BUREAU OF 

PRISONS

Timelier Reviews, 

Plan for Evaluations, 

and Updated Policies 

Could Improve Inmate 

Mental Health 

Services Oversight

Report to Congressional Requesters

July 2013

GAO-13-1

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-13-1, a report to 

congressional requesters

July 2013

BUREAU OF PRISONS

Timelier Reviews, Plan for Evaluations, and Updated 

Policies Could Improve Inmate Mental Health 

Services Oversight

Why GAO Did This Study

BOP is responsible for the care and 

custody—including mental health 

care—of more than 219,600 federal 

inmates. BOP identifies and treats

inmates’ mental health disorders, and 

has procedures in place to assess the 

provision of mental health services in 

its 119 facilities, and 15 private prisons 

operating under contract. GAO was 

requested to provide information on 

BOP’s costs and oversight of inmate 

mental health services. This report 

addresses: (1) BOP’s costs to provide

these services; (2) the extent to which 

BOP assesses whether its institutions 

comply with BOP policies for providing 

services; and (3) the extent to which 

BOP tracks the costs of providing 

mental health services to inmates in 

contract facilities, and assesses 

compliance with contract requirements. 

GAO analyzed obligated funds for 

fiscal years 2008 through 2012 for the 

two BOP divisions responsible for 

mental health services at BOP

institutions, examined the most recent 

review reports for a random sample of 

47 BOP institutions and all 15 contract 

facilities, examined BOP’s policies, and 

interviewed BOP officials. 

What GAO Recommends

GAO recommends that BOP (1) take 

steps to prioritize the completion of 

postponed program reviews, (2) 

develop a plan to evaluate treatment 

programs, and (3) develop and 

implement updated program 

statements. BOP concurred with the

first and third recommendations and 

partially concurred with the second.

GAO considered additional information 

provided by BOP about its plan to 

conduct evaluations and modified this 

recommendation accordingly.

What GAO Found

During a 5-year period—fiscal years 2008 through 2012—costs for inmate mental 

health services in institutions run by the Bureau of Prisons (BOP) rose in 

absolute dollar amount, as well as on an annual per capita basis. Specifically, 

mental health services costs rose from $123 million in fiscal year 2008 to $146

million in fiscal year 2012, with increases generally due to three factors—inmate 

population increases, general inflationary increases, and increased participation 

rates in psychology treatment programs such as drug abuse treatment programs. 

Additionally, the per capita cost rose from $741 in fiscal year 2008 to $821 in 

fiscal year 2012. It is projected that these costs will continue to increase with an

estimated per capita cost of $876 in fiscal year 2015, due, in part, to increased 

program funding and inflation. 

BOP conducts various internal reviews that assess institutions’ compliance with 

its policies related to mental health services, and it also requires institutions to 

obtain external accreditations. BOP’s internal program reviews are on-site audits 

of a specific program, including two that are relevant to mental health services—

psychology and health services. Most institutions in GAO’s sample received good 

or superior ratings on their psychology and health services program reviews, but 

these reviews did not always occur within BOP-established time frames, 

generally due to lack of staff availability. When reviews were postponed, delays 

could be lengthy, sometimes exceeding a year, even for those institutions with 

the lowest ratings in previous reviews. Moreover, BOP has not evaluated 

whether most of its psychology treatment programs are meeting their established 

goals and has not developed a plan to do so. BOP is developing an approach for 

reporting on the relative reduction in recidivism associated with major inmate 

programs, which may include some psychology treatment programs. Using this 

opportunity to develop a plan for evaluating its psychology treatment programs 

would help ensure that the necessary evaluation activities, as well as any needed 

program changes, are completed in a timely manner. Further, BOP’s program 

statements—its formal policies—related to mental health services contain 

outdated information. Policy changes are instead communicated to staff through 

memos. By periodically updating its program statements, BOP would be better 

assured that staff have a consistent understanding of its policies, and that these 

policies reflect current mental health care practices. 

BOP collects information on the daily cost to house the 13 percent of federal 

inmates in contract facilities, but it does not track the specific contractor costs of

providing mental health services. The performance-based, fixed-price contracts 

that govern the operation of BOP’s contract facilities give flexibility to the 

contractors to decide how to provide mental health services and do not require 

that they report their costs for doing so to BOP. BOP uses several methods to 

assess the contractors’ compliance with contract requirements and standards of 

care. BOP conducts on-site reviews to assess the services provided to inmates 

in contract facilities, including those for mental health. BOP uses results from 

these reviews, as well as reports from external accrediting organizations, the 

presence of on-site monitors, and internal reviews conducted by the contract 

facility, to assess contractor compliance and to ensure that the contractor is 

consistently assessing the quality of its operations.

View GAO-13-1. For more information, contact 

David C. Maurer at (202) 512-9627 or 

maurerd@gao.gov, or Debra A. Draper at 

(202) 512-7114 or draperd@gao.gov.
Page i GAO-13-1 Inmate Mental Health Services

Letter 1

Background 6

Mental Health Services Costs Have Increased in BOP-Operated 

Institutions since Fiscal Year 2008 and Are Expected to 

Continue to Increase 14

BOP Assesses Compliance with Its Policies for Inmate Mental 

Health Services, but Reviews Are Not Always Timely; BOP Has 

Not Evaluated the Effectiveness of Most Treatment Programs or 

Updated Most Policies 17

BOP Does Not Track Contractors’ Costs of Providing Inmate 

Mental Health Services but Does Assess Compliance with 

Requirements and Standards of Care 30

Conclusions 37

Recommendations for Executive Action 38

Agency Comments and Our Evaluation 39

Appendix I Objectives, Scope, and Methodology 41

Appendix II Bureau of Prisons’ Psychology Treatment Programs’ 

Descriptions and Numbers of Participants for FY 2008 

and 2012 49

Appendix III Bureau of Prisons (BOP)-Operated Institutions by Mental Health 

Care Levels as of February 2013 51

Appendix IV Inmate Intake and Mental Health Assessment Process 55

Appendix V Inmate Diagnoses by Inmate Mental Health Care Level and 

Gender, as of February 9, 2013 56

Contents
Page ii GAO-13-1 Inmate Mental Health Services

Appendix VI Findings from Program Review Reports, Accreditation Reports, 

and Contract Facility Monitoring Review Reports 58

Appendix VII Bureau of Prisons’ Elements of Modified Therapeutic 

Communities 66

Appendix VIII Bureau of Prisons Program Statements Related to Mental 

Health Services for Inmates 68

Appendix IX GAO Contacts and Staff Acknowledgments 69

Tables

Table 1: Number and Percentage of Federal Inmates in Bureau of 

Prisons (BOP)-Operated Facilities by Designated Inmate 

Mental Health Care Level, as of May 11, 2013 9

Table 2: On-site Reviews Related to Mental Health Services at 

Bureau of Prisons (BOP) Institutions 13

Table 3: Actual Costs and Percentage Changes of Inmate Mental 

Health Services, and Inmate Populations in Bureau of 

Prisons (BOP)-Operated Institutions 14

Table 4: Projected Costs and Percentage Changes of Inmate Mental 

Health Services, and Projected Inmate Populations in 

Bureau of Prisons (BOP)-Operated Institutions 16

Table 5: Timeliness of Bureau of Prisons (BOP) Psychology and 

Health Services Program Reviews 21

Table 6: Institutional Ratings in Psychology Services and Health 

Services Program Review Reports for BOP-Operated 

Institutions 58

Table 7: Most Common Deficiencies in Psychology Services and 

Health Services Program Reviews Related to Mental 

Health Services for BOP-Operated Institutions 59

Table 8: Examples of Deficiencies and Institutional Corrective 

Actions from Psychology Services Program Review 

Reports for BOP-Operated Institutions 61
Page iii GAO-13-1 Inmate Mental Health Services

Table 9: Most Common Deficiencies Cited in Joint Commission 

Ambulatory Care Accreditation Reports for BOP-Operated 

Institutions 63

Table 10: Most Common Deficiencies in Contract Facility 

Monitoring Reviews That May Be Related to Mental Health 

Services in Contract Facilities 64

Table 11: Most Common Deficiencies in Joint Commission 

Accreditation Reports Related to Mental Health Services in 

Contract Facilities 65

Figures

Figure 1: Bureau of Prisons’ (BOP) Organization for Providing 

Mental Health Services 8

Figure 2: The Bureau of Prisons’ Program Review Process 19
Page iv GAO-13-1 Inmate Mental Health Services

Abbreviations

ACA American Correctional Association

BOP Bureau of Prisons

BRAVE Bureau Rehabilitation and Values Enhancement

CFM Contract Facility Monitoring

DOJ Department of Justice

DSM-IV-TR Diagnostic and Statistical Manual, Version IV-TR

FCC Federal Correctional Complex

FCI Federal Correctional Institution

FDC Federal Detention Center

FMC Federal Medical Center

FPC Federal Prison Camp

FTC Federal Transfer Center

MCC Metropolitan Correctional Center

MCFP Medical Center for Federal Prisoners

MDC Metropolitan Detention Center

MH mental health

MTC modified therapeutic community

NR DAP Non-Residential Drug Abuse Treatment Program

ORE Office of Research and Evaluation

PA physician’s assistant

PDS Psychology Data System

PRG Program Review Guidelines

RDAP Residential Drug Abuse Program

SFF Secure Female Facility

SHU special housing unit

SOTP-NR Non-Residential Sex Offender Treatment Program 

SOTP-R Residential Sex Offender Treatment Program

STAGES Steps Toward Awareness, Growth and Emotional Strength

USP U.S. Penitentiary

This is a work of the U.S. government and is not subject to copyright protection in the 

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without further permission from GAO. However, because this work may contain 

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Page 1 GAO-13-1 Inmate Mental Health Services

441 G St. N.W.

Washington, DC 20548

July 17, 2013

The Honorable Elijah E. Cummings

Ranking Member

Committee on Oversight and Government Reform

House of Representatives

The Honorable Robert C. Scott

Ranking Member

Subcommittee on Crime, Terrorism, Homeland Security, and

 Investigations

Committee on the Judiciary

House of Representatives

The Honorable Richard J. Durbin

United States Senate

The mission of the Department of Justice’s (DOJ) Federal Bureau of 

Prisons (BOP) is to protect society by confining offenders in the controlled 

environments of prisons and community-based facilities that are safe, 

humane, cost-efficient, and appropriately secure. As part of its duties, 

BOP is responsible for delivering adequate medical care, including mental 

health services, in a manner consistent with accepted community 

standards for a correctional environment.1

 1

For the purposes of this review, we are defining mental health services as (1) psychiatric 

and psychological treatments provided to inmates, such as group and individual 

psychotherapy sessions, crisis intervention and counseling, and clinical case 

management; (2) psychology treatment programs—typically involving standard protocols 

that apply to all participants—including residential and nonresidential drug treatment 

programs, sex offender management programs, and other specialized mental health 

treatment programs; and (3) psychotropic medication used for the purposes of treating 

mental illness. 

Multiple courts over the years 

have established the constitutional requirement that prison systems must 

provide inmates with adequate medical and mental health care, and this 
Page 2 GAO-13-1 Inmate Mental Health Services

requirement applies to BOP, as well as state and local prisons.2

As of July 4, 2013, BOP was responsible for overseeing more than 

219,600 federal inmates—most of whom are housed in BOP’s 119 

institutions or 15 privately managed facilities with which BOP contracts for 

confinement.

To carry 

out its responsibility for delivering mental health care for inmates, BOP 

provides mental health services primarily through its Correctional 

Programs Division’s Psychology Services Branch and its Health Services 

Division.

3 Studies have shown that psychological treatment during 

incarceration is effective in reducing mental illness symptoms and in 

reducing recidivism.4 Moreover, according to an Urban Institute study, 

public health and correctional stakeholders view prisons as an opportunity 

to affect factors that contribute to criminal behavior and the cycle of 

repeated incarceration, such as untreated mental illness.5

 2

For example, in May 2011, the United States Supreme Court held in the case of Brown, 

Governor of California v. Plata, 131 S.Ct. 1910, that to remedy the violation of a federal 

right, specifically the severe and unlawful mistreatment of prisoners through grossly 

inadequate provision of medical and mental health care, it was necessary to institute a 

court-mandated prison population limit. The court recognized that for years the medical 

and mental health care provided by California’s prisons had fallen short of minimum 

constitutional requirements and had failed to meet prisoners’ basic health needs. 

Adequate medical and mental health care must meet minimum constitutional requirements 

and meet prisoners’ basic health needs.

There is no 

clear consensus on the rate of mental illness among federal prisoners, 

and estimated rates vary widely. For example, a 2006 Bureau of Justice 

Statistics report stated that about 45 percent of federal prisoners suffered 

from a mental health problem, which the report defined as symptoms of a 

3

Privately managed contract facilities house low-security, specialized populations such as 

sentenced criminal aliens. A criminal alien is a noncitizen in the United States, who may 

be present on a lawful basis or not, who has been convicted of a crime. During the course 

of our review, BOP had 15 contract facilities, which we included in our study; however, as 

of May 31, 2013, the contract for 1 facility was terminated and therefore as of this date 

BOP had 14 contract facilities. 

4

According to BOP guidance, mental illness includes: anxiety disorders (such as posttraumatic stress disorder), mood disorders (such as depression), psychotic disorders 

(such as schizophrenia), somatization disorders (which are a psychiatric condition in 

which the sufferer experiences multiple physical symptoms that are not explained by 

disease), eating disorders, and personality disorders (excluding antisocial personality 

disorder) that involve a rigid and unhealthy pattern of thinking and behaving.

5

Urban Institute, Opportunities for Cost Savings in Corrections Without Sacrificing Service 

Quality: Inmate Health Care (Washington, D.C.: February, 2013). 
Page 3 GAO-13-1 Inmate Mental Health Services

mental health disorder or a mental health problem that was diagnosed or 

treated within the previous 12 months, as reported by the inmate.6

Another study of a sampling of inmates newly admitted to BOP custody 

during fiscal years 2002 and 2003 estimated that 15.2 percent of the 

inmates were in need of psychological services, which the report defined 

as having received a current psychiatric diagnosis, having been 

prescribed antipsychotic or mood-stabilizing medication at any time in the 

inmate’s life, or having had an overnight hospital stay for mental health 

reasons at any time in the inmate’s life.7

In light of the importance of providing mental health services to BOP 

inmates, you asked us for information on BOP’s costs and procedures 

associated with providing inmate mental health care services. 

Specifically, this report addresses the following questions: (1) What have 

the costs been to provide mental health services in BOP-operated 

institutions over the past 5 fiscal years, and what are the projected costs? 

(2) To what extent does BOP assess whether BOP-operated institutions 

comply with BOP policies and other standards for providing inmate 

mental health services? (3) To what extent does BOP track the costs of 

providing mental health services to BOP inmates in contract facilities, and 

to what extent does BOP assess whether these facilities meet contract 

requirements and standards of care for inmate mental health services?

Differences between the two 

studies’ estimates are attributable, in part, to differences in how a mental 

health problem was defined.

To address the first question, we analyzed obligated funds for the past 5 

fiscal years—2008 through 2012—for the two BOP divisions that provide 

 6

Bureau of Justice Statistics, Bureau of Justice Statistics Special Report: Mental Health 

Problems of Prison and Jail Inmates (September 2006). The Bureau of Justice Statistics is 

a DOJ agency that collects, analyzes, publishes, and disseminates information on crime, 

criminal offenders, victims of crimes, and the operation of the justice systems at all levels 

of government.

7

Philip R. Magaletta, Pamela M. Diamond, Erik Faust, Dawn M. Daggett, and Scott D. 

Camp, “Estimating the Mental Illness Component of Service Need in Corrections: Results 

From the Mental Health Prevalence Project,” Criminal Justice and Behavior, vol. 36, no. 3

(March 2009), 229-244. The authors of this study excluded from their definition the most 

severely disturbed inmates who are housed in medical facilities and those who receive 

psychological services as a result of policy, such as those placed in segregated housing 

units. Segregated housing units are units within an institution where prisoners are kept 

apart from the general population in highly restrictive conditions for administrative 

reasons, such as pending transfer to another prison, or disciplinary reasons, such as 

violating prison rules. 
Page 4 GAO-13-1 Inmate Mental Health Services

mental health services—the Health Services Division and the Correctional 

Programs Division. To project future costs, we discussed BOP’s methods 

for cost projections with budget and program officials and independently 

examined BOP’s population projections and expected staffing positions 

for fiscal years 2013 through 2015.8

To address the second question, we reviewed all relevant BOP program 

statements, which are BOP’s formal policies and procedures, related to 

mental health services, as well as the accreditation standards of the two 

organizations that accredit BOP-run institutions—the American 

Correctional Association (ACA) and The Joint Commission.

To assess the reliability of BOP’s 

obligation data, we performed electronic data testing for obvious errors in 

accuracy and completeness, and interviewed agency officials 

knowledgeable about BOP’s budget to determine the processes in place 

to ensure the integrity of the data. We determined that the data were 

sufficiently reliable for the purposes of this report.

9 We analyzed 

the most recent program review reports, which present results of BOP onsite audits of program areas, for both health services and psychology 

services for a random sample of 47 of the 94 BOP-run institutions that 

were operating long enough to undergo a program review as of August 

2012.10

 8

We limited our projections to 3 years as projections that are further into the future are 

less reliable. 

We used the sample to determine the extent to which BOP 

assesses its institutions in accordance with its own policies. We 

compared BOP’s policies for inmate mental health care and processes for 

monitoring the provision of inmate mental health care at the institution 

level with the Standards for Internal Control in the Federal Government 

9

ACA’s mission includes the development and promotion of effective standards for the 

care, custody, training, and treatment of offenders. The Joint Commission accredits and 

certifies health care organizations and programs in the United States. 

