MENTAL HEALTH

Federal Procedures to 

Oversee Protection 

and Advocacy 

Programs Could Be 

Further Improved

Report to Congressional Committees

May 2018

GAO-18-450

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-18-450, a report to 

congressional committees

May 2018

MENTAL HEALTH

Federal Procedures to Oversee Protection and 

Advocacy Programs Could Be Further Improved

What GAO Found

The eight selected state Protection and Advocacy for Individuals with Mental 

Illness (PAIMI) programs GAO reviewed reported a range of positive outcomes

from their work on behalf of individuals with mental illness. For example, in fiscal 

year (FY) 2016, the selected programs reported resolving in the individual’s favor 

1,772 out of 2,390 cases (74 percent) related to complaints of alleged abuse, 

neglect, and rights violations. The remaining cases were reported as withdrawn 

by the client, closed due to lack of merit, or not resolved in the individual’s favor.

These programs also reported concluding a variety of broader, system-level 

activities—referred to as systemic activities—intended to benefit groups of 

individuals with mental illness. These systemic activities resulted in, for example, 

changes to procedures in mental health institutions and correctional facilities. 

Selected Outcomes Reported by Eight Protection and Advocacy for Individuals with Mental 

Illness Programs, Fiscal Year 2016

Type of activity Outcome

Individual cases Closed in favor of individual

 Rights violations 1,122

 Neglect 341

 Abuse 309

Total 1,772

Systemic activities Concluded successfully

 Facility monitoring 263

 Investigations 46

 Group advocacy (non-litigation) 29

 Other 29

Total 367

Source: GAO analysis of 2016 Substance Abuse and Mental Health Services Administration data. | GAO-18-450

The Substance Abuse and Mental Health Services Administration (SAMHSA), 

which oversees the state PAIMI programs, has a variety of procedures in place 

to monitor performance and compliance. However, two areas warrant additional

attention, as follows:

• SAMHSA has not consistently examined changes to performance 

benchmarks—the goals, objectives, and targets that PAIMI programs set

annually for their planned work. Programs are permitted to modify these 

benchmarks, and GAO found that four had done so. A new SAMHSA 

system implemented in 2017 could improve recording of benchmark 

changes, but SAMHSA lacks procedures to examine changes across 

years, which could help identify performance concerns.

• SAMHSA often failed to complete its periodic, in-depth reviews of 

programs and to provide findings of identified deficiencies to PAIMI 

programs on a timely basis. SAMHSA has plans to improve the efficiency 

of its review process. However, it is unclear the extent to which these 

plans will resolve the timeliness issues, which could delay resolution of 

any issues found in the reviews.

View GAO-18-450. For more information, 

contact Katherine Iritani at (202) 512-7114 or 

iritanik@gao.gov.

Why GAO Did This Study

PAIMI grant awards, established by 

Congress in 1986 and totaling $36 

million in 2016, are administered by 

SAMHSA to support state protection 

and advocacy programs. PAIMI 

programs protect and advocate for the 

rights of individuals with significant 

mental illness by investigating reports 

of incidents of abuse and neglect of 

such individuals in facilities such as 

hospitals, and in the community, 

among other activities. 

The 21st Century Cures Act included a 

provision for GAO to review the PAIMI 

programs and their compliance with 

federal statutory and regulatory 

requirements. This report examines (1) 

the outcomes reported by PAIMI 

programs in selected states, and (2) 

SAMHSA’s oversight of state PAIMI 

programs, including their compliance 

with federal requirements. GAO 

reviewed FY 2015 and 2016 PAIMI 

program documentation for eight of 57 

programs selected for variation in

funding amount, geographic location, 

and other factors. GAO also reviewed 

relevant SAMHSA policies and

procedures and assessed them 

against federal standards for internal 

control.

What GAO Recommends

GAO recommends that SAMHSA take 

steps to ensure that changes to 

performance benchmarks are 

examined over time, and to ensure

onsite reviews are completed—and 

findings are provided to state

programs—in a timely manner. The 

Department of Health and Human 

Services concurred with GAO’s 

recommendations.
Page i GAO-18-450 Mental Health Protection and Advocacy

Letter 1

Background 5

Selected State PAIMI Programs Reported Achievements in 

Ending and Preventing Abuse, Neglect, and Rights Violations of 

Those with Significant Mental Illness 9

SAMHSA Has Controls in Place to Oversee Program Compliance 

with PAIMI Requirements, but Oversight of Program 

Effectiveness Is More Limited 16

Conclusions 23

Recommendations for Executive Action 24

Agency Comments 24

Appendix I: Protection and Advocacy for Individuals with 

Mental Illness (PAIMI) Grants by Program, 

Fiscal Year 2016 26

Appendix II: Selected State PAIMI Program Priority Goal 

Categories in Fiscal Year 2016 28

Appendix III: Agency Comments from the Department of 

Health and Human Services 30

Appendix IV: GAO Contact and Staff Acknowledgments 32

Tables

Table 1: Selected Federal Requirements for State Protection and 

Advocacy for Individuals with Mental Illness (PAIMI) 

Programs 6

Table 2: Key Individual and Systemic Activities Performed by 

State Protection and Advocacy for Individuals with Mental 

Illness (PAIMI) Programs 7

Contents
Page ii GAO-18-450 Mental Health Protection and Advocacy

Table 3: Resolution of Closed Cases on Alleged Abuse, Neglect, 

and Rights Violations Reported by Selected Protection 

and Advocacy for Individuals with Mental Illness (PAIMI) 

Programs, Fiscal Year 2016 10

Table 4: Examples of Information Required in State Protection and 

Advocacy for Individuals with Mental Illness (PAIMI) 

Applications and Performance Reports, Fiscal Year 2016 17

Table 5: Examples of Compliance Findings from Annual 

Application and Performance Report Reviews Conducted 

by the Substance Abuse and Mental Health Services 

Administration (SAMHSA) of Protection and Advocacy for 

Individuals with Mental Illness (PAIMI) Programs, Fiscal 

Years 2015-2016 18

Table 6: Examples of Protection and Advocacy for Individuals with 

Mental Illness Program Compliance Findings from Onsite 

Monitoring Reviews Conducted by the Substance Abuse 

and Mental Health Services Administration (SAMHSA), 

Fiscal Years 2015-2016 20

Figures

Figure 1: Distribution of Closed Cases by Complaint Category 

Reported by Selected State Protection and Advocacy for 

Individuals with Mental Illness (PAIMI) Programs, Fiscal 

Year 2016 11

Figure 2: Number and Status of Systemic Activities Reported by 

Selected State Protection and Advocacy for Individuals 

with Mental Illness (PAIMI) Programs, Fiscal Year 2016 13

Figure 3: Selected State Protection and Advocacy for Individuals 

with Mental Illness (PAIMI) Program Priority Goal 

Categories, Fiscal Year 2016 29
Page iii GAO-18-450 Mental Health Protection and Advocacy

Abbreviations

HHS Department of Health and Human Services

NDRN National Disability Rights Network 

PAIMI Protection and Advocacy for Individuals with Mental Illness

SAMHSA Substance Abuse and Mental Health Services 

Administration

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Page 1 GAO-18-450 Mental Health Protection and Advocacy

441 G St. N.W.

Washington, DC 20548

May 24, 2018

The Honorable Lamar Alexander

Chairman

The Honorable Patty Murray

Ranking Member

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Greg Walden

Chairman

The Honorable Frank Pallone, Jr.

