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entitled 'District of Columbia Jail: Medical Services Generally Met 
Requirements and Costs Decreased, but Oversight Is Incomplete' which 
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Report to the Chairman, Committee on Government Reform, House of 
Representatives:

United States General Accounting Office:

GAO:

June 2004:

District of Columbia Jail:

Medical Services Generally Met Requirements and Costs Decreased, but 
Oversight Is Incomplete:

GAO-04-750:

GAO Highlights:

Highlights of GAO-04-750, a report to the Chairman, Committee on 
Government Reform, U.S. House of Representatives:  

Why GAO Did This Study:

Since the end of a court-ordered receivership overseeing medical 
services at the District of Columbia Jail in September 2000, the 
Department of Corrections (DoC) has contracted with the Center for 
Correctional Health and Policy Studies, Inc. (CCHPS) to provide inmate 
medical services. GAO was asked to provide information on (1) the 
medical services DoC contracted with CCHPS to provide, including 
CCHPSs monitoring of its services; (2) mechanisms DoC established to 
oversee CCHPSs services; (3) CCHPSs contract compliance and DoCs 
efforts to ensure compliance; and (4) the cost of medical services. To 
collect this information, GAO analyzed documents and interviewed 
officials from District agencies, CCHPS officials, and an independent 
reviewer hired by DoC to monitor medical services.

What GAO Found:

DoC has contracted with CCHPS to provide a broad range of medical 
services to inmates at the District of Columbia Jail and the 
Correctional Treatment Facility (CTF)an adjacent overflow facility. 
Services include health screenings at intake; primary care services, 
including care for chronic conditions; mental health care; and 
specialty care. In addition, CCHPS assists DoC in helping inmates 
obtain services not included in the contract, such as specialty or 
emergency services that cannot be offered on-site. As part of the 
contract, CCHPS also established a quality improvement program to 
monitor its services. A key component of the program is a quarterly 
analysis of random samples of inmate medical records to measure how 
consistently CCHPS delivers required services.

DoC established several mechanisms to oversee CCHPSs delivery of 
medical services to inmates. For example, DoC retained an independent 
reviewer to monitor the services provided by CCHPS on a quarterly 
basis. In addition, the contract gives DoC authority to impose monetary 
damages on CCHPS if it fails to meet any of 12 requirements specified 
in the contract, most of which relate to providing key services to a 
minimum percentage of inmates. The contract also requires CCHPS to 
submit quarterly and annual progress reports describing quality 
problems identified by the independent reviewer or its own monitoring 
and actions taken to correct them.

Although available evidence indicates that CCHPS has generally complied 
with the terms of its contract, DoC has not exercised sufficient 
oversight to provide assurance that problems are not occurring or are 
quickly corrected. The independent reviewer has consistently found that 
CCHPSs services meet the contracts overall requirements for access to 
care and quality, but has also reported that CCHPS has not always met 
certain requirements. For example, while CCHPS recently improved its 
performance in providing timely follow-up services to inmates with 
abnormal chest x-ray results, the independent reviewer had repeatedly 
found problems in this area. DoC has not taken actions that would allow 
it to be assured of CCHPSs compliance with contract requirements 
linked to monetary damages. The agency has not collected data or 
developed a formal procedure to determine whether CCHPS has met the 
requirements, and it lacks a procedure to impose damages if warranted. 
Also, DoC has not regularly enforced the contract requirement that 
CCHPS submit quarterly and annual progress reports describing quality 
problems and corrective actions, and CCHPS has often not submitted 
these reports.

From 2000 to 2003, the average daily cost of providing medical services 
to a Jail inmate decreased by almost one-third, from about $19 a day 
per inmate to about $13 a day. In 2003, DoC consolidated the services 
provided to inmates in the Jail and the CTF under one contract with 
CCHPS. In that year, during which 17,431 inmates were admitted to the 
Jail and the CTF, the total cost of providing medical services at both 
facilities was about $15.8 million.

What GAO Recommends:

GAO is recommending that the Mayor of the District of Columbia require 
the Director of DoC to (1) develop formal procedures, including 
collection of needed data, for determining whether CCHPS has met 
performance standards linked to monetary damages and for imposing these 
damages; and (2) ensure that CCHPS submits required quarterly and 
annual progress reports describing service problems and corrective 
actions. In reviewing a draft report, DoC did not comment on our 
recommendations, but provided additional information.

www.gao.gov/cgi-bin/getrpt?GAO-04-750.

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Marcia Crosse at (202) 
512-7119 or crossem@gao.gov.

[End of section]

Contents:

Letter:

Results in Brief:

Background:

CCHPS Provides a Range of Services to Inmates and Has Established 
Systems to Monitor Service Quality:

DoC Established Several Mechanisms to Oversee CCHPS's Delivery of 
Medical Services:

CCHPS Generally Meets Contract Requirements, but DoC's Oversight of 
CCHPS Is Incomplete:

Average Per Inmate Medical Cost at Jail Has Decreased:

Conclusions:

Recommendations for Executive Action:

Agency Comments and Our Evaluation:

Appendix I: Scope and Methodology:

Appendix II: Requirements Linked to Monetary Damages Provisions in the 
CCHPS Contract:

Appendix III: Performance Assessment Instruments Used to Monitor 
Services Provided by CCHPS:

Appendix IV: Comments from the District of Columbia Department of 
Corrections:

Appendix V: GAO Contact and Staff Acknowledgments:

GAO Contact:

Acknowledgments:

Tables:

Table 1: Medical Services Provided by CCHPS to Inmates at the Jail and 
the CTF, March 2004:

Table 2: Summary of Contract Requirements with Monetary Damages 
Provisions:

Table 3: Information on Performance Assessment Instruments Used to 
Monitor CCHPS's Services:

Figures:

Figure 1: Total Annual Cost of Medical Services at the District of 
Columbia Jail, 2000-2003:

Figure 2: Average Daily Inmate Population at the District of Columbia 
Jail, 2000-2003:

Figure 3: Average Daily Cost Per Inmate of Medical Services at the 
District of Columbia Jail, 2000-2003:

Abbreviations:

ACA: American Correctional Association: 
CCA: Corrections Corporation of America: 
CCHPS: Center for Correctional Health and Policy Studies, Inc.: 
CTF: Correctional Treatment Facility: 
DMH: District of Columbia Department of Mental Health: 
DoC: District of Columbia Department of Corrections: 
DoH: District of Columbia Department of Health: 
FMCS: Family and Medical Counseling Services, Inc.: 
FTE: full-time equivalent: 
HIV: human immunodeficiency virus: 
LPN: licensed practical nurse: 
MAR: medication administration record: 
NCCHC: National Commission on Correctional Health Care: 
NP: nurse practitioner: 
PA: physician assistant: 
RN: registered nurse:

United States General Accounting Office:

Washington, DC 20548:

June 30, 2004:

The Honorable Tom Davis: 
Chairman: 
Committee on Government Reform: 
House of Representatives:

Dear Mr. Chairman:

The District of Columbia Department of Corrections (DoC) is responsible 
for providing medical services to inmates of the District of Columbia 
Jail[Footnote 1] and the Correctional Treatment Facility (CTF), an 
overflow facility adjacent to the Jail. From August 1995 until 
September 2000, medical services at the Jail were under the control of 
a court-ordered Receiver because DoC had not complied with repeated 
court orders to provide adequate care to inmates. The Receiver 
contracted with the Center for Correctional Health and Policy Studies, 
Inc. (CCHPS), a private not-for-profit organization, to provide medical 
services at the Jail beginning in March 2000.[Footnote 2] When the 
receivership ended, the court returned responsibility for the Jail's 
medical services to DoC, which continued to contract with CCHPS. In 
April 2003, DoC expanded its contract with CCHPS to include medical 
services provided to inmates housed at the CTF.

In June 2000, shortly before the court terminated the receivership, we 
testified before the Subcommittee on the District of Columbia on 
selected issues related to medical services provided at the 
Jail.[Footnote 3] In response to questions about the cost and level of 
services, we reported that the per inmate cost of medical services at 
the Jail exceeded the cost in two other jurisdictions[Footnote 4] and 
that there were no specific criteria to determine an acceptable level 
of medical services and staffing at the Jail. You asked us to obtain 
information on the District of Columbia's progress in providing medical 
services to inmates since the receivership ended and what mechanisms 
exist to monitor the quality of these services. We are reporting on (1) 
the medical services DoC has contracted with CCHPS to provide to 
inmates held at the Jail and the CTF, including CCHPS's monitoring of 
those services; (2) the mechanisms DoC established to oversee the 
services provided by CCHPS; (3) CCHPS's compliance with the 
requirements in its contract and DoC's efforts to ensure CCHPS's 
compliance; and (4) the cost of providing medical services at the Jail 
from 2000 to 2003 and the current cost of medical services at the Jail 
and the CTF.

To examine the medical services provided to inmates, CCHPS's monitoring 
of those services, and DoC's oversight of CCHPS's contract compliance, 
we analyzed documents and interviewed officials from DoC and CCHPS. In 
doing our work, we relied, in part, on reports by a national expert in 
correctional health care who was hired by DoC to conduct independent 
reviews of CCHPS's medical services. We interviewed this expert, 
referred to as the independent reviewer, and analyzed all of the 
quarterly reports he submitted to DoC. In addition, we analyzed a 
random sample of grievances submitted by Jail and CTF inmates from 
April 1, 2003, through October 31, 2003. Although we focused primarily 
on services provided by CCHPS, we also reviewed documents and 
interviewed officials about the medical services provided to inmates 
off-site that are not a part of the CCHPS contract. We also analyzed 
documents and interviewed officials from other District of Columbia 
agencies with responsibilities related to inmate health care and from 
national organizations that accredit correctional health care 
facilities. In addition, we reviewed our previous work related to 
medical services at the Jail. To determine the cost of providing 
medical services at the Jail and the CTF, we analyzed documents and 
interviewed officials from the District of Columbia Office of 
Contracting and Procurement; DoC, including its Office of the Chief 
Financial Officer; and CCHPS. We also examined independently audited 
accounting data from the District of Columbia Office of Financial 
Operations and Systems. We determined that the medical services cost 
information we used in our analysis was reliable. The scope of our work 
included medical services provided to CTF inmates only since April 
2003, when DoC expanded its contract with CCHPS to include this 
facility. In reviewing DoC's activities, we assessed the agency's 
internal controls related to its contract with CCHPS. We did our work 
from August 2003 through June 2004 in accordance with generally 
accepted government auditing standards. (See app. I for additional 
details on our scope and methodology, including our cost 
calculations.)

Results in Brief:

DoC has contracted with CCHPS to provide a broad range of medical 
services to inmates of the Jail and the CTF, and the types of services 
available have changed little since CCHPS began providing care in 2000. 
These services include physical and mental health screening when 
inmates are admitted; primary care; mental health care; and chronic and 
specialty care, such as dental and orthopedic services. CCHPS also 
assists DoC in helping inmates obtain services not included in the 
contract, such as specialty care and emergency medical services that 
cannot be offered at the Jail or the CTF and community-based medical 
services for inmates after they are released. CCHPS has established a 
quality improvement program to fulfill its obligation to monitor the 
quality of its services. A key component of this program is a quarterly 
analysis of random samples of inmate medical records; these analyses 
use standardized performance assessment instruments to provide CCHPS 
with quantitative data measuring how consistently it delivers required 
services to inmates.

DoC established several mechanisms to oversee CCHPS's delivery of 
medical services to inmates at the Jail and the CTF. DoC's contract 
with CCHPS gives DoC authority to impose monetary damages on CCHPS if 
it fails to meet any of 12 requirements specified in the contract, most 
of which relate to providing key services to a minimum percentage of 
inmates. For example, DoC may impose damages if CCHPS does not conduct 
an intake screening within 24 hours for 95 percent of inmates. In 
addition, DoC's contract with CCHPS requires CCHPS to submit quarterly 
and annual progress reports that discuss any quality problems and the 
actions taken to correct them. DoC's independent reviewer monitors the 
services provided by CCHPS on a quarterly basis. During his reviews, 
the independent reviewer uses the same performance assessment 
instruments as CCHPS to monitor both CCHPS's delivery of medical 
services and the accuracy of CCHPS's internal performance analyses. The 
independent reviewer does not, however, specifically review CCHPS's 
compliance with the contract requirements associated with monetary 
damages.