10In some cases, a number of institutions belong to a Federal Correctional Complex 

(FCC). At FCCs, institutions with different missions and security levels are located in 

proximity to one another. For an FCC, BOP performs one program review for the entire 

complex and not for the individual institutions that make up the complex. For purposes of 

this report, we use the term institution to refer to either a single institution or a complex of 

institutions that is considered a single unit for program review purposes. Therefore, BOP 

conducted 94 program reviews for the 116 institutions that were operating long enough to 

have a program review as of August 2012. Three additional institutions were not operating 

long enough to undergo a program review as of August 31, 2012. Program reviews begin 

at an institution 18 to 24 months after the institution opens.
Page 5 GAO-13-1 Inmate Mental Health Services

and risk management principles.11 In addition, we analyzed the most 

recent accreditation reports from ACA and The Joint Commission 

conducted for this same sample of BOP-operated institutions.12 We 

interviewed officials from BOP’s Office of Research and Evaluation 

(ORE), which conducts research and evaluation of BOP programs, to 

determine what evaluations BOP has conducted of its psychology 

treatment programs in the past and what evaluations are ongoing or 

planned. We assessed BOP’s evaluation planning against standards for 

project management. We discussed these oversight activities with BOP 

officials responsible for managing the psychology treatment programs 

and conducting program reviews. Additionally, to obtain insights into the 

overall program review process, we observed two psychology services 

on-site program reviews.13

To address the third question, we reviewed BOP’s December 2008 

Quality Assurance Plan to identify the policies and procedures related to 

mental health care that guide the contract facility monitoring process, as 

well as all contracting documents for information on costs for mental 

health-related staff and services they provide. We analyzed all of the 

most recent reports from BOP’s 15 contract facilities’ monitoring reviews, 

which BOP designed to determine if the contractors are meeting the 

performance outcomes specified in the contracts. In addition, for each of 

these facilities, we analyzed the most recent accreditation reports from 

the ACA and Joint Commission reviews. We visited two contract 

Finally, we interviewed officials from the union 

representing BOP correctional workers who are involved in contract 

negotiations to gain an understanding of the negotiation process required 

to institute changes to mental health-related policies.

 11GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1

(Washington, D.C.: November 1999), and Project Management Institute, A Guide to the 

Project Management Body of Knowledge (PMBOK® Guide), 5th ed. (Newtown Square, 

PA: 2013). A Guide to the Project Management Body of Knowledge provides standards for 

project managers.

12As with program reviews, a single accreditation report may cover either a single 

institution or a complex with multiple institutions. For the 47 institutions in our sample, we 

analyzed 37 Joint Commission accreditation reports because not all BOP institutions are 

required to obtain Joint Commission accreditation. 

13We chose the two institutions because they provided different levels of care, and their 

program reviews were being conducted within the timeframe of our study. While the 

observations from these visits are not generalizable to all BOP institutions or to all 

program reviews, the visits provided important perspectives about the program review 

process.
Page 6 GAO-13-1 Inmate Mental Health Services

facilities—one to observe its annual Contract Facility Monitoring review, 

and the other to observe operations. While the selection of these two 

contract sites does not facilitate generalizations, our observations and 

conversations with staff provided important context on the operations of a 

privately operated prison. We interviewed BOP officials responsible for 

overseeing contracts, contractor operations, and procurement to discuss 

the extent to which they track costs and the structure of the arrangements 

with the contracted facilities. Finally, we obtained information on the 

provision of mental health services from three private firms that operate 

14 of the 15 contract facilities, as well as one subcontractor that provides 

mental health services for one of the primary contractors.14

We conducted this performance audit from April 2012 to July 2013 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 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Appendix I 

contains a more detailed discussion of our objectives, scope, and 

methodology.

BOP is responsible for approximately 219,600 inmates in federal custody. 

About 81 percent, or approximately 176,900 inmates, are housed in 119 

of BOP’s own federal institutions—operating at different security 

levels15

 14During the course of our review, the contract for one contract facility was terminated on 

May 31, 2013; the private firm that managed this facility declined to provide its views.

—and about 13 percent, or approximately 29,400 inmates, are 

housed in privately managed contract facilities—generally housing low15There are four security level designations for institutions that house males—minimum, 

low, medium, and high—and three for institutions that house females—minimum, low, and 

high. The security level designation of a facility depends on the level of security and staff 

supervision that the institution is able to provide, such as the presence of security towers, 

perimeter barriers, the type of inmate housing, and inmate-to-staff ratio. BOP also has 

administrative facilities that house inmates of all security levels. 

Background
Page 7 GAO-13-1 Inmate Mental Health Services

security inmates.16 BOP has eight operational divisions to oversee major 

BOP program areas, including the Correctional Programs Division and 

the Health Services Division, that manage the administration of mental 

health services.17

BOP’s Psychology Services Branch, which the Correctional Programs 

Division oversees (see fig. 1), provides most inmate mental health 

services in BOP-operated institutions, including the provision of 

individualized psychological care and 11 different treatment programs, 

which we describe in appendix II. BOP’s Health Services Division 

manages psychiatry and pharmacy services. Most mental health 

treatment is provided in what BOP calls its mainline, or regular, 

institutions. Acutely mentally ill inmates in need of psychiatric 

hospitalization, such as some inmates suffering from schizophrenia or 

bipolar disorder, may receive these services at one of BOP’s five 

psychiatric referral centers, which provide inpatient psychiatric services 

as part of their mission. About 71 percent of BOP’s psychiatrists work at 

the psychiatric referral centers with inmates most in need. At other BOPoperated institutions, psychiatrists focus primarily on medication 

management.

 16In addition to the federal institutions and contract facilities, BOP also houses about 

13,300, or 6 percent, of inmates that fall under community corrections management, which 

includes 185 residential reentry centers and in-home detention. Residential reentry 

centers provide a structured, supervised environment and counseling, job placement, and 

other services to facilitate inmates’ reentry to the community after a period of 

incarceration. We did not review mental health services provided in residential reentry 

centers because they were outside the scope of our work.

17In addition to Correctional Programs and Health Services, the other program divisions 

are Administration; Human Resource Management; Industries, Education, and Vocational 

Training; Information, Policy, and Public Affairs; Office of General Counsel; and Program 

Review.

Provision of Mental Health 

Services in the Federal 

Prison System
Page 8 GAO-13-1 Inmate Mental Health Services

Figure 1: Bureau of Prisons’ (BOP) Organization for Providing Mental Health Services

Note: This figure refers to services provided in BOP-operated institutions.

BOP implemented a mental health care level designation system for both 

institutions and inmates in 2010.18

 18BOP also has a separate medical care level designation system, which it implemented 

in 2004.

The system identifies the mental health 

needs of each inmate and matches the inmate to an institution with the 
Page 9 GAO-13-1 Inmate Mental Health Services

appropriate resources. Institution mental health care levels range from 1 

to 4, with 1 being institutions that care for the healthiest inmates and 4 

being institutions that care for inmates with the most acute needs. Inmate 

mental health care levels are also rated in this manner from level 1 to 

level 4. Table 1 describes each inmate mental health care level and the 

number of inmates by designation level. For a list of all BOP institutions 

and their respective mental health care level designations, see appendix 

III. For more information on the process of assessing inmates’ mental 

health issues and designating care levels, see appendix IV.

Table 1: Number and Percentage of Federal Inmates in Bureau of Prisons (BOP)-

Operated Facilities by Designated Inmate Mental Health Care Level, as of May 11, 

2013

Inmate mental 

health (MH) care 

level Description Number Percentage

MH care 1 Inmates with no identified mental health 

problem, as well as other inmates with 

stable mental health conditions 

requiring individual psychological 

contacts or clinical intervention no more 

than once every 3 to 6 months. 

155,165 92.46%

MH care 2 Inmates require clinical interventions 

regularly, usually quarterly to monthly. 

5,793 3.45

MH care 3 Inmates require clinical intervention 

frequently, usually weekly over an 

extended period of time.

589 0.35

MH care 4 Inmates require psychiatric 

hospitalization.

857 0.51

MH screen 1a 4,038 2.41

MH screen 2 1,093 0.65

MH screen 3 224 0.13

MH screen 4 61 0.04

Total 167,820 100%

Source: Bureau of Prisons.

a

According to BOP officials, “MH screen” is the initial mental health designation given to an inmate 

before the inmate has been assessed at the institution where he or she is assigned. Once an inmate 

is assigned and evaluated at the institution, the inmate is assigned a “MH care level.” The four

screening levels match the four care levels in the table.
Page 10 GAO-13-1 Inmate Mental Health Services

Among inmates with a level 4 mental health care designation the most 

common diagnosis among both male and female inmates was 

schizophrenia or another psychotic disorder,19 followed by a personality

disorder diagnosis.20

Inmates in contract facilities are predominantly low-security criminal 

aliens, designated as mental health care level 1 or 2. Inmates who 

ordinarily would be placed in a contract facility but are designated for a 

mental health care level higher than 2 are assigned to a BOP-operated 

facility where BOP can provide the requisite level of care needed to treat 

the inmate’s mental health condition. At some contract facilities, the 

contractor may subcontract the health care services, including mental 

health care services.

Appendix V contains information on inmate 

diagnoses by inmate mental health care level designation and gender.

BOP reviews prison operations through internal program reviews and 

external accreditation reviews. BOP established its internal program 

review process to assess each BOP-operated institution’s compliance 

with applicable regulations and policies, the adequacy of their internal 

controls, and the effectiveness, efficiency, and quality of their programs 

and operations. BOP’s Program Review Division, one of its eight 

operating divisions, leads the process. BOP policy states that each 

program or operation at each BOP institution, such as psychology 

services and health services—but also, for example, food services and 

religious services—is to be reviewed on at least a 3-year basis, but 

potentially more often depending on the institution’s prior review results. 

During each review, a team of reviewers with specialized experience 

 19Psychotic disorders other than schizophrenia include schizoaffective disorder (a mental 

condition that causes both a loss of contact with reality and mood problems), delusional 

disorder, and brief psychotic disorder.

20A personality disorder is an enduring pattern of inner experience and behavior that 

deviates markedly from the expectations of the individual’s culture, is pervasive and 

inflexible, has an onset in adolescence or early adulthood, persists over time, and leads to 

distress or impairment. BOP excludes consideration of antisocial personality disorder in 

designating an inmate to a mental health care level because, according to BOP officials, 

such a large proportion of BOP’s inmate population could be diagnosed with antisocial 

personality disorder. Another type of personality disorder is borderline personality 

disorder. Individuals with borderline personality disorder have long-term patterns of 

unstable or turbulent emotions that often result in impulsive actions and chaotic 

relationships with other people.

Internal and External 

Reviews of BOP-Operated 

Facilities
Page 11 GAO-13-1 Inmate Mental Health Services

visits the institution to assess the institution’s programs based on a set of 

Program Review Guidelines (PRG). The PRGs provide a framework for 

the reviewers to test the institution’s compliance with policies and 

procedures, as articulated through program statements. In particular, 

program reviews for psychology and health services involve assessments 

of individual inmate case files, observations of treatment programs, 

reviews of an institution’s policies and procedures, interviews with staff, 

and interviews with a small number of inmates. Following a visit to an 

institution, the Program Review Division issues a report noting 

deficiencies and findings. BOP defines deficiencies to include deviations 

from policy or regulation, weaknesses in internal controls, or lack of 

quality controls. Reviewers also assign one of five ratings to the 

institution.21

In addition to program reviews, BOP requires all of its institutions, as well 

as its contracted facilities, to be accredited by an external organization, 

ACA. ACA’s standards for adult correctional institutions include 63 

mandatory standards and 458 nonmandatory standards across five areas 

of a correctional institution’s operations.

The Program Review Division sends the final report to the 

institution and to the staff operating the program area that was assessed. 

Institutions are required to correct any deficiencies identified during the 

program review.

22 ACA’s standards include 7 

specifically related to mental health, 4 of which are mandatory.23

 21According to BOP, a superior rating indicates the program is performing all vital 

functions and a history of strong internal controls exists resulting in zero or very minimal 

deficiencies. A good rating demonstrates the program’s vital function areas are sound and 

internal controls are strong. An acceptable rating is the baseline rating, and each program 

is assumed to be performing at this level at the beginning of the review. BOP policy states 

that institutions with an acceptable rating may have deficiencies, but they do not detract 

from the adequate accomplishment of the vital functions. A deficient rating demonstrates 

that one or more vital functions of the program are not being performed at an acceptable 

level and internal controls are weak. An at-risk rating demonstrates that the program is 

impaired to the point that it is not accomplishing its overall mission and internal controls do 

not demonstrate substantial continued compliance. 

To be 

accredited, an institution must meet all mandatory standards and 90 

22The five areas are administration and management, physical plant, institutional 

operations, institutional services, and inmate programs.

23For example, one standard requires institutions to have a mental health program that 

includes, among other services, screening for mental health problems on intake, 

outpatient services, crisis intervention, and stabilization of the mentally ill.
Page 12 GAO-13-1 Inmate Mental Health Services

percent of applicable nonmandatory standards.24

BOP also requires all of its institutions with a medical care level of 2 or 

higher to be accredited for ambulatory care by a second external 

organization, The Joint Commission.

BOP incorporates 

ACA’s standards into the PRGs for its own program reviews. As a result 

of BOP’s inclusion of ACA’s standards in its program reviews, ACA relies 

significantly on findings from BOP’s own program review process and its 

confidence in this review process, when it reaccredits BOP-operated 

institutions, according to ACA officials.

25 The Joint Commission’s 

ambulatory care standards are not specific to mental health services, but 

apply to any type of medical or mental health service provided by an 

institution. For example, one standard requires organizations to provide 

patients with care, treatment, or services according to their individualized 

care plan. BOP’s Joint Commission accreditation covers services 

provided by the institution’s health services unit, including psychiatry and 

pharmacy services. Certain BOP institutions with specialized medical 

missions also obtain other Joint Commission accreditations.26

Table 2 provides information on the different types of internal and external 

on-site reviews that BOP institutions undergo, and the specific BOP 

components providing mental health services that each review covers.

 24Standards are not applicable if the institution does not serve the specific population 

covered by the standard or does not have a specific program covered by the standard. For 

instance, all standards relating specifically to the treatment of female inmates are not 

applicable to an institution that houses only male inmates.

25According to BOP officials, medical care level 1 institutions are not required to be 

accredited for ambulatory care by The Joint Commission. 

26Four BOP institutions—Federal Medical Center Rochester, U.S. Medical Center 

Springfield, Federal Medical Center Devens, and Metropolitan Correctional Center in New 

York—also have behavioral health accreditations because they have inpatient psychiatric 

units or a treatment program for individuals addicted to pain-relieving drugs, such as 

oxycodone or morphine. Two additional institutions—Federal Correctional Complex Butner 

and Federal Medical Center Carswell—have psychiatric units within inpatient hospital 

facilities that are also accredited under The Joint Commission’s hospital standards.
Page 13 GAO-13-1 Inmate Mental Health Services

Table 2: On-site Reviews Related to Mental Health Services at Bureau of Prisons

(BOP) Institutions

Review

Internally or 

externally 

conducted

Time between onsite reviewsBOP components

reviewed

Psychology Services 

program review

Internally Up to 3 years, 

depending on 

institution’s ratinga

Psychology Services, 

which include 

substance abuse 

programs and other 

psychology treatment 

programs

Health Services 

program review

Internally Up to 3 years, 

depending on 

institution’s ratinga

Psychiatry and 

pharmacy services

American Correctional 

Association (ACA) 

accreditation 

Externallyb 3 years Psychology, 

psychiatry, and 

pharmacy services

The Joint Commission 

accreditation

Externally 3 years Psychiatry and 

pharmacy services

Source: GAO analysis.

a

BOP policy requires subsequent program reviews be conducted every 3 years for institutions with a

good or superior rating, every 2 years for institutions with an acceptable rating, and every 18 months 

for institutions with a deficient rating. Institutions receiving an at-risk rating are reviewed again when 

the institution requests closure on the program review.

b

The ACA relies significantly on BOP’s own program review process when it reaccredits BOPoperated institutions. Reviewers from the ACA observe program reviews to determine that the 

process is sound, but may also cite institutions for any deficiencies the reviewers note during their 

observation.

BOP also conducts on-site assessments of its contract facilities, referred 

to as Contract Facility Monitoring (CFM) reviews. BOP has designed 

these reviews to assess whether contract facilities are meeting the 

performance outcomes that the contract specifies. BOP conducts a CFM 

review at each contract facility at least annually, and more frequently if 

BOP finds areas of concern in prior reviews, or if a facility recently 

became operational. In contrast to the internal program reviews for BOPoperated institutions, CFM reviews cover all aspects of the contract 

facility’s operations at once, instead of specifically focusing on a single 

program area, such as psychology services. Contract facilities are also 

required to obtain ACA and Joint Commission accreditations to comply 

with contractual requirements. The contracts indicate that these 

accreditations must be obtained within 24 months after the facility 

becomes operational, and the facility must maintain these accreditations 

through the life of the contract.

Reviews for BOP Contract 

Facilities
Page 14 GAO-13-1 Inmate Mental Health Services

During the 5-year period starting in fiscal year 2008 and ending in fiscal 

year 2012, costs for inmate mental health services in BOP-operated 

institutions rose in absolute dollar amount, as well as on an annual per 

capita—or per inmate—basis. BOP projects continued inmate population 

growth, and as a result, projections for these costs through 2015 are 

expected to continue to increase.

BOP’s total mental health services costs increased annually from fiscal 

year 2008 through fiscal year 2012. According to BOP officials, mental 

health services costs include related expenses from both its Correctional 

Programs Division and Health Services Division. As shown in table 3, 

when aggregating these costs, we found that total costs increased 

annually from $123 million in fiscal year 2008 to nearly $146 million in 

fiscal year 2012.

Table 3: Actual Costs and Percentage Changes of Inmate Mental Health Services, and Inmate Populations in Bureau of 

Prisons (BOP)-Operated Institutions

(Cost components and total actual costs are in millions of dollars; inmate population and cost per capita are actual numbers; 

percentage change is in percent)

Fiscal year

2008 2009 2010 2011 2012

Correctional Programs Division Psychology Servicesa $42.71 $44.71 $47.26 $49.66 $51.28

Psychology staff training 0.31 0.80 0.85 0.72 0.64

Drug abuse treatment programs 57.66 60.62 66.22 68.98 71.33

Sex Offender Management Programs 4.74 6.94 6.86 6.61 7.19

Health Services Division Psychotropic medication 11.52 11.58 11.29 9.35 8.49

Psychiatrist salaries and benefits 6.05 6.83 7.17 7.39 6.75

Total actual costs $123.00 $131.48 $139.64 $142.71 $145.69

Inmate population at the end of the fiscal year in BOP-operated 

institutions 

165,964 172,423 173,289 177,934 177,556

Total annual cost per capita $741.11 $762.56 $805.84 $802.05 $820.52

Percentage change in per capita cost from prior fiscal 

year

— 2.89 5.68 -0.47 2.30

Source: GAO analysis of BOP data.