Ranking Member

Committee on Energy and Commerce

House of Representatives

Congress passed the Protection and Advocacy for Individuals with Mental 

Illness (PAIMI) Act in 1986 in response to concerns about the vulnerability 

of individuals with mental illness to abuse and neglect, and gaps in state 

systems to address such issues.1 The PAIMI Act established a grant 

program to support independent, state-level protection and advocacy 

systems—referred to in this report as state PAIMI programs—designed to 

safeguard the rights of individuals with mental illness at risk for abuse or 

neglect.2 To qualify for federal grant support, state PAIMI programs must 

have specific authority to investigate incidents of potential abuse and 

neglect of individuals with significant mental illness; the ability to pursue 

administrative, legal, and other appropriate remedies to protect these 

individuals; and access to records needed to pursue these investigations 

 1

Pub. L. No. 99–319, 100 Stat. 478 (1986) (codified as amended at 42 U.S.C. §§ 10801-

10827). The law was originally entitled "Protection and Advocacy for Mentally Ill 

Individuals Act of 1986” but its title was amended in 2000. See Pub. L. No. 106-310, § 

3206(a), 114 Stat. 1101, 1193 (2000).

2

Protection and advocacy systems are disability rights agencies designated by the 

governor of each state or territory to provide legal representation and other advocacy 

services on behalf of qualifying individuals. Protection and advocacy systems were first 

established in 1975 under the Developmentally Disabled Assistance and Bill of Rights Act 

to administer the Protection and Advocacy for Individuals with Developmental Disabilities 

program. In addition, protection and advocacy systems now also administer the PAIMI 

program and several other protection and advocacy programs for individuals with 

disabilities.

Letter
Page 2 GAO-18-450 Mental Health Protection and Advocacy

and remedies.3 In addition to investigating complaints, the PAIMI Act 

requires PAIMI programs to protect and advocate for the rights of 

individuals with significant mental illness.

Given their authority, access rights, and presence across all states and 

territories, state PAIMI programs play an important role in supporting a 

vulnerable population of individuals with serious mental health disorders. 

The Substance Abuse and Mental Health Services Administration 

(SAMHSA), within the Department of Health and Human Services (HHS), 

administers and oversees the PAIMI programs. SAMHSA approves 

PAIMI grant applications annually and oversees program compliance with 

statutory and regulatory requirements, such as those regarding grievance 

procedures, public engagement, and appropriate use of federal funding. 

In fiscal year 2016, SAMHSA provided approximately $36 million in grants 

to 57 state-based PAIMI programs to fund these activities.4 While 

comprising a relatively small portion of SAMHSA’s total budget authority 

for mental health programs (about $1.1 billion in fiscal year 2016) the 

PAIMI grant program is the only federal program supporting protection 

and advocacy services for individuals with significant mental illness.

The 21st Century Cures Act of 2016 included a provision for GAO to 

review PAIMI program activities and their compliance with federal 

statutory and regulatory requirements.5 This report examines

1. the outcomes reported by the PAIMI programs in selected states; and

2. SAMHSA’s oversight of the state PAIMI programs, including 

procedures for ensuring compliance with federal statutory and 

regulatory requirements.

To examine the outcomes reported by PAIMI programs, we reviewed the 

annual program performance reports for a nongeneralizable selection of 

eight PAIMI programs for federal fiscal years 2015 and 2016: California, 

Georgia, Indiana, Louisiana, Massachusetts, Texas, Vermont, and 

 3

The PAIMI statute defines “individual with mental illness” as a person who has significant 

mental illness or emotional impairment, as determined by a mental health professional 

qualified under the laws and regulations of the state. For purposes of this report, we use 

the term “significant mental illness” to refer to this definition. 

4

In addition to 50 state programs, there is one for the District of Columbia, one for each of 

the five U.S. Territories, and one for the American Indian Consortium, which serves 

certain southwestern American Indian tribes.

5

See 21st Century Cures Act, Pub. L. No. 114-255, § 6023, 130 Stat. 1033, 1217 (2016).
Page 3 GAO-18-450 Mental Health Protection and Advocacy

Washington. We selected these programs based on a variety of factors 

such as size of the grant, number of clients served, program type (that is, 

whether the program was operated by the state or by a private nonprofit), 

and geographic region. Performance data we reviewed included both 

standard measures that all programs are required to report, such as the 

number of abuse or neglect complaints addressed, as well as specific 

measures reporting progress toward goals selected by each program. To 

assess the reliability of the program performance data, we reviewed 

related documentation, interviewed SAMHSA officials, and assessed the 

data for obvious errors. We determined that the performance data for the 

eight selected programs were sufficiently reliable for our reporting 

purposes. We also reviewed SAMHSA documentation of program 

performance for fiscal years 2011 and 2012 and an evaluation of the 

PAIMI programs commissioned by the agency and published in 2011.6 In 

addition, we interviewed state PAIMI program staff for four of the eight 

programs to obtain in-depth examples of program activities.7 We also 

interviewed members of two state PAIMI program advisory councils about 

their roles and their perspective about the state PAIMI programs.8 To 

obtain additional perspectives about the state PAIMI programs, we 

interviewed members of two national-level mental health organizations 

and two state-level mental health organizations.9

 6

See U.S. Department of Health and Human Services, Fiscal Year 2018 Substance Abuse 

and Mental Health Services Administration Justification of Estimates for Appropriations 

Committees (Washington, D.C) and Biennial Report to Congress, the President, and the 

National Council on Disability: Fiscal Years 2011 and 2012 (Washington, D.C.). See also 

Substance Abuse and Mental Health Services Administration, Evaluation of the Protection 

and Advocacy for Individuals with Mental Illness (PAIMI) Program, Phase III: Evaluation 

Report, HHS Publication No. PEP12-EVALPAIMI (Rockville, Md.: 2011).

7

We selected this subset of four programs—California, Georgia, Indiana, and Vermont—

from among the selected eight states based on variation in terms of grant size, program 

type, and geographic region. 

8

The PAIMI Act requires the protection and advocacy systems that administer the state 

PAIMI programs to establish advisory councils to advise programs on policies and 

priorities to be carried out. We selected two advisory councils to interview—California and 

Indiana—from among the selected states based on the size of their grants and type of 

operation of their programs.

9

For national-level organizations, we interviewed representatives from the National

Alliance for Mental Illness and from the National Disability Rights Network, which 

represents the protection and advocacy systems that administer the PAIMI programs and 

also has a contract with SAMHSA to provide technical assistance to the programs. For 

state-level organizations, we interviewed one state mental health agency and one statelevel mental health advocacy organization from states that varied in terms of grant size.
Page 4 GAO-18-450 Mental Health Protection and Advocacy

To assess SAMHSA oversight of the state PAIMI programs, we examined 

agency policies and procedures related to review and monitoring activities 

conducted by the agency, including checklists or guidelines for 

conducting annual reviews of program applications and program 

performance data and periodic onsite monitoring reviews. We assessed 

these policies and procedures against relevant statutory and regulatory 

program requirements and federal internal control standards on 

monitoring and the design of control activities.10 In addition, we developed 

and completed a data collection instrument that allowed us to 

systematically examine SAMHSA’s documentation of its review of annual 

program applications and program performance data for fiscal years 2015 

and 2016. We completed the instrument for the eight selected PAIMI 

programs, plus an additional two programs—Oklahoma and Puerto 

Rico—selected because the programs had been placed on “restricted 

status,” which triggers enhanced oversight.11 Furthermore, we reviewed 

the monitoring reports for nine PAIMI programs (Idaho, Illinois, Maryland, 

Ohio, Oklahoma, Oregon, Pennsylvania, Tennessee, and Washington) for 

which SAMHSA conducted an onsite review in fiscal years 2015 or 2016. 

We supplemented our review of documentation with interviews with 

SAMHSA officials, staff from six PAIMI programs, and staff from the 

association representing PAIMI programs, the National Disability Rights 

Network (NDRN).12

We conducted this performance audit from July 2017 to May 2018 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

 10See GAO, Standards for Internal Control in the Federal Government, GAO-14-704G 

(Washington, D.C.: September 2014). Internal control is a process effected by an entity’s 

oversight body, management, and other personnel that provides reasonable assurance 

that the objectives of an entity will be achieved. 

