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 
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. 

Highlights of GAO-04-750, a report to the 

Chairman, Committee on Government 

Reform, U.S. House of Representatives 

June 2004

DISTRICT OF COLUMBIA JAIL 

Medical Services Generally Met 

Requirements and Costs Decreased, but 

Oversight Is Incomplete 

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 CCHPS’s 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 CCHPS’s services 

meet the contract’s 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 CCHPS’s 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. 

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 CCHPS’s monitoring of 

its services; (2) mechanisms DoC 

established to oversee CCHPS’s 

services; (3) CCHPS’s contract 

compliance and DoC’s 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. 

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. 
Page i GAO-04-750 D.C. Jail Medical Services 

Letter 1

Results in Brief 3

Background 5

CCHPS Provides a Range of Services to Inmates and Has 

Established Systems to Monitor Service Quality 8

DoC Established Several Mechanisms to Oversee CCHPS’s 

Delivery of Medical Services 14

CCHPS Generally Meets Contract Requirements, but DoC’s 

Oversight of CCHPS Is Incomplete 15

Average Per Inmate Medical Cost at Jail Has Decreased 19

Conclusions 25

Recommendations for Executive Action 26

Agency Comments and Our Evaluation 27

Appendix I Scope and Methodology 30 

Appendix II Requirements Linked to Monetary Damages 

Provisions in the CCHPS Contract 33 

Appendix III Performance Assessment Instruments Used to 

Monitor Services Provided by CCHPS 35 

Appendix IV Comments from the District of Columbia Department 

of Corrections 41 

Appendix V GAO Contact and Staff Acknowledgments 47 

GAO Contact 47

Acknowledgments 47

Contents 
Page ii GAO-04-750 D.C. Jail Medical Services 

Tables 

Table 1: Medical Services Provided by CCHPS to Inmates at the Jail 

and the CTF, March 2004 10

Table 2: Summary of Contract Requirements with Monetary 

Damages Provisions 33

Table 3: Information on Performance Assessment Instruments 

Used to Monitor CCHPS’s Services 36

Figures 

Figure 1: Total Annual Cost of Medical Services at the District of 

Columbia Jail, 2000–2003 21

Figure 2: Average Daily Inmate Population at the District of 

Columbia Jail, 2000–2003 22

Figure 3: Average Daily Cost Per Inmate of Medical Services at the 

District of Columbia Jail, 2000–2003 23 
Page iii GAO-04-750 D.C. Jail Medical Services 

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 

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Page 1 GAO-04-750 D.C. Jail Medical Services 

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 Jail1

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-forprofit organization, to provide medical services at the Jail beginning in 

March 2000.2

 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.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 

jurisdictions4

 and that there were no specific criteria to determine an 

 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. 

United States General Accounting Office 

Washington, DC 20548 
Page 2 GAO-04-750 D.C. Jail Medical Services 

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.) 
Page 3 GAO-04-750 D.C. Jail Medical Services 

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 

Results in Brief 
Page 4 GAO-04-750 D.C. Jail Medical Services 

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. 
Page 5 GAO-04-750 D.C. Jail Medical Services 

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. 

The District of Columbia Jail and CTF house inmates awaiting trial or who 

have been sentenced for misdemeanors.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.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 

 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. 

Background 
Page 6 GAO-04-750 D.C. Jail Medical Services 

reviewing CCHPS’s clinical services and monitoring activities7 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,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 damages9

 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.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 

 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. 

10There 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. 
Page 7 GAO-04-750 D.C. Jail Medical Services 

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.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.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. 

 11This 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. 

12We also reported that these services and staffing levels appeared to stem from courtordered requirements. 
Page 8 GAO-04-750 D.C. Jail Medical Services 

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. 

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 call13 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.14 As part of the mental health screening, inmates are 

asked a series of questions.15 If inmates respond positively to any of these 

 13Sick 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. 

14Because 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 xray 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. 