Note: Numbers may not total because of rounding.

Mental Health 

Services Costs Have 

Increased in BOPOperated Institutions 

since Fiscal Year 2008 

and Are Expected to 

Continue to Increase

Mental Health Services 

Costs Increased from 

Fiscal Year 2008 through 

Fiscal Year 2012
Page 15 GAO-13-1 Inmate Mental Health Services

a

According to BOP officials, Psychology Services costs include all expenses related to providing 

routine psychological treatment to inmates in BOP-operated institutions, salaries and expenses for 

psychology staff, and some treatment programs. The costs do not include administrative oversight 

provided by the Central Office, which serves as the headquarters of BOP, or regional offices, which 

oversee the operations of the institutions within their respective geographic regions. Drug abuse 

treatment and sex offender management programs are not included in psychology services, but are 

budgeted separately.

We also found that in general, despite some annual variations, costs for 

most components of mental health services rose from the start to the end 

of the 5-year period. These increases were due in part to a concurrent 

population increase of more than 11,000 inmates during the period. To 

adjust for this, we estimated the annual per capita, or per inmate, costs by 

dividing the total costs for mental health services by the number of 

inmates—and this figure also increased over time, from about $741 in 

fiscal year 2008 to about $821 in fiscal year 2012. BOP officials told us 

that per capita increases are generally due to inflation.

With respect to overall cost increases for some programs, including the 

drug abuse treatment programs and the Sex Offender Management 

Programs, BOP attributed this growth to an increase in available slots, 

which has increased inmate participation in these programs. For example, 

according to BOP data, during the 5-year time period, participation in the 

Non-Residential Drug Abuse Program (NR DAP) increased by about 51

percent, from 13,361 participants in 2008 to 20,141 in 2012, and 

participation in the Sex Offender Treatment Program saw an overall 

increase of about 98 percent, from 373 participants in 2008 to 740 in 

2012. Additionally, while the participation rate for the Residential Drug 

Abuse Program (RDAP) remained relatively constant, BOP reduced the 

number of inmates on the waiting list by about 31 percent (see app. II).27

With respect to costs for psychotropic medication, this was the one line 

item whose related costs showed a downward trend.28

 27Pursuant to 18 U.S.C. § 3621(e), BOP is required to make available appropriate 

substance abuse treatment for each prisoner the BOP determines has a treatable 

condition of substance addiction or abuse, including the provision of residential substance 

abuse treatment for all eligible prisoners (and make arrangements for appropriate 

aftercare), subject to the availability of appropriations. 

According to BOP 

28The cost data for psychotropic medications may not be exact because some 

psychotropic medications can be used to treat certain non-mental health conditions and 

some non-psychotropic medications can be used to treat certain mental health conditions. 

For example, antihistamines used to treat allergies are considered psychotropic 

medications.
Page 16 GAO-13-1 Inmate Mental Health Services

officials, the decline in psychotropic medication costs is likely a result of a 

number of these medications becoming available in a generic version, 

which often means lower costs.

Including all the same elements in table 3, we projected costs through 

fiscal year 2015, and expect that mental health services costs will 

continue to increase (see table 4). In estimating annual future costs, we 

used fiscal year 2012 as a baseline and discussed with BOP officials their 

projections for underlying factors that would affect future changes in 

costs. Specifically, we used their data for anticipated inmate population 

growth and expected budgetary increases. For example, in its fiscal year 

2014 budget, BOP requested an additional $15 million to expand the 

RDAP, which, according to BOP officials, should enable BOP to reduce 

the wait list for this program. We also applied national inflation factors for 

the health care industry to account for inflationary increases.

Table 4: Projected Costs and Percentage Changes of Inmate Mental Health 

Services, and Projected Inmate Populations in Bureau of Prisons (BOP)-Operated 

Institutions

(Total projected costs are in millions; inmate population and cost per capita are actual 

numbers; percentage change is in percent)

Fiscal year

2013 2014 2015

Total projected costs $149.82 $155.86 $161.22

Projected inmate population in BOP-operated 

institutions

179,178 182,124 184,092

Total projected annual cost per capita $836.15 $855.81 $875.75

Percentage change in projected annual per capita 

cost from prior fiscal year

1.90 2.35 2.33

Source: GAO analysis of BOP data.

Mental Health Services 

Costs Are Projected to 

Grow through Fiscal Year 

2015
Page 17 GAO-13-1 Inmate Mental Health Services

BOP conducts various internal reviews to assess BOP-operated 

institutions’ compliance with its policies related to mental health services,

and BOP policy also requires institutions to obtain external accreditations. 

While most BOP-operated institutions received good or superior ratings in 

their psychology and health services program reviews, the majority of 

reviews we examined did not occur within the BOP-specified time frames. 

Additionally, BOP has not evaluated the effectiveness of most of its 

treatment programs and has not developed a plan to do so. Finally, 

BOP’s program statements related to mental health services, which 

formally document BOP’s policies and procedures, contain outdated 

information.

BOP’s psychology and health services program reviews identify the 

extent to which institutions are complying with BOP policies. While most 

institutions received good or superior ratings on these program reviews, 

we found that the reviews are not always conducted within the time 

frames BOP’s policies specify. The Psychology Services Branch also 

conducts other types of reviews to ensure compliance with mental health 

policies.

BOP’s program review process includes elements that allow the agency 

to identify whether its institutions are complying with BOP’s mental health 

services policies, and to be assured that institutions have corrected any 

problems that the review identified. (See fig. 2.) BOP’s PRGs related to 

mental health services are developed jointly by either its Psychology 

Services Branch or its Health Services Division, as appropriate, and its 

Program Review Division. All of the steps in the PRGs link to specific 

BOP policies. For example, a psychology services PRG step that requires 

reviewers to look at a sample of intake screening interviews is based on 

the agency’s policy that new inmates must receive an intake screening 

interview within 14 days of arrival, and that inmates’ identified treatment 

BOP Assesses 

Compliance with Its 

Policies for Inmate 

Mental Health 

Services, but Reviews 

Are Not Always 

Timely; BOP Has Not 

Evaluated the 

Effectiveness of Most 

Treatment Programs 

or Updated Most 

Policies

BOP Conducts Internal 

Reviews That Assess 

Compliance with Policies 

for Mental Health Services, 

but Most Reviews Do Not 

Occur on Time

Psychology Services and Health 

Services Program Reviews

Program Reviews: The Bureau of Prisons’ 

Program Review Division conducts separate 

program reviews of each program area at an 

institution. Reviewers assess an institution’s 

performance based on Program Review 

Guidelines and earn one of five ratings—

superior, good, acceptable, deficient, and at 

risk.

Source: GAO analysis of BOP information.
Page 18 GAO-13-1 Inmate Mental Health Services

needs receive appropriate follow-up. The psychology services PRGs also 

contain steps to review any psychology treatment program, such as 

RDAP,29 that an institution offers.30

 29RDAP targets inmates who volunteer for drug abuse treatment and have a verifiable and 

diagnosable substance abuse disorder. 

While not generalizable to all program 

reviews, the review teams conducting the two psychology services 

program reviews that we observed followed the applicable PRGs.

30The psychology services PRGs do not contain program review steps related to sexual 

offender treatment programs because BOP issued the related program statement in 

February 2013, and had not yet developed PRG steps related to these programs. 

According to BOP officials, they anticipate that a meeting to develop PRGs related to 

these programs will occur in May 2013.
Page 19 GAO-13-1 Inmate Mental Health Services

Figure 2: The Bureau of Prisons’ Program Review Process
Page 20 GAO-13-1 Inmate Mental Health Services

If a program review identifies a deficiency, BOP has a process in place to 

ensure that the institution takes action to correct the deficiency. 

Specifically, an institution must submit to the Program Review Division a 

corrective action plan or a certification by the warden that staff have 

resolved the deficiencies. Further, when an institution requests that a 

program review be closed, it must submit findings from a follow-up review 

that institution staff have conducted to demonstrate that their corrective 

actions have resolved the deficiency. Our review of the sample of 47 

program review files found that institutions were generally following this 

process.

We found that most institutions in our sample received a good or superior 

rating in the psychology and health services program review reports we 

examined. Among those reviews we examined, about 89 percent and 77 

percent of institutions, respectively, received a good or superior rating. 

The lowest rating among the psychology services program reviews was 

acceptable, while one institution received a deficient rating for its health 

services program review. The most common deficiencies cited in the 

psychology services program review reports related to the care provided 

in residential treatment programs,31 and a variety of issues related to 

suicide risk assessments, suicide watch logs, and follow-up care after a 

suicide watch.32

We found BOP was not always in compliance with the time frames stated 

in its policies for when program reviews should occur. About 65 percent of 

the psychology services program reviews that we examined were not 

conducted within the time frame stated in BOP policy,

Examples of the deficiencies BOP reviewers found in 

psychology services and health services program reviews, as well as 

examples of corrective action steps to address them, are included in 

appendix VI.

33

 31An example of a deficiency related to care provided in a residential treatment unit was 

that not all inmates who completed RDAP were enrolled in follow-up services in a timely 

manner. Inmates who complete the residential portion of RDAP are to receive follow-up 

services in their institution or in the community at a residential reentry center.

including about 

32A suicide risk assessment is a psychologist’s assessment of an inmate’s potential for 

suicide. Suicide watch logs are documentation of observations of an inmate’s behavior 

while the inmate is on suicide watch. After each suicide watch, a psychologist completes a 

report that documents the guidelines for the inmate’s follow-up care.

33The estimate is 66.0 percent. The differences in the reported estimates are due to 

rounding error. The associated 95 percent confidence interval is (54.3, 76.6).
Page 21 GAO-13-1 Inmate Mental Health Services

23 percent that were more than 6 months late, based on the institution’s 

prior ratings.34 (See table 5.) For example, one institution that had 

received an acceptable rating—and therefore should have been reviewed 

24 months later—did not get reviewed again for more than 38 months. 

Among the 47 health services program review reports that we examined, 

about 70 percent did not occur within BOP’s established time frames, 

including 6 percent that occurred more than 6 months late.35 According to 

BOP officials, institutions that do not receive timely program reviews are 

required to use their staff to conduct an internal operational review using 

the relevant PRGs,36

Table 5: Timeliness of Bureau of Prisons (BOP) Psychology and Health Services 

Program Reviews

which provides assurance to BOP that the institution 

is compliant with the agency’s policies. However, these operational 

reviews do not provide the same level of independence provided through 

BOP’s program review process.

Percent

Review 

conducted on 

time (confidence 

interval)

Less than 3 

months late 

(confidence 

interval)

3 to 6 months 

late (confidence 

interval)

More than 6 

months late 

(confidence 

interval)

Psychology 

Services

34% 

(23.4-45.7%)

23% 

(14.9-34.0%)

19% 

(10.6-29.8%)

23%

(14.9-34.0%)

Health Services 30 

(20.2-41.5)

51

(41.5-64.9)

13

(5.3-20.2)

6 

(3.2-14.9)

Source: GAO analysis of Bureau of Prisons’ psychology and health services program review reports.

Notes: Numbers may not add to 100 percent because of rounding. We reviewed the most recent 

health and psychology services program review reports for 47 institutions and calculated the time 

 34The estimate is 23.4 percent. The associated 95 percent confidence interval is (14.9, 

34.0).

35For the estimate of 70 percent, the confidence interval is 54.3 to 76.6 percent; and for 

the estimate of 6 percent , the confidence interval is 3.2 to 14.9 percent. 

36BOP requires all institutions to conduct their own internal audits in each program area. 

These reviews, called operational reviews, use the same PRGs that are used by Program 

Review staff during their reviews. Operational reviews are expected to be conducted 10 to 

14 months from the week of the previous program review. For those institutions with a 

good or superior rating, an additional operational program review should be conducted 22 

to 26 months from the week of the previous program review. In addition, according to BOP 

officials, if a program review is delayed, the institution is still required to conduct an annual 

operational review.
Page 22 GAO-13-1 Inmate Mental Health Services

elapsed between that review and the previous review. The 95 percent confidence intervals for the 

estimates are shown in parentheses.

According to BOP policy, institutions that previously received a superior 

or good rating are to be reviewed within 36 months. Institutions that 

received an acceptable rating are to be reviewed within 24 months, and 

institutions with a deficient rating are to be reviewed within 18 months.

Program Review officials told us that the tardiness of the program reviews 

was often due to staffing issues at the institution or within the Program 

Review Division. For example, one program review for an institution that 

had received an acceptable rating was delayed by 16 months, in part 

because one reviewer did not complete the required training in time to 

conduct the program review. Program Review officials told us that 

institutions can also request to postpone a review when, for example, a 

key staff position is vacant, such as the clinical director of the institution’s 

health services unit. According to Program Review officials, when an 

institution requests a program review postponement, the Program Review 

Division considers the results of the institution’s annual operational 

reviews to help determine whether it would be prudent to adjust the 

institution’s review schedule.37 Additionally, the Assistant Director for the 

Program Review Division approves any deviation in schedule.38

Although it is important that BOP officials review and approve 

postponements of program reviews, when reviews are postponed the 

delays can be lengthy, even for institutions with the lowest ratings. For 

example, BOP officials told us that to reduce travel costs, they delayed 

the review of an institution rated acceptable by 14 months to combine its 

review with that of another nearby institution’s review. Of the 11 

 37BOP requires institutions to conduct their own internal audits in each program area. 

These reviews, called operational reviews, use the same PRGs that are used by Program 

Review staff during program reviews. Operational reviews should be conducted 10 to 14 

months from the week of the previous program review. For those institutions with a good 

or superior rating, an additional operational program review should be conducted 22 to 26 

months from the week of the previous program review. In addition, according to BOP 

officials, if a program review is delayed, the institution is required to conduct an internal 

operational review annually.

38We found that institutions were generally following the time frames specified in BOP 

policy with regard to the submission of corrective action plans. Among the 35 institutions 

that were required to submit corrective action plans in response to a psychology services 

program review, 33 submitted the plans within BOP’s established time frame of 30 days. 

The remaining 2 submitted their corrective action plans within 10 additional days.
Page 23 GAO-13-1 Inmate Mental Health Services

institutions in our sample with an acceptable rating in their prior 

psychology services program review, 4 received their next review more 

than 6 months late and 3 of those were more than a year late. In contrast, 

among the 36 institutions with a prior rating of good or superior, 7 had 

their next review more than 6 months late, including 2 more than a year 

late. Because institutions with an acceptable rating are to be reviewed 

within 24 months—compared to 36 months for facilities with higher 

ratings—a 1-year delay is potentially more problematic . According to A 

Guide to the Project Management Body of Knowledge, which provides 

standards for project managers, agencies should place the highest 

priority on oversight of facilities, programs, or operations that are most at 

risk of not meeting key performance objectives; in BOP’s case this would 

be institutions with the lowest ratings.39 Therefore, when scheduling 

postponed reviews, proper risk management would call for BOP to give 

highest priority to those institutions with the lowest ratings. Because 

delays in program reviews may hamper BOP’s ability to adequately 

monitor inmate care, it is important for BOP to minimize delays, especially 

for the lowest-rated institutions. Furthermore, with BOP’s inmate 

population expected to increase through 2020,40

Program Review Division officials take steps to share information learned 

from program reviews with other relevant BOP officials. For example, 

officials from the Program Review Division and the chiefs of every division 

that they review, including the Psychology Services Branch and the 

Health Services Division, meet quarterly and discuss deficiencies 

identified during the previous quarter. Program Review officials also send 

wardens a summary that lists the most common deficiencies identified 

during the previous quarter’s reviews to alert the wardens to focus 

attention on certain program areas. For example, a November 2012 

quarterly report stated that the most frequent psychology services 

it will be even more 

important for BOP to ensure that it conducts timely program reviews to 

identify potential problems with access to care or compliance with its 

treatment policies that growing institutional crowding might exacerbate.

 39Project Management Institute, A Guide to the Project Management Body of Knowledge 

(PMBOK® Guide), Fifth Edition. We have used A Guide to the Project Management Body 

of Knowledge as criteria in previous reports, including Nonproliferation and Disarmament 

Fund: State Should Better Assure the Effective Use of Program Authorities, GAO-13-83.

40GAO, Bureau of Prisons: Growing Inmate Crowding Negatively Affects Inmates, Staff, 

and Infrastructure, GAO-12-743 (Washington, D.C.: Sept. 12, 2012).
Page 24 GAO-13-1 Inmate Mental Health Services

deficiency cited was that not all mental health care level 3 inmates had a 

treatment plan or were being seen on a monthly basis.41

An additional review activity that BOP’s Psychology Services Branch 

conducts is certification reviews of 2 of the 10 current residential and 

nonresidential psychology treatment programs—RDAP and the Challenge 

Program.42

The Psychology Services Branch is planning to implement remote 

reviews of treatment programs and has begun to implement remote 

reviews of clinical services. In March 2013, officials from Psychology 

Services told us they plan to implement procedures in 2013 for annual 

remote reviews for 9 of BOP’s 10 residential and nonresidential treatment 

programs.

The branch conducts the certification reviews to ensure that 

the program adheres to the 10 elements of a modified therapeutic 

community (MTC), the treatment model BOP uses for residential 

psychology treatment programs. (See app. VII for additional information 

on the elements of a MTC.) Psychology Services officials told us they 

would like to expand the certification process to all eight residential 

treatment programs, but expansion was contingent on securing additional 

funds for travel because the certification reviews are done at the program 

location.

43

 41According to BOP guidance, a psychologist or psychiatrist should meet with all inmates 

classified as mental health care level 3 more frequently than monthly.