11SAMHSA uses the term “restricted status” to describe grantees that are financially 

unstable, have inadequate financial management systems, or are poor programmatic 

performers. Programs deemed to be on restricted status require closer monitoring and 

have their funds restricted. They must submit requests for advance funding or 

reimbursement and provide detailed explanations to support costs claimed that are not in 

the approved budget. 

12The six programs—California, Georgia, Indiana, Oklahoma, Vermont, and Washington—

varied in terms of grant size, program type, geographic region, and restricted status. 
Page 5 GAO-18-450 Mental Health Protection and Advocacy

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Mental health disorders affect millions of adults and children in the United 

States and can range in severity. In 2016, an estimated 4.2 percent of the 

adult population—more than 10.4 million individuals—were considered to 

have a serious mental illness based on federal survey data.13 Individuals 

with mental illness may reside and receive care in a variety of settings, 

including inpatient institutional settings, such as public or private 

hospitals, other residential treatment facilities, or community-based 

settings. When originally established under the PAIMI Act, state PAIMI 

programs were required to investigate reports of potential abuse and 

neglect of individuals with significant mental illness residing in institutional 

facilities and to protect and advocate the rights of these individuals.14

Examples of institutional facilities covered under the PAIMI Act include 

hospitals, nursing homes, and correctional facilities. In 2000, the PAIMI 

Act was amended to allow certain PAIMI programs to also assist eligible 

individuals who live in community settings, including their own homes, 

although programs must still prioritize services for eligible individuals 

residing in institutional settings.15 For example, state PAIMI programs 

assist individuals with abuse, neglect, and rights violation cases in school 

settings.

State PAIMI programs are administered by either state agencies or nonprofit organizations that have been designated by the governor of each 

state to operate a protection and advocacy system. The state PAIMI 

programs are allotted federal grants through a formula that is based 

 13See SAMHSA, Key Substance Use and Mental Health Indicators in the United States: 

Results from the 2016 National Survey on Drug Use and Health (Rockville, Md: 

September, 2017). Serious mental illness refers to a diagnosable mental, behavioral, or 

emotional disorder such as schizophrenia or bipolar disorder that substantially limits an 

individual’s functioning in major life activities. Children also may be diagnosed with serious 

mental health disorders that limit their ability to function at home, in school, or in their 

communities, referred to as serious emotional disturbance. 

14See Pub. L. No. 99–319, § 102(3), 100 Stat. 478, 479 (1986). 

15See Children’s Health Act of 2000, Pub. L. No. 106-310, § 3206, 114 Stat. 1101, 1193 

(2000). State PAIMI programs may serve individuals who live in a community setting only 

if the total allotment nationally under the PAIMI statute for the fiscal year is $30 million or 

more.

Background

Key State PAIMI Program 

Requirements and 

Activities
Page 6 GAO-18-450 Mental Health Protection and Advocacy

equally on (1) the population in each state, and (2) the population in each 

state weighted by its relative per capita income.16 In 2016, state PAIMI 

program grants ranged from $229,300 to $3,133,536. (See appendix I for 

allotment by program.) To receive a PAIMI grant, each protection and 

advocacy organization must submit an annual application, and the PAIMI 

programs they operate must meet applicable statutory and regulatory 

requirements. (See table 1.)

Table 1: Selected Federal Requirements for State Protection and Advocacy for Individuals with Mental Illness (PAIMI) 

Programs

Requirement 

category

Selected program 

requirements

Independence The state PAIMI program must be independent of state agencies that provide treatment or services 

(other than advocacy services) to individuals with mental illness, and must develop policies and 

procedures to protect against conflicts of interest involving clients, employees, and others.

Capacity The state PAIMI program staff must be trained to provide services to mentally ill individuals and the 

program must have the capacity to protect and advocate the rights of individuals with mental illness.

Advisory council The state PAIMI program must establish an advisory council to provide independent advice and 

recommendations that includes attorneys, mental health professionals, members of the public who are 

knowledgeable about mental health, a provider of mental health services, individuals who have 

received or are receiving mental health services, and family members of these individuals. The chair 

of the council and at least 60 percent of the advisory council members must be individuals who have 

received or are receiving mental health services or their family members.

Priority goal setting The governing authority of the state PAIMI program must—jointly with the advisory council—annually 

set program priorities and must seek input annually from members of the public on program priorities 

and activities. The program priorities must specify short-term goals and objectives, with measureable 

outcomes, to implement the priorities.

Use of federal funds State PAIMI programs must use federal funds only to supplement, rather than supplant, existing state 

funds. Federal funds may not be used for lobbying activities or to support or defeat any candidate for 

public office.

Grievance procedures State PAIMI programs must establish procedures to address grievances from clients, prospective 

clients, and individuals receiving mental health services, and their family members or representatives. 

Written responses must be provided, and grievances must be reported to the governing authority and 

advisory council.

Source: GAO summary of selected provisions of the PAIMI Act and Substance Abuse and Mental Health Services Administration regulations. | GAO-18-450

Approved state PAIMI programs use their grants to protect and advocate 

for individual clients, such as investigating specific complaints. They may 

also conduct broader system-level protection and advocacy activities, 

such as facility monitoring, intended to benefit larger groups of individuals 

 16Under the PAIMI Act, relative per capita income refers to the per capita income in the 

United States divided by the per capita income of the state. In the territories, this quotient 

is considered to be one.
Page 7 GAO-18-450 Mental Health Protection and Advocacy

with significant mental illness. These systemic activities, as we refer to 

them in this report, include efforts to drive changes in policies and 

practices of the state’s mental health agency, treatment facilities, and

other systems, such as school systems, that impact people with 

significant mental illness. (See table 2.) 

Table 2: Key Individual and Systemic Activities Performed by State Protection and Advocacy for Individuals with Mental 

Illness (PAIMI) Programs

Category

Examples of activities performed 

by state PAIMI programs

Abuse Investigating reports of abuse, such as physical or verbal maltreatment, use of excessive force, or 

abusive institutional practices, such as use of restraint that is not in compliance with federal and state 

law and regulation.

Neglect Investigating reports of neglect, such as neglect of health, nutritional or clothing needs, failure to 

provide a safe environment including adequate staffing, or neglecting to provide adequate treatment 

planning, discharge services, or community care.

Denial of civil rights Investigating reports of denial of civil rights, such as the right to adequate conditions in facilities, 

freedom from undue restraint of liberty, provision of due process in involuntary treatment, and the right 

to informed consent.

Deaths Investigating individual deaths that may be related to seclusion or restraint, and pursuing systemic 

reform.

Group interventions Assisting groups of PAIMI-eligible individuals through activities such as facility monitoring or class 

action litigation.

Awareness and 

education

Providing information and referral services, public awareness activities, education, and training.

Source: GAO summary of Substance Abuse and Mental Health Services Administration documentation. | GAO-18-450

Each state PAIMI program, with input from the advisory council and 

governing authority, sets priority goals and short-term, measurable 

objectives and targets annually as performance benchmarks for the work 

it plans to conduct. Programs can also revise these benchmarks during 

the year to align with changing needs. For example, the types of 

individual cases programs accept and work on may depend on the types 

of complaints that are received, which may vary over time.
Page 8 GAO-18-450 Mental Health Protection and Advocacy

SAMHSA administers the PAIMI grants and is responsible for oversight 

and monitoring of the state PAIMI programs.17 To oversee the state 

PAIMI programs, SAMHSA conducts both ongoing reviews of the annual 

application and performance information submitted by the programs, and 

periodic, in-depth reviews:

• Ongoing monitoring activities. PAIMI grant applications are 

effective for 4-year periods, but programs submit additional grant 

applications annually to update certain information, such as the 

program budget and goals. SAMHSA awards PAIMI grants based on 

criteria such as whether the grantee submitted a statement of annual 

program priorities, including quantifiable targets and measurable 

outcomes.18 In addition to the application, programs must submit key 

data annually in a program performance report. The performance 

report must describe a program’s individual and systemic activities, 

accomplishments, and expenditures during the most recent fiscal year 

and must include a section prepared by the advisory council. The 

performance report requires programs to report on both standard 

measures required of all programs and on progress towards the 

program-specific priority goals, objectives, and targets.19 SAMHSA 

reviews information submitted by the programs annually through 

grants applications and performance reports, including completing a 

review checklist and following up with programs with questions.