15These 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 selfinjury, has a position of respect in the community, or is charged with a high-profile crime. 

CCHPS Provides a 

Range of Services to 

Inmates and Has 

Established Systems 

to Monitor Service 

Quality 

CCHPS Provides Screening 

and Treatment Services 

Required in Its Contract 

and Assists DoC in 

Obtaining Additional 

Services 
Page 9 GAO-04-750 D.C. Jail Medical Services 

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. 
Page 10 GAO-04-750 D.C. Jail Medical Services 

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

Service area Type and description of service Types of service providers 

Intake services Initial medical, mental health, and dental screening on 

admission to the Jail and referral for additional care if neededa

 Physicians, physician assistants 

(PA), licensed practical nurses 

(LPN), phlebotomistsb

Primary 

medical care 

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 

 Physicians, PAs, nurse practitioners 

(NP), registered nurses (RN) 

 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 

 Physicians, NPs, PAs 

 Halfway house services: assessment and coordination of care for 

inmates at one halfway house 

 NPs, RNs 

Mental health 

services 

“Outpatient” mental health services: services provided to inmates in the 

general housing population, including group therapy, one-on-one 

therapy, and medication management 

 Psychiatrists, psychologists, social 

workers, RNs, LPNs 

 “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 unitsc

 Psychiatrists, social workers, RNs, 

LPNs; interdisciplinary team also 

includes corrections officers and 

classification and parole officers 

Specialty care Dental services: basic dental care, including routine and surgical 

extractions, fitting dentures, filling cavities, and oral hygiene and 

education 

 Dentists, dental assistants, dental 

hygienists 

 On-site specialty services include cardiology, dermatology, gynecology, 

neurology, ophthalmology, orthopedics, general surgery, podiatry, and 

pulmonary clinics 

 Physicians, podiatrists 

Infirmary 

services 

Short-term management of inmates requiring observation or a level of 

care that cannot be provided in the general population 

 Physicians, RNs 

Ancillary 

services 

Includes pharmacy services, laboratory services, and providing 

prostheses and glasses 

 Pharmacists, pharmacy technicians, 

radiology technicians, dieticians, offsite 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. 

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 
Page 11 GAO-04-750 D.C. Jail Medical Services 

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.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.17 DoC pays for all off-site services through an 

interagency agreement with DoH;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,19 NCCHC accreditation 

 16Specialty 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. 

17Until 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. 

18DoC transfers funds to DoH, which in turn arranges payment to service providers through 

its contract with Greater Southeast and the Alliance. 

19Discharge 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. 
Page 12 GAO-04-750 D.C. Jail Medical Services 

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.20,21 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 inmates22 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.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.24

 20According 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). 

21DoC 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. 

22A 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. 

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

24Under 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). 
Page 13 GAO-04-750 D.C. Jail 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.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. 

 25As of May 2004, CCHPS and DoC were in the process of reviewing and revising these 

performance assessment instruments. 

CCHPS Developed a 

System to Monitor Its 

Medical Services 
Page 14 GAO-04-750 D.C. Jail 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.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 

 26In the past, DoC conducted occasional reviews of CCHPS’s services using the same 

performance assessment instruments as CCHPS. 

DoC Established 

Several Mechanisms 

to Oversee CCHPS’s 

Delivery of Medical 

Services 
Page 15 GAO-04-750 D.C. Jail Medical Services 

medical records studied.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.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. 

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 

 27His 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. 

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

review. 

CCHPS Generally 

Meets Contract 

Requirements, but 

DoC’s Oversight of 

CCHPS Is Incomplete 
Page 16 GAO-04-750 D.C. Jail Medical Services 

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. 

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.29

Although CCHPS has recently improved its performance, the independent 

 29The 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. 

CCHPS Generally Provides 

Required Medical Services 

and Internal Monitoring, 

but a Few Gaps Remain 
Page 17 GAO-04-750 D.C. Jail Medical Services 

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.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.31 In addition, advocacy groups with whom we 

spoke expressed concern about distribution of medications on weekends 

and to newly admitted inmates. 