Although available evidence indicates that CCHPS has generally complied 
with the terms of its contract, DoC has not exercised sufficient 
oversight to provide assurance that problems either are not occurring 
or are quickly corrected. The independent reviewer has consistently 
found that the medical services CCHPS provides to inmates meet the 
contract's requirements for access to care and quality. In addition, 
CCHPS has generally met the contract requirement that it implement a 
quality improvement program. For example, CCHPS has regularly used the 
performance assessment instruments to monitor its services, and the 
independent reviewer has concluded that CCHPS's assessments with these 
instruments are accurate. However, in a few areas CCHPS has not always 
met the contract's medical services and monitoring requirements. For 
example, while CCHPS recently improved its performance in providing 
timely follow-up to inmates with abnormal chest x-ray results, the 
independent reviewer had repeatedly found problems in this area since 
2000. Although the independent reviewer provides DoC with important 
information about CCHPS's performance, other limitations in DoC's 
oversight of CCHPS's services may hinder the agency's ability to be 
assured of CCHPS's compliance with the contract. For example, DoC lacks 
the necessary data and a formal procedure to determine whether CCHPS 
has met contract requirements linked to monetary damages; it also lacks 
a procedure to impose damages if they are warranted. In addition, DoC 
has not regularly enforced the contract requirement that CCHPS submit 
quarterly and annual progress reports describing quality problems and 
corrective actions. CCHPS has never submitted the quarterly reports and 
has not submitted all the required annual reports.

From 2000 to 2003, the average daily cost of providing medical services 
to a Jail inmate decreased by almost one-third, from about $19 a day 
per inmate to about $13 a day. This decrease in per inmate costs 
occurred because the total cost of providing medical services at the 
Jail decreased by about 3 percent during this period, while the average 
inmate population rose by about 41 percent. DoC and CCHPS officials 
told us that they controlled total costs by various means, including 
controlling personnel expenditures. On April 1, 2003, DoC consolidated 
the services provided to inmates in the Jail and the CTF under one 
contract with CCHPS. This contract revision also introduced a new 
pricing structure, which simplified DoC's administration of the 
contract. DoC now pays CCHPS on a per inmate basis, using a rate 
schedule ranging from $13.00 to $14.75 a day per inmate, depending on 
the size of the inmate population. In contract year 2003, which ended 
March 31, 2004, the total cost of providing medical services at the 
Jail and the CTF was about $15.8 million; during that year 17,431 
inmates were admitted to the two facilities.

We are recommending that the Mayor require the Director of DoC to 
develop formal procedures, including collection of needed data, for 
regularly assessing whether CCHPS has met contract requirements linked 
to monetary damages and for imposing these damages. We are also 
recommending that the Mayor require the Director of DoC to ensure that 
CCHPS submits required quarterly and annual progress reports on 
identified problems and corrective actions.

We provided a draft of this report to DoC for comment. In its response, 
DoC did not comment on our recommendations, but provided additional 
information about its contract with CCHPS and medical services for 
inmates of the Jail and the CTF. In addition, DoC elaborated on its 
oversight of the medical services provided by CCHPS.

Background:

The District of Columbia Jail and CTF house inmates awaiting trial or 
who have been sentenced for misdemeanors.[Footnote 5] The Jail was 
opened in 1976, and from 1985 to July 2002, a court order limited the 
population to 1,674 inmates. Since July 2002 the population has grown, 
and during March 2004, the facility had an average daily population of 
2,357. In addition to serving as an overflow facility, the CTF houses 
pregnant inmates, inmates with disabilities who need medical services, 
inmates in witness protection, and inmates who need to be separated 
from the general inmate population. Opened in 1992, the CTF is operated 
by a private company, the Corrections Corporation of America (CCA), 
under a contract with DoC. During March 2004, the CTF had an average 
daily population of 1,197.

In 1995, the U.S. District Court for the District of Columbia removed 
medical services at the Jail from DoC's control, placing these services 
under the temporary supervision of a court-appointed Receiver. This 
removal resulted from the District of Columbia's failure to address 
problems identified in two lawsuits brought against the Jail in 1971 
and 1975, which alleged that DoC was failing to provide minimally 
adequate medical care for inmates.[Footnote 6] Before it terminated the 
receivership in 2000, the Court hired a national expert in correctional 
health care to conduct an independent quality review of medical 
services provided by CCHPS to inmates at the Jail. DoC subsequently 
contracted directly with this expert to help develop a set of 
performance assessment instruments for reviewing CCHPS's clinical 
services and monitoring activities[Footnote 7] and to conduct quarterly 
on-site reviews of CCHPS.

DoC has a constitutional obligation to ensure that medical care is 
provided to inmates in its custody,[Footnote 8] and DoC's contract with 
CCHPS requires CCHPS to provide comprehensive medical services to all 
inmates assigned to the Jail and the CTF and to establish a quality 
improvement program to monitor the quality of medical services it 
provides. In some areas, particularly the assessment of inmates' health 
when they are admitted to the facilities, the contract lists specific 
services that CCHPS must provide, such as certain diagnostic tests. In 
other areas, such as services for inmates with chronic conditions, the 
requirement to provide care is less detailed. In addition to describing 
services that CCHPS is required to provide, the contract states that 
DoC can impose monetary damages[Footnote 9] on CCHPS if it does not 
meet 12 specific requirements. (See app. II for a description of the 
contract requirements that are linked to monetary damages.) Compliance 
with the requirements is to be determined through monitoring by DoC or 
its designee.

The contract with DoC also requires that CCHPS acquire and maintain 
accreditation for its medical services. The Jail's medical services are 
accredited by the National Commission on Correctional Health Care 
(NCCHC), while the CTF is accredited by the American Correctional 
Association (ACA). NCCHC and ACA, both national, not-for-profit 
organizations, offer voluntary accreditation processes for medical 
services provided in correctional facilities; relatively few jails 
nationwide are accredited by these organizations.[Footnote 10] NCCHC 
accredits only a correctional facility's medical services, while ACA 
accredits all aspects of the correctional facility, including medical 
services. Both organizations have developed detailed accreditation 
standards that include, for example, specific elements that are 
required in an inmate's initial medical assessment and in a facility's 
quality improvement program. The accreditation process for both 
organizations includes on-site inspections of the facility every 3 
years and submission of an annual report certifying that the facility 
continues to be in compliance with the accreditation standards. During 
on-site inspections, inspectors interview staff, review documentation 
provided by the facility, and examine a sample of inmate medical 
records. NCCHC and ACA inspectors submit their findings to expert 
panels, who make the accreditation decisions.

One component of the quality improvement program required by both NCCHC 
and ACA is a grievance system that allows inmates an opportunity to 
question or complain about their care. Inmates at the Jail or the CTF 
who have concerns about medical services can complete a grievance form 
and submit it to the warden's office in their facility. The warden's 
staff records the grievance in their system and then forwards it to 
CCHPS. CCHPS's medical director and quality improvement coordinator 
review the grievance and work with the clinicians involved to determine 
if the inmate's complaint is valid and, if so, how it should be 
addressed. If it is determined that an inmate needs to receive care, 
CCHPS schedules an appointment. After CCHPS has reviewed the grievance, 
it sends a report to the warden, who then provides a response to the 
inmate.

In June 2000, we testified before the House Committee on Government 
Reform, Subcommittee on the District of Columbia, about the provision 
of medical services at the Jail.[Footnote 11] We reported that the per 
inmate cost at the Jail was higher than those at the two other 
jurisdictions reviewed, and that services and staffing levels also 
exceeded those of the other jurisdictions.[Footnote 12] We also found 
that there were no specific criteria that determine an acceptable level 
of medical service and staffing at a jail. Rather, the range of 
services was a function of many local factors, including the specific 
demands and constraints placed on the facility's service delivery 
system.

CCHPS Provides a Range of Services to Inmates and Has Established 
Systems to Monitor Service Quality:

As required by the contract, CCHPS provides a broad range of medical 
services to Jail and CTF inmates, and the types of services CCHPS 
provides at the Jail have not changed significantly over the life of 
the contract. In addition, CCHPS assists DoC in helping inmates obtain 
services beyond those included in CCHPS's contract, such as emergency 
and specialty care that cannot be provided at the Jail or the CTF. 
CCHPS also assists DoC in its efforts to work with other District of 
Columbia agencies and community providers to link soon-to-be-released 
inmates in need of medical services with services in the community. As 
part of its contract with DoC, CCHPS has also developed a system to 
monitor the quality of the medical services it provides to inmates. A 
key component of this program is quarterly analyses of random samples 
of inmate medical records to measure how consistently CCHPS delivers 
required services to inmates.

CCHPS Provides Screening and Treatment Services Required in Its 
Contract and Assists DoC in Obtaining Additional Services:

As required by the contract, CCHPS provides a broad range of medical 
services to Jail and CTF inmates, including primary care services such 
as sick call[Footnote 13] and chronic care; mental health care; and 
specialty care, such as dental and orthopedic services. (See table 1 
for a description of these services.) At intake, all inmates receive a 
health assessment--referred to as an intake screening--that screens for 
physical and mental health conditions. The inmates receive a physical 
examination and are asked about current and past health problems, 
substance abuse, and medication use. In addition, they receive a chest 
x-ray and skin test to identify possible tuberculosis.[Footnote 14] As 
part of the mental health screening, inmates are asked a series of 
questions.[Footnote 15] If inmates respond positively to any of these 
questions, or if they are a juvenile or in jail for the first time, 
they are referred for a comprehensive mental health assessment. Based 
on the findings of the intake screening, inmates in need of medical 
care may receive treatment in a chronic or specialty care clinic, 
receive therapy for mental health problems, or be placed in one of two 
specialized mental health units. According to CCHPS officials, in 2002 
they conducted an average of 1,654 intake screenings each month. About 
20 percent of these inmates were referred to a chronic care clinic, and 
about 34 percent were referred for further mental health assessment.

Table 1: Medical Services Provided by CCHPS to Inmates at the Jail and 
the CTF, March 2004:

Service area: Intake services; 
Type and description of service: Initial medical, mental health, and 
dental screening on admission to the Jail and referral for additional 
care if needed[A]; 
Types of service providers: Physicians, physician assistants (PA), 
licensed practical nurses (LPN), phlebotomists[B].

Service area: Primary medical care; 
Type and description of service: Sick call and primary care services: 
assessment of inmates requesting to be seen by a clinician and possible 
referral to a physician or specialty care clinic; 
Types of service providers: Physicians, PAs, nurse practitioners (NP), 
registered nurses (RN).

Service area: Primary medical care; 
Type and description of service: Chronic care services: ongoing 
management of chronic diseases, primarily asthma, diabetes, epilepsy 
and other seizure disorders, hypertension, and human immunodeficiency 
virus (HIV) and other infectious diseases; 
Types of service providers: Physicians, NPs, PAs.

Service area: Primary medical care;
Type and description of service: Halfway house services: assessment and 
coordination of care for inmates at one halfway house; 
Types of service providers: NPs, RNs.

Service area: Mental health services; 
Type and description of service: "Outpatient" mental health services: 
services provided to inmates in the general housing population, 
including group therapy, one-on-one therapy, and medication management; 
Types of service providers: Psychiatrists, psychologists, social 
workers, RNs, LPNs.

Service area: Mental health services;
Type and description of service: "Inpatient" mental health services: 
services provided in two specialized units of the Jail for inmates with 
acute or serious chronic mental health problems; inmates needing 
inpatient services are housed in these units[C]; 
Types of service providers: Psychiatrists, social workers, RNs, LPNs; 
interdisciplinary team also includes corrections officers and 
classification and parole officers.

Service area: Specialty care; 
Type and description of service: Dental services: basic dental care, 
including routine and surgical extractions, fitting dentures, filling 
cavities, and oral hygiene and education; 
Types of service providers: Dentists, dental assistants, dental 
hygienists.

Service area: Specialty care; 
Type and description of service: On- site specialty services include 
cardiology, dermatology, gynecology, neurology, ophthalmology, 
orthopedics, general surgery, podiatry, and pulmonary clinics; 
Types of service providers: Physicians, podiatrists.

Service area: Infirmary services; 
Type and description of service: Short-term management of inmates 
requiring observation or a level of care that cannot be provided in the 
general population; 
Types of service providers: Physicians, RNs.

Service area: Ancillary services; 
Type and description of service: Includes pharmacy services, 
laboratory services, and providing prostheses and glasses; 
Types of service providers: Pharmacists, pharmacy technicians, 
radiology technicians, dieticians, off-site providers related to 
laboratory services, glasses, etc. 

Source: GAO analysis of documents from the Center for Correctional 
Health and Policy Studies, Inc., and the District of Columbia 
Department of Corrections.

[A] All inmates are admitted to the Jail and the CTF through the Jail's 
Receiving and Discharge Unit, so all intake screening takes place in 
the Jail.

[B] Phlebotomists are medical technicians who collect blood.

