The District of Columbia Jail and CTF house inmates awaiting trial or who have been sentenced for misdemeanors. The Jail was opened in 1976, and from 1985 to July 2002, a court order limited the population to 1,674 inmates. Since July 2002 the population has grown, and during March 2004, the facility had an average daily population of 2,357. In addition to serving as an overflow facility, the CTF houses pregnant inmates, inmates with disabilities who need medical services, inmates in witness protection, and inmates who need to be separated from the general inmate population. Opened in 1992, the CTF is operated by a private company, the Corrections Corporation of America (CCA), under a contract with DoC. During March 2004, the CTF had an average daily population of 1,197. In 1995, the U.S. District Court for the District of Columbia removed medical services at the Jail from DoC’s control, placing these services under the temporary supervision of a court-appointed Receiver. This removal resulted from the District of Columbia’s failure to address problems identified in two lawsuits brought against the Jail in 1971 and 1975, which alleged that DoC was failing to provide minimally adequate medical care for inmates. Before it terminated the receivership in 2000, the Court hired a national expert in correctional health care to conduct an independent quality review of medical services provided by CCHPS to inmates at the Jail. DoC subsequently contracted directly with this expert to help develop a set of performance assessment instruments for reviewing CCHPS’s clinical services and monitoring activities and to conduct quarterly on-site reviews of CCHPS. DoC has a constitutional obligation to ensure that medical care is provided to inmates in its custody, and DoC’s contract with CCHPS requires CCHPS to provide comprehensive medical services to all inmates assigned to the Jail and the CTF and to establish a quality improvement program to monitor the quality of medical services it provides. In some areas, particularly the assessment of inmates’ health when they are admitted to the facilities, the contract lists specific services that CCHPS must provide, such as certain diagnostic tests. In other areas, such as services for inmates with chronic conditions, the requirement to provide care is less detailed. In addition to describing services that CCHPS is required to provide, the contract states that DoC can impose monetary damages on CCHPS if it does not meet 12 specific requirements. (See app. II for a description of the contract requirements that are linked to monetary damages.) Compliance with the requirements is to be determined through monitoring by DoC or its designee. The contract with DoC also requires that CCHPS acquire and maintain accreditation for its medical services. The Jail’s medical services are accredited by the National Commission on Correctional Health Care (NCCHC), while the CTF is accredited by the American Correctional Association (ACA). NCCHC and ACA, both national, not-for-profit organizations, offer voluntary accreditation processes for medical services provided in correctional facilities; relatively few jails nationwide are accredited by these organizations. NCCHC accredits only a correctional facility’s medical services, while ACA accredits all aspects of the correctional facility, including medical services. Both organizations have developed detailed accreditation standards that include, for example, specific elements that are required in an inmate’s initial medical assessment and in a facility’s quality improvement program. The accreditation process for both organizations includes on-site inspections of the facility every 3 years and submission of an annual report certifying that the facility continues to be in compliance with the accreditation standards. During on-site inspections, inspectors interview staff, review documentation provided by the facility, and examine a sample of inmate medical records. NCCHC and ACA inspectors submit their findings to expert panels, who make the accreditation decisions. One component of the quality improvement program required by both NCCHC and ACA is a grievance system that allows inmates an opportunity to question or complain about their care. Inmates at the Jail or the CTF who have concerns about medical services can complete a grievance form and submit it to the warden’s office in their facility. The warden’s staff records the grievance in their system and then forwards it to CCHPS. CCHPS’s medical director and quality improvement coordinator review the grievance and work with the clinicians involved to determine if the inmate’s complaint is valid and, if so, how it should be addressed. If it is determined that an inmate needs to receive care, CCHPS schedules an appointment. After CCHPS has reviewed the grievance, it sends a report to the warden, who then provides a response to the inmate. In June 2000, we testified before the House Committee on Government Reform, Subcommittee on the District of Columbia, about the provision of medical services at the Jail. We reported that the per inmate