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 

 30The 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. 

31CCHPS has developed a set of nursing sick call protocols to guide nurses providing sick 

call services. 

DoC’s Oversight 

Limitations Reduce Its 

Assurance That CCHPS 

Complies with Contract 
Page 18 GAO-04-750 D.C. Jail Medical Services 

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.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.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,34 the independent 

reviewer has reported on several occasions that CCHPS does not analyze 

 32CCHPS’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. 

33The independent reviewer provided DoC with the data from his quarterly reviews through 

March 2001. Since then, he has generally not provided data. 

34CCHPS’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 threefourths 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. 
Page 19 GAO-04-750 D.C. Jail Medical Services 

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.35

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 

 35DoC 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. 

Average Per Inmate 

Medical Cost at Jail 

Has Decreased 
Page 20 GAO-04-750 D.C. Jail Medical Services 

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. 

From initiation of the CCHPS contract in 2000 to 2003, the average daily 

per inmate cost of medical services at the Jail36 decreased by almost onethird, 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,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. 

 36Although 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. 

37Adjusted 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. 

Cost of Medical Services at 

Jail Decreased, Despite 

Growth of Inmate 

Population 
Page 21 GAO-04-750 D.C. Jail Medical Services 

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

2000–2003 

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. 

11.7a

10.7

11.5 11.4

0

2

4

6

8

10

12

14

2000b 2001b 2002b 2003c

Dollars in millions

Sources: GAO analysis of data from the District of Columbia Department of Corrections, Department 

of Financial Operations and Systems, and the Center for Correctional Health and Policy Studies, Inc.
Page 22 GAO-04-750 D.C. Jail Medical Services 

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

2003 

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. 

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 2003.38 (See fig. 3.) 

 38We 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. 

1,662 1,685

2,153

2,342

0

500

1,000

1,500

2,000

2,500

2000a 2001a 2002a 2003a

Number of inmates

Source: GAO analysis of data from the District of Columbia Department of Corrections.
Page 23 GAO-04-750 D.C. Jail Medical Services 

Figure 3: Average Daily Cost Per Inmate of Medical Services at the District of 

Columbia Jail, 2000–2003 

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. 

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.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 

 39Personnel expenditures represent about three-fourths of CCHPS’s costs. 

19.33a

17.39

14.61

13.32

0

4

8

12

16

20

24

2000b 2001b 2002b 2003c

Dollars

Sources: GAO analysis of data from the District of Columbia Department of Corrections, Department 

of Financial Operations and Systems, and the Center for Correctional Health and Policy Studies, Inc.
Page 24 GAO-04-750 D.C. Jail Medical Services 

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,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 27.41 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.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. 

In 2003, the total cost for medical services in the Jail and the CTF was 

about $15.8 million;43 over the course of that year 17,431 inmates were 

admitted to both facilities.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 

 40In 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. 

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

42At 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. 

43Cost data for 2003 are from April 1, 2003, through March 31, 2004, approximating the DoCCCHPS contract year. 

44In 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. 

Cost in 2003 Reflected 

Addition of the CTF and 

Change to a Per Diem 

Pricing Structure 
Page 25 GAO-04-750 D.C. Jail Medical Services 

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.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. 

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 

 45The new per diem pricing system retains two reconciliations each year for 

pharmaceutical supplies due to the high variability of pharmaceutical costs. 

Conclusions 
Page 26 GAO-04-750 D.C. Jail Medical Services 

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. 

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. 

Recommendations for 

Executive Action 
Page 27 GAO-04-750 D.C. Jail Medical Services 

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. 

Agency Comments 

and Our Evaluation 
Page 28 GAO-04-750 D.C. Jail Medical Services 

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 
Page 29 GAO-04-750 D.C. Jail Medical Services 

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, 

Marcia Crosse 

Director, Health Care—Public Health 

 and Military Health Care Issues 
Appendix I: Scope and Methodology 

Page 30 GAO-04-750 D.C. Jail Medical Services 

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. 