[C] There are no inpatient mental health units in the CTF, so inmates 
in the CTF in need of inpatient services are transferred to the Jail's 
inpatient units.

[End of table]

There have been no significant changes in the types of medical services 
provided by CCHPS since the start of its contract with DoC. However, 
there have been some minor changes, including modifications to on-site 
specialty clinics. For example, in 2001, the requirement for an oral 
surgery clinic was deleted from the contract, and more recently CCHPS 
combined the ophthalmology and optometry clinics. In addition, CCHPS 
began offering endocrinology and infectious disease clinics on-site--
even though they are not required by the contract--to improve inmates' 
access to these services and continuity of care. CCHPS officials had 
expected the consolidation of medical services at the Jail and the CTF 
to result in some service efficiencies, such as combining the on-site 
specialty clinics offered at both facilities; however, CCHPS and DoC 
officials told us it has not been feasible to easily move inmates 
between facilities because of security issues. CCHPS therefore 
continues to offer all on-site specialty clinics at both facilities.

When inmates need medical services that cannot be provided at the Jail 
or the CTF, CCHPS refers them to providers in the community. These off-
site services, including emergency care and certain specialty services, 
are not part of the CCHPS contract; instead, DoC has an agreement with 
the District of Columbia Department of Health (DoH) to provide services 
to inmates through Greater Southeast Community Hospital.[Footnote 16] 
When Greater Southeast is not able to provide the needed services, it 
in turn refers the inmates to other members of the DC Healthcare 
Alliance and other community providers.[Footnote 17] DoC pays for all 
off-site services through an interagency agreement with DoH;[Footnote 
18] in 2003 there were 4,169 appointments for inmates off-site.

Although DoC's contract with CCHPS does not specify that CCHPS provide 
discharge planning services to inmates,[Footnote 19] NCCHC 
accreditation standards include discharge planning activities. Both 
CCHPS and DoC have made efforts to plan for the release of inmates with 
medical conditions and to link them to community-based medical 
services.[Footnote 20],[Footnote 21] For example, CCHPS's policies 
require that inmates receive a 2-week supply of medications at the time 
of their release. In addition, CCHPS provides support to DoC's 
collaboration with the District of Columbia Department of Mental Health 
(DMH) to help Jail inmates[Footnote 22] obtain access to community 
mental health services when they are released.

CCHPS supports DoC's and DoH's discharge planning efforts to link 
inmates who have certain chronic and communicable diseases, such as 
tuberculosis, to community-based medical services. In addition, through 
a joint program of DoH's HIV/AIDS Administration and DoC, Family and 
Medical Counseling Services, Inc. (FMCS), a community-based provider, 
offers HIV testing and links HIV-positive inmates to services in the 
community when they are released.[Footnote 23] CCHPS refers inmates 
requesting an HIV test to FMCS and provides FMCS with office space, 
computers, and access to the inmate's electronic medical record in the 
CCHPS system.[Footnote 24]

CCHPS Developed a System to Monitor Its Medical Services:

As part of its contract with DoC, CCHPS is responsible for monitoring 
the quality of the medical services it provides to Jail and CTF 
inmates, and CCHPS has established a quality improvement program to 
fulfill this responsibility. A key component of the program is a 
quarterly analysis of random samples of inmate medical records using 
standardized performance assessment instruments. These quarterly 
analyses provide CCHPS with quantitative data about its performance in 
certain areas. Each assessment instrument measures CCHPS's performance 
of a specific set of activities; these activities are generally more 
detailed than the requirements described in the contract.[Footnote 25] 
(See app. III for a summary description of the instruments.) Using the 
samples of medical records and other documentation to complete the 
performance assessment instruments, CCHPS clinicians determine how 
consistently CCHPS delivers required services to inmates. Currently, 
there are 23 performance assessment instruments, 20 of which measure 
medical services provided to inmates in various service areas. For 
example, the intake services instrument includes a measurement of the 
percentage of inmates who received a chest x-ray for tuberculosis 
within 24 hours of admission. The remaining 3 instruments measure the 
extent to which CCHPS has conducted other components of its quality 
improvement program, such as validating that clinical staff are 
licensed.

In addition to these quarterly analyses of medical services, CCHPS's 
quality improvement program also includes other reviews, such as annual 
reviews of urgent care and radiological safety procedures, monthly 
reviews of inmate grievances and of any inmate deaths, and ongoing 
reviews of infection control activities. The program also requires 
CCHPS to conduct at least two in-depth studies a year, each of which 
focuses on a specific issue, such as a medical service problem that has 
been identified by the quarterly analyses.

DoC Established Several Mechanisms to Oversee CCHPS's Delivery of 
Medical Services:

DoC has developed several mechanisms to oversee CCHPS's delivery of 
medical services to inmates and enforce CCHPS's compliance with the 
contract. For example, DoC's contract with CCHPS gives DoC the 
authority to impose monetary damages if CCHPS fails to meet any of 12 
requirements specified in the contract, most of which relate to CCHPS's 
performance in providing key medical services. For most of these 
requirements, the contract authorizes DoC to impose the damages if 
CCHPS fails to deliver the required service to a minimum percentage of 
inmates--for example if CCHPS does not conduct an intake screening 
within 24 hours for 95 percent of inmates. (See app. II for additional 
information on the contract requirements that are linked to monetary 
damages.) Some of the requirements relate to CCHPS's staff, including 
ensuring that staff have required licenses and credentials. In 
addition, the contract contains a requirement that CCHPS have an 
infection control program approved by DoC. DoC, or its designee, is 
responsible for determining CCHPS's compliance with these 12 contract 
requirements.

To further assist DoC in overseeing CCHPS's delivery of services, the 
contract also stipulates that CCHPS will submit quarterly and annual 
progress reports to DoC. These progress reports are to include a 
description of quality problems, such as those identified by CCHPS's 
quality improvement program or the independent reviewer, and actions 
taken to correct them. DoC also requires CCHPS to maintain 
accreditation of its services. In addition, DoC staff responsible for 
oversight of the contract are frequently on-site at the Jail and the 
CTF observing the contractor, and, as of May 2004, DoC had plans to 
begin jointly conducting the quarterly analyses of inmate medical 
records with CCHPS.[Footnote 26]

Furthermore, DoC's independent reviewer conducts quarterly reviews of 
CCHPS's activities. Each review consists of two principal components. 
First, the independent reviewer checks the accuracy of CCHPS's internal 
use of the standardized performance instruments. To do this, he uses 
the same performance assessment instruments that CCHPS uses in its 
quality improvement program to examine a sample of the analyses CCHPS 
has completed, and assesses whether CCHPS accurately characterized the 
medical records studied.[Footnote 27] Second, in addition to validating 
CCHPS's analyses, the independent reviewer uses the performance 
instruments to independently assess the quality of CCHPS's services by 
analyzing a separate random sample of inmate medical records in 
selected service areas, such as mental health services.[Footnote 28] 
While CCHPS uses the performance assessment instruments as a quality 
improvement vehicle, the independent reviewer's use of these 
instruments contributes to his assessment of whether CCHPS is meeting 
its contractual obligations. However, the independent reviewer does not 
specifically evaluate CCHPS's compliance with the contract requirements 
associated with monetary damages.

As part of his review, the independent reviewer also assesses other 
components of CCHPS's quality improvement program, visits the medical 
units at the Jail and the CTF, and interviews CCHPS staff. After 
conducting the review, the independent reviewer provides DoC with a 
written report describing his general findings, including service areas 
in which CCHPS excels or needs to improve. Since August 2000, the 
independent reviewer has conducted 14 quarterly on-site reviews of 
CCHPS.

CCHPS Generally Meets Contract Requirements, but DoC's Oversight of 
CCHPS Is Incomplete:

Most available evidence indicates that CCHPS has generally complied 
with the contract, but DoC has not exercised sufficient oversight to be 
assured that problems are not occurring or are quickly corrected. The 
independent reviewer has reported that CCHPS's services meet the 
contract's requirements for access to care and quality. In addition, 
CCHPS has generally met the contract requirement that it implement a 
quality improvement program. However, in a few areas, CCHPS has not 
always met the contract's requirements, such as submitting required 
quarterly and annual progress reports describing quality problems and 
actions taken to correct them. Although the independent reviewer 
provides important information about CCHPS's performance, limitations 
in DoC's oversight of CCHPS may hinder the agency's ability to be 
assured of CCHPS's compliance with the contract. For example, DoC has 
not enforced the contract requirement that CCHPS provide it with 
quarterly and annual progress reports. Furthermore, although DoC has 
authority to impose monetary damages on CCHPS if it does not meet 
certain requirements included in the contract, DoC has not collected 
data needed to impose these damages or developed formal procedures for 
determining whether CCHPS has met these requirements and for imposing 
damages if CCHPS has not met them.

CCHPS Generally Provides Required Medical Services and Internal 
Monitoring, but a Few Gaps Remain:

On the basis of his review, the independent reviewer has consistently 
reported that CCHPS's medical services meet the contract's requirements 
for access to care and quality. He has also reported that services meet 
the "required constitutional standards of care." In addition, he told 
us that, in his opinion, CCHPS is one of the best correctional health 
care providers in the country. According to the independent reviewer, 
some activities, such as documenting the administering of medication, 
have been performed consistently over the life of the contract. Other 
activities have improved over time. For example, in one report, the 
independent reviewer noted that CCHPS's chronic disease guidelines were 
outdated, but later reported that CCHPS had appropriately revised the 
guidelines.

In addition, CCHPS generally meets the contract requirement that it 
implement a quality improvement program. CCHPS has used the performance 
assessment instruments each quarter to monitor its services, and the 
independent reviewer has concluded that CCHPS accurately uses these 
instruments to assess its medical services. For example, based on data 
from its quarterly analyses, CCHPS identified problems in inmates' 
access to dental care. As a result, CCHPS conducted a study to identify 
ways to improve access to this service and eventually established a 
system that gave higher priority to care for inmates with more serious 
dental problems. CCHPS's subsequent review found that access had 
improved.

While CCHPS's medical services and monitoring efforts generally meet 
the requirements of the contract, in a few areas CCHPS has not always 
met requirements. For example, the contract requires that CCHPS provide 
timely follow-up services to inmates with abnormal chest x-ray 
results.[Footnote 29] Although CCHPS has recently improved its 
performance, the independent reviewer had repeatedly found that CCHPS 
did not always provide timely follow-up services to these inmates. The 
independent reviewer also recently determined that CCHPS is not 
performing reviews of inmate deaths. This is an NCCHC requirement, and 
CCHPS's quality improvement program specifies that CCHPS should conduct 
such reviews monthly.

In addition, CCHPS has not regularly submitted the required quarterly 
and annual progress reports providing information on quality problems 
and its actions to correct them. CCHPS has never submitted quarterly 
reports, and submitted only one annual report. Furthermore, the annual 
progress report CCHPS did submit provided only limited information. For 
example, it did not discuss CCHPS's lack of timely follow-up on 
abnormal x-ray results, although the independent reviewer had 
repeatedly identified this as a problem.

Inmates have expressed concerns about other medical services required 
by the contract. Our analysis of a sample of the 369 inmate grievances 
submitted from April 2003 through October 2003 found that many 
complaints related to inmates' ability to gain access to requested sick 
call and primary care services and to the timely distribution of 
medications.[Footnote 30] For example, some inmates complained that 
they had submitted multiple requests to be seen during sick call and 
had not yet been seen. CCHPS's internal monitoring has also identified 
problems related to sick call services, such as inconsistent use of the 
protocols developed to guide inmate health assessments.[Footnote 31] In 
addition, advocacy groups with whom we spoke expressed concern about 
distribution of medications on weekends and to newly admitted inmates.

DoC's Oversight Limitations Reduce Its Assurance That CCHPS Complies 
with Contract:

Although the independent reviewer provides important information about 
CCHPS's services, DoC has other weaknesses in its oversight of CCHPS 
that reduce its ability to be assured that CCHPS is complying with the 
contract and that problems are not occurring. DoC has never used its 
authority to impose monetary damages on CCHPS for failing to meet 
certain contract requirements. This is in part because it lacks the 
necessary data and a formal procedure for determining whether CCHPS has 
met the requirements; it also lacks a procedure for imposing damages if 
they are warranted. To evaluate CCHPS's compliance with many of the 
requirements that are linked to monetary damages, DoC needs data that 
indicate the percentage of inmates for whom CCHPS provided the required 
service. One potential source for such data is the performance 
assessment instruments used by CCHPS and the independent reviewer, 
which measure many of the activities included in these contract 
requirements.[Footnote 32] However, at present, DoC neither regularly 
collects data itself nor requires the independent reviewer or CCHPS to 
submit data they collect through their quarterly analyses of 
services.[Footnote 33] DoC officials also were not able to provide any 
documents that articulated how, and how often, they would evaluate 
CCHPS's compliance with the contract requirements associated with 
monetary damages, and DoC has not provided CCHPS with information on 
the status of its compliance. Furthermore, if DoC were able to 
determine that CCHPS was not meeting a contract requirement, it has not 
determined whether it would immediately impose damages on CCHPS or 
first give CCHPS an opportunity to correct the problem.

