Q3 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
Q3 2025 HS Audit Deficiencies Summary
This is a third-quarter 2025 audit deficiency report issued by the Indiana Department of Correction (IDOC) Health Services Division documenting performance measure compliance findings for correctional health services. The report identifies audit results for the third quarter (July, August, September 2025) following the Department's quality assurance review process, which includes ad hoc site visits, interviews, inspections, and electronic medical record reviews conducted across correctional facilities. The IDOC requires all performance measure audits to achieve a passing score of 90 percent or better per category, with any deficiency triggering a 14-day rebuttal period allowing the health services vendor to present corrective information before final Department determination.
For Q3 2025, two facilities failed to meet the 90 percent compliance threshold following rebuttal periods: Sick Call services at Plainfield Correctional Facility and Mental Health Units at Indiana Women's Prison. As prescribed in the contract terms, the vendor is required to reimburse the Department $5,000 per facility for each audit failing to meet the 90 percent standard to cover additional Department oversight and administrative action. The total reimbursement liability for Q3 2025 audit deficiencies is $10,000 (2 facilities × $5,000), to be paid as a credit on the vendor's next invoice following notification of non-compliance.
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Text version
Third 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 of90% 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 Vend or 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 to be non-compliant, audits that did not meet the 90% threshold for the third quarter (July, August, September) after the rebuttals are:
Sick Call
• Plainfield Correctional Facility
Mental Health Units
• Indiana Women's Prison
2 Facilities x $5,000.00 = $10,000.00
11 _J( �--· � Andy Dunigan, Executive<£:':tor Healthcare Operations
Date f 1
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