Appendix I: Scope and Methodology 
Appendix I: Scope and Methodology 

Page 31 GAO-04-750 D.C. Jail Medical Services 

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 DoCCCHPS contract year. Total cost and inmate population data for 2003 are 

from April 1, 2003, through March 31, 2004, approximating the DoCCCHPS 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 
Appendix I: Scope and Methodology 

Page 32 GAO-04-750 D.C. Jail Medical Services 

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. 
Appendix II: Requirements Linked to 

Monetary Damages Provisions in the CCHPS 

Contract 

Page 33 GAO-04-750 D.C. Jail Medical Services 

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 

 Monetary damages may be imposed if: Damages calculation method 

Medical services Less than 95 percent of Jail intake health screenings are completed within 

24 hours. 

$200 times the number of 

occurrences during the period 

being measureda

 

 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. 

$200 times the number of 

occurrences during the period 

being measureda

 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. 

$100 times the number of 

occurrences during the period 

being measureda

 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. 

$100 times the number of 

occurrences above the 10-percent 

threshold during the period being 

measureda

 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. 

$100 times the number of 

occurrences above the 15-percent 

threshold during the period being 

measureda

 More than 15 percent of the eligible diabetics tested as part of an audit are 

found to have a Hemoglobin A1cb

 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. 

$100 times the number of 

occurrences above the 15-percent 

threshold during the period being 

measureda

 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. 

$100 times the number of days for 

each inmate not followed in the 

chronic care clinic 

Infection control The contractor does not maintain a DoC-approved infection control plan 

within 1 month of the contract award. 

$500 times the number of days the 

approved infection control plan is 

not in effect 

Appendix II: Requirements Linked to 

Monetary Damages Provisions in the CCHPS 

Contract 
Appendix II: Requirements Linked to 

Monetary Damages Provisions in the CCHPS 

Contract 

Page 34 GAO-04-750 D.C. Jail Medical Services 

 Monetary damages may be imposed if: Damages calculation method 

Staffing The contractor does not maintain valid and current licenses and 

certifications as required for all health care providers. 

$500 times the number of 

occurrences per day for each 

healthcare provider, calculated 

from the date of the finding 

 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. 

None identified 

 The contractor leaves vacant a principal leadership positionc for greater than 

60 days. If a qualified individual is performing the functions of a principal 

leadership position, this position is not considered vacant. 

One and one-half the salary rate 

per hour plus fringe hourly rate 

defined in the contractd

 times the 

number of required hours the 

position is left vacant after 60 days

 The contractor leaves vacant any required position as accepted by DoC in 

the contract for greater than 120 days. 

One and one-half the salary rate 

per hour plus fringe hourly rate 

defined in the contractd

 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. 
Appendix III: Performance Assessment 

Instruments Used to Monitor Services 

Provided by CCHPS 

Page 35 GAO-04-750 D.C. Jail Medical Services 

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.1

 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. 

 1

As of May 2004, CCHPS and DoC were in the process of reviewing and revising these 

performance assessment instruments. 

Appendix III: Performance Assessment 

Instruments Used to Monitor Services 

Provided by CCHPS 
Appendix III: Performance Assessment 

Instruments Used to Monitor Services 

Provided by CCHPS 

Page 36 GAO-04-750 D.C. Jail Medical Services 

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

Service area/type Measure Sample used Source of sample 

Intake services 

Intake evaluation • 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 

20 randomly selected 

inmate medical 

recordsa

 

General inmate 

population 

• Performed pregnancy test 10 randomly selected 

inmate medical records 

Female inmate 

population 

Primary medical care 

Asthma care • At intake or within the past 3 months, conducted 

measurement of the amount of air an inmate can 

push out of his/her lungs 

10 randomly selected 

inmate medical 

recordsb

• 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 worsenedc

 