In addition, DoC has generally not enforced the contract requirement 
that CCHPS submit quarterly and annual progress reports describing 
quality problems and actions taken to correct them. These reports would 
allow DoC to obtain information on how CCHPS is addressing compliance 
or other performance problems identified by CCHPS's own monitoring or 
the independent reviewer. For example, the independent reviewer has 
repeatedly reported that CCHPS did not consistently screen and treat 
female inmates for chlamydia and gonorrhea. In addition, while CCHPS 
usually responds to inmate grievances in a timely way,[Footnote 34] the 
independent reviewer has reported on several occasions that CCHPS does 
not analyze grievances in a sufficiently thorough way to identify 
systemic problems in CCHPS's services. Enforcing the requirement that 
CCHPS submit regular progress reports would better enable DoC to ensure 
that CCHPS promptly corrects such problems.

An area where DoC has been slow to carry out its oversight 
responsibility relates to the contract requirement for an infection 
control plan. To maintain its NCCHC accreditation, CCHPS must have an 
infection control plan, and the April 2003 modification of the contract 
required that CCHPS's plan be approved by DoC. Although CCHPS submitted 
an infection control plan to DoC for approval in August 2003, DoC did 
not complete its review and approve the plan until June 2004.

In addition to having gaps in its oversight of services provided by 
CCHPS, DoC is not providing systematic oversight to ensure that, when 
CCHPS refers inmates to off-site services, inmates receive those 
services promptly. DoC officials believe the closure of District of 
Columbia General Hospital in 2001 and the shift of off-site services to 
Greater Southeast Community Hospital have resulted in delays in 
obtaining off-site care for inmates, particularly in certain specialty 
areas, such as orthopedics and dermatology. The independent reviewer 
and CCHPS have also expressed concerns about access to off-site 
services. CCHPS, which is responsible for arranging and monitoring off-
site appointments, documented earlier delays in obtaining these 
appointments, but at the time of our review, it no longer possessed 
this documentation. Despite its concerns, DoC has not systematically 
documented more recent delays in obtaining off-site appointments for 
inmates, is not able to provide any data on the nature or length of 
delays, and has no plans to study this issue.[Footnote 35]

Average Per Inmate Medical Cost at Jail Has Decreased:

From 2000 to 2003, DoC's average daily cost of providing medical 
services to an inmate at the Jail decreased by almost one-third. This 
resulted from a decrease in the total cost of providing medical 
services to inmates despite an increase in the inmate population. DoC 
and CCHPS officials told us they controlled costs in various ways, 
including reducing personnel expenditures. In 2003, DoC consolidated 
the services provided to inmates in the Jail and the CTF under one 
CCHPS contract and introduced a daily per inmate pricing structure, 
known as per diem pricing. The total cost to provide medical services 
to inmates at the Jail and the CTF in 2003 was about $15.8 million, an 
average of $13.28 per inmate.

Cost of Medical Services at Jail Decreased, Despite Growth of Inmate 
Population:

From initiation of the CCHPS contract in 2000 to 2003, the average 
daily per inmate cost of medical services at the Jail[Footnote 36] 
decreased by almost one-third, from about $19 a day to about $13 a day. 
The average decrease resulted from a decline in the total cost of 
services, combined with a rise in the inmate population. During this 
period, the total cost of providing medical services at the Jail 
decreased from about $11.7 million to about $11.4 million,[Footnote 37] 
about 3 percent. (See fig. 1.) At the same time, the average daily 
population in the Jail increased by about 680 inmates, about 41 
percent. (See fig. 2.) In fiscal year 1999, the last full year in which 
the Receiver directly provided medical services at the Jail, the total 
cost was about $12.6 million and the average per inmate cost was about 
$21 a day.

Figure 1: Total Annual Cost of Medical Services at the District of 
Columbia Jail, 2000-2003:

[See PDF for image]

[A] If adjusted for medical inflation, the total cost for 2000 would 
have been about $13.2 million. Medical inflation adjustments were 
calculated using the medical care component of the Consumer Price Index 
for urban consumers.

[B] Data for 2000, 2001, and 2002 are from March 12 of the year through 
March 11 of the following year, coinciding with the DoC-CCHPS contract 
year.

[C] Data for 2003 are from April 1, 2003, through March 31, 2004, 
approximating the DoC-CCHPS contract year and coinciding with the April 
1, 2003, contract changes.

[End of figure]

Figure 2: Average Daily Inmate Population at the District of Columbia 
Jail, 2000-2003:

[See PDF for image]

[A] Data for 2000, 2001, 2002, and 2003 are from April 1 of each year 
through March 31 of the following year, approximating the DoC-CCHPS 
contract year.

[End of figure]

As a result of the combination of decreased cost and increased inmate 
population, DoC's average daily cost of providing medical services to 
an inmate at the Jail since CCHPS began providing services fell by 
almost one-third from 2000 to 2003.[Footnote 38] (See fig. 3.)

Figure 3: Average Daily Cost Per Inmate of Medical Services at the 
District of Columbia Jail, 2000-2003:

[See PDF for image]

Note: Average daily cost per inmate is calculated by dividing the total 
cost for the period by the average inmate population for the period, 
and then dividing by the number of days in the period.

[A] If adjusted for medical inflation, the total cost for 2000 would 
have been about $13.2 million, resulting in an average daily cost per 
inmate for 2000 of about $22. Medical inflation adjustments were 
calculated using the medical care component of the Consumer Price Index 
for urban consumers.

[B] Average daily cost per inmate for 2000, 2001, and 2002 is based on 
population data from April 1 of each year through March 31 of the 
following year, approximating the DoC-CCHPS contract year. It is also 
based on total cost data from March 12 of each year through March 11 of 
the following year, coinciding with the DoC-CCHPS contract year.

[C] Average daily cost per inmate for 2003 is based on total cost and 
population data from April 1, 2003, through March 31, 2004, 
approximating the DoC-CCHPS contract year.

[End of figure]

DoC and CCHPS officials told us that they were able to reduce the total 
cost of providing medical services at the Jail through various means. 
For example, in 2003, DoC officials stopped paying CCHPS a management 
fee. DoC also negotiated with CCHPS officials to reduce employee 
salaries and fringe benefits, and CCHPS made more efficient use of its 
staff.[Footnote 39] For example, CCHPS was able to eliminate 
unnecessary testing done at intake, such as conducting repeat chest x-
rays for recently returned inmates, which allowed CCHPS to increase 
staff time available for providing other services. In addition, CCHPS 
officials told us they have selectively replaced higher salaried staff 
with lower salaried staff; in one case they changed a vacated 
pharmacist position to a pharmacy technician position.

CCHPS also controlled personnel expenditures by reducing the overall 
number of staff at the Jail, while still meeting NCCHC standards for 
physician staffing levels. When the contract began in March 2000, CCHPS 
had about 125 full-time equivalent (FTE) positions at the 
Jail,[Footnote 40] and there were about 18 Jail inmates for each 
clinical staff member. As of April 2003, CCHPS's FTEs at the Jail had 
decreased to about 114, and the number of inmates for each clinical 
staff member had risen to about 27.[Footnote 41] NCCHC requires jails 
to maintain one physician on-site for 3.5 hours a week for every 100 
inmates, and as of April 2003, CCHPS exceeded this standard by having 
one physician on-site for about 4.3 hours a week for every 100 
inmates.[Footnote 42] Until April 2003, DoC established required 
staffing levels for CCHPS as a part of its contract, but the contract 
now allows CCHPS, with DoC's approval, to adjust staffing levels in 
response to inmate population changes.

Cost in 2003 Reflected Addition of the CTF and Change to a Per Diem 
Pricing Structure:

In 2003, the total cost for medical services in the Jail and the CTF 
was about $15.8 million;[Footnote 43] over the course of that year 
17,431 inmates were admitted to both facilities.[Footnote 44] In the 
same year, DoC consolidated medical services for CTF inmates into the 
contract for services for Jail inmates. It also introduced a daily per 
inmate pricing structure--known as per diem pricing--to calculate the 
rates paid to CCHPS. This pricing structure uses a per diem rate 
schedule, which is a sliding scale of prices that declines slightly as 
the combined inmate population increases. The schedule starts at $14.75 
per inmate when the inmate population is below 2,200, and incrementally 
falls to $13.00 per inmate when the population exceeds 3,200. For 
example, if the combined population on a particular day were 2,000 
inmates, the per diem rate would be $14.75 and the total cost to DoC 
for that day would be $29,500. According to DoC officials, the per diem 
rate declines when the inmate population rises to reflect economies of 
scale. Over the course of 2003, the per diem rate charged to DoC for 
services at the jail and the CTF averaged $13.28 per inmate.

The per diem pricing structure has simplified DoC's contract 
administration by generally eliminating the need for a reconciliation 
process. Prior to April 2003, the contract required that DoC and CCHPS 
complete quarterly reconciliations to determine the difference between 
CCHPS's expected staff costs at the beginning of the contract year and 
CCHPS's actual staff costs during the year.[Footnote 45] These 
differences resulted primarily from inmate population changes. However, 
as DoC and CCHPS negotiated the final amount of each reconciliation, 
the process became increasingly lengthy and several unresolved 
reconciliations accumulated. Over the first 3 years of the contract, 
for example, DoC completed only 4 of the 12 scheduled reconciliations. 
When the per diem pricing structure was implemented in 2003, all 
incomplete reconciliations were resolved in a final reconciliation 
settlement.

Conclusions:

DoC has provided a broad range of medical services to inmates at the 
Jail and the CTF since the receivership ended in September 2000. 
CCHPS's medical services have generally met the contract's requirements 
for access to care and quality, and CCHPS has demonstrated a commitment 
to providing inmates with the services they need by adding on-site 
specialty clinics to improve access and continuity of care. CCHPS also 
regularly and accurately monitors its services to ensure that it is 
providing appropriate care. However, CCHPS has not always met all 
contract requirements for service delivery and quality improvement 
activities.

Although DoC has taken an important step toward ensuring the quality of 
services that CCHPS provides to inmates by retaining the independent 
reviewer, it has not taken several other actions that would help it 
better oversee the care that inmates receive. For example, DoC has 
limited its ability to hold CCHPS accountable for meeting the contract 
requirements that are linked to monetary damages. For monetary damages 
to be a viable oversight and contract enforcement mechanism, DoC would 
need to obtain data that demonstrate whether CCHPS is providing 
required services to the minimum percentage of the inmate population 
stipulated by the contract. However, DoC has not collected these data. 
DoC would also need to develop formal procedures for assessing CCHPS's 
compliance with the requirements and for imposing monetary damages if 
they are warranted.

Furthermore, DoC has not enforced the requirement that CCHPS regularly 
submit progress reports describing how it is correcting problems 
identified through performance monitoring, including any problems that 
may place CCHPS out of compliance with the contract. If CCHPS provided 
this information, DoC could ensure that CCHPS promptly took corrective 
action to respond to problems identified by the independent reviewer or 
CCHPS's own monitoring, such as CCHPS's failure to promptly follow up 
on abnormal chest x-ray results. Having the capacity to enforce the 
contract requirements linked with monetary damages and requiring CCHPS 
to submit regular progress reports would strengthen DoC's ability to 
ensure that CCHPS provides important medical services to inmates.

Recommendations for Executive Action:

To help ensure that CCHPS provides required medical services to inmates 
of the District of Columbia Jail and the CTF, we recommend that the 
Mayor require the Director of DoC to take the following two actions:

* Develop formal procedures--including collection of needed data--to 
regularly assess whether CCHPS's performance meets the contract 
requirements that are linked to monetary damages and to impose these 
damages.

* Ensure that CCHPS submits to DoC the required quarterly and annual 
progress reports, which should describe identified problems and the 
actions CCHPS has taken to correct them.

Agency Comments and Our Evaluation:

We provided a draft of this report to DoC for comment. In its response 
DoC did not comment on our recommendations, but provided additional 
information about its contract with CCHPS and medical services for 
inmates of the Jail and the CTF. In addition, DoC elaborated on its 
oversight of medical services provided by CCHPS. (DoC's comments are 
reprinted in app. IV.)