• Periodic monitoring. SAMHSA conducts four to five onsite

monitoring reviews of state PAIMI programs each year, which officials 

told us means a given program would be reviewed approximately 

every 10 years. Programs are reviewed on a rotating basis, but some 

may be reviewed more frequently if concerns have been identified, 

 17The protection and advocacy systems that operate PAIMI programs also receive other 

federal grants to conduct work on behalf of individuals with other types of disabilities. For 

example, the Administration for Community Living oversees the Protection and Advocacy 

for Individuals with Developmental Disabilities program.

18For more information about SAMHSA’s review of PAIMI grants, see GAO, Mental 

Health: Better Documentation Needed to Oversee Substance Abuse and Mental Health 

Services Administration Grantees, GAO-15-405 (Washington, D.C.: May 12, 2015).

19Examples of standard measures include the number of individuals served during the 

fiscal year; the number of complaints resolved during the fiscal year, by type of complaint 

and by complaint resolution (i.e., favorably resolved, unfavorably resolved, withdrawn or 

terminated, or no merit); and the number of systemic activities conducted, among other 

things. 

SAMHSA Oversight of 

State PAIMI Programs
Page 9 GAO-18-450 Mental Health Protection and Advocacy

according to officials. The onsite monitoring process, which includes 

an onsite visit and review of program documentation, is intended to 

monitor program compliance and provide guidance on improving 

program effectiveness. SAMHSA has procedures for the scope and 

time frame of the reviews.

The eight selected state PAIMI programs reported favorably resolving a 

majority of individuals’ cases related to alleged abuse, neglect, or rights 

violations. In addition, these selected programs reported concluding a 

variety of systemic activities, with a significant focus on monitoring and 

addressing issues of abuse or neglect at facilities. Through their work with 

individuals and completion of systemic activities, the selected programs 

reported meeting a majority of their priority goals and objectives.

Selected programs reported favorably resolving about 74 percent of 

individual cases related to alleged abuse, neglect, or rights violations in 

fiscal year 2016, on average (see table 3).20 The remaining 26 percent of 

cases were reported as withdrawn by the client, closed due to lack of 

merit, or were not resolved in the individual’s favor.21 Across the 

programs there was variation in the percentage of cases resolved 

favorably, with two of the selected programs reporting half, or less than 

half, of their cases resolved favorably, and one program reporting nearly 

100 percent of cases closed favorably. SAMHSA officials and NDRN staff 

cited a number of factors that could contribute to the variation, including 

complexity of the complaint, variation in the programs’ criteria for 

accepting cases, program resources, or characteristics of the court or 

state mental health system. For example, SAMHSA officials told us that 

 20An individual case is opened when a PAIMI-eligible individual with a complaint is 

accepted as a client by the protection and advocacy system. A case record or case file is 

opened for that individual.

21Specifically, the eight programs reported favorably resolving 1,772 cases—309 abuse 

cases, 341 neglect cases, and 1,122 rights violation cases—out of 2,390 cases that were 

closed in fiscal year 2016 overall. The other 618 cases were reported as withdrawn by the 

client, closed due to lack of merit, or were not resolved in the individual’s favor. 

Selected State PAIMI 

Programs Reported 

Achievements in 

Ending and 

Preventing Abuse, 

Neglect, and Rights 

Violations of Those 

with Significant 

Mental Illness

Outcomes of Individual 

Cases
Page 10 GAO-18-450 Mental Health Protection and Advocacy

possible explanations for variation could include a program accepting 

particularly challenging cases, or a program obtaining additional funding 

from other nonfederal grants that could provide greater legal staff support 

in addressing complaints. 

Table 3: Resolution of Closed Cases on Alleged Abuse, Neglect, and Rights 

Violations Reported by Selected Protection and Advocacy for Individuals with 

Mental Illness (PAIMI) Programs, Fiscal Year 2016

State

Number of 

cases closeda Percentage of cases resolved in client’s favorb

Washington 351 99.7

California 857 90.1

Indiana 82 87.8

Massachusetts 107 86.0

Georgia 129 83.7

Louisiana 70 72.9

Vermont 111 52.3

Texas 683 39.4

Total 2,390 74.1

Source: GAO analysis of 2016 Substance Abuse and Mental Health Services Administration data. | GAO-18-450

a

Number of client records or case files closed by an advocate or attorney after providing service and 

determining that the client either had no need of further services or that the program had no other 

services available to address the problem(s).

b

Indicates the case was closed in the client’s favor, such as when the client was satisfied with the 

result of the program’s work or the violation in the stated case problem area was remedied. The other 

cases were reported as withdrawn by the client, closed due to lack of merit, or not resolved in the 

client’s favor.

All eight selected programs reported closing cases in each of the three 

categories of complaints: abuse, neglect, and rights violations during 

fiscal year 2016.22 Five of the eight programs reported that a majority of 

their cases were related to complaints about rights violations, which 

occurred in both facility- and community-based settings (see fig. 1). 

 22In addition to this casework, selected state PAIMI programs also reported conducting 82 

investigations into the deaths of individuals with significant mental illness in fiscal year 

2016. One death involved an incident of seclusion, and none involved incidents of 

restraint. SAMHSA officials told us that the extent of investigations into deaths varies 

considerably across programs largely due to whether states, and other sources, report 

deaths of PAIMI-eligible individuals to the program and, if so, whether the information 

provided distinguishes between particular causes of death.
Page 11 GAO-18-450 Mental Health Protection and Advocacy

These complaints included denials of legal assistance or privacy rights, 

employment discrimination, or—the most frequently reported case 

complaint—failure to provide special education consistent with state 

requirements. Issues of abuse and neglect of individuals with mental 

illness were also common. The most frequent complaint reported by the 

eight selected programs related to neglect was a lack of discharge 

planning for release from a facility, and for alleged abuse, it was failure to 

provide appropriate mental health treatment.

Figure 1: Distribution of Closed Cases by Complaint Category Reported by Selected State Protection and Advocacy for 

Individuals with Mental Illness (PAIMI) Programs, Fiscal Year 2016

Program staff reported examples of how state PAIMI programs resolved 

cases related to abuse, neglect, and rights violations for individuals in 

institutions and the community:

• Program staff in California described a rights violation case of a young 

girl with a mental health disability who was eligible for special 

education services, but the district placed her in a restricted, 

segregated school setting where she was restrained multiple times. 

The program staff negotiated her move to a general education 

campus with classroom behavior support. The PAIMI program 
Page 12 GAO-18-450 Mental Health Protection and Advocacy

monitored her transition, including ensuring her inclusion in school 

activities, academic remediation, and social skill development. 

• Program staff in Georgia reported that they were contacted by a 

woman in a hospital who was overmedicated such that they could not 

initially understand what she was saying. The staff worked with her 

hospital treatment team to adjust her medication and the woman 

became more articulate. In working to address her overmedication, 

the staff further discovered there were not appropriate discharge 

plans for her and so they worked to ensure that she was discharged 

into an appropriate facility.

