Bureau of Prisons: Timelier Reviews, Plan for Evaluations, and Updated Policies Could Improve Inmate Mental Health Services Oversight
Published: 2013-07-17T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.
section_title: What GAO Recommends
paragraphs: 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.

section_title: Letter
paragraphs: 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. 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  requirement applies to BOP, as well as state and local prisons.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.
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. mental health disorder or a mental health problem that was diagnosed or  treated within the previous 12 months, as reported by the inmate.  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. Differences between the two  studies’ estimates are attributable, in part, to differences in how a mental  health problem was defined.
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?
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  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. 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.
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   We analyzed  Correctional Association (ACA) and The Joint Commission. the most recent program review reports, which present results of BOP on- site 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.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   We used the sample to determine the extent to which BOP  and risk management principles. In addition, we analyzed the most  recent accreditation reports from ACA and The Joint Commission  conducted for this same sample of BOP-operated institutions. 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. 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.
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  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. Appendix I  contains a more detailed discussion of our objectives, scope, and  methodology.
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.
subsections: section_title: Background
paragraphs: 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  levelshoused in privately managed contract facilities—generally housing low- —and about 13 percent, or approximately 29,400 inmates, are  security inmates. 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.
subsections: section_title: Provision of Mental Health Services in the Federal Prison System
paragraphs: 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 BOP- operated institutions, psychiatrists focus primarily on medication  management.
BOP implemented a mental health care level designation system for both  institutions and inmates in 2010. The system identifies the mental health  needs of each inmate and matches the inmate to an institution with the  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.
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, followed by a personality  disorder diagnosis. Appendix V contains information on inmate  diagnoses by inmate mental health care level designation and gender.
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.
section_title: Internal and External Reviews of BOP-Operated Facilities
paragraphs: 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  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. 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.
The five areas are administration and management, physical plant, institutional  operations, institutional services, and inmate programs. percent of applicable nonmandatory standards.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.
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. 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.
The Joint Commission’s  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.
According to BOP officials, medical care level 1 institutions are not required to be  accredited for ambulatory care by The Joint Commission.
section_title: Reviews for BOP Contract Facilities
paragraphs: 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 BOP- operated 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.
section_title: Mental Health Services Costs Have Increased in BOP- Operated Institutions since Fiscal Year 2008 and Are Expected to Continue to Increase
paragraphs: 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.
subsections: section_title: Mental Health Services Costs Increased from Fiscal Year 2008 through Fiscal Year 2012
paragraphs: 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.
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).
With respect to costs for psychotropic medication, this was the one line  item whose related costs showed a downward trend. According to BOP 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.
section_title: Mental Health Services Costs Are Projected to Grow through Fiscal Year 2015
paragraphs: 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.
section_title: 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
paragraphs: 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.
subsections: section_title: BOP Conducts Internal Reviews That Assess Compliance with Policies for Mental Health Services, but Most Reviews Do Not Occur on Time
paragraphs: 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  needs receive appropriate follow-up. The psychology services PRGs also  contain steps to review any psychology treatment program, such as  RDAP, that an institution offers. While not generalizable to all program  reviews, the review teams conducting the two psychology services  program reviews that we observed followed the applicable PRGs.
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, and a variety of issues related to  suicide risk assessments, suicide watch logs, and follow-up care after a  suicide watch. 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.
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, including about 23 percent that were more than 6 months late, based on the institution’s  prior ratings. (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. 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, 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.
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. Additionally, the Assistant Director for the  Program Review Division approves any deviation in schedule.
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  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. 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,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.   it will be even more  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  deficiency cited was that not all mental health care level 3 inmates had a  treatment plan or were being seen on a monthly basis.
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. 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.
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 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.
There 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. was receiving.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.
section_title: External Accreditation Reviews Assess Whether BOP Is Meeting Established Standards of Care
paragraphs: 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.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.
All of The Joint Commission’s standards are  We reviewed the most recent ACA and ambulatory care Joint  Commission accreditation reports for our sample of 47 institutions.
For 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. 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.
section_title: BOP Has Not Evaluated Most of Its Psychology Treatment Programs and Has Not Yet Developed a Plan To Do So
paragraphs: 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.
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. ORE completed its review of RDAP in 2000  and the Bureau Rehabilitation and Values Enhancement (BRAVE)  Program in 2001 and found positive results. For example, inmates who  participated in RDAP had less recidivism after 3 years of release than  inmates who did not go through the program. 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  working on an evaluation of the Sex Offender Treatment Program. 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.
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).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.
After we provided a draft of this report to DOJ for comment,  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  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. 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.
section_title: BOP Program Statements Related to Mental Health Services Contain Outdated Information
paragraphs: 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).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.