DoC emphasized in its comments that the independent reviewer acts at 
the request and on behalf of the agency. We noted in the draft report 
that DoC's hiring of the independent reviewer was an important step 
toward ensuring the quality of CCHPS's services and described the 
independent reviewer's role in DoC's oversight of CCHPS. DoC expressed 
concern that the issues discussed in the independent reviewer's reports 
are intended to identify opportunities for CCHPS to improve, but that 
the draft report portrayed them as problems or deficiencies. While some 
issues raised by the independent reviewer could be characterized as 
opportunities for service improvement, we found that others indicated 
performance shortfalls related to specific contract requirements.

In its comments, DoC discussed our finding that CCHPS has not regularly 
submitted the quarterly and annual reports required by the contract; 
these reports are to provide DoC with information on problems 
identified by CCHPS's performance monitoring or by the independent 
reviewer and on CCHPS's corrective actions. DoC stated that instead of 
the quarterly reports, it relies on certain monthly reports and regular 
verbal communication. DoC's comments describe two types of monthly 
reports, one providing various data on off-site services and the other 
relating to two performance measures reported to the Office of the 
Mayor. However, undocumented verbal communications and these narrowly 
focused monthly reports are not a substitute for the quarterly progress 
reports called for in the contract and do not enable DoC to ensure that 
CCHPS is addressing identified problems. DoC's comments acknowledge 
that CCHPS has not submitted all required annual reports. We do not 
agree that the information provided in the December 2002 report on the 
reconciliation of CCHPS's expected and actual costs, which DoC cites in 
its comments, provided DoC with the type of information required in the 
annual progress reports. For example, this report contains no 
information about how CCHPS planned to improve its performance in 
screening and treating female inmates for chlamydia and gonorrhea.

DoC highlighted its role in reducing the cost of medical services 
provided to inmates by CCHPS. In the final report we provided 
additional information on DoC's role. DoC also noted that the average 
daily cost of services decreased from about $19 to about $13, which we 
stated in our draft report, and that this will result in savings over 
the remaining life of the contract. However, while the average daily 
cost per inmate in 2003 was $13.32, under the current rate schedule, 
daily per inmate costs may range from $13.00 when the combined Jail and 
CTF population exceeds 3,200 to $14.75 when the inmate population is 
below 2,200. Therefore, costs over the remaining life of the contract 
will depend largely on the inmate population.

In response to DoC's comments, we replaced the term "financial 
penalties" with "monetary damages." While the comments state that DoC 
has other remedies for contract nonperformance, we believe that the 
authority to impose monetary damages is also a useful means of ensuring 
CCHPS's compliance with the contract.

In its comments, DoC described changes in the District's health care 
system that have affected the provision of off-site medical services 
for inmates. Because the focus of our report was on services provided 
by CCHPS through its contract with DoC, a detailed discussion of these 
developments was not within the scope of the report. DoC also stated 
that there was a past study on delays in obtaining off-site 
appointments for inmates and that there is no need to conduct an 
additional study. The draft report did not recommend that DoC conduct 
an additional study, but reported that DoC and the independent reviewer 
have identified problems with access to off-site services and that DoC 
has not collected data on delays.

We incorporated other information provided by DoC in its comments on 
our draft report where appropriate.

As agreed with your office, unless you publicly announce its contents 
earlier, we plan no further distribution of this report until 30 days 
after its issue date. At that time, we will send copies to the DoC 
Director, interested congressional committees, and other parties. We 
will also make copies available to others on request. In addition, the 
report will be available at no charge on the GAO Web site at http://
www.gao.gov. If you or your staff have any questions about this 
report, please call me at (202) 512-7119. Another contact and key 
contributors are listed in appendix V.

Sincerely yours,

Signed by: 

Marcia Crosse: 
Director, Health Care--Public Health and Military Health Care Issues:

[End of section]

Appendix I: Scope and Methodology:

We examined the medical services provided by the Center for 
Correctional Health and Policy Studies, Inc. (CCHPS) to inmates at the 
Jail and the Correctional Treatment Facility (CTF), including CCHPS's 
internal monitoring; the District of Columbia Department of 
Corrections' (DoC) oversight of those services; CCHPS's contract 
compliance; and the cost of services under the contract. To provide 
information on CCHPS's and DoC's activities, we reviewed documents and 
interviewed officials from those two organizations. DoC documents we 
reviewed included contracting documents such as the original request 
for proposals and subsequent modifications, reports of inmate 
population volume, and specialty clinic utilization statistics. In 
reviewing DoC's activities, we assessed DoC's internal controls related 
to the contract with CCHPS. CCHPS documents we reviewed included 
policies and procedures, staffing plans, annual progress reports, and 
quarterly performance analyses. We also interviewed the independent 
reviewer hired by DoC and analyzed the reviewer's quarterly reports to 
examine CCHPS's medical services and CCHPS's quality improvement 
activities. In addition, we analyzed documents and interviewed 
officials from the National Commission on Correctional Health Care and 
the American Correctional Association to obtain information on their 
correctional health care accreditation standards, their accreditation 
review processes, and their findings on DoC facilities. We also 
reviewed our previous work on medical services at the Jail. We reviewed 
issues related to medical services provided to CTF inmates only since 
April 2003, when DoC expanded its contract with CCHPS to include 
medical services for inmates at that facility.

To obtain information on inmate complaints about medical services the 
contract requires CCHPS to provide and on CCHPS's responses to these 
complaints, we conducted an independent analysis of randomly selected 
samples of grievances submitted by inmates at the Jail and the CTF. Of 
the 201 grievances at the Jail and the 168 grievances at the CTF during 
the period April 1, 2003, through October 31, 2003, we randomly 
selected 75 grievances for each analysis, for a total sample size of 
150. DoC was able to provide us with the detailed information needed 
for our analysis on 72 of the 75 grievances selected from the Jail and 
on 72 of the 75 grievances selected from the CTF. Grievances for which 
DoC could not provide the requested information were excluded from each 
analysis. For both the Jail and the CTF samples of inmate grievances, 
we analyzed the timeliness of CCHPS's response, the subject of the 
grievance, and the extent to which CCHPS's response addressed the 
principal areas of concerns cited in the complaint. The final sample 
size of 144 grievances produced estimates about types of grievances and 
timeliness of responses with a margin of error of plus or minus 5.0 
percent at the 95-percent confidence level.

Although we focused principally on medical services provided by CCHPS 
under its contract with DoC, we also obtained information about inmate 
services that are not part of the CCHPS contract--such as off-site 
services--by reviewing documents and interviewing officials from CCHPS, 
DoC, and the District of Columbia Department of Health (DoH). Documents 
we reviewed included contracts between DoH and community providers and 
utilization data on off-site services provided to inmates. We also 
interviewed officials from the District of Columbia Department of 
Mental Health, a community health care provider, and groups providing 
legal services to inmates.

To calculate the total annual and average per inmate costs of the 
medical services that CCHPS provided, we reviewed documents such as 
DoC's budget records, purchase order summaries, contract pricing 
modifications, and CCHPS invoices. We interviewed officials from the 
District of Columbia Office of Contracting and Procurement; DoC, 
including its Office of the Chief Financial Officer; and CCHPS. We also 
examined independently audited accounting data from the District of 
Columbia Office of Financial Operations and Systems. We determined that 
the medical services cost information we reviewed was reliable, based 
on documentation provided by the District of Columbia Office of 
Financial Operations and Systems stating that the source of the data 
was the System of Accounting and Reporting, the District of Columbia's 
official accounting records, which is subject to an independent audit 
each year. We made certain assumptions to define four comparable 12-
month periods that approximated the DoC-CCHPS contract year. Although 
there are slight differences between the time periods defined for total 
costs and inmate population averages, the length of each period was 1 
year. Total cost data for 2000, 2001, and 2002 are from March 12 of 
each year through March 11 of the following year, coinciding with the 
DoC-CCHPS contract year, while inmate population data for 2000, 2001, 
and 2002 are from April 1 of each year through March 31 of the 
following year, approximating the DoC-CCHPS contract year. Total cost 
and inmate population data for 2003 are from April 1, 2003, through 
March 31, 2004, approximating the DoC-CCHPS contract year. We 
calculated the average daily inmate population for each annual period 
by first calculating an average daily population for each of the 12 
months within the period, and then averaging the monthly averages.

We applied an accrual methodology to calculate the total costs 
associated with each annual period. The DoC-CCHPS contract during the 
years 2000 through 2002 specified a fixed contract price at the 
beginning of each year, subject to reconciliations during the year. 
Reconciliations conducted during contract years often resulted in 
adjustments to DoC payments in a subsequent contract year. By applying 
an accrual method, we attributed reconciliation costs to the years from 
which they originated rather than the years in which they were paid. We 
performed our work from August 2003 through June 2004 in accordance 
with generally accepted government auditing standards.

[End of section]

Appendix II: Requirements Linked to Monetary Damages Provisions in the 
CCHPS Contract:

The contract between DoC and CCHPS contains certain requirements that 
CCHPS must meet. If these requirements are not met, DoC has the 
authority to impose specified monetary damages on CCHPS. Table 2 
summarizes the requirements linked with monetary damages.

Table 2: Summary of Contract Requirements with Monetary Damages 
Provisions:

Medical services; 
Monetary damages may be imposed if: Less than 95 percent of Jail intake 
health screenings are completed within 24 hours; 
Damages calculation method: $200 times the number of occurrences during 
the period being measured[A].

Medical services; 
Monetary damages may be imposed if: Less than 95 percent of eligible 
inmates' tuberculosis skin tests are placed and read within the 
prescribed time frame. For this item "eligible inmates" are inmates in 
the Jail or the CTF more than 96 hours; 
Damages calculation method: $200 times the number of occurrences during 
the period being measured[A].

Medical services; 
Monetary damages may be imposed if: Less than 95 percent of eligible 
inmates with positive tuberculosis skin tests receive timely follow-up. 
For this item "eligible inmates" are inmates in the Jail or the CTF 
more than 30 days; 
Damages calculation method: $100 times the number of occurrences during 
the period being measured[A].

Medical services; 
Monetary damages may be imposed if: More than 10 percent of the 
eligible inmates known to have an abnormal blood pressure do not have 
a plan to control blood pressure levels documented in the medical 
record within 14 days. For this item "eligible inmates" are inmates in 
the Jail or the CTF more than 15 days; 
Damages calculation method: $100 times the number of occurrences above 
the 10-percent threshold during the period being measured[A].

Medical services; 
Monetary damages may be imposed if: More than 15 percent of the 
eligible inmates known to have human immunodeficiency virus (HIV) have 
a clinical status warranting treatment for prevention of pneumonia, and 
are not receiving it within 2 weeks of identification of the need for 
treatment. For this item "eligible inmates" are inmates in the Jail or 
the CTF more than 15 days; 
Damages calculation method: $100 times the number of occurrences above 
the 15-percent threshold during the period being measured[A].

Medical services; 
Monetary damages may be imposed if: More than 15 percent of the 
eligible diabetics tested as part of an audit are found to have a 
Hemoglobin A1c[B] level greater than 7 percent and there is no 
documented clinical strategy to improve the outcome. For this item 
"eligible inmates" are inmates in the Jail or the CTF more than 15 days 
who are known to have diabetes; 
Damages calculation method: $100 times the number of occurrences above 
the 15-percent threshold during the period being measured[A].

Medical services; 
Monetary damages may be imposed if: Less than 95 percent of eligible 
inmates with chronic illness (hypertension, diabetes, HIV, asthma, 
seizures) are followed clinically according to the chronic care 
guidelines and seen at least every 90 days; 
Damages calculation method: $100 times the number of days for each 
inmate not followed in the chronic care clinic.

Infection control; 
Monetary damages may be imposed if: The contractor does not maintain a 
DoC-approved infection control plan within 1 month of the contract 
award; 
Damages calculation method: $500 times the number of days the approved 
infection control plan is not in effect.

Staffing; 
Monetary damages may be imposed if: The contractor does not maintain 
valid and current licenses and certifications as required for all 
health care providers; 
Damages calculation method: $500 times the number of occurrences per 
day for each healthcare provider, calculated from the date of the 
finding.

Staffing; 
Monetary damages may be imposed if: The contractor does not have 
evidence of annual tuberculosis screening and hepatitis B immunization 
for all health care staff. The contractor's direct patient care 
personnel fail to maintain current cardiopulmonary resuscitation 
certification; 
Damages calculation method: None identified.