Staff plan to conduct these reviews from BOP’s headquarters 

using electronic medical records; the reviews are expected to focus on 

areas such as staff utilization, treatment planning and services, and 

documentation quality. The Psychology Services Branch has also started 

to conduct remote reviews of selected clinical services provided. In early 

2013, the Psychology Services Branch conducted a remote review of the 

mental health classification at each institution for inmates whose mental 

health care level did not appear to align with the level of care the inmate 

42The Challenge Program is a residential program designed to facilitate favorable 

institutional adjustment and successful reintegration into the community through the 

elimination of drug abuse or the management of mental illness. The Challenge Program 

targets high-security inmates with a history of drug abuse or a major mental illness. During 

the course of most of our review, BOP had 11 psychology treatment programs. At the end 

of fiscal year 2012, BOP discontinued one of its programs, the Habilitation Program.

43There are no remote review procedures for the Commitment and Treatment Program—a 

civil commitment treatment program for persons certified as sexually dangerous—because 

BOP has not yet issued a relevant program statement. 

Additional Psychology Services 

Branch Reviews

Certification of Use of Modified 

Therapeutic Community Model: The 

Psychology Services Branch certifies new 

RDAPs and Challenge programs within 6

months of the treatment program becoming 

operational to ensure that the institution is 

adhering to the modified therapeutic 

community model of treatment. This model 

stresses values and behaviors that are 

needed in the outside community, such as 

responsibility to self and others, and thinking 

and acting in accordance with the norms of 

the community.

Source: GAO analysis of BOP information.

Remote Reviews: The Psychology Services 

Branch considers remote reviews to be a 

mechanism for the central office to provide 

ongoing technical assistance to institutions. 

Headquarters staff conduct the reviews and 

send the results to the institution. 

Source: BOP Psychology Services.
Page 25 GAO-13-1 Inmate Mental Health Services

was receiving.44 Psychology Services officials also plan to conduct 

remote reviews of suicide risk assessments to evaluate whether the 

assessments are well reasoned and, for at-risk inmates, treatment began 

when the inmate was on suicide watch.

In addition to requiring program reviews, BOP policy also requires 

institutions to obtain external accreditations to assess whether they are 

meeting external standards of care. ACA assesses all facets of 

correctional institutions, including mental health services, while The Joint 

Commission focuses on the services provided by the institution’s Health 

Services Unit.

In both accreditation reviews, mental health care represents a small 

component of the review’s overall focus. ACA identifies seven standards 

specific to mental health care, four of which are mandatory. For example, 

one standard specifies what should be covered during an inmate’s mental 

health screening.45

We reviewed the most recent ACA and ambulatory care Joint 

Commission accreditation reports for our sample of 47 institutions.

All of The Joint Commission’s standards are 

mandatory. If, during the on-site review, examiners find insufficient 

compliance with a standard, the institution must submit documentation to 

The Joint Commission that it has resolved the issue prior to being granted 

full accreditation.

46

 44For each institution, headquarters staff did a reclassification of one or two of the inmates 

who were receiving a level of care higher than their mental health care level designation 

indicated. Headquarters staff then sent these one or two examples of reclassification, 

along with a list of all inmates who may require reclassification at the institution, to the 

institution for further review.

We 

45The other three mandatory standards relate to the required elements of an institution’s 

mental health program, mental health screenings for inmates transferred from another 

institution within the same system, and suicide prevention plans. The three non-mandatory 

mental health standards relate to providers’ credentials, the timeliness of certain mental 

health evaluations, and the placement of inmates with severe mental illness or 

developmental disorders.

46For the 47 institutions in our sample, we reviewed 37 Joint Commission accreditation 

reports. Nine of the 47 institutions were medical care level 1 institutions and therefore not 

required to be accredited by The Joint Commission. An additional institution changed from 

a Level 1 to a Level 2 institution and had not gone through accreditation. Level 1 

institutions serve the healthiest inmates.

External Accreditation 

Reviews Assess Whether 

BOP Is Meeting 

Established Standards of 

Care
Page 26 GAO-13-1 Inmate Mental Health Services

found limited findings related to mental health care in both the ACA and 

Joint Commission accreditation reports, meaning that the institutions 

generally were complying with applicable standards. Findings from our 

analysis are detailed in appendix VI.

We also reviewed the accreditation reports of the four BOP-operated 

institutions that have Joint Commission accreditations for behavioral 

health care. All four institutions received full accreditation. One of the 

institutions had no findings, and for two institutions, The Joint 

Commission examiners found that the suicide risk screenings did not 

specify the inmate’s protective factors, which are factors that decrease an 

inmate’s risk of suicide.

BOP’s ORE has not evaluated and has not yet developed a plan to 

evaluate 7 of BOP’s 10 treatment programs to assess whether they are 

meeting their established goals; of the 3 others, ORE completed two 

reviews over 11 years ago and has one under way. Evaluation can play a 

key role in program management, providing feedback on both program 

design and execution, and providing agencies with important information 

to improve performance.47 ORE completed its review of RDAP in 2000 

and the Bureau Rehabilitation and Values Enhancement (BRAVE) 

Program in 2001 and found positive results.48 For example, inmates who 

participated in RDAP had less recidivism after 3 years of release than 

inmates who did not go through the program.49

 47GAO, Designing Evaluations, 2012 Revision, 

BOP used the results from 

ORE’s RDAP and BRAVE evaluations in its budget justifications to 

support continued funding in these areas. In addition, ORE is currently 

GAO-12-208G (Washington, D.C.: Jan. 

2012).

48The BRAVE program, which addresses institutional adjustment, antisocial attitudes and 

behaviors, and motivation to change, is for inmates 32 years old and younger serving 

sentences of at least 60 months. 

49Specifically, 44.3 percent of male inmates who completed RDAP were likely to be 

rearrested or have their supervision revoked because of a violation of their conditions of 

supervision within 3 years after release to supervision in the community. In comparison, 

52.5 percent of inmates who did not receive treatment were rearrested or had their 

supervision revoked within 3 years. For women, 24.5 percent of those who completed 

RDAP were likely to be rearrested or have their supervision revoked within 3 years after 

release, compared with 29.7 percent of the untreated women. Among female inmates, the 

effect of treatment was not statistically significant. See Federal Bureau of Prisons, Office 

of Research and Evaluation, TRIAD Drug Treatment Evaluation Project Final Report of 

Three-Year Outcomes: Part 1 (Washington, D.C.: 2000).

BOP Has Not Evaluated 

Most of Its Psychology 

Treatment Programs and 

Has Not Yet Developed a 

Plan To Do So

Evaluations: An evaluation determines 

whether a program is meeting its intended 

outcomes. Intended outcomes of psychology 

treatment programs could include lower 

recidivism rates, lower rates of misconduct, or 

better management of mental illness 

symptoms. 

Source: GAO analysis of BOP information.
Page 27 GAO-13-1 Inmate Mental Health Services

working on an evaluation of the Sex Offender Treatment Program.50

BOP has not yet developed a plan for evaluating any additional 

psychology treatment programs. As part a statutory requirement, BOP is 

to provide an annual report containing statistics demonstrating the relative 

reductions in recidivism associated with major inmate programs (including 

residential drug treatment, vocational training, and prison industries 

programs).

ORE 

officials said this study will likely take a number of years because they are 

examining the program’s effect on recidivism rates, which requires waiting 

until after the inmates have been released for some period of time.

51

Given the annual reporting requirement and the lack of clarity regarding 

how BOP intends to meet this reporting requirement, it is important that 

BOP develop a plan, within its available resources, for evaluating its 

psychology treatment programs. The plan would indicate whether the 

evaluations would focus solely on recidivism, or also include additional 

After we provided a draft of this report to DOJ for comment, 

BOP officials told us they have begun to develop an approach to 

complete the first report, which they plan to submit to Congress in 2016. 

BOP officials said that as of June 2013, they were in the process of 

determining which psychology treatment programs to include in the 2016 

report and could not provide us with documentation as to what programs 

they were considering or the criteria they would use to determine which 

programs would be included. Furthermore, BOP was unable to provide 

documentation as to whether the first report would focus solely on 

recidivism or whether the report would also include additional outcomes 

that these programs are intended to affect, such as inmate disciplinary 

actions or self-management of a mental illness.

 50The Sex Offender Treatment Program is a high-intensity 12- to 18-month program 

designed for high-risk sexual offenders.

51Second Chance Act of 2007, Pub. L. No. 110-199, § 231, 122 Stat. 657, 683-86 (2008) 

(codified at 42 U.S.C. § 17541). By statute, the Director of BOP is to submit a report 

containing statistics demonstrating the relative reduction in recidivism for inmates released 

by the BOP within that fiscal year and the 2 prior fiscal years, comparing inmates who 

participated in major inmate programs (including residential drug treatment, vocational 

training, and prison industries) with inmates who did not participate in such programs. The 

Director of BOP is to select a measure for recidivism (such as rearrest, reincarceration, or 

any other valid, evidence-based measure) that the Director considers appropriate and that 

is consistent with the research undertaken by the Bureau of Justice Statistics under 

statute. Further, the report is not required to include statistics for a fiscal year that begins 

before April 9, 2008. According to BOP, subsequent to the Second Chance Act of 2007, 

BOP was appropriated $2.6 million to conduct the activities related to the report. 
Page 28 GAO-13-1 Inmate Mental Health Services

outcomes. Standard practices for project management call for agencies to 

define specific goals in a plan, as well as to describe how the goals and 

objectives are to be achieved; including identifying the needed resources 

and target time frames for achieving desired results.52 With a plan, BOP 

could have greater assurance that the activities necessary to conduct the 

evaluations of the psychology treatment programs, as well as any needed 

program changes that may be identified during those evaluations, would 

be completed in a timely manner.

More than half of the BOP program statements—which outline BOP’s 

formal policies and procedures—related to mental health services are out 

of date, despite BOP’s acknowledgment that policies need to be current. 

Five of the eight program statements we identified as related to inmate 

mental health services have not been updated within the past 5 years, 

including two that have not been updated in 18 years (see app. VIII).53

Psychology Services officials told us that they want to update the program 

statements for psychology services and institution management of 

mentally ill inmates, both of which were last updated in 1995. BOP needs 

to negotiate with its union on all changes to existing program statements 

that affect the conditions of employment of members of the collective 

bargaining unit, if the unit chooses to negotiate. Until recently, BOP, in 

conjunction with the union, has placed a higher priority on negotiating 

other program statements. In May 2013, the union and BOP came to an 

agreement to restart the negotiation process and BOP’s Psychology 

Services Branch was drafting changes to the two program statements.

For example, although BOP’s psychology services program statement 

states that it “is periodically updated to reflect the rapidly changing nature 

of professional psychology within a correctional setting,” BOP has not 

updated the statement since 1995.

 52Project Management Institute, A Guide to the Project Management Body of Knowledge 

(PMBOK® Guide), Fifth Edition.

53The two program statements that have not been updated since 1995 are the program 

statement that serves as the Psychology Services Manual, which establishes policies, 

procedures, and guidelines for the provision of psychology services throughout BOP, and 

the program statement on institution management of mentally ill inmates, which 

establishes policies, procedures, and guidelines for the management of mentally ill 

inmates at regular (i.e., nonmedical) correctional institutions.

BOP Program Statements 

Related to Mental Health 

Services Contain Outdated 

Information
Page 29 GAO-13-1 Inmate Mental Health Services

However, until program statements are updated, they will continue to 

contain information that does not reflect current practices or relates to 

systems or processes that are no longer in use. For example, in the 18 

years since the program statements for psychology services and 

institution management of mentally ill inmates were last updated, BOP’s 

total inmate population increased significantly; BOP revamped its system 

for assessing and classifying mental illness in the inmate population; and 

several new medications, programs, and treatment models have been 

established. The outdated program statements, which officially articulate 

BOP policy, also do not reflect important developments in the provision of 

mental health services, such as the increased emphasis on evidencebased treatments.

According to the BOP program statement on management directives, 

program statements serve as the formal policies guiding agency 

operations, thereby setting the expectations for how BOP-operated 

institutions should operate. BOP states that less formal documents, such 

as memos, should generally not be used to communicate requirements or 

instructions because these documents are not authenticated, numbered, 

annually reviewed, or historically traced. We found, however, that in the 

absence of officially updated policy in key areas related to mental health 

services, the Psychology Services Branch is relying on internal memos to 

implement some changes. For example, in 2009, BOP’s assistant 

directors for the Correctional Programs Division and the Health Services 

Division issued a memo to all wardens to implement the newly 

established mental health care level designations for inmates. The memo 

contains the necessary details about how inmates should be designated 

to the four different mental health care levels, making obsolete the 

elements of the program statement that describe an older inmate 

classification system. Formally documented policies and procedures 

provide guidance to staff in the performance of their duties and help to 

ensure activities are performed consistently across an agency, according 

to the standards for internal controls in the federal government.54

BOP officials said they plan to update the agency’s outdated program 

statements and implement the revised program statements, but have not 

Standards for internal controls also require that agencies regularly review 

their policies and procedures and update as necessary.

 54GAO/AIMD-00-21.3.1. 
Page 30 GAO-13-1 Inmate Mental Health Services

said when this process will begin or when it will be completed. Taking 

action to update and implement its program statements regarding inmate 

mental health care would help BOP better position itself to ensure 

consistent adherence to policies and reduce any confusion that may alter 

the provision or quality of inmate mental health care. By updating the 

program statements, BOP reduces the risk of, among other things, having 

psychology staff not understanding their required duties and 

inconsistently implementing treatment program activities, which may lead 

to unintended variation in services and outcomes for inmates across 

BOP-operated institutions.

BOP does not track its contractors’ costs of providing mental health 

services to the 13 percent of BOP inmates housed in privately managed 

facilities. The performance-based,55 fixed-price contracts that govern the 

operation of BOP’s privately managed facilities give flexibility to the 

contractors to decide how to provide mental health services. 

Nevertheless, BOP assesses the contractors’ compliance with contract 

requirements and accreditation standards related to mental health 

through Contract Facility Monitoring (CFM) reviews, external accreditation 

reviews, and other reviews.

BOP tracks the overall daily cost for housing the 13 percent of federal 

inmates—who are generally designated as mental health care level 1—in 

its 15 contract facilities, but BOP does not track the specific costs of 

providing mental health services to these inmates. This is because the 

BOP contracts that govern the operation of these privately managed 

facilities are performance-based, fixed-price contracts that only require 

the contractors to provide BOP with their costs on a per inmate per day 

basis.56

 55According to BOP, performance-based contracts generally establish the performance 

standards for the contractor, including those related to mental health services, and it is up 

to the individual contractors to determine how they will meet those standards. BOP’s fixedpriced contracts only require the contractors to provide BOP with their costs on a per 

inmate per day basis.

According to officials from BOP’s Administration Division, which 

56This daily rate covers all the costs the facility incurs to house the inmate, including for 

mental health services. BOP inmates housed in contract facilities are designated as a low 

security level, and most have a mental health care level designation of 1 or 2.

BOP Does Not Track 

Contractors’ Costs of 

Providing Inmate 

Mental Health 

Services but Does 

Assess Compliance 

with Requirements 

and Standards of Care

BOP Does Not Track 

Contractors’ Cost of 

Providing Inmate Mental 

Health Services in 

Contract Facilities
Page 31 GAO-13-1 Inmate Mental Health Services

oversees contracting for BOP, the structure of the fixed-price contract 

model prohibits BOP from asking contractors to provide more specific 

cost information. While other contract models exist, guidance from the 

Office of Federal Procurement Policy within the Office of Management 

and Budget encourages agencies to issue fixed-price contracts, when 

appropriate, because they provide greater incentive for the contractor to 

control costs and perform efficiently.

BOP officials told us that because the contracts are performance-based, 

when contractors do not meet the terms of work in the fixed-price 

contract, BOP reduces the contract price to reflect the value of the 

services actually performed.57

Two of the three BOP contractors we spoke with—which are the primary 

contractors responsible for operations at 11 of the 15 private facilities

BOP officials told us they have done this 

for deficiencies related to mental health. For example, BOP officials 

stated that from 2008 to present, they imposed deductions ranging from 

over $75,000 to $1,000,000 on contractors for 91 deficiencies, including 6 

for mental health, found during the CFM reviews. The mental health 

deficiencies that make up some of these deductions were mostly related 

to mental health screenings not being completed in a timely manner or in 

accordance with standards.

58—

said that they track mental health services costs internally and take them 

into account when calculating the per diem inmate cost they use when 

bidding for BOP contracts.59

 57Pursuant to the contract and the Federal Acquisition Regulation, 48 C.F. R. § 52.246-4, 

if any of the services do not conform with contract requirements and the defects in 

services cannot be corrected by performance, the government may reduce the contract 

price to reflect the reduced value of the services performed.

Additionally, two of the primary contractors 

told us that they subcontract for health services, including mental health 

services, and do not know the subcontractors’ specific cost for providing 

mental health services. We spoke with one subcontractor that told us it 

tracks these costs internally. We requested this cost information from that 

subcontractor and two of the three primary contractors we spoke with, but 

58One of the contractor companies operates several private facilities, but for two of those 

facilities it acts as a subcontractor to operate the facility. Throughout this report we will 

refer to this company as a primary contractor.

59We did not speak to one primary contractor that manages 1 of BOP’s 15 contract 

facilities: the contractor declined to participate in interviews because the contract was

terminated as of May 31, 2013.
Page 32 GAO-13-1 Inmate Mental Health Services

were unable to obtain this information because the contractors consider it 

proprietary and confidential.60

BOP uses a number of approaches to assess each contractor’s 

compliance with its mental health requirements and standards. These 

include CFM reviews; reports from external reviews that accrediting 

bodies perform; reports from internal reviews that the contractors 

conduct; and the monthly, less formal inspections and continuous 

monitoring activities performed by the two to four BOP staff stationed onsite at each privately managed facility—one of whom is a contracting 

officer. BOP officials stated that the combination of these various 

accountability mechanisms gives them assurance that the contract 

facilities are providing the appropriate mental health services to federal 

inmates.

BOP conducts annual on-site CFM reviews at each contract facility, the 

objective of which is to assess whether the contract facilities are meeting 

performance outcomes outlined in the contract. Following a CFM review, 

BOP issues a report to the facility noting deficiencies and findings from 

the review.