First 5 of the 10 

randomly selected 

inmate medical records 

reviewed above 

Inmates with asthma 

Diabetes care • Measured blood sugar levels on intake 10 randomly selected 

inmate medical 

recordsb

General inmate 

population 

• 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 

10 randomly selected 

diabetic inmate medical 

records 

• 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 worsenedc

First 5 of the 10 

randomly selected 

diabetic inmate medical 

records reviewed 

above 

Inmates with diabetes 
Appendix III: Performance Assessment 

Instruments Used to Monitor Services 

Provided by CCHPS 

Page 37 GAO-04-750 D.C. Jail Medical Services 

Service area/type Measure Sample used Source of sample 

Human Immunodeficiency 

Virus (HIV) care 

• Tested for level of certain white blood cells with 

CD4 markerd

 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 worsenedc

• Vaccinated against pneumococcal infection 

including pneumonia 

• Administered influenza vaccine during flu season, 

October – February. 

10 randomly selected 

inmate medical 

recordsb

Inmates with HIV 

Hypertension care • Noted blood pressure reading at intake 10 randomly selected 

inmate medical 

recordsb

General inmate 

population 

• Initiated treatment, or plan to treat, within 14 days 

of identification of high blood pressure 

10 randomly selected 

medical records of 

inmates with high blood 

pressure 

Inmates with high 

blood pressure 

• 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 worsenedc

First 5 of the 10 

randomly selected 

medical records of 

inmates with high blood 

pressure reviewed 

above 

Positive tuberculosis skin 

test cases 

• Clinical evaluation of inmate and treatment decision 

made within 14 daysc

10 randomly selected 

inmate medical 

recordse

Inmates with positive 

tuberculosis skin tests 

Nursing sick call 

performance 

• Assessment of inmate’s condition appropriate to 

chief complaintf

• Recorded relevant vital signs, such as breathing 

rate, pulse, and temperaturef

• Treatment plan appropriate to conditionf

2 inmate medical 

records from each of 

18 inmate housing 

unitsg

Sick call requests 

from inmates 

Mental Health Services 

Chronic mental health care • Psychiatric progress evaluations conducted by 

psychiatrist every 2 weeks 

• Inmate’s interdisciplinary treatment plan reviewed 

by staff within 4 weeks 

10 randomly selected 

inmate medical records 

Inmates in male 

inpatient mental 

health housing units 
Appendix III: Performance Assessment 

Instruments Used to Monitor Services 

Provided by CCHPS 

Page 38 GAO-04-750 D.C. Jail Medical Services 

Service area/type Measure Sample used Source of sample 

Acute mental health care • 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 

10 randomly selected 

inmate medical records 

Inmates in male 

inpatient mental 

health housing units 

Abnormal Involuntary 

Movement Scale (AIMS) 

testing 

• Documented testing (AIMS test) to determine 

possible side effects of antipsychotic drugs within 

30 days of intake or within past 6 months 

10 inmate records from 

male inpatient mental 

health housing unit and 

10 inmate medical 

records from general 

population 

Pharmacy list of 

inmates taking 

antipsychotic drugs 

Appropriate medication for 

mental health treatment 

• Diagnosis consistent with use of medicationh

10 randomly selected 

inmate medical records 

Pharmacy list of 

inmates taking certain 

medications, e.g., for 

schizophrenia 

Level of certain drugs for 

bipolar disorder (depakote 

and lithium) 

• Reported level of medications every 3 months 

• Physician review of medication levels with 

appropriate response noted in medical recordsh

10 randomly selected 

inmate medical records 

Pharmacy list of 

inmates receiving 

depakote and lithium 

Specialty care 

Urgent care performance • Care timelyf

• Documented appropriate vital signs, such as 

breathing rate, pulse, and temperaturef

• Appropriate assessment of condition and plan to 

treatf

10 urgent care visitsi Inmates seen in 

urgent care 

Specialty clinic services • 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 