Staffing; 
Monetary damages may be imposed if: The contractor leaves vacant a 
principal leadership position[C] for greater than 60 days. If a 
qualified individual is performing the functions of a principal 
leadership position, this position is not considered vacant; 
Damages calculation method: One and one-half the salary rate per hour 
plus fringe hourly rate defined in the contract[D] times the number of 
required hours the position is left vacant after 60 days.

Staffing; 
Monetary damages may be imposed if: Monetary damages may be imposed if: 
The contractor leaves vacant any required position as accepted by DoC 
in the contract for greater than 120 days; 
Damages calculation method: Damages calculation method: One and one-
half the salary rate per hour plus fringe hourly rate defined in the 
contract[D] times the number of required hours the position is left 
vacant after 120 days.

Source: GAO analysis of the District of Columbia Department of 
Corrections documents.

[A] The contract states that these damages will not exceed a 30-day 
period. However, DoC officials were not able to explain whether this 
means that the period being measured is not to exceed 30 days or that 
the damages cannot be imposed for a period exceeding 30 days.

[B] Hemoglobin A1c is a blood sugar average used to determine how well 
diabetes is being controlled. The contract defines a normal hemoglobin 
A1c level as less than 6.8 percent.

[C] Principal leadership position is defined as the medical director, 
mental health director, health services administrator, executive 
administrator, or director of nursing.

[D] According to DoC officials, the hourly rates are defined using the 
most recent wage rates specified in the contract.

[End of table]

[End of section]

Appendix III: Performance Assessment Instruments Used to Monitor 
Services Provided by CCHPS:

In 2000, DoC, CCHPS, and the independent reviewer hired by DoC to 
monitor CCHPS's medical services developed performance assessment 
instruments to allow them to determine how consistently CCHPS delivered 
required medical services to inmates and whether it conducted 
activities included in its quality improvement program.[Footnote 46] 
Table 3 describes the measures included in the performance assessment 
instruments, as well as the samples measured and the sources of the 
samples. When reviewing services, the person conducting the assessment 
determines whether each bulleted measure has been met.

Table 3: Information on Performance Assessment Instruments Used to 
Monitor CCHPS's Services:

Service area/type: Intake services: Intake evaluation; 
Measure: 
* Performed complete health assessment by licensed physician, physician 
assistant (PA), or nurse practitioner (NP) at intake to the Jail, 
including a physical and oral examination and review of bodily systems, 
such as the cardiovascular system; a medical and substance abuse 
history; check of vital signs (breathing rate, pulse, temperature); and 
analysis of a urine sample; 
* Placed tuberculosis skin test, if applicable, and read within 48-72 
hours; performed chest x-ray, if applicable, within 24 hours; 
* Documented syphilis lab test result; 
* Conducted further mental health evaluation within 24 hours, if 
indicated by positive response to screening questions asked at intake; 
Sample used: 20 randomly selected inmate medical records[A]; 
Source of sample: General inmate population.

Service area/type: Intake services: Intake evaluation; 
Measure: 
* Performed pregnancy test; 
Sample used: 10 randomly selected inmate medical records; 
Source of sample: Service area/ type: Female inmate population.

Service area/type: Primary medical care: Asthma care; 
Measure: 
* At intake or within the past 3 months, conducted measurement of the 
amount of air an inmate can push out of his/her lungs; 
Sample used: 10 randomly selected inmate medical records[B]; 
Source of sample: Inmates with asthma.

Service area/type: Primary medical care: Asthma care; 
Measure: 
* Followed chronic disease guideline; 
assessment included degree to which disease has been controlled and 
strategy to improve outcome if degree of control is fair or poor or if 
patient's status has worsened[C]; 
Sample used: First 5 of the 10 randomly selected inmate medical 
records reviewed above.

Service area/type: Primary medical care: Diabetes care; 
Measure: 
* Measured blood sugar levels on intake; 
Sample used: 10 randomly selected inmate medical records[B]; 
Source of sample: General inmate population.

Service area/type: Primary medical care: Diabetes care; 
Measure: 
* Performed blood test that measures average blood sugar over a period 
of time (Hemoglobin A1c), and if test indicated diabetes, a clinical 
strategy for treating the inmate was documented in medical record 
within 40 days of admission to facility or within past 3 months; 
Sample used: 10 randomly selected diabetic inmate medical records; 
Source of sample: Inmates with diabetes.

Service area/type: Primary medical care: Diabetes care; 
* Followed chronic disease guideline; 
assessment included degree to which disease has been controlled and 
strategy to improve outcome if degree of control is fair or poor or if 
patient's status has worsened[C]; 
Sample used: First 5 of the 10 randomly selected diabetic inmate 
medical records reviewed above.

Service area/type: Human Immunodeficiency Virus (HIV) care; 
Measure: 
* Tested for level of certain white blood cells with CD4 marker[D] and 
HIV viral count within 40 days or within the past 3 months; 
* Offered treatment for prevention of pneumonia within 2 weeks if level 
of certain white blood cells with CD4 marker is low; 
* Considered or ordered anti-HIV drugs within 2 weeks if level of 
certain white blood cells with CD4 marker is moderately low; 
* Followed chronic disease guideline; 
assessment included degree to which disease has been controlled and 
strategy to improve outcome if degree of control is fair or poor or if 
patient's status has worsened[C]; 
* Vaccinated against pneumococcal infection including pneumonia; 
* Administered influenza vaccine during flu season, October - February; 
Sample used: 10 randomly selected inmate medical records[B]; 
Source of sample: Inmates with HIV.

Service area/type: Hypertension care; 
Measure: 
* Noted blood pressure reading at intake; 
Sample used: 10 randomly selected inmate medical records[B]; 
Source of sample: General inmate population.

Service area/type: Hypertension care; 
Measure: 
* Initiated treatment, or plan to treat, within 14 days of 
identification of high blood pressure; 
Sample used: 10 randomly selected medical records of inmates with high 
blood pressure; 
Source of sample: Inmates with high blood pressure.

Service area/type: Hypertension care; 
Measure: 
* Followed chronic disease guideline; 
assessment included degree to which disease has been controlled and 
strategy to improve outcome if degree of control is fair or poor or if 
patient's status has worsened[C]; 
Sample used: First 5 of the 10 randomly selected medical records of 
inmates with high blood pressure reviewed above.

Service area/type: Positive tuberculosis skin test cases; 
Measure: 
* Clinical evaluation of inmate and treatment decision made within 14 
days[C]; 
Sample used: 10 randomly selected inmate medical records[E]; 
Source of sample: Inmates with positive tuberculosis skin tests.

Service area/type: Nursing sick call performance; 
Measure: 
* Assessment of inmate's condition appropriate to chief complaint[F]; 
* Recorded relevant vital signs, such as breathing rate, pulse, and 
temperature[F]; 
* Treatment plan appropriate to condition[F]; 
Sample used: 2 inmate medical records from each of 18 inmate housing 
units[G]; 
Source of sample: Sick call requests from inmates.

Service area/type: Mental Health Services: Chronic mental health care; 
Measure: 
* Psychiatric progress evaluations conducted by psychiatrist every 2 
weeks; 
* Inmate's interdisciplinary treatment plan reviewed by staff within 4 
weeks; 
Sample used: 10 randomly selected inmate medical records; 
Source of sample: Inmates in male inpatient mental health housing 
units.

Service area/type: Mental Health Services: Acute mental health care; 
Measure: 
* Initial mental health assessment done by clinical staff within 7 
working days; 
* Initial psychiatric evaluation done by psychiatrist within 24 hours; 
* Subsequent psychiatric progress evaluations by psychiatrist every 
week; 
* Developed interdisciplinary treatment plan within 5 working days; 
* Inmate's interdisciplinary treatment plan reviewed within 4 weeks; 
Sample used: 10 randomly selected inmate medical records; 
Source of sample: Inmates in male inpatient mental health housing 
units.

Service area/type: Mental Health Services: Mental Health Services: 
Abnormal Involuntary Movement Scale (AIMS) testing; 
Measure: 
* Documented testing (AIMS test) to determine possible side effects of 
antipsychotic drugs within 30 days of intake or within past 6 months; 
Sample used: 10 inmate records from male inpatient mental health 
housing unit and 10 inmate medical records from general population; 
Source of sample: Pharmacy list of inmates taking antipsychotic drugs.

Service area/type: Mental Health Services: Mental Health Services: 
Appropriate medication for mental health treatment; 
Measure: 
* Diagnosis consistent with use of medication[H]; 
Sample used: 10 randomly selected inmate medical records; 
Source of sample: Pharmacy list of inmates taking certain medications, 
e.g., for schizophrenia.

Service area/type: Mental Health Services: Level of certain drugs for 
bipolar disorder (depakote and lithium); 
Measure: 
* Reported level of medications every 3 months; 
* Physician review of medication levels with appropriate response noted 
in medical records[H]; 
Sample used: 10 randomly selected inmate medical records; 
Source of sample: Pharmacy list of inmates receiving depakote and 
lithium.

Service area/type: Specialty care: Urgent care performance; 
Measure: 
* Care timely[F]; 
* Documented appropriate vital signs, such as breathing rate, pulse, 
and temperature[F]; 
* Appropriate assessment of condition and plan to treat[F]; 
Sample used: 10 urgent care [VISITSI]; 
Source of sample: Inmates seen in urgent care.

Service area/type: Specialty care: Specialty clinic services; 
Measure: 
* Progress note in medical record reflects need for consultation; 
* Consultation ordered by physician, PA, or NP; 
* Consultation accomplished within 30 days of order; 
* Documentation of appropriate follow-up consistent with consultant's 
recommendation or rationale for not following consultant's 
recommendation; 
Sample used: 5 randomly selected inmate medical records from each 
specialty clinic[J]; 
Source of sample: Inmates seen in specialty clinic.

Service area/type: Specialty care: Communicable disease treatment; 
Measure: 
* Screened female inmates for gonorrhea and chlamydia within 14 days of 
admission to the facility; 
Sample used: 10 randomly selected inmate medical records; 
Source of sample: General inmate population.

Service area/type: Specialty care: Communicable disease treatment; 
Measure: 
* Patients with positive test for syphilis received appropriate 
treatment (based on federal guidelines) within 5 days of receiving 
laboratory report[C]; 
* Patients with positive test for gonorrhea received appropriate 
treatment (based on federal guidelines) within 3 days of receiving 
laboratory report[C]; 
* Patients with positive test for chlamydia received appropriate 
treatment (based on federal guidelines) within 3 days of receiving 
laboratory report[C]; 
Sample used: 10 randomly selected inmate medical records for each 
disease; 
Source of sample: Inmates identified as positive for gonorrhea, 
chlamydia, or syphillis.

Service area/type: Dental care; 
Measure: 
* Timeliness of treatment appropriate to condition: Trauma/symptoms of 
infection or intense pain - within 24 hours; 
Any other acute condition - within 7 days; 
* Documentation that oral health education materials were provided to 
patients; 
* Clear and complete documentation of visits and procedures, including 
medical history; 
Sample used: 10 randomly selected inmate medical records; 
Source of sample: Inmates seen in dental clinic.

Service area/type: Ancillary services: Chest X-ray reporting and 
follow-up; 
Measure: 
* Timely reporting of chest x-ray results, appropriate clinician 
acknowledgment of results, and appropriate follow-up of abnormal chest 
x-ray results within 48 hours[C]; 
Sample used: 10 randomly selected inmate medical records; 
Source of sample: Log of all x-rays taken.

Service area/type: Ancillary services: Nonchest X-ray reporting and 
follow-up; 
Measure: 
* Timely reporting of x-ray results, appropriate clinician 
acknowledgment of results, and appropriate follow-up of abnormal x-ray 
results within 48 hours of when the x-ray is performed[C]; 
Sample used: 10 randomly selected inmate medical records; 
Source of sample: Log of all x-rays taken.

Service area/type: Ancillary services: Laboratory services[K]; 
Measure: 
* Report laboratory results within 24 hours, as appropriate; 
* Clinical acknowledgment of laboratory results and appropriate 
clinical response[C]; 
Sample used: 10 randomly selected inmate medical records; 
Source of sample: No source identified in performance assessment 
instruments.

Service area/type: Ancillary services: Medication administration 
records (MAR)[L]; 
Measure: 
* Number of omissions in inmate records in the medication 
administration books; 
* Number of cases in which inmates refused medications on three 
consecutive occasions noted in the medication administration books; 
* Number of cases in which inmates who refused medications on three 
consecutive occasions received appropriate follow-up[M]; 
Sample used: 5 MARs books; 
Source of sample: MARs books.