cost at the Jail was higher than those at the two other jurisdictions reviewed, and that services and staffing levels also exceeded those of the other jurisdictions. We also found that there were no specific criteria that determine an acceptable level of medical service and staffing at a jail. Rather, the range of services was a function of many local factors, including the specific demands and constraints placed on the facility’s service delivery system. As required by the contract, CCHPS provides a broad range of medical services to Jail and CTF inmates, and the types of services CCHPS provides at the Jail have not changed significantly over the life of the contract. In addition, CCHPS assists DoC in helping inmates obtain services beyond those included in CCHPS’s contract, such as emergency and specialty care that cannot be provided at the Jail or the CTF. CCHPS also assists DoC in its efforts to work with other District of Columbia agencies and community providers to link soon-to-be-released inmates in need of medical services with services in the community. As part of its contract with DoC, CCHPS has also developed a system to monitor the quality of the medical services it provides to inmates. A key component of this program is quarterly analyses of random samples of inmate medical records to measure how consistently CCHPS delivers required services to inmates. As required by the contract, CCHPS provides a broad range of medical services to Jail and CTF inmates, including primary care services such as sick call and chronic care; mental health care; and specialty care, such as dental and orthopedic services. (See table 1 for a description of these services.) At intake, all inmates receive a health assessment—referred to as an intake screening—that screens for physical and mental health conditions. The inmates receive a physical examination and are asked about current and past health problems, substance abuse, and medication use. In addition, they receive a chest x-ray and skin test to identify possible tuberculosis. As part of the mental health screening, inmates are asked a series of questions. If inmates respond positively to any of these questions, or if they are a juvenile or in jail for the first time, they are referred for a comprehensive mental health assessment. Based on the findings of the intake screening, inmates in need of medical care may receive treatment in a chronic or specialty care clinic, receive therapy for mental health problems, or be placed in one of two specialized mental health units. According to CCHPS officials, in 2002 they conducted an average of 1,654 intake screenings each month. About 20 percent of these inmates were referred to a chronic care clinic, and about 34 percent were referred for further mental health assessment. There have been no significant changes in the types of medical services provided by CCHPS since the start of its contract with DoC. However, there have been some minor changes, including modifications to on-site specialty clinics. For example, in 2001, the requirement for an oral surgery clinic was deleted from the contract, and more recently CCHPS combined the ophthalmology and optometry clinics. In addition, CCHPS began offering endocrinology and infectious disease clinics on-site—even though they are not required by the contract—to improve inmates’ access to these services and continuity of care. CCHPS officials had expected the consolidation of medical services at the Jail and the CTF to result in some service efficiencies, such as combining the on-site specialty clinics offered at both facilities; however, CCHPS and DoC officials told us it has not been feasible to easily move inmates between facilities because of security issues. CCHPS therefore continues to offer all on-site specialty clinics at both facilities. When inmates need medical services that cannot be provided at the Jail or the CTF, CCHPS refers them to providers in the community. These off-site services, including emergency care and certain specialty services, are not part of the CCHPS contract; instead, DoC has an agreement with the District of Columbia Department of Health (DoH) to provide services to inmates through Greater Southeast Community Hospital. When Greater Southeast is not able to provide the needed services, it in turn refers the inmates to other members of the DC Healthcare Alliance and other community providers. DoC pays for all off-site services through an interagency agreement with DoH; in 2003 there were 4,169 appointments for inmates off-site. Although DoC’s contract with CCHPS does not specify that CCHPS provide discharge planning services to inmates, NCCHC accreditation standards include discharge planning activities. Both CCHPS and DoC have made efforts to plan for the release of inmates with medical conditions and to link them to community-based medical services. For example, CCHPS’s policies require that inmates receive a 2-week supply of medications at the time of their release. In addition, CCHPS provides support to DoC’s collaboration with the District of Columbia Department of Mental