Q1 2025 HS Audit Deficiencies Line 11 Line 74.pdf
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- Attached to
- RFP DOC Correctional Health ServicesBid Documents State and local contract opportunity
- Solicitation number
- 27-87787
- Issued by
- Hendricks County, Indiana
About this file
This is a First Quarter 2025 Audit Deficiencies report from the Indiana Department of Correction documenting performance measure compliance failures for health services provided across correctional facilities. The report evaluates Health Services Division audit results conducted through site visits, interviews, inspections, and medical record reviews, with a required passing score of 90 percent or better per performance measure category. Facilities that fail to meet the 90 percent threshold receive a fourteen-day rebuttal period to present corrective information before final departmental determination. During the first quarter of 2025 (January through March), thirteen facilities failed compliance audits across four performance measure categories: Preventive Services and Wellness (four facilities), Diagnostic and Specialty Care (three facilities), Emergency Services and Hospital Care (two facilities), and Addiction Recovery Services (four facilities). These facilities include Plainfield Correctional Facility, Branchville Correctional Facility, Heritage Trails Correctional Facility, Pendleton Correctional Facility, Miami Correctional Facility, and Edinburgh Correctional Facility.
Per contract terms, the Health Services Vendor is required to reimburse the Department a minimum of $5,000 per audit failing the 90 percent standard for each facility, applied as a credit against the next invoice submission. The first quarter 2025 deficiencies across thirteen facilities at $5,000 per facility total $65,000 in required reimbursement. This audit deficiency report directly correlates to the ongoing Indiana Department of Correction Correctional Health Services contract, which establishes performance standards requiring 90 percent pass rates across 485 established measures with identical minimum reimbursement penalties of $10,000 per deficiency per facility for failures not corrected during the thirty-day cure period, indicating systematic performance monitoring and accountability mechanisms embedded within the vendor agreement.
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Text version
First Quarter 2025 Audit Deficiencies
Per contract and amendment:
All Performance Measures have been included in the Department's audit tools. The Department's Health Services Division will conduct audits of health care services through ad hoc site visits, interviews, inspections, and review of health records to assess and monitor contract compliance, adherence to Department policy and procedure, and compliance with Performance Measures. As a part of such audit quality assurance staff will pull an adequate number of medical record packets and review the Electronic Medical Record (EMR). Each audit of one or more performance measure requires a passing score of 90% or better per category that has an available assessment penalty per facility. Less than 90% is considered a fail. If an audit measure does not meet the passing score, a fourteen (14) day rebuttal period will begin. The Department and Health Services Vendor will discuss the failed audit scores and the Health Services Vendor may present information to correct the failed measures. At the end of the 14-day period, the Department will make the final decision as to whether the information provided successfully corrected the deficiencies and therefore no financial penalty would apply. There shall be only one opportunity given to correct a deficiency.
On a quarterly basis, the Health Services Vendor will be provided with a summary of all quality assurance activities completed during that Quarter. Any audit under 90% found at a facility will require the Health Services Vendor to reimburse the Department for additional action, oversight and review expended by the Department in responding administratively to the deficiency. The minimum cost to the Department of such additional action, oversight and review shall be $5,000 per audit under 90% at each facility. Each audit under 90% found during an audit shall be subject to this reimbursement. This reimbursement shall be paid as a credit on the next invoice to the Department after notification.
After a review and found non-compliant, audits not meeting the 90% threshold for the 1st quarter 2025 (January, February, March) after the rebuttals are:
Preventive Services and Wellness:
• Plainfield CF
• Branchville CF
• Heritage Trails CF
• Pendleton CF
Diagnostic and Specialty Care:
• Miami CF
• Plainfield CF
• Pendleton CF
Emergency Services and Hospital Care:
• Plainfield CF
• Heritage Trails CF
Addiction Recovery Services:
• Miami CF
• Plainfield CF
• Branchville CF
• Edinburgh CF
13 Facilities X $5,000.00 = $65,000.00
Executive Director Healthcare Operations
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