Service area/type: Quality improvement activities: Credentialing; 
Measure: 
* Validated current license for physician, PA, and NP staff and U.S. 
Drug Enforcement Administration registration for physician and NP 
staff; 
* Validated current license - nursing staff; 
* Validated current license - dental staff; 
* Validated current license - mental health staff; 
Sample used: 10 randomly selected clinician files from each provider 
type, and from the combined physician/PA/NP staff; 
Source of sample: Nursing files, dental files, mental health files, 
and combined physician/PA/NP files.

Service area/type: Quality improvement activities: Complaints and 
grievances; 
Measure: 
* Analyzed trends in terms of numbers and category distribution of 
complaints and grievances; 
* Percentage of complaints and grievances appropriately addressed 
within 14 days; 
Sample used: All medical grievances; 
Source of sample: CCHPS log of inmate grievances.

Service area/type: Quality improvement activities: Quality improvement 
program; 
Measure: 
* Annual work plan; 
* Activities reviewed include management of communicable diseases, 
pharmacy and therapeutics, reviews of inmate deaths, clinical 
guidelines, and adherence to standards. In addition, there is regular 
performance measurement of access to and availability, continuity, and 
coordination of care; 
complaints about care; 
and acute, chronic, and communicable disease care. Focus studies should 
be performed where problems exist. Barriers to care should be 
identified and interventions should be designed to reduce the barriers. 
Remeasurement should occur to document meaningful improvement; 
Sample used: Not applicable; 
Source of sample: Not applicable. 

Source: GAO analysis of the Center for Correctional Health and Policy 
Studies, Inc. information.

[A] This sample is limited to the first eight if all eight have been 
done appropriately. The sample is chosen from the 2-week period 
beginning 4 weeks prior to the review.

[B] The sample is chosen from the inmates seen within the 3 months 
prior to the review.

[C] Performance assessment requires clinical judgment by physician, PA, 
or NP.

[D] CD4 cells are a type of white blood cell that fights infection. HIV 
destroys CD4 cells, which weakens the immune system.

[E] The sample is chosen from the inmates seen within the month prior 
to the review.

[F] Performance assessment requires clinical judgment by physician, PA, 
NP, or registered nurse (RN).

[G] The sample covers 3 days within the 2-week period prior to the 
review.

[H] Performance assessment requires clinical judgment by physician.

[I] The sample is chosen from 3 days within the 3-week period prior to 
the review.

[J] This sample is composed of five records from each specialty clinic 
within the 3 months prior to the review. The specialty clinics are the 
cardiology, dermatology, eye, gynecology, neurology, orthopedics, 
podiatry, and pulmonary clinics.

[K] Because of problems, such as difficulty linking CCHPS's 
computerized inmate medical records to laboratory results, these 
measures have not been used in recent reviews, and are being reviewed.

[L] MARs are written records of medications ordered for and distributed 
to inmates. MARs for each inmate are placed in larger "books," 
separated by housing unit and organized alphabetically by inmate, which 
are then taken to the housing units when medications are distributed. 
RNs distributing medications to inmates are required to note on the MAR 
that the inmate received the medication, or to provide information on 
why the medication was not given to the inmate.

[M] Inmates who refuse three or more consecutive doses of medication or 
refuse to take medications consistently are referred to their primary 
provider for evaluation.

[End of table]

[End of section]

Appendix IV: Comments from the District of Columbia Department of 
Corrections:

GOVERNMENT OF THE DISTRICT OF COLUMBIA: 
DEPARTMENT OF CORRECTIONS:

Office of the Director:

June 22, 2004:

Ms. Marcia Crosse, Director: 
Health Care Public Health and Military Health Care Issues: 
U.S. General Accounting Office: 
441 G Street, N.W.: 
Washington, D.C. 20548:

Dear Ms. Crosse:

Enclosed please find the Department of Corrections' comments to the 
General Accounting Office Draft Report on Medical Services at the 
Central Detention Facility. As requested, we have reviewed the draft 
report and are providing supplemental information relating to medical 
services.

We appreciate the efforts of your staff while conducting the study. We 
look forward to continuing our cooperative relationship regarding any 
concerns relating to medical services at the Central Detention 
Facility. If you have questions or need any additional information, 
please contact me at (202) 671-2128 or Brenda Baldwin-White, Deputy 
General Counsel at (202) 671-2042.

Sincerely,

Signed by: 

Odie Washington: 
Director: 

OW/Is:

Enclosure:

RESPONSE TO THE GENERAL ACCOUNTING OFFICE (GAO) REPORT ON MEDICAL 
SERVICES AT THE DISTRICT OF COLUMBIA CENTRAL DETENTION FACILITY:

The D. C. Department of Corrections (DOC) welcomes the opportunity to 
respond to and supplement the findings in the Draft Report on Medical 
Services at the Central Detention Facility. The primary findings were 
based on the Contract, which is the original Request for Proposal (RFP) 
developed by the Court Appointed Receiver in 1999. The Center for 
Correctional Health and Policy Studies, Inc., (CCHPS), a District of 
Columbia not-for-profit corporation, made the Best and Final Offer. The 
provision of medical and mental health services, by CCHPS commenced on 
March 12, 2000 at the CDF. The GAO Draft Report also focused on the 
quarterly reports of the Department of Corrections' medical expert 
consultant. Therefore and accordingly, the following responses are 
offered.

1. The Contract, based on the 1999 RFP:

The entire landscape for accessing medical care changed in the early 
summer of 2001, when DCGH, the public hospital closed and medical care 
was privatized for the residents of the District of Columbia. Oversight 
needs shifted with the paradigm. DOC made a management decision to have 
CCHPS make monthly reports in lieu of quarterly reports. There was a 
critical need to revamp the reporting requirements of the 1999 RFP to 
successfully meet the new demands of the Memorandum of Understanding 
with the Department of Health/Health Care Safety Net Administration and 
their contract with Greater Southeast Community Hospital, (GSCH), the 
prime vendor. The D. C. DOC was placed in the role as the intermediary 
in arranging for all hospital and other medical services.

Clearly, the RFP never anticipated the closure of the District of 
Columbia General Hospital (DCGH) when it was developed. The closure of 
the DCGH and the new methodology for payment dictated that new and 
immediate solutions be identified and implemented to ensure continuity 
of care for the inmate population of the 
DOC, as well as, employing mechanisms and measures for operation within 
the new system. DCGH was the designated facility for external medical 
care for primary, secondary, tertiary and specialized care, and was 
also conveniently located on the same campus. Part and parcel to the 
specialized care was a twenty (20) bed Locked Ward for inpatient care. 
Transporting inmate patients to DCGH did not present many public safety 
challenges or overtime expenditures, and its proximity to the Central 
Detention Facility made it immediately accessible for emergent, urgent 
and routine ambulatory visit.

As part of the new reporting requirements implemented, a Utilization 
Management Nurse was stationed on-site at Greater Southeast Community 
Hospital (GSCH) to provide a gatepost for inmate in and outpatient 
activities. In lieu of written quarterly reports, daily patient 
summaries, monthly hospital 
discharges, (by facility), monthly surgical procedures, rank order of 
diagnoses were all gathered and tabulated monthly and forwarded to the 
DOC. DOC representatives met with the CCHPS staff regularly and 
conversed by telephone daily, sometimes two (2) and three (3) times per 
day, as dictated by the new and different health care issues that 
surfaced, as the new privatized system evolved. Many of the meetings 
and telephone calls also included, but were not limited to 
representatives from the DOH/HCSNA, GSCH and Chartered Health Care (the 
administrative service organization).

As a result of the above utilization management efforts instituted by 
DOC, the agency remained below the pre-established contractual 
benchmarks for inpatient and outpatient activity, thus resulting in 
savings of $1,000,698 for Reconciliation of Contract Year One of the 
DOH/HCSNA contract with GSCH. These savings, paid by GSCH, were passed 
directly from DOC, into the District of Columbia coffers to help to 
offset the deficit in fiscal year 2003.

Additional monthly reporting by CCHPS included two (2) performance 
measures. These performance measures went to the Mayor and Deputy Mayor 
for Public Safety and Justice through the Director of DOC. One of the 
performance measures was to maintain accreditation in the National 
Commission on Correctional Health Care (NCCHC) and the other was to 
conduct medical screenings or comprehensive medical evaluations on 100% 
of all intakes within 36 hours.

The DOC, as an organization, met the challenges presented by the new 
privatized system with the development and implementation of new 
reporting requirements for successful operation in the new privatized 
health care system.

2. The Quarterly Reports of the DOC's Expert Medical Consultant/
Oversight - The expert medical consultant provided clinical oversight 
and direction for medical and mental health services at the Central 
Detention Facility, and when medical services were consolidated, the 
Correctional Treatment Facility. These services were provided at the 
request of DOC and on behalf of DOC. These quarterly reports gave a 
status report of medical and mental health care received by the inmate 
population. In addition, the findings of the expert medical consultant 
were further discussed and hammered out in the CCHPS Quarterly Quality 
Council meetings. DOC representatives were present at Quarterly Quality 
Council meetings.

The DOC relied heavily on the reports of the expert medical consultant 
and reviewed each report with the Medical Director of CCHPS. There is a 
perceived disagreement between the expert medical consultant and the 
Medical Director of CCHPS, due in part to the difference in management 
styles and diverse medical backgrounds. This is an acceptable 
professional difference. Each may address a medical service problem 
differently and this has been recognized by the DOC staff. During the 
continual monitoring process DOC weighed both opinions and 
directed CCHPS to proceed on a consensus direction for the self-
improvement recommendation. However, even with keeping these 
differences in mind, the DOC has periodically requested and received 
abatement plans from CCHPS. It should be further noted that the Medical 
Director sits on the DOC executive/senior staff and attends all 
meetings. During these meetings the Medical Director has raised issues 
and concerns to the executive staff that have been addressed by DOC 
management and vice-versa.

The expert medical consultant was, and currently remains, a significant 
partner for the clinical oversight function for the DOC. The quarterly 
clinical quality feedback that he provided is an integral part of the 
DOC's continuous quality assurance and self-improvement efforts to 
identify opportunities for self-improvement in health and medical 
services within the Department of Corrections, as explained in a 
September 5, 2003 letter to the GAO from the DOC. (See Attached Letter, 
Subject: Expert Medical Consultant's Reports.) The key points of the 
letter are quoted below.

"As we provide these reports to you, we note that areas identified for 
improvement are often seen as problems by those not familiar with the 
tenets of quality assurance, monitoring and auditing. In deed, there 
are those who would readily seek to exploit Dr. Greifinger's findings 
and recommendations for personal gain by initiating lawsuits based 
solely on those findings and recommendations without proof of any 
demonstrated harm to any inmates. Such lawsuits are often later 
declared frivolous, but nevertheless prove to be distracting and costly 
during their pendency. Moreover, misuse of reports such as these 
undermines their value as a management and quality assurance tool."

It appears that the opportunities identified for self-improvement 
listed in the reports were perceived as problems or deficiencies. This 
revelation is unfortunate for all involved in this process.

In addition to the new monthly reports that were requested and 
discussed under the section on the contract on page one of this report, 
quarterly reporting by CCHPS to DOC was made either verbally or through 
the quarterly reconciliation meetings. There were also a myriad of 
other meetings called by DOC.

Quarterly contract monitoring and auditing were also completed, as 
evidenced by the November 25, 2003 letter submitted to the General 
Accounting Office. (See attached letter, Subject: Contract Monitoring 
of Medical Services.) The letter clearly defines the following:

* The expert medical consultant's role is clearly established as 
oversight by and for DOC;

* The DOC provided the momentum and was the driving force in 
establishing the overall direction for the expert medical consultant, 
and:

* The monitoring of services conducted by DOC.

3. Annual Reporting - There appears to have been some confusion in 
regard to the timing and submission of annual reports. There was no 
annual report for the base year of the contract. The base year of the 
contract was March 12, 2000 through March 11, 2001. The annual report 
dated July 18, 2002, which was submitted to the DOC and subsequently to 
the General Accounting Office, was for Option 
Year One, March 12, 2001 through March It, 2002. The annual report for 
Option Year 2, March 12, 2002 through March 11, 2003, was partially 
covered in Option Year 2 Reconciliation Issues. Option Year 3, March 
12, 2003 through March 11, 2004, is now due and has a due date of June 
15, 2004. All future annual reports will be completed.

4. Cost Containment Efforts - The DOC and CCHPS have embarked upon 
projects to contain costs throughout the life of the contract. The 
following examples include, but are not limited to the highlights noted 
below.