With respect to mental health, each contract requires that “all inmates are 

[to be] screened for mental health, substance abuse, and other behavioral 

problems and receive appropriate intervention, treatment, and programs 

to promote a healthy, safe, and secure environment.” According to BOP, 

this language is more generic than prescriptive because of the contracts’

performance-based nature. The contract also specifies that private 

facilities must obtain and maintain ACA and Joint Commission 

accreditation. BOP officials told us that while BOP gives contractors 

discretion in deciding how to deliver mental health services—and does 

not dictate adherence to BOP’s mental health policies—they believe that 

requiring contractors to achieve and sustain the same accreditations as 

BOP institutions helps ensure a high level of service.

BOP developed a Quality Assurance Plan that sets out the areas that 

BOP is to assess during the CFM reviews. The plan includes auditing 

 60We did not request cost information from one contractor because a subcontractor 

provides mental health services in its BOP contract facilities; this subcontractor is not the 

same subcontractor we interviewed. 

BOP Assesses Compliance 

with Mental Health 

Requirements and 

Standards in Several Ways

BOP’s Contract Facility 

Monitoring Reviews
Page 33 GAO-13-1 Inmate Mental Health Services

check lists that cover the spectrum of services that BOP requires its 

contractors to provide, and includes six specific steps for assessing 

contractors’ provision of mental health services. BOP staff with expertise 

in medical and mental health issues are part of the review team 

conducting the reviews, and the six steps include components such as 

checking that all inmates are screened for mental health, substance 

abuse, and other behavioral problems and receive appropriate 

intervention, treatment, and programs.

BOP’s CFM process is designed to determine overall contractor 

performance. Our review of the recent CFM reports for all 15 private 

facilities, related discussions with three primary contractors that manage 

14 of BOP’s 15 contract facilities and one subcontractor, and our direct 

observation of a CFM review at 1 contract facility found that the process 

generally was implemented in accordance with policy. In addition, our 

review of the CFM review time frames for the 15 contract facilities from 

2008 through 2012 found that the reviews are generally taking place on 

time, with each facility being reviewed at least once annually.

According to BOP officials, they track and characterize the deficiencies 

from the CFM reports at a high level, such as whether they are related to 

health services, but they do not specifically track whether those 

deficiencies are related to mental health. Across the CFM review reports 

we assessed, we found four policy areas where deficiencies that could be 

related to mental health services were cited at more than 1 facility—

Inmate Classification and Program Review, Health Information 

Management, Patient Care, and Medical Designation and Referral 

Services for federal Inmates.61

 61In conducting our analysis, we determined that a deficiency was related to mental health 

if it involved psychology, psychiatry, or pharmacy care, as these areas have relevance to 

the provision of mental health services.

In particular, the deficiencies in these 

policy areas involve the identification and documentation of inmate 

program needs; inmate health records having missing, incomplete, or 

inaccurate information; and health documents not being written so that 

correctional staff can understand the inmate’s health needs. Inmate 

program needs, inmate health records, and other health documents may 

include mental health information. For more information on the 

deficiencies BOP identified in the CFM reports, see appendix VI.
Page 34 GAO-13-1 Inmate Mental Health Services

On completion of the CFM, BOP reviewers provide the contract facility 

with their report. BOP requires the contract facility to prepare a corrective 

action plan within 30 days and submit it to the on-site monitors and BOP 

Privatization Management Branch. BOP’s on-site staff review the 

corrective action plan, and if they accept the plan, they oversee its 

implementation to ensure that the facility is taking action and that the

actions appropriately address the deficiency. Our conversations with the 

on-site monitors indicated that this oversight is taking place at the 

locations we visited. Our analysis found that of the 100 CFM reviews 

conducted from 2008 through 2012 that required a contract facility to 

submit a corrective action plan, 16 were not submitted within the 30 days. 

However, those that missed the deadline were all submitted no later than 

2 months after the specified deadline. If the on-site staff reject the plan, 

they can discuss issues with the contract facility staff and supervisors 

within BOP’s Privatization Management Branch—which oversees 

contractor compliance—to provide feedback so the contractor can make 

needed changes and resubmit the plan for approval. If BOP continues to 

have concerns about the corrective action plan, it can file a “notice of 

concern.” However, BOP officials told us this is a rare occurrence that has 

not happened recently because most contractors have been working with 

BOP for some time and are familiar with the contract requirements. BOP 

officials also told us that all the staff involved with overseeing contractor 

compliance meet regularly to discuss any common findings and 

observations from the CFM reviews and the corresponding corrective 

action plans. They said the objective of their discussions is to ensure that 

staff are aware of the findings and to facilitate any future changes to the 

structure of the contracts that the Privatization Management Branch staff 

may need to undertake to address some of these issues.

Like BOP-operated facilities, contract facilities are also required to obtain 

ACA and Joint Commission accreditations and are assessed under the 

same standards, and contract facilities must be accredited no later than 

24 months after becoming operational. According to BOP officials, 

establishing a 24-month window for contract facilities to receive 

accreditation is appropriate because this is consistent with the 

requirements for BOP facilities. Once a contract facility is accredited, both 

ACA and The Joint Commission evaluate it once every 3 years to 

substantiate continued accreditation. As of April 2013, 13 of the 15 BOP 

contract facilities have received ACA and Joint Commission 

accreditations. The 2 contract facilities that have not received ACA and 

Joint Commission accreditations became operational in 2011 and 

therefore must undergo their reviews in 2013 to meet the contract’s 

requirements.

External Accreditation Reviews 

by ACA and Joint Commission
Page 35 GAO-13-1 Inmate Mental Health Services

Once ACA and The Joint Commission complete their respective reviews, 

they provide BOP with copies of their reports to verify that the contract 

facility is in compliance with the accreditation standards. If the facility is 

not compliant with any of the standards, BOP requires the contract facility 

to develop and submit to both BOP’s on-site staff and the Privatization 

Management Branch a corrective action plan that outlines the changes 

the facility is making to comply with the accreditation standards. The onsite staff review the plan and verify that the corrective actions have been 

implemented. ACA and The Joint Commission also require the 

contractors to provide them with copies of the respective corrective action

plans, and each accrediting body conducts its own follow-up to confirm 

that actions have been taken before finalizing an accreditation decision.

Our analysis of the most recent ACA accreditation reports for the 13 

contract facilities that were reviewed found that all but one of the facilities 

were compliant with all ACA standards related to mental health services, 

including pharmacy care, psychology, and psychiatry services. The facility 

that was found not compliant with all of ACA’s mental health-related 

standards was as a result of the facility’s failure to develop and utilize a 

health care staffing plan and the reviewers’ related concerns about the 

mental health staffing levels at the facility.62 Our review of the most recent 

Joint Commission accreditation reports found that 6 of the 13 contract 

facilities were fully in compliance with the ambulatory care standards we 

determined were related to mental health services—a small subset of the 

192 standards by which they are assessed. The Joint Commission found

the remaining 7 facilities to be either partially or insufficiently compliant 

with these standards.63

 62This contract facility had since submitted its corrective action plan to ACA and was 

granted reaccreditation.

The areas related to mental health in ambulatory 

care accreditation standards that were most frequently cited include 

medication management, such as medication labeling and storage 

issues, and the lack of documentation of the competency of medical staff, 

including mental health staff. In addition to the ambulatory care 

accreditation that contract facilities are required to obtain, 1 of the 7 

facilities specifically chose to also be accredited on behavioral health 

63According to The Joint Commission, a facility is found to be partially compliant if it has 

two occurrences of noncompliance with the standard’s area during the review. A facility is 

found to be insufficiently compliant with the standards if it has three or more occurrences 

of noncompliance in the standard’s area during the review. As a part of the scoring, The 

Joint Commission considers the potential risk to patient care or safety for noncompliance. 
Page 36 GAO-13-1 Inmate Mental Health Services

standards, and that facility was found to be insufficiently compliant with 3 

of those standards.64 These compliance issues related to: inmate 

assessments not including information on addictions other than alcohol or 

drugs; inmate treatment plans not including goals and metrics to measure 

an inmate’s progress; and the lack of documentation of an assessment of 

clinical competence for staff being hired.65

In addition to accreditation and its own reviews, BOP conducts oversight 

of contract facilities by requiring them to conduct routine internal 

assessments of their operations. BOP requires contractors to develop a 

Quality Control Plan, which serves as the basis for these internal reviews, 

and to share the results of their reviews with the BOP on-site monitors, 

who verify in their monthly reviews that the internal reviews have 

occurred. According to officials from the contractors that manage 14 of 

BOP’s 15 contract facilities, when they develop their Quality Control 

Plans, they generally use BOP policies and accreditation standards as a 

resource to ensure that the company’s policies either meet or exceed 

BOP’s own standards. For example, one contractor noted that it requires 

inmates who have just completed suicide watches to be seen by a mental 

health provider daily for the first 5 days, weekly for the next 2 months, and 

then monthly thereafter. This requirement is more specific than BOP’s 

own policies, which leave discretion to the chief psychologist to determine 

how frequently an inmate needs to be seen by mental health staff.

For more information on the 

specific ambulatory care and behavioral health standards for which the 

contract facilities were not in compliance, see appendix VI.

66

According to BOP officials, the contractors’ Quality Control Plans are 

much more detailed than BOP’s Quality Assurance Plan because the 

contractors are monitoring many more areas than BOP does in order to 

 64The ambulatory care accreditation covers the broad categories of surgical, 

medical/dental, and diagnostic/therapeutic services, and represents a variety of settings, 

including outpatient hospitals and prisons. The behavioral health accreditation focuses on 

organizations that provide services to persons with intellectual and developmental 

disabilities, as well as mental health and chemical dependency services.

65As of April 2013, all 7 of the facilities that had been found to be either partially or 

insufficiently compliant with Joint Commission standards have since submitted their 

corrective action plans to The Joint Commission and were granted reaccreditation.

66According to the contractor, it wanted to have more specific time frames because it 

relies more on master’s-level clinicians than on the doctoral-level clinicians more prevalent 

at BOP institutions. 

Contractor Internal 

Assessments and Quality 

Control Plans
Page 37 GAO-13-1 Inmate Mental Health Services

ensure they are properly prepared for BOP’s review. Our review of the 

Quality Control Plans that we received from two of the three primary 

contractors and the subcontractor we spoke with found that all of their 

Quality Control Plans had mental health-related elements that were 

aligned with those in BOP’s Quality Assurance Plan, and two of the three 

plans assessed additional areas beyond those established in BOP’s plan. 

For example, each of the Quality Control Plans contained steps to review 

psychological assessments of inmates in the special housing units, which 

are also included in BOP’s plan. An example of a plan going beyond 

BOP’s plan is that one contractor has reviewers evaluate inmate medical 

records to determine whether the psychiatrist documented that less 

restrictive treatment options have been exercised without success.

Providing mental health services to the federal inmate population is an 

important part of BOP’s broader mission to safely, humanely, and 

securely confine offenders in prisons and community-based facilities. As 

BOP’s inmate population has grown, so have its costs for mental health 

services. Likewise, as the inmate population is projected to continue to 

increase and BOP plans to continue maximizing inmate participation in its 

treatment programs, it is expected that future costs for mental health 

services will also rise. Given the fiscal pressures facing BOP—as with the 

rest of the government—it is critical that the agency focus its efforts on 

ensuring the prudent use of resources.

At the same time, it is important for BOP to provide mental health 

services that comply with its internal policies and external accreditation 

requirements. Program reviews provide important insight into whether 

these requirements are being met and inmates are being provided the 

appropriate services. We found that BOP was frequently unable to 

complete required monitoring within its own established time frames. To 

its credit, BOP schedules program reviews with the intention that those 

institutions with the lowest ratings are reviewed more frequently, and any 

delays in reviews require approval by BOP officials. However, when 

reviews are postponed, the delays can be lengthy—sometimes over a 

year—even for those institutions with the lowest ratings. Because delays 

in program reviews hamper BOP’s ability to adequately monitor inmate 

care, when scheduling postponed reviews BOP should take action to 

minimize delays and give highest priority to those institutions with the 

lowest ratings.

BOP would have greater assurance that it is effectively using its 

resources if it had better information on whether the programs were 

Conclusions
Page 38 GAO-13-1 Inmate Mental Health Services

meeting their intended objectives and if any program changes were 

needed. While BOP has evaluated a few, but not all, of its psychology 

treatment programs and is in the process of determining what information 

to include in its statutorily required report related to recidivism, it would be 

beneficial for BOP to develop a plan that identifies the resources 

necessary and target time frames to carry out future evaluations 

specifically related to psychology treatment programs, consistent with 

standards for project management. With such a plan, BOP would have 

greater assurance that the activities necessary to conduct the evaluations 

of the psychology treatment programs, and any needed changes 

identified through the evaluations, would be completed in a timely 

manner.

Finally, BOP has many outdated program statements related to mental 

health services, including two which are more than 15 years old. 

According to BOP, program statements serve as the formal policies 

guiding agency operations across the entire federal prison system, setting 

the foundation for how all institutions should operate. BOP policy states 

that less formal documents, such as memos, should generally not be 

used to communicate requirements or instructions, yet BOP is relying on 

internal memos to implement some key policy changes. By updating and 

implementing mental health care-related program statements, BOP would 

better ensure that its policies reflect currently accepted treatment 

practices and standards. This would also ensure that all BOP staff have a 

common set of guidelines to direct their activities, which would also better 

ensure appropriate services and outcomes for inmates across BOPoperated institutions.

To improve BOP’s ability to oversee BOP-operated institutions’

compliance with inmate mental health policies and monitor the 

effectiveness of treatment programs for mentally ill inmates, we 

recommend that the Director of BOP take the following two actions:

• when program reviews are delayed, ensure institutions with the lowest 

ratings receive the highest priority for the completion of reviews; and

• develop a plan to carry out future evaluations of BOP’s psychology 

treatment programs, within available resources; the plan should 

include the identification of necessary resources and target time 

frames.

Recommendations for 

Executive Action
Page 39 GAO-13-1 Inmate Mental Health Services

To ensure policies related to inmate mental health care accurately reflect 

current practices, we recommend that the Director of BOP take the 

following action:

• develop and implement updated program statements to ensure that 

these statements reflect currently accepted treatment practices and 

standards.

We provided a draft of this report to DOJ for review and comment. DOJ 

did not provide official written comments to include in this report. 

However, in an e-mail received on June 27, 2013, a BOP audit liaison

official stated that BOP concurred with the first and third 

recommendations and partially concurred with the second 

recommendation, which called for the Director of BOP to assess which 

psychology treatment programs could be evaluated within the agency’s 

existing resources and develop a plan to conduct future evaluations. After 

we provided the draft to DOJ for comment, BOP provided additional 

information about its program evaluation plans, which we reviewed and 

incorporated in this report as appropriate.

Specifically, as part of the additional information, BOP officials stated that 

the agency is in the process of developing an approach to assess which 

additional programs to evaluate. According to the BOP officials, as of 

June 2013, they are making plans to complete the first report required 

under the Second Chance Act of 2007 and are in the process of 

determining which psychology treatment programs to include in the 

report. However, BOP officials could not provide any documentation as to

the criteria to be used in selecting which programs would be included in 

the report or whether the report would include information on outcomes, 

in addition to the required outcome on recidivism. After evaluating the 

additional information BOP provided, we modified the second 

recommendation to reflect the assessments and planning discussions 

that BOP has under way and to highlight the importance of developing a 

plan, including elements such as time frames, for such evaluations.

BOP also provided technical comments, which we incorporated as 

appropriate.

We are sending copies of this report to the Director of BOP, selected 

congressional committees, and other interested parties. In addition, this 

Agency Comments 

and Our Evaluation
Page 40 GAO-13-1 Inmate Mental Health Services

report is available at no charge on the GAO website at 

http://www.gao.gov.

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

contact Dave Maurer at (202) 512-9627 or MaurerD@gao.gov, or Debra 

A. Draper at (202) 512-7114 or DraperD@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. Key contributors to this report are listed in 

appendix IX.

David C. Maurer, Director

Homeland Security and Justice Team

Debra A. Draper, Director

Health Care Team
Appendix I: Objectives, Scope, and 

Methodology

Page 41 GAO-13-1 Inmate Mental Health Services

Our objectives for this report were to address the following questions:

1. What have the costs been to provide mental health services in Bureau 

of Prisons (BOP)-operated institutions over the past 5 fiscal years, 

and what are the projected costs?

2. To what extent does BOP assess whether BOP-operated institutions 

comply with BOP policies for providing inmate mental health services?

3. To what extent does BOP track the costs of providing mental health 

services to BOP inmates in contract facilities, and to what extent does 

BOP assess whether these facilities meet contract requirements, 

including standards of care for inmate mental health services?

To address the question on the BOP’s costs over the past 5 fiscal years 

and projected costs to provide inmate mental health services in BOPoperated institutions, we interviewed officials from BOP’s Administrative 

Division, Psychology Services Branch, and Health Services Division to 

understand what constitutes mental health services, what costs are 

relevant to providing these services, what factors drive changes in cost, 

and BOP’s current practices for developing budgets and expenditure 

plans in these areas. Because BOP does not report a comprehensive 

mental health services cost, as costs are included in two BOP divisions 

(the Health Services Division and the Correctional Programs Division), we 

analyzed obligated funds for fiscal years 2008 through 2012 for these two 

divisions. Specifically, within Health Services, we examined obligations 

for psychiatry staff and for pharmaceuticals, including psychotropic 

medication. Within Correctional Programs, we looked at the obligated 

funds for Psychology Services, psychology staff training, drug abuse 

treatment programs, and Sex Offender Management Programs. To 

determine the per capita costs for the same time period, we divided the 

total cost by the inmate population at the end of the fiscal year in all BOPoperated institutions. In addition, to project future costs, we discussed 

with these same officials their methods for cost projections and 

independently examined BOP’s population projection and expected 

staffing positions for fiscal years 2013 through 2015. We limited our 

projections to 3 years, since the further into the future an estimate is, the 

less reliable it becomes. Additionally, there could be future changes in law 

or agency initiatives that may significantly impact the integrity of longerterm projections. To determine projected costs, we used the total cost of 

inmate mental health services for fiscal year 2012 as the baseline, and 

Appendix I: Objectives, Scope, and 

Methodology
Appendix I: Objectives, Scope, and 

Methodology

Page 42 GAO-13-1 Inmate Mental Health Services

adjusted this by BOP’s projected population and the IHS Global Insight 

Outlook inflation factor.1

To address the question on the extent to which BOP assesses whether 

BOP-operated institutions comply with BOP policies for providing inmate 

mental health services, we reviewed all relevant policies and program 

statements related to mental health services provided to inmates. 

