommended by
dentist

Not covered

Not specifically
addressed

Covered

Covered 50%

Orthodontics

Not covered

Not covered

Not specifically
addressed

Covered 100% up to
age 19; $1,250
copayment for age 19
and over

Covered 60%

Covered once every two
years with potential $5
copayment.

Covered for glaucoma
testing

Covered once every
two years if medically
necessary

Not applicable - covered
under State Vision Plan

Covered, once per year

Covered unless prisoner has
adequate glasses;
replacements covered no
more than once every two
years.

One pair of eyeglasses
after cataract surgery

Covered once every
year if determined that
it is medically
necessary

Not applicable - covered
under State Vision Plan

Copayment applies and
plan covers only once in
24-month period

VISION CARE:
Routine vision examinations and
glaucoma testing

Corrective lenses and frames

This comparison identifies most health care services available to prisoners and compares those services to the services available to individuals enrolled in Medicare, Medicaid, the
State's health maintenance and dental maintenance plans, and the State's health and dental plans. The analysis shows that services available to prisoners are similar to that of
individuals enrolled in the State's health maintenance and dental maintenance plans and the State's health and dental plans. The analysis also shows that services available to
prisoners either meet or exceed services available to individuals enrolled in Medicare and Medicaid.
DOC informed us that based on the Eighth and Fourteenth Amendments to the United States Constitution, it is required to provide health care necessary to treat serious medical
needs. The basic rights of prisoners and the responsibilities of states have also been defined by federal case law, which establishes that prisoners must be provided a right to
access, a right to care that is ordered, and a right to professional medical judgment.
DOC indicated that serious medical needs of prisoners are needs that are diagnosed by a physician as mandatory treatment or that are obvious to a lay person, needs that require
a doctor's attention, and/or needs that cause pain, discomfort, or a threat to good health. Federal courts have also upheld the prisoner's right to receive care consistent with the
community standard of care. Prisoners, by virtue of their incarceration, are the only individuals who have a constitutionally mandated right to health care.
These legal bases were used by DOC in developing its policies and procedures for prisoner health care services.
Sources for:
Prisoner Health Care Services - DOC policies and discussions with Bureau of Health Care Services as of August 30, 2006.
Medicare - Medicare & You 2006, issued by the U.S. Department of Health and Human Services.
Medicaid - State of Michigan Medicaid State Plan under Title XIX of the Social Security Act as of August 30, 2006.
State HMO and DMO - State of Michigan Employee Benefits Summary & Enrollment Information as of August 14, 2006.
State Health, PPO, Dental, and Vision Plans - State of Michigan Employee Benefits Summary & Enrollment Information as of August 14, 2006.

49
471-0300-06

GLOSSARY

50
471-0300-06

Glossary of Acronyms and Terms

BHCS

Bureau of Health Care Services.

chronic care clinics

Regularly scheduled health care treatments for prisoners
diagnosed with chronic conditions. Chronic care clinics are
established for pulmonary, cardiovascular, neurologic,
endocrine, gastrointestinal, and infectious conditions.

CMS

Correctional Medical Services.

DMO

dental maintenance organization.

DOC

Department of Corrections.

effectiveness

Program success in achieving mission and goals.

EMR

electronic medical record.

formulary

The book of prescription drugs and their uses. The book
includes generic prescription drugs approved for use and the
brand name equivalents, as applicable, with instructions on
the process for approving the use of brand name equivalents
or nonformulary prescription drugs.

HCIT

Health Care Improvement Team.

HMO

health maintenance organization.

managed health care
system

A system that combines the financing and delivery of health
care services to patients by arranging with providers to
provide patient services.

material condition

A reportable condition that could impair the ability of
management to operate a program in an effective and
efficient manner and/or could adversely affect the judgment

51
471-0300-06

of an interested person concerning the effectiveness and
efficiency of the program.
medical service
provider

A physician, physician assistant, or nurse practitioner
licensed by the State of Michigan or certified to practice
within the scope of his/her training.

nonformulary drug

A prescription drug that is not included in the listing of
prescription drugs approved for use unless approved by a
regional medical officer.

performance audit

An economy and efficiency audit or a program audit that is
designed to provide an independent assessment of the
performance of a governmental entity, program, activity, or
function to improve public accountability and to facilitate
decision making by parties responsible for overseeing or
initiating corrective action.

PPO

preferred provider organization.

reportable condition

A matter that, in the auditor's judgment, represents either an
opportunity for improvement or a significant deficiency in
management's ability to operate a program in an effective
and efficient manner.

RFI

request for information.

RFP

request for proposal.

selected prisoner
health care services

Medical, dental, and vision services required to be provided
to prisoners.
The Bureau of Health Care Services,
Department of Corrections, is also responsible for providing
mental health and substance abuse services; however, these
services, as well as routine vision examinations, were not
included in the scope of this audit.

Serapis

The electronic medical record
Department of Corrections.

471-0300-06

52
oag

system

used

by

the

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MICHIGAN
OFFICE OF THE AUDITOR GENERAL

AUDIT REPORT

THOMAS H. MCTAVISH, C.P.A.
AUDITOR GENERAL