To address individual cases, selected programs reported using a variety 

of strategies, ranging from administrative actions to legal remedies.23

Programs reported that the most frequently utilized strategy (used 62 

percent of the time in fiscal year 2016) was “short-term assistance”—

time-limited advice or counseling, such as assisting a client with preparing 

a letter or making a phone call to resolve an issue. Selected programs 

reported using legal remedies about 5 percent of the time in fiscal year 

2016.

 23Per the PAIMI Act, programs are required to exhaust in a timely manner all 

administrative remedies where appropriate. If these remedies are determined to not 

resolve the matter within a reasonable time, the program may pursue alternative 

remedies, including the initiation of legal action.
Page 13 GAO-18-450 Mental Health Protection and Advocacy

The eight selected programs conducted a range of systemic activities, 

and reported successfully concluding a total of 367 of these activities in 

fiscal year 2016 (see figure 2).24

Figure 2: Number and Status of Systemic Activities Reported by Selected State Protection and Advocacy for Individuals with 

Mental Illness (PAIMI) Programs, Fiscal Year 2016 

Notes: In annual program performance reports, state PAIMI programs are required to report the 

status of their systemic activities within three categories: concluded successfully, concluded 

unsuccessfully, and ongoing.

a

Although state PAIMI programs are restricted from using federal funds to engage in lobbying 

activities, they may engage in some forms of legislative and regulatory advocacy. 42 C.F.R. §§ 

51.6(b), 51.31(f) (2017). Examples of legislative and regulatory advocacy from selected programs 

include monitoring testimony, responding to an invitation to comment in a public forum, or 

disseminating information about proposed legislation at a training.

 24SAMHSA requires programs to report the status of their systemic activities within three 

categories: concluded successfully, concluded unsuccessfully, and ongoing. 

Outcomes of Systemic 

Activities
Page 14 GAO-18-450 Mental Health Protection and Advocacy

Facility monitoring was reported as the most frequent systemic activity in 

fiscal year 2016, comprising about 71 percent of the total systemic 

activities concluded by the selected programs. The selected programs 

described a range of activities involving facility monitoring. For example, 

California reported that the program had an effort focused on monitoring 

the conditions at selected county jail systems and juvenile halls. As part 

of that work, the program reported that it released five public reports and 

worked with counties on policy improvements, such as reducing the use 

of pepper spray on youth. Another program, Louisiana, reported that staff 

used to conduct regular monitoring visits to a state’s psychiatric hospital 

and addressed patient complaints that they heard during these visits. 

However, with limited resources and other emerging urgent issues at 

other facilities, the program decided to cease the regular monitoring and 

now conducts as-needed visits to the hospital in response to specific 

complaints from the patients or staff.

In addition to facility monitoring activities, other systemic activities 

conducted varied across the selected programs, reflecting differences in 

their resources and priorities. Some systemic activities—such as class 

action litigation—take significant time and resources to undertake, and 

program staff may consider various factors before beginning one. For 

example, program staff from Indiana told us the program filed a lawsuit 

alleging restrictive housing of prisoners with significant mental illness that 

involved 4 years of negotiations. In addition, program staff from Vermont 

told us after engaging in successful litigation against hospitals that helped 

reduce unnecessary force, isolation, and coercion tactics, the program reprioritized and focused on other issues, such as helping individuals 

integrate into the community from facilities. However, the program 

recently noticed an increase in force, isolation, and coercion tactics and 

predicted another shift in focus to once more address those issues.

Through their efforts to resolve individual cases and systemic activities, 

selected programs reported largely meeting the performance 

benchmarks—priority goals, objectives, and targets—they determine for 

themselves.25 For example, the Georgia program reported that to meet its 

 25Each state PAIMI program may establish its own goals and activities as long as those 

activities further the purpose of PAIMI programs outlined in the PAIMI Act, which is to 

protect and advocate the rights of individuals with mental illness to ensure the 

enforcement of the U.S. Constitution and federal and state statutes and to investigate 

incidents of abuse and neglect of such individuals.

Performance on Program 

Priority Goals
Page 15 GAO-18-450 Mental Health Protection and Advocacy

fiscal year 2016 priority goal of protecting individuals with psychiatric 

disabilities in Georgia from abuse and neglect, its objective was to 

investigate and advocate to address allegations of abuse and neglect, 

including suspicious or unexplained deaths and inappropriate treatment 

or medication issues for people with psychiatric disabilities. The 

measurable target for this objective was to conduct 50 such 

investigations. In its performance report for the fiscal year, the program 

reported that it had completed 51 investigations of allegations of 

extensive abuse and neglect during the performance year. Overall, the 

selected programs reported meeting more than 95 percent of their priority 

goals in fiscal year 2016.26 While selected programs varied in their priority 

goals, all had a goal that focused on protecting individuals from abuse, 

neglect, and rights violations. (See Appendix II for more information about 

the types of priority goals set by the selected programs.) When objectives 

were not met, the programs reported, for instance, focusing on other 

priorities or that an activity was still ongoing and could not be included as 

part of their performance for the year.

Although the eight selected PAIMI programs reported that they largely 

met their goals, they also reported several overarching challenges to their 

efforts to do so, such as limited resources, lack of access authority, or 

delays in access (e.g., to documents, records, or institutions). For 

instance, the selected programs collectively reported that 617 PAIMIeligible clients were not served within 30 days due to insufficient funding 

in fiscal year 2016. Additionally, five selected programs reported delays in 

access to records. For example, Vermont program staff reported delays in 

receiving records related to the status of prisoner grievances or medical 

records, and Texas program staff reported delays and use of significant 

attorney resources to address facilities that challenge their ability to 

access records or premises.

 26Program objectives are activities undertaken to achieve a goal. We considered a priority 

goal to be met when there were no unmet objectives pertaining to that goal.
Page 16 GAO-18-450 Mental Health Protection and Advocacy

SAMHSA has controls in place for monitoring the PAIMI programs’

compliance with statutory and regulatory requirements through its 

ongoing and periodic in-depth monitoring activities. We found evidence 

that SAMHSA had identified and resolved a variety of compliance issues 

through these activities.

On an annual basis, SAMHSA monitors compliance with statutory and 

regulatory program requirements by reviewing information reported by the 

programs through the application and program performance report. (See 

table 4.) SAMHSA’s project officers review and approve the applications 

and performance reports submitted by the state PAIMI programs using a 

checklist developed by the agency that prompts them to record specific 

information, such as whether there are vacant advisory council seats. Not 

all areas of compliance are covered by the checklist; however, SAMHSA 

officials told us that the entire application and performance report are 

reviewed, and that a project officer’s approval signature on a checklist 

indicates that potential issues observed during a review have been 

resolved satisfactorily.

SAMHSA Has 

Controls in Place to 

Oversee Program 

Compliance with 

PAIMI Requirements, 

but Oversight of 

Program 

Effectiveness Is More 

Limited

SAMHSA Has Controls in 

Place to Monitor 

Compliance with Program 

Requirements

Ongoing Monitoring
Page 17 GAO-18-450 Mental Health Protection and Advocacy

Table 4: Examples of Information Required in State Protection and Advocacy for Individuals with Mental Illness (PAIMI) 

Applications and Performance Reports, Fiscal Year 2016

Reporting Requirements

Statutory or 

regulatory requirement Applicationa Program 

performance reportb

Advisory council report 

(submitted as an attachment 

to the performance report)

At least 60 percent of advisory 

council membership shall be 

individuals who have received or 

are receiving mental health 

services, or family members of 

such individuals.

Number and percentage of 

advisory council members who 

are current or former recipients 

of mental health services or the 

family members of such 

individuals.

Number and percentage of 

advisory council members 

who are current or former 

recipients of mental health 

services or the family 

members of such individuals.