Health (DMH) to help Jail inmates obtain access to community mental health services when they are released. CCHPS supports DoC’s and DoH’s discharge planning efforts to link inmates who have certain chronic and communicable diseases, such as tuberculosis, to community-based medical services. In addition, through a joint program of DoH’s HIV/AIDS Administration and DoC, Family and Medical Counseling Services, Inc. (FMCS), a community-based provider, offers HIV testing and links HIV-positive inmates to services in the community when they are released. CCHPS refers inmates requesting an HIV test to FMCS and provides FMCS with office space, computers, and access to the inmate’s electronic medical record in the CCHPS system. As part of its contract with DoC, CCHPS is responsible for monitoring the quality of the medical services it provides to Jail and CTF inmates, and CCHPS has established a quality improvement program to fulfill this responsibility. A key component of the program is a quarterly analysis of random samples of inmate medical records using standardized performance assessment instruments. These quarterly analyses provide CCHPS with quantitative data about its performance in certain areas. Each assessment instrument measures CCHPS’s performance of a specific set of activities; these activities are generally more detailed than the requirements described in the contract. (See app. III for a summary description of the instruments.) Using the samples of medical records and other documentation to complete the performance assessment instruments, CCHPS clinicians determine how consistently CCHPS delivers required services to inmates. Currently, there are 23 performance assessment instruments, 20 of which measure medical services provided to inmates in various service areas. For example, the intake services instrument includes a measurement of the percentage of inmates who received a chest x-ray for tuberculosis within 24 hours of admission. The remaining 3 instruments measure the extent to which CCHPS has conducted other components of its quality improvement program, such as validating that clinical staff are licensed. In addition to these quarterly analyses of medical services, CCHPS’s quality improvement program also includes other reviews, such as annual reviews of urgent care and radiological safety procedures, monthly reviews of inmate grievances and of any inmate deaths, and ongoing reviews of infection control activities. The program also requires CCHPS to conduct at least two in-depth studies a year, each of which focuses on a specific issue, such as a medical service problem that has been identified by the quarterly analyses. DoC has developed several mechanisms to oversee CCHPS’s delivery of medical services to inmates and enforce CCHPS’s compliance with the contract. For example, DoC’s contract with CCHPS gives DoC the authority to impose monetary damages if CCHPS fails to meet any of 12 requirements specified in the contract, most of which relate to CCHPS’s performance in providing key medical services. For most of these requirements, the contract authorizes DoC to impose the damages if CCHPS fails to deliver the required service to a minimum percentage of inmates—for example if CCHPS does not conduct an intake screening within 24 hours for 95 percent of inmates. (See app. II for additional information on the contract requirements that are linked to monetary damages.) Some of the requirements relate to CCHPS’s staff, including ensuring that staff have required licenses and credentials. In addition, the contract contains a requirement that CCHPS have an infection control program approved by DoC. DoC, or its designee, is responsible for determining CCHPS’s compliance with these 12 contract requirements. To further assist DoC in overseeing CCHPS’s delivery of services, the contract also stipulates that CCHPS will submit quarterly and annual progress reports to DoC. These progress reports are to include a description of quality problems, such as those identified by CCHPS’s quality improvement program or the independent reviewer, and actions taken to correct them. DoC also requires CCHPS to maintain accreditation of its services. In addition, DoC staff responsible for oversight of the contract are frequently on-site at the Jail and the CTF observing the contractor, and, as of May 2004, DoC had plans to begin jointly conducting the quarterly analyses of inmate medical records with CCHPS. Furthermore, DoC’s independent reviewer conducts quarterly reviews of CCHPS’s activities. Each review consists of two principal components. First, the independent reviewer checks the accuracy of CCHPS’s internal use of the standardized performance instruments. To do this, he uses the same performance assessment instruments that CCHPS uses in its quality improvement program to examine a sample of the analyses CCHPS has completed, and assesses whether CCHPS accurately characterized the medical records studied. Second, in addition to validating CCHPS’s analyses, the independent reviewer uses the performance instruments to independently assess the quality