Program statements outline BOP’s formal policies and procedures. We 

also met with BOP officials responsible for oversight in the Psychology 

Services Branch, Health Services Division, and Program Review Division 

to understand each unit’s oversight activities and how the units 

communicate with each other and with institution staff. We compared 

BOP’s policies for inmate mental health care and processes for 

monitoring the provision of inmate mental health care at the institution 

level with the Standards for Internal Control in the Federal Government 

and risk management principles.

For the projected per capita costs, we divided the 

projected cost by the projected population. To assess the reliability of 

BOP’s obligation data, we (1) performed electronic data testing and 

looked for obvious errors in accuracy and completeness, and (2)

interviewed agency officials knowledgeable about BOP’s budget to 

determine the processes in place to ensure the integrity of the data. We 

determined that the data were sufficiently reliable for the purposes of this 

report.

2 We conducted site visits to two 

institutions because they serve inmate populations with significant mental 

health care needs—one institution with several psychology treatment 

programs and another with a level 4 mental health care designation.3

 1

IHS Global Insight is a firm that provides comprehensive economic and financial 

information on countries, regions, and industries.

During each of these site visits, we discussed with institution staff the 

programming provided to inmates with mental health conditions and the 

institution’s experience with BOP oversight activities. Although not 

generalizable, the visits provided important insights into the services 

2

GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1

(Washington, D.C.: November 1999), and Project Management Institute, A Guide to the 

Project Management Body of Knowledge, Fifth Edition © (Newtown Square, Pennsylvania: 

2013). A Guide to the Project Management Body of Knowledge provides standards for 

project managers.

3

Institution mental health care levels range from 1 to 4, with 1 being institutions that care 

for the healthiest inmates and 4 being institutions that care for inmates with the most acute 

needs.
Appendix I: Objectives, Scope, and 

Methodology

Page 43 GAO-13-1 Inmate Mental Health Services

provided to inmates and oversight of staff working at the institutional level. 

We also interviewed officials from BOP’s Office of Research and 

Evaluation (ORE) to determine what evaluations ORE has conducted of 

psychology treatment programs in the past and what evaluations are 

ongoing or planned for the future. We assessed BOP’s evaluation 

planning against project management standards.

To understand BOP’s program review process, and the psychology and 

health services findings from recent program reviews, we conducted 

additional site visits to two institutions for the purpose of shadowing 

program review staff as they performed a psychology services program 

review. We chose the two institutions because they provided different 

levels of care—one institution was a mental health care level 4 and 

another was a mental health care level 1—and because the program 

reviews were being conducted within the time frame of our study. While 

the observations from these visits are not generalizable to all BOP 

institutions or to all program reviews, the visits provided important insights 

into the program review process.

In addition, we conducted a content analysis of recent psychology and 

health services program review reports. To conduct the content analyses, 

we selected a simple random sample of 47 BOP institutions from the 

study population of 94 BOP institutions that had been operating long 

enough to undergo a program review as of August 31, 2012.4

 4

In some cases, a number of institutions belong to a Federal Correctional Complex (FCC). 

At FCCs, multiple institutions with different missions and security levels are located in 

proximity to one another. For an FCC, BOP performs one program review for the entire 

complex, and not for the individual institutions that make up the complex. For purposes of 

this report, we use the term institution to refer to either a single institution or a complex of 

institutions that is considered a single unit for program review purposes. Therefore, BOP 

conducted 94 program reviews for the 116 institutions that had been operating long 

enough to undergo a program review as of August 31, 2012. Three additional institutions 

were not operating long enough to undergo a program review as of August 31, 2012. 

Program reviews begin at an institution 18 to 24 months after the institution opens.

Because 

we followed a probability procedure based on random selections, our 

sample is only one of a large number of samples that we might have 

drawn. Since each sample could have provided different estimates, we 

express our confidence in the precision of our particular sample’s results 

as a 95 percent confidence interval (e.g., plus or minus 7 percentage 

points). This is the interval that would contain the actual population value 

for 95 percent of the samples we could have drawn. Due to the small size 
Appendix I: Objectives, Scope, and 

Methodology

Page 44 GAO-13-1 Inmate Mental Health Services

of the population, we used a hypergeometric distribution to estimate the 

95 percent confidence intervals for our sample estimates.5

For each of the 47 institutions included in our sample, we received from 

BOP the most recent psychology and health services program review 

reports. In order to minimize the chance of nonsampling errors occurring 

in our file review, we took the following steps. A GAO analyst first 

reviewed each psychology and health services program review report to 

capture the dates of each review to determine the timeliness of the review 

in relation to the previous review, and the deficiencies identified in the 

final program review report. BOP defines deficiencies as deviations from 

policy or regulation, weaknesses in internal controls, or lack of quality 

controls. A separate GAO analyst verified each of the data elements 

collected. Our content analysis captured all deficiencies cited in 

psychology services reviews and deficiencies related to pharmacy and 

psychiatry in health services reviews. A GAO analyst independently 

created categories for the psychology and health services deficiencies 

and then sorted the deficiencies into the applicable categories. A 

separate GAO analyst verified the categorization of the psychology and 

health services deficiencies. For psychology services program review 

reports, we also received and reviewed additional documentation from 

BOP including (1) institutional responses to the program review’s findings 

(which include a corrective action plan to address any identified 

deficiencies), (2) the Program Review Division’s acceptance of the 

institution’s submitted corrective actions, (3) the institution’s submission of 

results from a follow-up audit conducted by institution staff to ensure that 

deficiencies were resolved, and (4) the Program Review Division’s 

closure of the program review. According to this additional 

documentation, we determined whether institutions were submitting their 

corrective action plans and follow-up audit results in accordance with 

BOP policy. We also reported illustrative examples of deficiencies and the 

corrective action plans that institutions developed to address deficiencies. 

We did not review this additional documentation from the health services 

program review reports because most of the deficiencies cited in the 

reports were unrelated to inmate mental health care.

 5

The hypergeometric distribution is used when sampling without replacement from a small 

population whose elements can be classified into two mutually exclusive categories (i.e.,

Yes/No).
Appendix I: Objectives, Scope, and 

Methodology

Page 45 GAO-13-1 Inmate Mental Health Services

To understand the accreditation process for BOP institutions, we 

interviewed officials and reviewed standards from the American 

Correctional Association (ACA) and The Joint Commission, the two 

accrediting organizations for BOP institutions.6 We also interviewed an 

official from the National Commission on Correctional Health Care, 

another organization that accredits correctional health care programs, to 

understand differences in standards among the three accrediting 

organizations. We conducted a content analysis of the most recent 

ambulatory care accreditation reports from ACA and The Joint 

Commission for the same random sample of institutions that we used for 

the analysis of program reviews. We reviewed 37 Joint Commission 

ambulatory care accreditation reports.7

We interviewed officials from the union representing BOP correctional 

workers who are involved in contract negotiations to gain an 

understanding of the negotiation process required to institute changes to 

mental health-related policies. Finally, to obtain context about correctional 

mental health programs, we interviewed correctional mental health 

experts, including representatives from the American Psychological 

Association, academics, and practitioners who have worked in the 

correctional setting. While the views of these experts are not 

For our review of the ambulatory 

care accreditation reports, we focused on findings related to psychiatry 

and pharmacy care, as these were the areas covered by the review most 

applicable to inmate mental health care. The Joint Commission’s 

accreditation is for those services provided by the institution’s health 

services unit and does not include psychology services. Because of the 

level of detail presented in the reports, findings related to pharmacy care 

are not specific to the administration of psychotropic drugs. We also 

reviewed the findings from The Joint Commission’s behavioral health 

accreditation reports for the four BOP institutions with behavioral health 

accreditations.

 6

ACA’s mission includes the development and promotion of effective standards for the 

care, custody, training, and treatment of offenders. The Joint Commission accredits and 

certifies health care organizations and programs in the United States.

7

As with program reviews, a single accreditation report may cover either a single 

institution or a complex with multiple institutions. For the 47 institutions in our sample, we 

analyzed 37 Joint Commission accreditation reports. Nine of the 47 institutions were 

medical care level 1 institutions and therefore are not required to be accredited by The 

Joint Commission. An additional institution changed from a level 1 to a level 2 institution 

and had not gone through accreditation. Level 1 institutions serve the healthiest inmates.
Appendix I: Objectives, Scope, and 

Methodology

Page 46 GAO-13-1 Inmate Mental Health Services

representative of all correctional mental health experts, they provided us 

with perspectives on BOP’s inmate mental health care system.

To address the question about the extent to which BOP tracks the costs 

of providing mental health services to BOP inmates in contract facilities, 

and the extent to which BOP assesses whether these facilities meet 

contract requirements and established accreditation standards for inmate 

mental health services, we reviewed the contracts for all of the 15 

contract facilities that housed BOP inmates during the course of our 

review to see what cost information they included. We also reviewed 

federal guidance from the Office of Management and Budget on 

recommended contracting mechanisms for federal agencies.8 We spoke 

with BOP officials responsible for procurement and the contracting 

process as well as each of the three primary contractors that operate 14 

of BOP’s 15 contract facilities,9

To understand BOP’s requirements for the provision of mental health 

services and oversight activities for the contract facilities, we reviewed 

each contract for the 15 contract facilities. We also reviewed BOP’s 

Quality Assurance Plan, the contractors’ Quality Control Plans, and the 

ACA and Joint Commission accreditation standards to identify the policies 

and procedures related to mental health that guide the various reviews of 

contract facility operations. We also reviewed the most recent contract 

facility monitoring reports, and ACA and Joint Commission accreditation 

review reports to determine the deficiencies identified that may be related 

to mental health. We also met with officials from BOP’s Administration 

Division, Privatization Management Branch, and Program Review 

Division who are responsible for overseeing contracts to understand each 

and one of the subcontractors that 

provides mental health services for one of the primary contractors to 

discuss the extent to which they track the costs of providing mental health 

services to inmates in contract facilities. One primary contractor that 

managed 1 of BOP’s 15 contract facilities declined to participate in 

interviews because the contract was terminated as of May 31, 2013.

 8

Executive Office of the President, Office of Management and Budget, Office of Federal 

Procurement Policy, Memorandum for Chief Acquisition Officers and Senior Procurement 

Executives: Increasing Competition and Structuring Contracts for the Best Results 

(Washington, D.C.: Oct. 27, 2009).

9

One of the contractor companies operates several private facilities, and for one of those 

facilities it has a subcontract from the primary contractor to operate the facility. Throughout 

this report we refer to this company as a primary contractor.
Appendix I: Objectives, Scope, and 

Methodology

Page 47 GAO-13-1 Inmate Mental Health Services

unit’s oversight activities, how the units communicate with each other and 

with contract facility staff, and how BOP contracts are structured. In 

addition, we spoke with officials from ACA and The Joint Commission to 

understand their accreditation standards and oversight activities. We also 

interviewed officials from each of the three primary contractors that 

operate 14 of BOP’s 15 contract facilities as discussed above, as well as 

one subcontractor that provides mental health services for one of the 

primary contractors, to discuss the types of mental health services 

provided and internal and external oversight mechanisms for contract 

facility operations. In addition, we conducted site visits to two contract 

facility, one to observe the Contract Facility Monitoring (CFM) review 

process, and another to observe operations. We chose the first facility 

because the review was being conducted at the facility during the time

frame of our study. We chose the second because it was a fairly new 

contract, which would provide a comparison to the first facility with a more 

established contract. While the selection of these two contract facilities 

does not facilitate generalizations, our observations and conversations 

with staff provided important context on the operations of privately 

operated prisons.

To understand the deficiencies BOP identified in its contract facility

monitoring reports that may be related to mental health, we performed a 

content analysis of all of the most recent reports from BOP’s 15 contract 

facilities’ monitoring reviews to determine the most frequent findings 

related to mental health. For our analysis, we determined that a 

deficiency may be related to mental health if it is related to pharmacy, 

psychiatry, or psychology services within the contract facility. We also 

reported illustrative examples of deficiencies. Similarly, for each of the 15 

contract facilities, we analyzed the most recent accreditation reports from 

the ACA and Joint Commission reviews to determine the most prevalent 

findings related to mental health services.

To understand the types of mental health services that are being 

assessed and the extent to which BOP’s review differs from the contract 

facility’s internal reviews, we obtained the Quality Control Plan from the 

subcontractor and two of the primary contractors and compared these 

plans with BOP’s Quality Assurance Plan, which is used to guide the 

contract facility monitoring process. One contractor was not willing to 

provide its plan because it considers the information to be proprietary and 

confidential.

We conducted this performance audit from April 2012 to July 2013 in

accordance with generally accepted government auditing standards. 
Appendix I: Objectives, Scope, and 

Methodology

Page 48 GAO-13-1 Inmate Mental Health Services

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 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.
Appendix II: Bureau of Prisons’ Psychology 

Treatment Programs’ Descriptions and 

Numbers of Participants for FY 2008 and 2012

Page 49 GAO-13-1 Inmate Mental Health Services

Program name Program description

Fiscal 

year

Number of 

inmate 

participants

Number of 

inmates on 

waiting list at 

the end of the 

fiscal year 

Non-Residential 

Drug Abuse 

Treatment Program 

(NR DAP)

NR DAP is available to inmates at every institution. The purpose of the 

NR DAP program is to afford all inmates with a drug problem the 

opportunity to receive drug treatment. NR DAPs are conducted for 90-

120 minutes per week for 12 to 24 weeks. 

2008 13,361 2,392

2012 20,141 9,825

Residential Drug 

Abuse Treatment 

Program (RDAP)

RDAP targets inmates who volunteer for drug abuse treatment and 

have a verifiable and diagnosable substance use disorder. Inmates in 

RDAP complete a minimum of 500 hours of programming in 9 to 12 

months. BOP also offers RDAPs for inmates with co-occurring 

substance use disorders and serious mental health disorders. BOP 

may reduce, by up to 1 year, the sentence of an inmate convicted of a 

nonviolent offense who successfully completes RDAP.

2008 14,721 6,980

2012 14,482 4,807

Challenge Program The Challenge Program is a residential program designed to facilitate 

favorable institutional adjustment and successful reintegration into the 

community through the elimination of drug abuse or the management 

of mental illnesses. The Challenge Program targets high-security 

inmates with a history of drug abuse or a major mental illness.

2008 1,613 284

2012 2,139 482

Bureau 

Rehabilitation and 

Values 

Enhancement 

(BRAVE) Program

The BRAVE program is a residential program intended to facilitate 

favorable institutional adjustment and reduce instances of misconduct. 

The program encourages inmates to interact in a positive manner with 

staff members and take advantage of opportunities to engage in selfimprovement during their incarceration. BRAVE targets inmates who 

are 32 years old or younger, with a sentence of at least 60 months, 

and who are serving a sentence with BOP for the first time. BRAVE 

includes 350 hours of programming over 6 months.

2008 255 38

2012 199 24

Habilitation Program The Habilitation Program was a residential program that targeted highsecurity, low-functioning inmates who could not successfully adapt to a 

penitentiary environment, but who may have the ability to function well 

at medium-security level institutions. The Habilitation Program was 

discontinued in fiscal year 2012.

2008 29 4

2012 19 1

Skills Program The Skills Program is a residential program designed for inmates with 

significant cognitive limitations and psychological difficulties that create 

adaptive problems in prison and in the community. Inmates 

participating in the program must have a serious mental illness or 

behavioral disorder and a need for intensive treatment services.

2008 72 2

2012 40 9

Steps Toward 

Awareness, Growth 

and Emotional 

Strength (STAGES) 

Programa

STAGES is a residential program that provides treatment to male 

mental health care level 3 inmates with a primary diagnosis of 

borderline personality disorder. Individuals with borderline personality 

disorder have long-term patterns of unstable or turbulent emotions that 

often result in impulsive actions and chaotic relationships with other 

people. The program is designed to increase the time between the 

inmate’s disruptive behaviors and foster living in the general 

population or a community setting. The program includes 12 to 24 

months of residential treatment.

2008 — —

2012 17 2

Appendix II: Bureau of Prisons’ Psychology 

Treatment Programs’ Descriptions and 

Numbers of Participants for FY 2008 and 2012
Appendix II: Bureau of Prisons’ Psychology 

Treatment Programs’ Descriptions and 

Numbers of Participants for FY 2008 and 2012

Page 50 GAO-13-1 Inmate Mental Health Services

Program name Program description

Fiscal 

year

Number of 

inmate 

participants

Number of 

inmates on 

waiting list at 

the end of the 

fiscal year 

Step-Down Unit 

Programs

Step-Down Units provide an intermediate level of mental health care 

for seriously mentally ill inmates. These residential units provide 

intensive treatment for inmates released from psychiatric 

hospitalization or may function as Step-Up Units to intervene and 

house inmates before they require hospitalization.

2008 NA NA

2012 90 9

Resolve Program The Resolve Program is a trauma treatment program for female 

inmates. The Resolve Program consists of two components: a psychoeducational workshop and a nonresidential program for inmates with 

trauma-related disorders.

2008 208 589

2012 2,358 1,636

Sex Offender 

Management 

Programsb

2008 373 381

2012 740 1,776

• Non-Residential

Sex Offender 

Treatment 

Program 

(SOTP-NR)

SOTP-NR is a voluntary, moderate-intensity program designed for low- to 

moderate-risk sexual offenders. Inmates in SOTP-NR must complete no 

less than 144 hours of programming over the course of 9 to 12 months.

• Residential Sex 

Offender 

Treatment 

Program 

(SOTP-R)

SOTP-R is a voluntary, high-intensity program designed for high-risk 

sexual offenders. Inmates in SOTP-R must complete no less than 400 

hours of programming over the course of 12 to 18 months.

Commitment and 

Treatment Programc The Commitment and Treatment Program is a civil commitment 

program for persons certified as sexually dangerous persons. It is a 

civil commitment program for the confinement and treatment of 

persons deemed sexually dangerous by the court. The program was 

established in response to requirements from the Adam Walsh Child 

Protection and Safety Act of 2006.d

2008 — —

2012 23 No waiting list

Source: GAO analysis of Bureau of Prisons information.