State PAIMI program shall 

annually provide the public with 

an opportunity to comment on 

the activities and priorities of 

the program.

Statement signed by program 

that includes an assurance that 

the program has developed its 

priorities to include providing 

the public with an opportunity 

for comment

Does the program have 

procedures established 

for public comment? 

(Yes/No)

Does the program have 

procedures established for 

public comment? (Yes/No)

State PAIMI program 

shall establish a grievance 

procedure for clients and 

prospective clients.

Statement signed by program 

that includes an assurance that 

the program has written 

grievance policies and practices 

that comply with regulations.

Does the program have 

a grievance policy? 

(Yes/No)

Is the advisory council aware 

of and knowledgeable of the 

program’s established 

grievance policies and 

procedures? (Yes/No)

PAIMI funds may not be used 

to support lobbying activities to 

influence proposed or pending 

federal legislation or 

appropriations.

Statement signed by program 

that includes an assurance that 

funds may not be used for such 

activities.

Completed standard form for 

disclosing lobbying activities.

Source: GAO analysis of applicable statute and regulations and Substance Abuse and Mental Health Services Administration documentation. | GAO-18-450

a

PAIMI grant applications are effective for 4-year periods. For the first year of the period, the state 

PAIMI program is required to submit an initial application that outlines priorities for the entire 4 years. 

For the remaining 3 years, the program submits a supplemental application each year for continued 

funding that provides updated information for certain sections of the application, such as for priority 

goals and objectives or for the budget. For fiscal years 2015 and 2016, the PAIMI programs 

submitted application updates. The most recent application period began in fiscal year 2017.

b

PAIMI programs submit performance reports on an annual basis. 

In our review of fiscal year 2015 and 2016 documentation, we found 

evidence that the application and performance report review process 

helped identify and resolve a range of potential compliance issues. For 

example, SAMHSA followed up with one program in which the advisory 

council had failed to meet the threshold of 60 percent of its membership 

being individuals who have received or are receiving mental health 

services, or are family members of such individuals. Failing to meet this 

threshold could raise concerns about whether a program is sufficiently 

engaging individuals and family members affected by mental illness as 
Page 18 GAO-18-450 Mental Health Protection and Advocacy

required by regulation. In this instance, SAMHSA requested a plan of 

action to recruit and maintain members to meet the threshold, which the 

program provided along with updated information that they had 

successfully recruited an additional member that put the council make-up 

over the threshold. In another example, SAMHSA followed up with one 

program that had reported not meeting 3 of 6 objectives and requested a 

plan of action for reducing the number of unmet objectives. The program 

subsequently provided information that it had incorrectly categorized 

some objectives they had met as “not met.” (See table 5.)

Table 5: Examples of Compliance Findings from Annual Application and Performance Report Reviews Conducted by the 

Substance Abuse and Mental Health Services Administration (SAMHSA) of Protection and Advocacy for Individuals with 

Mental Illness (PAIMI) Programs, Fiscal Years 2015-2016

Compliance category Example

Priority goals, objectives, 

and targets

Target population for one program’s priority goals and objectives did not specify PAIMI-eligible 

individuals, to ensure that PAIMI funding was appropriate for the program’s activities.a

Program activities Inconsistencies in the number of attorneys and advocates one program reported, related to the 

statutory requirement that programs have the capacity to protect and advocate for individuals 

with mental illness.

Outreach efforts Plans for outreach efforts to diversify participation in the advisory council—a regulatory 

requirement—were vague and unclear in how they would address the program’s need for greater 

diversity. 

Advisory council Program’s advisory council did not include an attorney as a member, as mandated in statute.

Source: GAO analysis of SAMHSA documentation. | GAO-18-450

a

Individuals with mental illness eligible to receive PAIMI services are defined under the PAIMI Act as 

those with significant mental illness or emotional impairment, as determined by a mental health 

professional qualified under the laws and regulations of the state.

In addition to the annual application and performance report reviews, 

SAMHSA officials told us that they use monthly conversations with other 

federal agencies, referred to as federal partners, to help them identify 

potential compliance issues. These federal partners oversee federal 

grants for other populations of people with disabilities made to the 

protection and advocacy systems that administer the PAIMI program.27

SAMHSA officials told us that coordination with these federal partners 

helped identify risks in at least two of our selected programs, Puerto Rico 

and Oklahoma. For example, one of the federal partners conducted an 

onsite monitoring visit to Puerto Rico and found several issues with its 

protection and advocacy system, such as inadequately trained staff and 

 27Federal partners include the Administration on Community Living, the Rehabilitation 

Services Administration, and the Social Security Administration. 
Page 19 GAO-18-450 Mental Health Protection and Advocacy

conflicts of interest arising from a lack of independence from the 

governor’s office.28 Puerto Rico’s protection and advocacy system failed 

to develop an adequate corrective action plan to address the federal 

partner’s findings, leading the federal partner to place the system in 

restricted—that is, high-risk—status. According to SAMHSA officials, 

these actions led them to more closely monitor Puerto Rico’s PAIMI 

program, resulting in the identification of the protection and advocacy 

system’s failure to comply sufficiently with PAIMI program requirements. 

For example, SAMHSA found that Puerto Rico’s PAIMI program did not 

have the capacity to protect and advocate for individuals with mental 

illness, as required by statute, because they had an insufficient number of 

attorneys. Furthermore, the federal partner that originally placed Puerto 

Rico’s protection and advocacy system in restricted status requested that 

SAMHSA do so as well. As a result, SAMHSA also placed the Puerto 

Rico PAIMI program in restricted status.

In addition to its ongoing monitoring, SAMHSA has procedures to oversee 

state PAIMI program compliance during its periodic onsite monitoring 

reviews. When SAMHSA conducts an onsite monitoring review, its 

procedures specify that officials are to interview program staff, governing 

board members, and advisory council members; as well as review a 

sample of case record files and other documentation of program 

activities. The state PAIMI program is also to submit a detailed set of 

documentation to support the program’s compliance with statutory and 

regulatory requirements. Agency officials are to review this information 

and report back to the programs on any compliance issues or 

recommendations to improve program processes.29

In our review of fiscal year 2015 and 2016 documentation for the nine

onsite monitoring reviews SAMHSA conducted, we found evidence that 

this process helped identify and resolve a range of potential compliance 

issues. For example, SAMHSA found that one program’s bylaws could be 

misinterpreted to permit lobbying for legislation for PAIMI-eligible 

individuals using PAIMI funding, when federal law prohibits grants 

programs from using federal funds to engage in such activity. As a result, 

 28Puerto Rico’s protection and advocacy system that administers the PAIMI program and 

other similar federal grants is a state-run organization.

29In addition to its review of compliance with statutory and regulatory requirements, 

SAMHSA conducts a review of a program’s financial compliance with applicable financial 

requirements such as generally accepted accounting principles and regulations governing 

federal grantee financial administration. 

Periodic Onsite Monitoring 

Reviews
Page 20 GAO-18-450 Mental Health Protection and Advocacy

the program’s governing board reviewed and modified the bylaws to 

clearly indicate that PAIMI funds are not to be used for lobbying.

As another example, SAMHSA found that one program did not have 

sufficient documentation to support that the advisory council chair was an 

individual who had received or was receiving mental health services, or a 

family member of such an individual, as required by regulations. As a 

result, the program revised its practice to include having the advisory 

council chair verify in writing that he or she meets the criteria for serving 

in the position. (See table 6.)

Table 6: Examples of Protection and Advocacy for Individuals with Mental Illness Program Compliance Findings from Onsite 

Monitoring Reviews Conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), Fiscal Years 

2015-2016

Compliance category Example

Governing board Governing board lacked written policies and procedures for the evaluation regarding the 

executive director, as required by regulation.