of CCHPS’s services by analyzing a separate random sample of inmate medical records in selected service areas, such as mental health services. While CCHPS uses the performance assessment instruments as a quality improvement vehicle, the independent reviewer’s use of these instruments contributes to his assessment of whether CCHPS is meeting its contractual obligations. However, the independent reviewer does not specifically evaluate CCHPS’s compliance with the contract requirements associated with monetary damages. As part of his review, the independent reviewer also assesses other components of CCHPS’s quality improvement program, visits the medical units at the Jail and the CTF, and interviews CCHPS staff. After conducting the review, the independent reviewer provides DoC with a written report describing his general findings, including service areas in which CCHPS excels or needs to improve. Since August 2000, the independent reviewer has conducted 14 quarterly on-site reviews of CCHPS. Most available evidence indicates that CCHPS has generally complied with the contract, but DoC has not exercised sufficient oversight to be assured that problems are not occurring or are quickly corrected. The independent reviewer has reported that CCHPS’s services meet the contract’s requirements for access to care and quality. In addition, CCHPS has generally met the contract requirement that it implement a quality improvement program. However, in a few areas, CCHPS has not always met the contract’s requirements, such as submitting required quarterly and annual progress reports describing quality problems and actions taken to correct them. Although the independent reviewer provides important information about CCHPS’s performance, limitations in DoC’s oversight of CCHPS may hinder the agency’s ability to be assured of CCHPS’s compliance with the contract. For example, DoC has not enforced the contract requirement that CCHPS provide it with quarterly and annual progress reports. Furthermore, although DoC has authority to impose monetary damages on CCHPS if it does not meet certain requirements included in the contract, DoC has not collected data needed to impose these damages or developed formal procedures for determining whether CCHPS has met these requirements and for imposing damages if CCHPS has not met them. On the basis of his review, the independent reviewer has consistently reported that CCHPS’s medical services meet the contract’s requirements for access to care and quality. He has also reported that services meet the “required constitutional standards of care.” In addition, he told us that, in his opinion, CCHPS is one of the best correctional health care providers in the country. According to the independent reviewer, some activities, such as documenting the administering of medication, have been performed consistently over the life of the contract. Other activities have improved over time. For example, in one report, the independent reviewer noted that CCHPS’s chronic disease guidelines were outdated, but later reported that CCHPS had appropriately revised the guidelines. In addition, CCHPS generally meets the contract requirement that it implement a quality improvement program. CCHPS has used the performance assessment instruments each quarter to monitor its services, and the independent reviewer has concluded that CCHPS accurately uses these instruments to assess its medical services. For example, based on data from its quarterly analyses, CCHPS identified problems in inmates’ access to dental care. As a result, CCHPS conducted a study to identify ways to improve access to this service and eventually established a system that gave higher priority to care for inmates with more serious dental problems. CCHPS’s subsequent review found that access had improved. While CCHPS’s medical services and monitoring efforts generally meet the requirements of the contract, in a few areas CCHPS has not always met requirements. For example, the contract requires that CCHPS provide timely follow-up services to inmates with abnormal chest x-ray results. Although CCHPS has recently improved its performance, the independent reviewer had repeatedly found that CCHPS did not always provide timely follow-up services to these inmates. The independent reviewer also recently determined that CCHPS is not performing reviews of inmate deaths. This is an NCCHC requirement, and CCHPS’s quality improvement program specifies that CCHPS should conduct such reviews monthly. In addition, CCHPS has not regularly submitted the required quarterly and annual progress reports providing information on quality problems and its actions to correct them. CCHPS has never submitted quarterly reports, and submitted only one annual report. Furthermore, the annual progress report CCHPS did submit provided only limited information. For example, it did not discuss CCHPS’s lack of timely follow-up on abnormal x-ray results, although the independent reviewer had repeatedly identified this as a problem. Inmates have expressed concerns about other medical services required by the contract. Our analysis