Notes: Participation is defined as the number of unique inmates who participated in the program at 

any time during the fiscal year.

— = Program was not operating.

NA= Not available

a

The STAGES Program was activated in fiscal year 2012.

b

The number of inmates participating in the Sex Offender Management Programs includes those 

inmates participating in both SOTP-NR and SOTP-R.

c

Participation in the Commitment and Treatment Program is defined as the number of new 

participants each year. Therefore, the numbers represent the number of new inmates admitted each 

year and do not reflect the total number of inmates in the program for each fiscal year.

d

Pub. L. No. 109-248, 120 Stat. 587 (2006).
Appendix III: Bureau of Prisons (BOP)-

Operated Institutions by Mental Health Care 

Levels as of February 2013

Page 51 GAO-13-1 Inmate Mental Health Services

Mental health (MH) care level Institution name Institution location

MH care 1a Atwater USP Atwater, CA

Bennettsville FCI Bennettsville, SC

Berlin FCI Berlin, NH

Big Sandy USP Inez, KY

Herlong FCI Herlong, CA

Lee USP Pennington Gap, VA

Manchester FCI Manchester, KY

McDowell FCI Welch, WV

McKean FCI Lewis Run, PA

Oxford FCI Oxford, WI

Pollock FCC Pollock, LA

Ray Brook FCI Ray Brook, NY

Safford FCI Safford, AZ

Sandstone FCI Sandstone, MN

Three Rivers FCI Three Rivers, TX

Yankton FPC Yankton, SD

Yazoo City FCC Yazoo City, MS

MH care 2b Aliceville FCI Aliceville, AL

Ashland FCI Ashland, KY

Bastrop FCI Bastrop, TX

Beaumont FCC Beaumont, TX

Beckley FCI Beaver, WV

Big Spring FCI Big Spring, TX

Brooklyn MDC Brooklyn, NY

Bryan FPC Bryan, TX

Butner Low FCI Butner, NC

Butner Medium II FCI Butner, NC

Canaan USP Waymart, PA

Chicago MCC Chicago, IL

Cumberland FCI Cumberland, MD

Duluth FPC Duluth, MN

Edgefield FCI Edgefield, SC

El Reno FCI El Reno, OK

Elkton FCI Lisbon, OH

Englewood FCI Littleton, CO 

Appendix III: Bureau of Prisons (BOP)-

Operated Institutions by Mental Health Care 

Levels as of February 2013
Appendix III: Bureau of Prisons (BOP)-

Operated Institutions by Mental Health Care 

Levels as of February 2013

Page 52 GAO-13-1 Inmate Mental Health Services

Mental health (MH) care level Institution name Institution location

Estill FCI Estill, SC

Florence FCC Florence, CO

Forrest City FCC Forrest City, AR

Fort Dix FCI Fort Dix, NJ

Gilmer FCI Glenville, WV

Guaynabo MDC Guaynabo, PR

Honolulu FDC Honolulu, HI

Houston FDC Houston, TX

Jesup FCI Jesup, GA

La Tuna FCI Anthony, TX

Leavenworth USP Leavenworth, KS

Lewisburg USP Lewisburg, PA

Lompoc FCC Lompoc, CA

Loretto FCI Loretto, PA

Los Angeles MDC Los Angeles, CA

Marion USP Marion, IL

McCreary USP Pine Knot, KY

Memphis FCI Memphis, TN

Mendota FCI Mendota, CA

Miami FCI Miami, FL

Miami FDC Miami, FL

Milan FCI Milan, MI

Montgomery FPC Montgomery, AL

Morgantown FCI Morgantown, WV

New York MCC New York, NY

Oakdale FCC Oakdale, LA

Oklahoma City FTC Oklahoma City, OK

Otisville FCI Otisville, NY

Pekin FCI Pekin, IL

Pensacola FPC Pensacola, FL

Petersburg FCC Hopewell, VA

Philadelphia FDC Philadelphia, PA

Phoenix FCI Phoenix, AZ

San Diego MCC San Diego, CA

Schuylkill FCI Minersville, PA

Seagoville FCI Seagoville, TX

SeaTac FDC Seattle, WA
Appendix III: Bureau of Prisons (BOP)-

Operated Institutions by Mental Health Care 

Levels as of February 2013

Page 53 GAO-13-1 Inmate Mental Health Services

Mental health (MH) care level Institution name Institution location

Sheridan FCI Sheridan, OR

Talladega FCI Talladega, AL

Tallahassee FCI Tallahassee, FL

Texarkana FCI Texarkana, TX

Victorville FCC Victorville, CA

Williamsburg FCI Salters, SC

MH care 3c Alderson FPC Alderson, WV

Allenwood FCC White Deer, PA 

Atlanta USP Atlanta, GA

Butner Medium I FCI Butner, NC

Carswell FMC Fort Worth, TX

Coleman FCC Sumterville, FL

Danbury FCI Danbury, CT

Devens FMC Ayer, MA

Dublin FCI Dublin, CA

Fairton FCI Fairton, NJ

Fort Worth FCI Fort Worth, TX

Greenville FCI Greenville, IL

Hazelton USP/SFF Bruceton Mills, WV

Lexington FMC Lexington, KY

Marianna FCI Marianna, FL

Terminal Island FCI San Pedro, CA

Terre Haute FCC Terre Haute, IN

Tucson FCC Tucson, AZ

Waseca FCI Waseca, MN

MH care 4d Butner FMC Butner, NC

Carswell FMC Fort Worth, TX

Devens FMC Ayer, MA

Rochester FMC Rochester, MN

Springfield MCFP Springfield, MO

Legend:

FCC refers to Federal Correctional Complex

FCI refers to Federal Correctional Institution

FDC refers to Federal Detention Center

FMC refers to Federal Medical Center

FPC refers to Federal Prison Camp

FTC refers to Federal Transfer Center

MCC refers to Metropolitan Correctional Center
Appendix III: Bureau of Prisons (BOP)-

Operated Institutions by Mental Health Care 

Levels as of February 2013

Page 54 GAO-13-1 Inmate Mental Health Services

MCFP refers to Medical Center for Federal Prisoners

MDC refers to Metropolitan Detention Center

SFF refers to Secure Female Facility

USP refers to U.S. Penitentiary

Source: Bureau of Prisons.

Notes: Butner is an FCC consisting of four facilities with different MH care levels—two that are MH 

care level 2, one that is MH care level 3, and one that is MH care level 4—therefore in this table 

Butner is listed four times. Carswell and Devens are each a single institution but are rated as both MH 

care levels 3 and 4, and are therefore each listed twice in this table. There are 14 FCCs—Allenwood, 

Beaumont, Butner, Coleman, Florence, Forrest City, Lompoc, Oakdale, Petersburg, Pollock, Terre 

Haute, Tucson, Victorville, and Yazoo City. Each FCC represents more than one institution.

a

All MH care level 1 institutions are classified as care level 1 for both medical and mental health 

needs. Inmates in these facilities tend to have minimal treatment needs.

b

MH care level 2 institutions have Psychology Services staffing that serves inmates classified as care 

level 2 who require a moderate level of intervention.

c

MH care level 3 inmates—who require significant mental health interventions but not inpatient 

treatment—are served by institutions with enhanced staff specifically designated to address these 

needs. This enhanced staffing may involve a fully staffed residential treatment program, such as the 

STAGES Program, or a care level 3 psychologist with an outpatient caseload of care level 3 mental 

health cases. Therefore, entire institutions are not designated as care level 3 for mental health; 

rather, specific programs/psychologists are designated to provide services for care level 3 mental 

health cases. (STAGES is a residential program that provides treatment to male mental health care 

level 3 inmates with a primary diagnosis of borderline personality disorder. Individuals with borderline 

personality disorder have long-term patterns of unstable or turbulent emotions that often result in 

impulsive actions and chaotic relationships with other people.)

d

MH care level 4 institutions are classified as care level 4 for both medical and mental health needs. 

Inmates in these facilities have acute needs that require inpatient treatment.
Appendix IV: Inmate Intake and Mental Health 

Assessment Process

Page 55 GAO-13-1 Inmate Mental Health Services

 

Appendix IV: Inmate Intake and Mental 

Health Assessment Process
Appendix V: Inmate Diagnoses by Inmate 

Mental Health Care Level and Gender, as of 

February 9, 2013

Page 56 GAO-13-1 Inmate Mental Health Services

Class of mental disorder

Inmate 

mental 

health care 

level 1a

Inmate 

mental 

health care 

level 2

Inmate 

mental 

health care 

level 3

Inmate 

mental 

health care 

level 4b

Male inmates

Total number of male 

inmates

144,700 4,541 432 809

Anxiety disordersc 1,128 538 54 17

Mood disordersd 2,801 2,001 162 62

Personality disorderse 2,360 1,055 232 168

Schizophrenia and other 

psychotic disordersf 251 1,115 244 402

Somatoform disordersg 3 1 1 2

Other disorders not used in 

mental health care level 

designationsh

34,538 2,180 284 282

Female inmates

Total number of female 

inmates

10,449 991 124 46

Anxiety disordersc 573 320 36 4

Mood disordersd 671 540 77 9

Personality disorderse 260 240 84 9

Schizophrenia and other 

psychotic disordersf 11 70 45 25

Somatoform disordersg 0 1 0 0

Other disorders not used in 

mental health care level 

designationsh

3,820 583 82 22

Source: GAO analysis of data from the Bureau of Prisons (BOP).

Notes: Inmates with multiple diagnoses are included under all applicable classes of disorders. 

Therefore, the numbers of inmates in the classes cannot be totaled. Classes of mental disorders are 

from the Diagnostic and Statistical Manual, Version IV-TR (DSM-IV-TR), which is the standard 

classification system of mental disorders used by mental health practitioners in the United States. The 

specified classes of mental disorders are those that BOP uses to determine an inmate’s mental 

health care level assignment. Diagnosis information was drawn from records that explain an inmate’s 

mental health care level or from open treatment plans.

a

Mental health care level 1 includes inmates without mental health problems and inmates with 

diagnosed mental health conditions who do not need to be seen more than once every 3 months. 

According to BOP, 120,023 male inmates and 7,144 female inmates at mental health care level 1 did 

not have a diagnosed mental health disorder as of February 2013.

b

According to BOP, a precise number of diagnoses at mental health care level 4 is not available 

because those inmates directly designated to medical referral centers may not have diagnostic 

information in the Psychology Data System, BOP’s electronic medical record system for 

psychological services, because paper charts are still in use at these facilities. Additionally, diagnoses 

may be pending if inmates are undergoing forensic evaluations, which are evaluations for a court.

Appendix V: Inmate Diagnoses by Inmate 

Mental Health Care Level and Gender, as of 

February 9, 2013
Appendix V: Inmate Diagnoses by Inmate 

Mental Health Care Level and Gender, as of 

February 9, 2013

Page 57 GAO-13-1 Inmate Mental Health Services

c

Anxiety disorders include generalized anxiety disorder, panic disorder, post-traumatic stress 

disorder, obsessive compulsive disorder, and specific phobias.

d

Mood disorders include major depressive disorder, dysthmia (chronic low-level depression), and 

bipolar disorders.

e

BOP excludes consideration of antisocial personality disorder in designating an inmate to a mental 

health care level. A personality disorder is an enduring pattern of inner experience and behavior that 

deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an 

onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. 

Borderline personality disorder is a personality disorder in which individuals have long-term patterns 

of unstable or turbulent emotions that often result in impulsive actions and chaotic relationships with 

other people.

f

Other psychotic disorders include schizoaffective disorder (a mental condition that causes both a loss 

of contact with reality and mood problems), delusional disorder, and brief psychotic disorder.

g

The common feature of the somatoform disorders is the presence of physical symptoms that suggest 

a general medical condition but are not fully explained by a general medical condition, by the direct 

effects of a substance, or by another mental disorder (e.g., panic disorder).

h

This category represents diagnoses for all mental health disorders that are not used to designate an 

inmate to a mental health care level. The largest category is for substance abuse disorders.
Appendix VI: Findings from Program Review 

Reports, Accreditation Reports, and Contract 

Facility Monitoring Review Reports

Page 58 GAO-13-1 Inmate Mental Health Services

The Bureau of Prisons (BOP) conducts program reviews of each program 

area at all of the agency’s institutions. According to the results of the 

program review, institutions receive one of five ratings: superior, good, 

acceptable, deficient, and at risk. The scores indicate the institution’s 

level of compliance with BOP’s policies and strength of internal controls. 

We reviewed the most recent psychology services and health services 

internal program review reports for the 47 BOP institutions in our sample. 

We found that 89.4 percent of the institutions were rated as good or 

superior in the psychology services program reviews, compared with 76.6 

percent rated as good or superior in the health services program 

reviews.1

Table 6: Institutional Ratings in Psychology Services and Health Services Program 

Review Reports for BOP-Operated Institutions

Table 7 provides information on the rating levels garnered by 

the institutions.

Rating

Percentage 

(number of institutions) Confidence interval

Psychology Services program 

reviews

Superior 44.7% (21) 34.0-56.4%

Good 44.7 (21) 34.0-56.4

Acceptable 10.6 (5) 5.3-20.2

Deficient 0 (0) 0-5.3

At risk 0 (0) 0-5.3

Health Services program reviews

Superior 23.4 (11) 14.9-34.0

Good 53.2 (25) 41.5-64.9

Acceptable 21.3 (10) 12.8-31.9

Deficient 2.13(1) 1.1-8.5

At risk 0 (0) 0-5.3

Source: GAO analysis of BOP data.

Note: We reviewed the most recent report for a random sample of 47 of the 94 institutions that had 

been operating long enough to receive a program review. For purposes of this report, we use the 

term institutions to refer to both single institutions and a complex of two or more institutions that are 

reviewed as a single unit for purposes of program reviews. The estimates shown in this table are 

generalizable to the population. The confidence intervals shown in the table were calculated at the 95 

percent level of confidence. According to BOP, a superior rating indicates the program is performing 

 1

The associated 95 percent confidence interval for 89.4 percent is (79.8, 94.7), and for 

76.6 percent is (66.0, 85.1). 

Appendix VI: Findings from Program Review 

Reports, Accreditation Reports, and Contract 

Facility Monitoring Review Reports

Results from Analysis 

of Psychology 

Services and Health 

Services Program 

Review Reports
Appendix VI: Findings from Program Review 

Reports, Accreditation Reports, and Contract 

Facility Monitoring Review Reports

Page 59 GAO-13-1 Inmate Mental Health Services

all vital functions and a history of strong internal controls exists, resulting in zero or very minimal 

deficiencies. A good rating demonstrates the program’s vital function areas are sound and internal 

controls are strong. Institutions with an acceptable rating may have deficiencies, but they do not 

detract from the adequate accomplishment of the vital functions. A deficient rating demonstrates that 

one or more vital functions of the program are not being performed at an acceptable level and internal 

controls are weak. An at-risk rating demonstrates that the program is impaired to the point that it is 

not accomplishing its overall mission and internal controls do not demonstrate substantial continued 

compliance.

We also analyzed the most frequently cited deficiencies identified in the 

psychology services and health services reports that we reviewed. 

Among the findings from the psychology services program review reports, 

10 institutions had a deficiency related to care provided to inmates in a 

residential treatment program. Table 8 shows the most frequently cited 

deficiencies in the psychology services and health services program 

review reports that we reviewed. The table also includes examples of 

deficiencies in each category.

Table 7: Most Common Deficiencies in Psychology Services and Health Services Program Reviews Related to Mental Health 

Services for BOP-Operated Institutions

Number of institutions 

with deficiency Examples of deficiencies cited at BOP institutions

Psychology services 

program review 

deficiencies

Issues related to care 

provided to inmates in 

residential treatment 

programs

10 • Inmates who completed the Residential Drug Abuse Treatment 

Program (RDAP) were not always enrolled in follow-up services in a 

timely manner.

• Not all of the inmates in the Challenge Program had treatment plans 

that were individualized and had goals commensurate with the 

inmate’s treatment needs.

• Treatment plans for RDAP inmates are not completed in a timely 

fashion.

Issues related to suicide 

risk assessments, suicide 

watch, or post suicide 

watch care

10 • Not all inmates removed from suicide watch received follow-up 

consistent with the clinician’s plan.

• Not all inmates placed on suicide watch have documentation of a 

daily visit by a psychologist in the suicide watch logs or the 

Psychology Data System (PDS).

• Not all suicide risk assessments were entered into PDS within 24 

hours of the referral.

Issues related to the care

provided to inmates in 

nonresidential treatment 

programs

9 • Not all inmates who have successfully completed nonresidential 

treatment have received a program completion award.

• Not all treatment plans for inmates participating in nonresidential 

drug treatment are completed in a timely fashion.

• The identification, referral, and interview process, which informs the 

chief psychologist of female inmates recommended for trauma 

education, is inadequate.
Appendix VI: Findings from Program Review 

Reports, Accreditation Reports, and Contract 

Facility Monitoring Review Reports

Page 60 GAO-13-1 Inmate Mental Health Services

Number of institutions 

with deficiency Examples of deficiencies cited at BOP institutions

Health services program 

review deficiencies

Issues related to 

documentation of 

diagnosis information

12 • Inmates in mental health chronic care clinics do not always have 

Diagnostic and Statistical Manual of Mental Disorders, VersionFourth Edition (DSM-IV) axis codes documented on the problem list 

and follow-up chronic care clinic visits, as necessary.a

• Initial psychiatric visits did not always have all DSM-IV axes 

documented and addressed appropriately.b

Issues with the 

management and 

administration of 

medication

6 • Management and administration of pharmaceuticals (medications) 

were not always in accordance with policy.

• Providers with prescribing authority do not reevaluate a prescription 

prior to its renewal, and a medication was prescribed without proper 

diagnosis.

• Medications were prescribed when not clinically indicated. Also, a 

prescription was renewed without reevaluation.

Issues related to the 

administration and storage 

of controlled substances

6 • Medication Administration Records are not always completed for 

inmates on controlled substances.

• Medication orders for controlled substances were reordered without 

the proper ongoing documentation.

• Not all orders for controlled substances were cosigned by a 

physician on his/her next work day.

Issues related to the safe 

storage of needles and 

syringes

5 • Not all needles and syringes in the main stock were inventoried and 

stored correctly.