Conflicts of interest Conflict of interest policies and procedures did not reference contractors and subcontractors, 

which are among those listed under the conflict of interest requirements in regulation.

Confidentiality Grievance policy did not contain an assurance of confidentiality, as required by regulation.

Advisory council Advisory council failed to fill membership vacancies required by statute and regulation, such as 

an attorney, over multiple years.

Program priorities Advisory council was not included in developing the program priorities alongside the governing 

authority, as required by statute and regulation.

Grievance policy Grievance policy included provisions for clients, potential clients, and other individuals who had 

contact with the program but did not include systemic grievance procedures to resolve 

grievances from individuals who have received or are receiving mental health services in the 

state, family members of such individuals, or representatives of such individuals or family 

members, as required by statute and regulation.

Eligibility A portion of the case records selected for review lacked sufficient documentation of the client’s 

program eligibility.

Source: GAO analysis of SAMHSA documentation. | GAO-18-450

We identified two weaknesses that could be limiting SAMHSA’s oversight 

of program effectiveness. First, SAMHSA’s PAIMI program monitoring did 

not consistently record changes to program priority goals, objectives, and 

targets—collectively, “benchmarks”—made during a performance year, 

and the agency did not have procedures for examining such changes 

over time. Second, the agency did not provide timely information to 

programs on identified deficiencies from onsite monitoring. As of March 

2018, SAMHSA was in the process of implementing new processes for its 

oversight of state PAIMI programs that officials believe will streamline the 

SAMHSA Has Not 

Consistently Examined 

Changes to Program 

Benchmarks or Completed 

and Provided Onsite 

Review Findings in a 

Timely Manner
Page 21 GAO-18-450 Mental Health Protection and Advocacy

agency’s monitoring activities. However, these changes may not fully 

address the weaknesses we identified.

We found that SAMHSA did not always record changes programs made 

to their performance benchmarks and did not have procedures for 

examining benchmark changes over time. According to federal internal 

control standards, an agency should evaluate the results of its 

monitoring—in this case, the information collected regarding benchmark 

modifications—to determine program performance.30

In our review of SAMHSA’s oversight of 10 programs for fiscal years 2015 

and 2016, we found that SAMHSA did not consistently record program 

modifications to performance benchmarks.31 Specifically, we found that 

four programs appeared to have modified their performance benchmarks 

during the year—in some cases upward when results exceeded original 

targets, and in other cases downward when results were lower than 

original targets. However, these changes were not recorded by SAMHSA 

reviewers in the review checklists.32 For instance, one program revised 17 

of its 21 targets to closely match the program’s actual results, but these 

changes were not recorded in the area of the review checklist that 

prompts the project officer to note if such changes were made.

According to SAMHSA officials, in fiscal year 2017, SAMHSA transitioned 

from paper forms to a web-based system for submission and review of 

applications and performance reports. Officials told us that under the new 

system, programs will be required to consult with SAMHSA officials about 

and submit modifications to performance benchmarks through the 

system. The system will record and display both the original priority goals, 

objectives, and targets as approved at the time of the application, as well 

as any modifications a program submits throughout the year. The system 

will also record that information over time, providing the ability to review 

and track program modifications to benchmarks over multiple years.

 30See GAO-14-704G.

31As described previously, the 10 programs included the eight selected state programs 

and the two additional programs that were on restricted status.

32In addition to recording changes in the checklist, SAMHSA officials told us that they may 

document communication with the PAIMI programs by keeping a log of phone calls or by 

saving emails to a special drive. For two of the four programs we identified that appeared 

to modify their benchmarks, SAMHSA officials were also unable to provide any records of 

communication regarding those modifications. 

Inconsistent Recording of 

Changes to Performance 

Benchmarks and Lack of 

Procedures for Examining 

Changes across Years
Page 22 GAO-18-450 Mental Health Protection and Advocacy

SAMHSA’s new system should improve recording of benchmark changes, 

however, SAMHSA lacks procedures for examining such changes across 

years to assess whether the changes could indicate larger performance 

issues. SAMHSA officials acknowledged that they did not have specific 

procedures in place directing project officers to examine changes to 

performance benchmarks across multiple years, but said that other 

relevant procedures were in place. For example, officials noted that 

programs are not able to modify benchmarks without approval by 

SAMHSA project officers. However, without implementing procedures 

aimed specifically at examining trends in benchmark modifications across 

years, SAMHSA lacks assurances that its project officers will consistently 

examine whether a particular program is regularly making changes to 

benchmarks that may be indicative of a potential performance problem, 

such as revising its targets downwards over multiple years.

We found that SAMHSA generally failed to meet its timelines for 

producing and providing onsite monitoring review reports to the state 

PAIMI programs under review during fiscal years 2015 and 2016. This 

inability to produce and provide onsite monitoring reports to PAIMI 

programs in a timely manner is inconsistent with SAMHSA’s internal 

requirements and with federal internal control standards regarding 

evaluating issues and remediating deficiencies on a timely basis.33

Specifically, for onsite monitoring reviews, SAMHSA’s procedures specify 

the agency is to provide an initial report to the reviewed program within 

150 days of the onsite visit.34 However, for eight of the nine monitoring

review reports we reviewed for fiscal years 2015 and 2016, SAMHSA 

provided the report more than a year after the visit. One program that had 

just received its report at the time of our review told us that it was difficult 

to plan the necessary changes to its work without an official report with 

findings and recommendations to help guide them in restructuring their 

operations. Program staff said they had moved ahead and made some 

 33See GAO-14-704G.

34At the end of an onsite monitoring visit, SAMHSA officials conduct an exit meeting 

where they communicate any preliminary findings they have identified to program staff. 

Following the site visit, SAMHSA officials finish reviewing any documentation, during 

which they may identify additional findings. Upon concluding the documentation review, 

SAMHSA officials prepare an initial report to provide to the program. Upon receipt, the 

program has 30 days to review and suggest factual corrections. SAMHSA then reconciles 

the program’s comments as it deems appropriate and issues a final report. 

Failure to Provide Timely 

Information on Identified 

Deficiencies
Page 23 GAO-18-450 Mental Health Protection and Advocacy

changes but were uncertain whether those changes would be deemed 

sufficient because of the lack of feedback from the agency.

SAMHSA officials told us that they may have missed some deadlines as a 

result of competing priorities and restricted resources—for example, 

recently only two of four PAIMI project officer positions have been 

occupied. Officials reported that the agency was taking steps to 

streamline the process to make it more efficient and to bring on more staff 

resources. The officials said that in 2018 SAMHSA planned to shift 

responsibility for the project officers’ portion of the onsite reviews to a 

dedicated onsite monitor, which they hoped would expedite the review 

process.35 In addition, the agency had taken steps to streamline its onsite 

monitoring review process, such as by revising and standardizing its 

reporting template.36

There are uncertainties with regard to how effective these changes will be 

in increasing timeliness. For example, the planned efficiencies target 

some, but not all, of the key components of the reviews. In particular, 

SAMHSA officials told us that these review process changes do not 

pertain to the portion of the onsite review that focuses on state PAIMI 

program compliance with applicable fiscal requirements. Officials noted 

that the SAMHSA office that conducts the fiscal portion of the review has 

had staff shortages for the past 16 months and is not able to operate 

within normal time frames for completing this portion of the report.37

Without meeting its deadlines for completing its review and providing

timely, detailed information and feedback to PAIMI programs, SAMHSA 

cannot ensure that identified issues are resolved in a timely manner, thus 

potentially endangering the effectiveness of the programs.

Individuals with mental illness can face abuse, neglect, and rights 

violations in both institutional and community treatment settings, including 

 35As of March 2018, SAMHSA’s planned timeline was for the monitor to accompany an 

experienced project officer on onsite visits in the spring and then, if determined ready, 

take over the visits in summer 2018.