of a sample of the 369 inmate grievances submitted from April 2003 through October 2003 found that many complaints related to inmates’ ability to gain access to requested sick call and primary care services and to the timely distribution of medications. For example, some inmates complained that they had submitted multiple requests to be seen during sick call and had not yet been seen. CCHPS’s internal monitoring has also identified problems related to sick call services, such as inconsistent use of the protocols developed to guide inmate health assessments. In addition, advocacy groups with whom we spoke expressed concern about distribution of medications on weekends and to newly admitted inmates. Although the independent reviewer provides important information about CCHPS’s services, DoC has other weaknesses in its oversight of CCHPS that reduce its ability to be assured that CCHPS is complying with the contract and that problems are not occurring. DoC has never used its authority to impose monetary damages on CCHPS for failing to meet certain contract requirements. This is in part because it lacks the necessary data and a formal procedure for determining whether CCHPS has met the requirements; it also lacks a procedure for imposing damages if they are warranted. To evaluate CCHPS’s compliance with many of the requirements that are linked to monetary damages, DoC needs data that indicate the percentage of inmates for whom CCHPS provided the required service. One potential source for such data is the performance assessment instruments used by CCHPS and the independent reviewer, which measure many of the activities included in these contract requirements. However, at present, DoC neither regularly collects data itself nor requires the independent reviewer or CCHPS to submit data they collect through their quarterly analyses of services. DoC officials also were not able to provide any documents that articulated how, and how often, they would evaluate CCHPS’s compliance with the contract requirements associated with monetary damages, and DoC has not provided CCHPS with information on the status of its compliance. Furthermore, if DoC were able to determine that CCHPS was not meeting a contract requirement, it has not determined whether it would immediately impose damages on CCHPS or first give CCHPS an opportunity to correct the problem. In addition, DoC has generally not enforced the contract requirement that CCHPS submit quarterly and annual progress reports describing quality problems and actions taken to correct them. These reports would allow DoC to obtain information on how CCHPS is addressing compliance or other performance problems identified by CCHPS’s own monitoring or the independent reviewer. For example, the independent reviewer has repeatedly reported that CCHPS did not consistently screen and treat female inmates for chlamydia and gonorrhea. In addition, while CCHPS usually responds to inmate grievances in a timely way, the independent reviewer has reported on several occasions that CCHPS does not analyze grievances in a sufficiently thorough way to identify systemic problems in CCHPS’s services. Enforcing the requirement that CCHPS submit regular progress reports would better enable DoC to ensure that CCHPS promptly corrects such problems. An area where DoC has been slow to carry out its oversight responsibility relates to the contract requirement for an infection control plan. To maintain its NCCHC accreditation, CCHPS must have an infection control plan, and the April 2003 modification of the contract required that CCHPS’s plan be approved by DoC. Although CCHPS submitted an infection control plan to DoC for approval in August 2003, DoC did not complete its review and approve the plan until June 2004. In addition to having gaps in its oversight of services provided by CCHPS, DoC is not providing systematic oversight to ensure that, when CCHPS refers inmates to off-site services, inmates receive those services promptly. DoC officials believe the closure of District of Columbia General Hospital in 2001 and the shift of off-site services to Greater Southeast Community Hospital have resulted in delays in obtaining off-site care for inmates, particularly in certain specialty areas, such as orthopedics and dermatology. The independent reviewer and CCHPS have also expressed concerns about access to off-site services. CCHPS, which is responsible for arranging and monitoring off-site appointments, documented earlier delays in obtaining these appointments, but at the time of our review, it no longer possessed this documentation. Despite its concerns, DoC has not systematically documented more recent delays in obtaining off-site appointments for inmates, is not able to provide any data on the nature or length of delays, and has no plans to study this issue. From 2000 to 2003, DoC’s average daily cost of providing medical services to an inmate at the Jail decreased by almost one-third. This resulted from a decrease in the total cost of providing medical services to inmates despite an increase in the inmate population. DoC and CCHPS