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.
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 evidence- based 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.  Standards for internal controls also require that agencies regularly review  their policies and procedures and update as necessary.
BOP officials said they plan to update the agency’s outdated program  statements and implement the revised program statements, but have not  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.
section_title: BOP Does Not Track Contractors’ Costs of Providing Inmate Mental Health Services but Does Assess Compliance with Requirements and Standards of Care
paragraphs: BOP does not track its contractors’ costs of providing mental health  services to the 13 percent of BOP inmates housed in privately managed   fixed-price contracts that govern the  facilities. The performance-based,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.
subsections: section_title: BOP Does Not Track Contractors’ Cost of Providing Inmate Mental Health Services in Contract Facilities
paragraphs: 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. According to officials from BOP’s Administration Division, which  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. 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.
Two of the three BOP contractors we spoke with—which are the primary  contractors responsible for operations at 11 of the 15 private facilities — said that they track mental health services costs internally and take them  into account when calculating the per diem inmate cost they use when   Additionally, two of the primary contractors  bidding for BOP contracts.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  were unable to obtain this information because the contractors consider it  proprietary and confidential.
section_title: BOP Assesses Compliance with Mental Health Requirements and Standards in Several Ways
paragraphs: 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 on- site 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   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  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. 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.
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.
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 on- site 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. 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. 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  standards, and that facility was found to be insufficiently compliant with 3  of those standards. 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. For more information on the  specific ambulatory care and behavioral health standards for which the  contract facilities were not in compliance, see appendix VI.
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.
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  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.
section_title: Conclusions
paragraphs: 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  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 BOP- operated institutions.
section_title: Recommendations for Executive Action
paragraphs: 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.
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.
section_title: Agency Comments and Our Evaluation
paragraphs: 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  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.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: 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 BOP- operated 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 BOP- operated 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 longer- term projections. To determine projected costs, we used the total cost of  inmate mental health services for fiscal year 2012 as the baseline, and  adjusted this by BOP’s projected population and the IHS Global Insight  Outlook inflation factor. 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.
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. 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. 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  of the population, we used a hypergeometric distribution to estimate the  95 percent confidence intervals for our sample estimates.
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.
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. 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.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.
For our review of the ambulatory  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  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. 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, 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.
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  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.
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.
section_title: Appendix II: Bureau of Prisons’ Psychology Treatment Programs’ Descriptions and Numbers of Participants for FY 2008 and 2012
paragraphs: Appendix II: Bureau of Prisons’ Psychology  Treatment Programs’ Descriptions and  Numbers of Participants for FY 2008 and 2012 Program description  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.
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.
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.
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 self- improvement 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.
Habilitation Program  The Habilitation Program was a residential program that targeted high- security, 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.
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.
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.
Program description  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.
The Resolve Program is a trauma treatment program for female  inmates. The Resolve Program consists of two components: a psycho- educational workshop and a nonresidential program for inmates with  trauma-related disorders.
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.
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.
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.  — = Program was not operating.
NA= Not available  The STAGES Program was activated in fiscal year 2012.  The number of inmates participating in the Sex Offender Management Programs includes those  inmates participating in both SOTP-NR and SOTP-R.  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.
section_title: Appendix III: Bureau of Prisons (BOP)- Operated Institutions by Mental Health Care Levels as of February 2013
section_title: Appendix IV: Inmate Intake and Mental Health Assessment Process
section_title: Appendix V: Inmate Diagnoses by Inmate Mental Health Care Level and Gender, as of February 9, 2013
section_title: Appendix VI: Findings from Program Review Reports, Accreditation Reports, and Contract Facility Monitoring Review Reports
subsections: section_title: Results from Analysis of Psychology Services and Health Services Program Review Reports
paragraphs: 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. Table 7 provides information on the rating levels garnered by  the institutions.
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.
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.
section_title: Results from Analysis of ACA and Joint Commission Accreditation Reports for BOP-Operated Institutions
paragraphs: 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. 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.
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.
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.
section_title: Findings from the BOP and Accreditation Review Reports for Contract Facilities
paragraphs: 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.
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.
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.
section_title: Appendix VII: Bureau of Prisons’ Elements of Modified Therapeutic Communities
paragraphs: Appendix VII: Bureau of Prisons’ Elements of  Modified Therapeutic Communities 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.
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.  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 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.  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.  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.
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.  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 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 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.
section_title: Appendix VIII: Bureau of Prisons (BOP) Program Statements Related to Mental Health Services for Inmates
section_title: Appendix IX: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Staff Acknowledgments
paragraphs: 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.