The consolidation of the medical contracts at the Central Detention 
Facility and Correctional Treatment Facility was a colossal task for 
all those involved in this process. DOC made diligent efforts to have 
one medical care provider at the two (2) facilities for seamless 
medical care. In early 2002 this process was begun and in September 
2002, CCHPS became the provider for medical and mental health services 
at the Correctional Treatment Facility, contracting with the 
Corrections Corporation of America (CCA). The total consolidation of 
the contract was achieved in April 2003. The culmination of these 
diligent efforts changed the method of payment from one based on 
staffing to one based upon a per diem, according to inmate population. 
In essence, the average daily cost went from $19.00 per day to $13.00 
per day, which over the remaining life of the contract will result in 
substantial savings.

The Medical Director of CCHPS conducted a study which showed a delay in 
obtaining some specialty clinic appointments. From the day-to-day 
operations, DOC was aware of the delay and moved swiftly to obtain 
action in obtaining medical services for the inmate population. There 
is no need to conduct another study at this time. In another effort to 
establish quicker access to specialty medical care for the inmate 
population, to contain costs and in the interest of pubic safety, 
CCHPS' leadership staff identified medical services which had been 
curtailed by GSCH, DCGH and/or other providers and implemented in-house 
services, e. g., dermatology, endocrine, infectious disease and 
obstetrics/gynecology.

While CCHPS was a partner in controlling costs, primarily through 
reducing personnel expenditures, in large part, cost reduction was due 
to DOC's continuous review of the staffing and approving the staffing 
requirements. In addition, DOC reduced management costs to CCHPS by 
withdrawing the $400,000 annual management fee that was previously 
awarded to CCHPS. Other reductions were achieved by reviews of CCHPS' 
budgets that were presented to the DOC during renegotiations. Several 
items in the budget were disapproved by DOC, as the items did not 
benefit the cost objective (contract). Further, pharmacy costs were set 
aside for reconciliation on a six (6) months basis. Due to the surge in 
population, the DOC recognized that the contractor could not predict 
pharmacy costs and elected to treat this cost separately and not on a 
fixed fee basis.

Costs were decreased by and through the oversight provided by DOC.

S. Liquidated Damages:

The District of Columbia as a matter of policy does not impose 
penalties via the Liquidated Damages Clause, but attempts to recover 
costs the District would incur should the contractor not perform. For 
this reason the clause states "in place of actual damages" the District 
would access its estimated actual damages as specified in the contract. 
This is not a penalty but a cost recovery mechanism for the District, 
should the contractor not perform to the standard. The District has 
other remedies for non-performance such as termination for default.

6. Infection Control Plan:

The Infection Control Plan was initially reviewed and approved by the 
DOC. However, in the interest of obtaining clinical input, the plan was 
referred to the expert medical consultant for his input. The Infection 
Control Plan has now been fully approved and is currently being 
finalized for publication and distribution.

Thank you for the opportunity to respond to the Draft Report. 

[End of section]

Appendix V: GAO Contact and Staff Acknowledgments:

GAO Contact:

Helene F. Toiv, (202) 512-7162:

Acknowledgments:

In addition to the person named above, key contributors to this report 
were Emily Gamble Gardiner, Marc Feuerberg, Krister Friday, and Anne 
Montgomery.

FOOTNOTES

[1] The Jail is also known as the Central Detention Facility.

[2] The contract with CCHPS was renewable annually for up to 4 years 
after the initial contract year.

[3] See U.S. General Accounting Office, District of Columbia 
Receivership: Selected Issues Related to Medical Services at the D.C. 
Jail, GAO/T-GGD-00-173 (Washington, D.C.: June 30, 2000).

[4] This earlier report reviewed costs and services in Baltimore and 
Prince George's County, Maryland.

[5] While terms of incarceration may vary, under District of Columbia 
law, convictions for many misdemeanors can result in incarceration for 
up to 180 days. See e.g., D.C. Code  22-404;  22-1510;  22-3232;  
47-4101. In addition to pretrial detainees and convicted prisoners, the 
Jail and the CTF also house inmates waiting for transfer to other 
correctional facilities, including Federal Bureau of Prisons 
facilities, as well as inmates who have been returned to the District 
of Columbia area for various reasons, including parole hearings or 
court testimonies.

[6] See Campbell v. McGruder, 416 F.Supp. (D.D.C. May 24, 1976), 580 
F.2d 521 (D.C. Circ. 1978) and Inmates of D.C. Jail v. Jackson, 416 F. 
Supp 111 (D.D.C. May 24, 1976). The CTF was not part of these lawsuits.

[7] The instruments were developed jointly by the independent reviewer, 
CCHPS, and DoC.

[8] The Eighth Amendment to the Constitution of the United States 
prohibits "cruel and unusual punishment." The U.S. Supreme Court, in 
Estelle v. Gamble, concluded that "deliberate indifference to the 
serious medical needs of prisoners" violates this prohibition. 429 U.S. 
97 104 (1976). 

[9] Monetary damages, also referred to as liquidated damages, are 
amounts stipulated in a contract that a contractor agrees to pay for 
failing to comply with contractual requirements, such as requirements 
that work be completed by a certain time.

[10] There are currently over 3,000 jails nationwide. According to 
NCCHC, as of March 2004, approximately 232 jails had been accredited 
through its voluntary program. As of November 2003, approximately 165 
jails had been or were in the process of becoming accredited by ACA's 
voluntary program.

[11] This testimony focused only on the medical services receivership 
and the contract with CCHPS as it pertained to the Jail, and did not 
consider any issues related to the CTF. See GAO/T-GGD-00-173.

[12] We also reported that these services and staffing levels appeared 
to stem from court-ordered requirements.

[13] Sick call services consist of clinical services provided to 
inmates who have requested routine or nonemergency medical care. 
Inmates submit a form requesting to be seen during sick call and are 
scheduled to be seen by a nurse in sick call rooms located in the 
Jail's housing units. Inmates in the CTF are seen in a centralized 
location in the medical unit.

[14] Because tuberculosis occurs more frequently in correctional 
settings than in the general population and because of the ease with 
which it can be transmitted, it is considered a significant health 
issue for correctional facilities. Pregnant inmates and inmates who 
have been in the Jail or the CTF within the last 6 months and have a 
record of a normal chest x-ray do not receive a chest x-ray at intake. 
Similarly, inmates who have recently been in the facilities and 
received a skin test for tuberculosis with normal results are not 
required to have another. However, according to CCHPS officials, even 
if inmates have had a skin test within 3 to 4 weeks, they often perform 
another test to ensure that the inmate has not been exposed to 
tuberculosis while in the community.

[15] These pertain to whether the inmate currently uses or has ever 
used mental health services, has experienced a recent significant loss, 
has ever attempted suicide or self-injury, has a position of respect in 
the community, or is charged with a high-profile crime.

[16] Specialty services that are provided off-site include certain 
diagnostic tests and surgeries. While these services are not part of 
CCHPS's contract, CCHPS has a utilization management nurse located at 
Greater Southeast to assist in managing off-site hospital and specialty 
services.

[17] Until 2001, medical services for certain District residents, 
including inmates, were offered through the not-for-profit Public 
Benefits Corporation and District of Columbia General Hospital. In 
2001, the Public Benefits Corporation was abolished and most services 
at District of Columbia General Hospital were discontinued. The 
District and Greater Southeast entered into a contract to form the DC 
Healthcare Alliance to provide medical services to uninsured or 
underinsured District residents, as well as inmates. The Alliance, 
which is overseen by DoH, is composed of Greater Southeast and other 
local health care providers subcontracted to Greater Southeast.

[18] DoC transfers funds to DoH, which in turn arranges payment to 
service providers through its contract with Greater Southeast and the 
Alliance.

[19] Discharge planning refers to the process of providing soon-to-be-
released inmates with medications and assistance in obtaining follow-up 
medical services when they are released.

[20] According to DoC officials, their concern about discharge planning 
has increased as a result of a July 2000 decision by the Supreme Court 
of New York. This decision held that each inmate receiving mental 
health services during incarceration in New York City was entitled to 
receive discharge planning services, so long as the services do not 
delay or postpone the inmate's release date. See Brad H. v. City of New 
York, 712 N.Y.S.2d 336 (Sup. Ct. 2000), aff'd, 176 N.Y.S2d 852 (App. 
Div. 2000).

[21] DoC and other District agencies bear the cost of these discharge 
planning services, although CCHPS provides some on-site support, 
including access to computers and office space.

[22] A DMH staff member works on-site at the Jail to provide assistance 
to inmates. Because of resource limitations, this DMH staff member 
currently works only with Jail inmates unless contacted by CTF staff 
about a specific CTF inmate. However, DMH officials told us that they 
hope to eventually expand discharge planning services to CTF inmates 
with mental health problems.

[23] FMCS also offers inmates pre-and post-test counseling and 
prevention information.

[24] Under the Health Insurance Portability and Accountability Act 
privacy rule, CCHPS's disclosure of an inmate's personally identifiable 
health information to an outside health care provider is allowed where 
necessary for treatment, payment, or health care operations. See 45 
C.F.R.  164.502(a)(1)(ii) and 164.506 (2003).

[25] As of May 2004, CCHPS and DoC were in the process of reviewing and 
revising these performance assessment instruments.

[26] In the past, DoC conducted occasional reviews of CCHPS's services 
using the same performance assessment instruments as CCHPS.

[27] His assessments cover a selection of service areas included in the 
23 instruments. As he has become more confident of the accuracy of 
CCHPS's monitoring, he has reduced the number of service areas he 
includes in his reviews, and may validate only one or two areas during 
a review.

[28] These service areas can be areas of his own choosing or areas DoC 
has asked him to review.

[29] The contract requires CCHPS to provide inmates with a chest x-ray 
at intake to screen for tuberculosis, to review the results of the x-
ray within 72 hours, and to provide appropriate referral for follow-up 
or additional evaluation if needed.

[30] The 369 grievances represent individual grievances. In some 
instances inmates submitted multiple grievances. During this period, 
over 10,000 inmates were admitted to the Jail and the CTF, and the 
combined average daily population was 3,169.

[31] CCHPS has developed a set of nursing sick call protocols to guide 
nurses providing sick call services.

[32] CCHPS's analyses produce data on its compliance with 9 of the 12 
requirements linked with monetary damages--all those related to medical 
services. The independent reviewer's analyses do not necessarily 
produce data on all 9 because he does not specifically review these 9 
service areas and does not review the same service areas during each 
review.

[33] The independent reviewer provided DoC with the data from his 
quarterly reviews through March 2001. Since then, he has generally not 
provided data.

[34] CCHPS's policies and procedures state that the elapsed time from 
when CCHPS receives a grievance to when it issues a written response 
should be 10 days or less. In almost three-fourths of the cases we 
reviewed, CCHPS met this standard. According to the written responses 
we reviewed, many inmates had already received care by the time CCHPS 
wrote its response.

[35] DoC uses data provided by CCHPS to track utilization of off-site 
services, but does not obtain or collect information related to the 
timeliness of those services.

[36] Although DoC consolidated medical services for the Jail and the 
CTF under a single contract in April 2003, we were able to identify the 
cost attributable to the Jail for the entire year. See app. I for 
additional information on our cost and population calculations for each 
annual period.

[37] Adjusted for medical inflation, the total cost would have 
decreased by about $1.8 million from 2000 to 2003. Medical inflation 
adjustments were calculated using the medical care component of the 
Consumer Price Index for urban consumers.

[38] We calculated the average daily cost per inmate by dividing the 
total cost for the period by the average inmate population for the 
period, and then dividing by the number of days in the period.

[39] Personnel expenditures represent about three-fourths of CCHPS's 
costs.

[40] In March 2000, CCHPS was required by the contract to have 125.2 
FTE positions at the Jail. By April 2003, the contract no longer 
specified the number of FTE positions CCHPS had to have.

[41] In April 2003, there were also 51.7 FTEs at the CTF.

[42] At the time of the transition from the receivership to the CCHPS 
contract, members of Congress expressed concern that CCHPS's staffing 
level was very high; however, there is no single standard for an 
acceptable level of medical staffing at a jail. NCCHC's most recent 
standards indicate that, despite the general expectation for physician 
staffing ratios, the number and type of health care professionals 
required depends on a variety of factors.

[43] Cost data for 2003 are from April 1, 2003, through March 31, 2004, 
approximating the DoC-CCHPS contract year.

[44] In 2003, the combined average daily population of the Jail and the 
CTF was 3,257. These data are from April 1, 2003, through March 31, 
2004, approximating the DoC-CCHPS contract year.

[45] The new per diem pricing system retains two reconciliations each 
year for pharmaceutical supplies due to the high variability of 
pharmaceutical costs.

[46] As of May 2004, CCHPS and DoC were in the process of reviewing and 
revising these performance assessment instruments.

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