• Not all syringes, including prefilled needles and syringes, were 

inventoried and stored correctly.

Source: GAO analysis of BOP data.

Notes: We reviewed the most recent Health Services and Psychology Services program review 

reports for a random sample of 47 of the 94 institutions that had been operating long enough to 

receive a program review. For purposes of this report, we use the term institution to refer to both 

single institutions and a complex of two or more institutions that are reviewed as a single unit for 

purposes of program reviews. These results are not generalizable to the population of BOP 

institutions.

a

The Diagnostic and Statistical Manual of Mental Disorders, Version IV, is the standard classification 

system for mental disorders used by mental health practitioners.

b

The DSM-IV is organized into a five-part axis system, with each axis representing a part of a 

patient’s overall assessment.

Following a program review, BOP institutions are required to submit a 

corrective action plan to the Program Review Division addressing all 

reported deficiencies. Institutions must submit these plans within 30 days 

of when the program review report is issued. Table 9 provides examples 

of corrective actions submitted by BOP institutions in response to 

deficiencies identified in psychology services program review reports.
Appendix VI: Findings from Program Review 

Reports, Accreditation Reports, and Contract 

Facility Monitoring Review Reports

Page 61 GAO-13-1 Inmate Mental Health Services

Table 8: Examples of Deficiencies and Institutional Corrective Actions from Psychology Services Program Review Reports for 

BOP-Operated Institutions

Deficiency Example of an institution’s corrective action plan

Not all 60-day progress reviews for inmates 

participating in RDAP are completed in a timely 

manner.

The institution responded that it developed and implemented a timetable for 

conducting 60-day reviews. 

A review of 10 treatment plans revealed the 

following: (1) Three were missing signatures. (2) 

Four inmates did not receive treatment in 

accordance with the treatment plan. Goals for 

treatment were not always referenced in the notes. 

(3) Four were not updated as needed. (4) Two 

were not closed out at the completion of treatment.

The institution responded that all signed treatment plans will be scanned into the 

Psychology Data System (PDS) for easy review and access. When entering PDS 

notes on inmates with treatment plans, the notes will be directly related to the 

inmate’s treatment plan goals. All treatment plans will be reviewed and updated 

at least annually. PDS rosters will be run on a monthly basis to guarantee that all 

treatment plans of departed inmates have been closed.

Not all inmates received appropriate follow-up after 

crisis intervention.

The institution responded that the chief psychologist now requires immediate 

notification of any instance of crisis intervention to ensure documentation is 

appropriate. In addition, a PDS roster of crisis intervention contacts is run at least 

monthly to ensure follow-up, if warranted, has been conducted as stipulated.

Inmates with PSY ALERT codes are not being 

cleared for release to the general population.a The institution responded that a new tracking mechanism has been developed 

and is currently being utilized to identify all inmates who arrive with a PSY 

ALERT code. This tracking mechanism incorporates a roster that will be run on a 

daily basis to identify inmates in the pipeline who are PSY ALERT. All inmates 

with this code will be screened by a psychologist prior to their release to the 

general population. This screening will be reported in PDS under the heading 

“Psychology Alert screening.”

Not all inmates housed in special housing units 

(SHU) for 30 days or more received a timely 30-day 

SHU review by a psychologist.

The Institution responded that the system of control previously utilized was 

abandoned and a new system established. Currently, inmates housed in SHUs 

are being tracked on a 28-day rotation with all inmates receiving a SHU review 

contact on the first day of the week in which their review is due.

Source: GAO analysis of BOP data.

Notes: We did not analyze corrective action plans associated with deficiencies identified in health 

services program review reports because most of those deficiencies were not related to mental health 

care.

a

Inmates with a PSY ALERT code are not to be released into the general population until they have 

been assessed by a psychologist.
Appendix VI: Findings from Program Review 

Reports, Accreditation Reports, and Contract 

Facility Monitoring Review Reports

Page 62 GAO-13-1 Inmate Mental Health Services

BOP requires that all of its institutions obtain accreditation from the 

American Correctional Association (ACA) and that all institutions with a 

medical care level of 2 or higher obtain accreditation for ambulatory care 

from The Joint Commission.2

In our review of the most recent ACA accreditation reports, we found one 

deficiency that although not directly related to a mental health standard, 

had a connection with mental health services. ACA reported that 

correctional officers in the special housing unit were not conducting 

required 30-minute checks of inmates that help ensure that inmates are 

not attempting suicide or harming themselves or others. The institution 

responded that it would reemphasize the importance of the checks and 

that lieutenants, who are generally responsible for the day-to-day staffing 

of correctional services, would check the logs on every shift to ensure the 

checks were taking place.

We reviewed the most recent accreditation 

reports from ACA and The Joint Commission for our sample of 47 BOP 

institutions. Only 37 of the BOP institutions had Joint Commission 

accreditation reports because nine are medical care level 1 facilities and 

are not required to obtain Joint Commission accreditation and the final 

institution recently changed to a medical care level 2 institution but had 

not yet received its Joint Commission accreditation.

The Joint Commission’s ambulatory care standards relate to all aspects 

of an institution’s health services. The Joint Commission accredits only 

those services at BOP institutions that are provided by the institution’s 

health services unit. Table 10 provides information on The Joint 

Commission findings at BOP institutions related to psychiatric care and 

pharmacy care.

 2

Four BOP institutions—Federal Medical Center Rochester, U.S. Medical Center 

Springfield, Federal Medical Center Devens, and Metropolitan Correctional Center in New 

York—also have behavioral health accreditations because they have inpatient psychiatric 

units or a treatment program for individuals addicted to pain relieving drugs, such as 

oxycodone or morphine. Two additional institutions—Federal Correctional Complex Butner 

and Federal Medical Center Carswell—have psychiatric units within inpatient hospital 

facilities that are also accredited under The Joint Commission’s hospital standards.

Results from Analysis 

of ACA and Joint 

Commission 

Accreditation Reports 

for BOP-Operated 

Institutions
Appendix VI: Findings from Program Review 

Reports, Accreditation Reports, and Contract 

Facility Monitoring Review Reports

Page 63 GAO-13-1 Inmate Mental Health Services

Table 9: Most Common Deficiencies Cited in Joint Commission Ambulatory Care Accreditation Reports for BOP-Operated 

Institutions

Number of BOP institutions 

with partial or insufficient 

compliance with standarda Examples of observations at BOP institutions resulting in findings of partial or insufficient compliance 

Psychiatry

Provider certification 1 • A psychiatrist’s board certification had expired and the 

institution had not verified that the psychiatrist had a 

current certification.b

Pharmacy •

Safe management of high-alert 

and hazardous medicationsc 5 • The institution did not have an institution-specific list of 

high-alert and hazardous medications.

• Two high-concentration medications were not included 

on the institution’s list of high-alert medications.

Use of look-alike/sound-alike 

medicationsd 5 • Not all look-alike/sound-alike medications had a highalert label.

• While the institution had developed a list of soundalike medications and implemented a process for risk 

reduction for those medications, the institution had not 

implemented a list or process for reducing the 

possibility of look-alike errors for injectable 

medications.

Safe storage of medication 5 • The temperature ranges for a medication refrigerator 

were found to be out of range, and the institution did 

not take action to change the refrigerator’s 

temperature or move the medications stored in the 

refrigerator.

• Medications that had expired were still available for 

use.

Source: GAO analysis of Joint Commission data.

a

If an institution is found to be in partial or insufficient compliance with any Joint Commission 

standard, the institution must submit evidence of compliance with the standard before an 

accreditation decision is made.

b

According to an official from BOP’s Office of Quality Management, BOP policy does not require 

psychiatrists to be board certified.

c

High-alert medications are those medications involved in a high percentage of errors or unexpected 

occurrences involving death or serious injury, as well as medications that carry an increased risk for 

abuse or other adverse outcomes.

d

Look-alike drugs are two drugs in which the names of the drugs can be confused with each other 

and result in medication errors. Sound-alike drugs are two drugs that, when their names are spoken, 

can be confused with each other and result in medication errors.
Appendix VI: Findings from Program Review 

Reports, Accreditation Reports, and Contract 

Facility Monitoring Review Reports

Page 64 GAO-13-1 Inmate Mental Health Services

In our review of each of the recent Contract Facility Monitoring (CFM)

reports for the 15 private facilities, we found four main policy areas where 

deficiencies that could be related to mental health care were cited at more 

than 1 facility—Inmate Classification and Program Review, Health 

Information Management, Patient Care, and Medical Designation and 

Referral Services for Federal Inmates (see table 11). We determined that 

these deficiencies may be related to mental health because they can 

involve mental health professionals, such as psychiatrists, psychologists 

or licensed professional counselors; pharmacy care, which can include 

psychotropic medications; or health information that may include 

information on mental health.

Table 10: Most Common Deficiencies in Contract Facility Monitoring Reviews That May Be Related to Mental Health Services 

in Contract Facilities

Number of institutions 

with deficiency Examples of deficiencies cited in each category

Contract facility monitoring 

review policy area

Inmate classification and 

program review

7 • Program needs of the inmates need to be identified in program 

review reports, measured in terms to demonstrate an inmate’s 

progress through treatment, and reviewed at the treatment team 

meetings. Inmate program needs could include mental health 

treatment programs that would be discussed with mental health staff 

at treatment team meetings.

Health information 

management

5 • Information that may include mental health information is missing 

from inmate health records.

• Errors in inmate health records, which may include mental health 

information, were inadequately corrected.

Patient care 3 • Patient care records for inmates seeking mental health clinic 

evaluations were incomplete.

Medical designation and 

referral services for 

federal inmates

2 • Forms containing important medical information, which may include 

mental health information, for inmates in transit from one institution to 

another were not always written in lay terms for correctional staff to 

understand.

Source: GAO analysis of BOP data.

Our analysis of the most recent ACA accreditation reports for the 13 

contract facilities that have been reviewed found that all but one of the 

facilities were compliant with all ACA standards related to mental health 

services involving pharmacy care, and psychology and psychiatry 

services. The facility that was found not compliant with all of ACA’s 

mental health-related standards was as a result of the facility’s failure to 

develop and utilize a health care staffing plan and the reviewers’ related 

concerns about the mental health staffing levels at the facility.

Findings from the 

BOP and 

Accreditation Review 

Reports for Contract 

Facilities
Appendix VI: Findings from Program Review 

Reports, Accreditation Reports, and Contract 

Facility Monitoring Review Reports

Page 65 GAO-13-1 Inmate Mental Health Services

Our review of the most recent Joint Commission accreditation reports for 

each of the 13 contract facilities The Joint Commission reviewed found 

that 6 of the 13 were fully in compliance with the ambulatory care 

standards related to mental health services. The Joint Commission found 

the remaining 7 facilities to be either partially or insufficiently compliant 

with the ambulatory care accreditation standards related to mental health 

services (see table 12). In addition to the ambulatory care accreditation 

that contract facilities are required to obtain, 1 of the 7 facilities 

specifically chose to also be accredited on behavioral health standards, 

and that facility was found to be insufficiently compliant with three of 

those standards.3

Table 11: Most Common Deficiencies in Joint Commission Accreditation Reports Related to Mental Health Services in 

Contract Facilities

Type of accreditation Examples of deficiencies cited in each category

The Joint Commission deficiency 

category 

1. Medication management Ambulatory care • Medications were mislabeled or stored improperly.

• A list of look-alike/sound-alike medications was not 

developed.

2. Documentation of the competency of 

medical and behavioral health staff

Ambulatory care/ 

behavioral health care 

• The initial assessment of staff clinical competence was not 

documented.

• An assessment of clinical competency was not 

documented for staff during performance reviews.

• No primary source verification of the education of the 

clinical psychologist.

3. Inmate assessments Behavioral health care • Inmate assessments did not include information on 

addictions other than alcohol or drugs.

4. Inmate treatment plans Behavioral health care • Inmate treatment plans did not include goals and metrics 

to measure an inmate’s progress.

Source: GAO analysis of Joint Commission Accreditation reports.

 3

The ambulatory care accreditation covers the broad categories of surgical, 

medical/dental, and diagnostic/therapeutic services, and represents a variety of settings, 

including outpatient hospitals and prisons. The behavioral health accreditation focuses on 

organizations that provide services to persons with intellectual and developmental 

disabilities, as well as mental health and chemical dependency services.
Appendix VII: Bureau of Prisons’ Elements of 

Modified Therapeutic Communities

Page 66 GAO-13-1 Inmate Mental Health Services

Element of a modified 

therapeutic community Examples of standards contained in each element

Community as method • Inmates can verbalize the program philosophy.

• Feedback from the group is a routine intervention.

• Treatment plans and interventions are directly tied to 

the inmate and his or her peers.

• Group sessions are dominated by peer interactions.

Unit appearance • The unit is separate from the general population.

• The community philosophy is posted.

• Group rooms and unit are decorated with treatment 

themes.

• All participants are involved in sanitation.

Rules and norms • Participants are engaging in positive behaviors.

• A team approach to treatment is used.

• Inmates can verbalize the rules and norms of the 

modified therapeutic community.

• Problem behaviors are dealt with as a treatment team 

and by the group.

• Incentives are based on achievement of personal 

growth.

Staff roles • Staff and inmates display mutual respect in their 

interactions.

• Staff model appropriate communications and behavior.

• Staff meet weekly for scheduled time as a treatment 

team.

• Record keeping should provide a story about the inmate 

with obvious individuality.

• Staff conduct daily rounds in the community.

Supervision and training • Staff function as a team.

• Supervision is skill focused and conducted through 

regular, direct observation.

• Supervisors provide training and conduct semi-annual 

needs assessments of each staff member.

Transition • Staff have determined expectations for participants for 

each treatment phase.

• Participants can describe the behaviors expected of 

them as well as prohibited behaviors.

• Participants can describe their treatment goals and 

treatment plan.

• Inmates and staff provide an orientation to new inmates 

to the unit.

Appendix VII: Bureau of Prisons’ Elements of 

Modified Therapeutic Communities 
Appendix VII: Bureau of Prisons’ Elements of 

Modified Therapeutic Communities

Page 67 GAO-13-1 Inmate Mental Health Services

Element of a modified 

therapeutic community Examples of standards contained in each element

Community activities • A programming schedule is posted.

• Senior participants role model and actively seek to help 

junior participants.

• Community meetings are held daily, and all staff are 

present whenever possible.

• Homework and group projects are interactive in nature 

and require all to participate.

Treatment phase through 

journals

• Inmates receive journals and use them sequentially.

• Inmates complete journals during nongroup time and 

have them reviewed in group.

• Journal concepts are evident in all aspects of the 

program.

• Staff test inmate behavior, not just knowledge.

Small therapy groups • Small therapy groups include participants from every 

phase.

• Participants remain in the same process group with the 

same facilitator throughout treatment.

• Farewell and welcome rituals are utilized for incoming 

and departing group members.

• Group sessions include discussions and expressions of 

painful emotions in a prosocial manner.

• Sessions are dominated by peer interactions.

Community jobs • Community jobs are described, posted, and selected 

based on therapeutic need.

• Participants are able to describe their jobs and how they 

relate to the modified therapeutic community and 

recovery.

• Staff monitor job assignments and work groups in the 

community and use incentives and sanctions to promote 

positive behavior and reduce negative behavior.

Source: GAO analysis of Bureau of Prisons information.

Notes: The Residential Drug Abuse Treatment Program targets inmates at the end of their sentence 

who volunteer for drug abuse treatment and have a verifiable and diagnosable substance abuse 

condition. The Challenge Program is a residential program designed to facilitate favorable institutional 

adjustment and successful reintegration into the community for high-security inmates with a history of 

substance abuse or a major mental illness.
Appendix VIII: Bureau of Prisons (BOP) 

Program Statements Related to Mental Health 

Services for Inmates

Page 68 GAO-13-1 Inmate Mental Health Services

BOP program statement Description

Date program 

statement was last 

updated

Psychology Services Manual Establishes operational policy, procedures, and guidelines for the 

delivery of psychological services within BOP

March 7, 1995

Institution Management of Mentally Ill 

Inmates

Establishes policy, procedures, standards, and guidelines for 

managing mentally ill inmates in all regular (i.e., nonmedical) 

correctional institutions

March 31, 1995

Psychiatric Services Establishes policy, procedures, and guidelines related to the 

identification of inmates in need of psychiatric services, psychiatric 

diagnostic and treatment services, and continuity of psychiatric care

January 15, 2005

Suicide Prevention Program Establishes the components of a suicide prevention program that 

should be in place at each institution

April 5, 2007

Forensic and Other Mental Health 

Evaluations

Describes the procedures BOP shall follow to prepare a 

psychological or psychiatric evaluation on an inmate committed to its 

custody

April 16, 2008

Psychology Treatment Programs Establishes policy, procedures, and guidelines for the delivery of 

psychology treatment programs 

March 16, 2009

Psychiatric Evaluation and Treatment Describes procedures for voluntary and involuntary psychiatric 

evaluation, hospitalization, care, and treatment, in a suitable facility, 

for persons in BOP custody

July 13, 2011

Sex Offender Programs Establishes procedures and guidelines for Sex Offender Treatment 

and Management Services in BOP

February 15, 2013

Source: GAO analysis of BOP program statements.

Appendix VIII: Bureau of Prisons (BOP)

Program Statements Related to Mental 

Health Services for Inmates
Appendix IX: GAO Contacts and Staff 

Acknowledgments

Page 69 GAO-13-1 Inmate Mental Health Services

David C. Maurer, (202) 512-9627 or maurerd@gao.gov

Debra A. Draper, (202) 512-7114 or draperd@gao.gov

In addition to the contacts named above, Joy Booth, Assistant Director; 

Dawn Locke, Assistant Director; Eva Rezmovic, Assistant Director; 

Helene Toiv, Assistant Director; Lori Achman; Pedro Almoguera; Carl 

Barden; Carol Cha; Billy Commons; Katherine Davis; Eric Hauswirth; 

Valerie Kasindi; Amanda Miller; Julie Silvers; Julia Vieweg; and William 

Woods made significant contributions to this report.

Appendix IX: GAO Contacts and Staff 

Acknowledgments

GAO Contacts

Staff 

Acknowledgments

(441072)
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