5 randomly selected 

inmate medical records 

from each specialty 

clinicj

Inmates seen in 

specialty clinic 

Communicable disease 

treatment 

• Screened female inmates for gonorrhea and 

chlamydia within 14 days of admission to the facility

10 randomly selected 

inmate medical records 

General inmate 

population 

• Patients with positive test for syphilis received 

appropriate treatment (based on federal guidelines) 

within 5 days of receiving laboratory reportc

• Patients with positive test for gonorrhea received 

appropriate treatment (based on federal guidelines) 

within 3 days of receiving laboratory reportc

• Patients with positive test for chlamydia received 

appropriate treatment (based on federal guidelines) 

within 3 days of receiving laboratory reportc

10 randomly selected 

inmate medical records 

for each disease 

Inmates identified as 

positive for gonorrhea, 

chlamydia, or syphillis 
Appendix III: Performance Assessment 

Instruments Used to Monitor Services 

Provided by CCHPS 

Page 39 GAO-04-750 D.C. Jail Medical Services 

Service area/type Measure Sample used Source of sample 

Dental care • 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 

10 randomly selected 

inmate medical records 

Inmates seen in 

dental clinic 

Ancillary services 

Chest X-ray reporting and 

follow-up 

• Timely reporting of chest x-ray results, appropriate 

clinician acknowledgment of results, and 

appropriate follow-up of abnormal chest x-ray 

results within 48 hoursc

10 randomly selected 

inmate medical records 

Log of all x-rays taken

Nonchest X-ray reporting 

and follow-up 

• 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 performedc

10 randomly selected 

inmate medical records 

Log of all x-rays taken

Laboratory servicesk • Report laboratory results within 24 hours, as 

appropriate 

• Clinical acknowledgment of laboratory results and 

appropriate clinical responsec

10 randomly selected 

inmate medical records 

No source identified in 

performance 

assessment 

instruments 

Medication administration 

records (MAR)l

• 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-upm

5 MARs books MARs books 

Quality improvement activities 

Credentialing • 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 

10 randomly selected 

clinician files from each 

provider type, and from 

the combined 

physician/PA/NP staff 

Nursing files, dental 

files, mental health 

files, and combined 

physician/PA/NP files 

Complaints and grievances • Analyzed trends in terms of numbers and category 

distribution of complaints and grievances 

• Percentage of complaints and grievances 

appropriately addressed within 14 days 

All medical grievances CCHPS log of inmate 

grievances 
Appendix III: Performance Assessment 

Instruments Used to Monitor Services 

Provided by CCHPS 

Page 40 GAO-04-750 D.C. Jail Medical Services 

Service area/type Measure Sample used Source of sample 

Quality improvement 

program 

• 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. 

Not applicable 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. 
Appendix IV: Comments from the District of 

Columbia Department of Corrections 

Page 41 GAO-04-750 D.C. Jail Medical Services 

Appendix IV: Comments from the District of 

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

Columbia Department of Corrections 

Page 42 GAO-04-750 D.C. Jail Medical Services 
Appendix IV: Comments from the District of 

Columbia Department of Corrections 

Page 43 GAO-04-750 D.C. Jail Medical Services 
Appendix IV: Comments from the District of 

Columbia Department of Corrections 

Page 44 GAO-04-750 D.C. Jail Medical Services 
Appendix IV: Comments from the District of 

Columbia Department of Corrections 

Page 45 GAO-04-750 D.C. Jail Medical Services 
Appendix IV: Comments from the District of 

Columbia Department of Corrections 

Page 46 GAO-04-750 D.C. Jail Medical Services 
Appendix V: GAO Contact and Staff 

Acknowledgments 

Page 47 GAO-04-750 D.C. Jail Medical Services 

Helene F. Toiv, (202) 512-7162 

In addition to the person named above, key contributors to this report 

were Emily Gamble Gardiner, Marc Feuerberg, Krister Friday, and Anne 

Montgomery. 

Appendix V: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Acknowledgments 

(290315) 
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