36For example, SAMHSA reviewed the reporting template and in 2017 eliminated some 

portions deemed unnecessary, such as a background section on state demographics.

37According to officials, the SAMHSA office that conducts the fiscal portion of the review 

provides PAIMI programs with preliminary findings—which may be the same as the 

findings provided in the onsite monitoring report—during an exit meeting or shortly after 

the onsite monitoring visit.

Conclusions
Page 24 GAO-18-450 Mental Health Protection and Advocacy

their own homes. The protection and advocacy services provided by state 

PAIMI programs play an important role in reducing these serious issues 

for this vulnerable population. Therefore, it is important to monitor how 

effective the programs are in addressing such issues. SAMHSA has a 

number of procedures in place to monitor program compliance with 

statutory and regulatory requirements, which enable the agency to 

identify and resolve potential issues with program compliance, and it is 

taking steps to streamline and improve its compliance oversight. At the 

same time, the agency’s processes for oversight of program effectiveness 

could be improved, such as by examining trends in mid-performance 

changes programs make to their priority goals, objectives, and targets 

across multiple years. Without such monitoring, SAMHSA may not 

recognize a pattern of changes that signal larger concerns about that 

program’s effectiveness. Finally, SAMHSA has not been timely in 

completing its onsite monitoring reviews or providing the results of these 

reviews to the programs. Although SAMHSA has plans to make reviews 

more efficient and to add resources, it is unclear to what extent these 

steps will resolve the lack of timeliness.

We are making the following two recommendations to SAMHSA:

The Assistant Secretary for Mental Health and Substance Use should 

establish procedures to better ensure that mid-performance changes to 

program priority goals, objectives, and targets are examined across 

multiple years. (Recommendation 1)

The Assistant Secretary for Mental Health and Substance Use should 

take steps, including the steps it has planned, to ensure onsite reviews 

are completed and findings are provided to programs on a timely basis.

(Recommendation 2)

We provided a draft of this report to HHS for comment. In its written 

comments, HHS concurred with both of our recommendations and 

indicated that it will examine ways to implement them. HHS’s comments 

are reprinted in appendix III. HHS also provided technical comments, 

which we incorporated as appropriate.

Recommendations for 

Executive Action

Agency Comments
Page 25 GAO-18-450 Mental Health Protection and Advocacy

We are sending copies of this report to the appropriate congressional 

committees, the Secretary of Health and Human Services, and other 

interested parties. In addition, the report is available at no charge on the 

GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or at iritanik@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix IV.

Katherine M. Iritani

Director, Health Care
Appendix I: Protection and Advocacy for 

Individuals with Mental Illness (PAIMI) Grants 

by Program, Fiscal Year 2016

Page 26 GAO-18-450 Mental Health Protection and Advocacy

Program Grant amount 

Alabama $456,202

Alaska 428,000

Arizona 620,810

Arkansas 428,000

California 3,133,536

Colorado 437,326

Connecticut 428,000

Delaware 428,000

District of Columbia 428,000

Florida 1,724,396

Georgia 924,616

Hawaii 428,000

Idaho 428,000

Illinois 1,068,437

Indiana 601,509

Iowa 428,000

Kansas 428,000

Kentucky 428,000

Louisiana 428,000

Maine 428,000

Maryland 461,758

Massachusetts 507,383

Michigan 900,554

Minnesota 447,204

Mississippi 428,000

Missouri 538,623

Montana 428,000

Nebraska 428,000

Nevada 428,000

New Hampshire 428,000

New Jersey 684,418

New Mexico 428,000

New York 1,522,543

North Carolina 900,754

North Dakota 428,000

Ohio 1,026,130

Appendix I: Protection and Advocacy for 

Individuals with Mental Illness (PAIMI) 

Grants by Program, Fiscal Year 2016
Appendix I: Protection and Advocacy for 

Individuals with Mental Illness (PAIMI) Grants 

by Program, Fiscal Year 2016

Page 27 GAO-18-450 Mental Health Protection and Advocacy

Program Grant amount 

Oklahoma 428,000

Oregon 428,000

Pennsylvania 1,068,002

Rhode Island 428,000

South Carolina 455,079

South Dakota 428,000

Tennessee 587,219

Texas 2,268,331

Utah 428,000

Vermont 428,000

Virginia 672,622

Washington 573,924

West Virginia 428,000

Wisconsin 496,018

Wyoming 428,000

American Samoa 229,300

Guam 229,300

Northern Mariana Islands 229,300

Puerto Rico 538,623

Virgin Islands 229,300

American Indian Consortium 229,300

Source: Substance Abuse and Mental Health Services Administration. | GAO-18-450
Appendix II: Selected State PAIMI Program 

Priority Goal Categories in Fiscal Year 2016

Page 28 GAO-18-450 Mental Health Protection and Advocacy

State Protection and Advocacy for Individuals with Mental Illness (PAIMI) 

programs determine their priority goals each fiscal year to prioritize the 

work they hope to accomplish.1 Our analysis of the priority goals reported 

in the annual program performance reports by eight selected state PAIMI 

programs found that all programs had at least one priority goal focused 

on Protection and Civil Rights in fiscal year 2016 (see fig. 3).

Access/Discrimination was the next most frequently set priority goal 

category—with seven of the eight programs establishing these goals. We 

also reviewed program goal categories from fiscal year 2015 and 

identified few significant differences between 2015 and 2016.

Eight priority goal categories emerged from our analysis:

• Access/Discrimination: This category refers to issues broadly 

related to access to services or benefits, and reduction of 

discrimination, e.g., advocating for access to legal services or 

elimination of barriers to housing, employment, and education 

services.

• Community Integration: This category refers to issues of integrating 

the individual into community facilities or ensuring they can be 

independent outside of a facility.

• Education: This category refers to specific issues related to access 

or equality in education services.

• Employment: This category refers to specific issues related to 

access to employment.

• Health Care Services: This category refers to specific issues related 

to access to health care services within the community or state.

• Housing: This category refers to specific issues related to access to 

housing.

• Information/Outreach: This category refers to activities related to 

distributing publications or performing outreach to individuals.

• Protection and Civil Rights: This category refers to issues broadly 

related to rights violations and protection from restraint, seclusion, or 

other abuse or neglect.

 1

Each state PAIMI program may establish its own goals and activities as long as those 

activities further the purpose of PAIMI programs outlined in the PAIMI Act, which is to 

protect and advocate the rights of individuals with mental illness to ensure the 

enforcement of the U.S. Constitution and federal and state statutes and to investigate 

incidents of abuse and neglect of such individuals.

Appendix II: Selected State PAIMI Program 

Priority Goal Categories in Fiscal Year 2016
Appendix II: Selected State PAIMI Program 

Priority Goal Categories in Fiscal Year 2016

Page 29 GAO-18-450 Mental Health Protection and Advocacy

Figure 3: Selected State Protection and Advocacy for Individuals with Mental Illness (PAIMI) Program Priority Goal 

Categories, Fiscal Year 2016
Appendix III: Agency Comments from the 

Department of Health and Human Services

Page 30 GAO-18-450 Mental Health Protection and Advocacy

Appendix III: Agency Comments from the 

Department of Health and Human Services
Appendix III: Agency Comments from the 

Department of Health and Human Services

Page 31 GAO-18-450 Mental Health Protection and Advocacy
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 32 GAO-18-450 Mental Health Protection and Advocacy

Katherine M. Iritani, (202) 512-7114 or iritanik@gao.gov

In addition to the contact named above, Susan Barnidge, Assistant 

Director; Hannah Marston Minter, Analyst-in-Charge; Joanna Wu 

Gerhardt; and Emily Beller Holland made key contributions to this report. 

Also contributing were Jennie Apter, Muriel Brown, and Emily Wilson.

Appendix IV: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(102181)
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