officials told us they controlled costs in various ways, including reducing personnel expenditures. In 2003, DoC consolidated the services provided to inmates in the Jail and the CTF under one CCHPS contract and introduced a daily per inmate pricing structure, known as per diem pricing. The total cost to provide medical services to inmates at the Jail and the CTF in 2003 was about $15.8 million, an average of $13.28 per inmate. From initiation of the CCHPS contract in 2000 to 2003, the average daily per inmate cost of medical services at the Jail decreased by almost one- third, from about $19 a day to about $13 a day. The average decrease resulted from a decline in the total cost of services, combined with a rise in the inmate population. During this period, the total cost of providing medical services at the Jail decreased from about $11.7 million to about $11.4 million, about 3 percent. (See fig. 1.) At the same time, the average daily population in the Jail increased by about 680 inmates, about 41 percent. (See fig. 2.) In fiscal year 1999, the last full year in which the Receiver directly provided medical services at the Jail, the total cost was about $12.6 million and the average per inmate cost was about $21 a day. As a result of the combination of decreased cost and increased inmate population, DoC’s average daily cost of providing medical services to an inmate at the Jail since CCHPS began providing services fell by almost one-third from 2000 to 2003. (See fig. 3.) DoC and CCHPS officials told us that they were able to reduce the total cost of providing medical services at the Jail through various means. For example, in 2003, DoC officials stopped paying CCHPS a management fee. DoC also negotiated with CCHPS officials to reduce employee salaries and fringe benefits, and CCHPS made more efficient use of its staff. For example, CCHPS was able to eliminate unnecessary testing done at intake, such as conducting repeat chest x-rays for recently returned inmates, which allowed CCHPS to increase staff time available for providing other services. In addition, CCHPS officials told us they have selectively replaced higher salaried staff with lower salaried staff; in one case they changed a vacated pharmacist position to a pharmacy technician position. CCHPS also controlled personnel expenditures by reducing the overall number of staff at the Jail, while still meeting NCCHC standards for physician staffing levels. When the contract began in March 2000, CCHPS had about 125 full-time equivalent (FTE) positions at the Jail, and there were about 18 Jail inmates for each clinical staff member. As of April 2003, CCHPS’s FTEs at the Jail had decreased to about 114, and the number of inmates for each clinical staff member had risen to about 27. NCCHC requires jails to maintain one physician on-site for 3.5 hours a week for every 100 inmates, and as of April 2003, CCHPS exceeded this standard by having one physician on-site for about 4.3 hours a week for every 100 inmates. Until April 2003, DoC established required staffing levels for CCHPS as a part of its contract, but the contract now allows CCHPS, with DoC’s approval, to adjust staffing levels in response to inmate population changes. In 2003, the total cost for medical services in the Jail and the CTF was about $15.8 million; over the course of that year 17,431 inmates were admitted to both facilities. In the same year, DoC consolidated medical services for CTF inmates into the contract for services for Jail inmates. It also introduced a daily per inmate pricing structure—known as per diem pricing—to calculate the rates paid to CCHPS. This pricing structure uses a per diem rate schedule, which is a sliding scale of prices that declines slightly as the combined inmate population increases. The schedule starts at $14.75 per inmate when the inmate population is below 2,200, and incrementally falls to $13.00 per inmate when the population exceeds 3,200. For example, if the combined population on a particular day were 2,000 inmates, the per diem rate would be $14.75 and the total cost to DoC for that day would be $29,500. According to DoC officials, the per diem rate declines when the inmate population rises to reflect economies of scale. Over the course of 2003, the per diem rate charged to DoC for services at the jail and the CTF averaged $13.28 per inmate. The per diem pricing structure has simplified DoC’s contract administration by generally eliminating the need for a reconciliation process. Prior to April 2003, the contract required that DoC and CCHPS complete quarterly reconciliations to determine the difference between CCHPS’s expected staff costs at the beginning of the contract year and CCHPS’s actual staff costs during the year. These differences resulted primarily from inmate population changes. However, as DoC and CCHPS negotiated the final amount of each reconciliation, the process became increasingly lengthy and several unresolved reconciliations accumulated. Over the first 3 years of the contract, for example, DoC completed only 4 of the 12 scheduled reconciliations. When the per diem pricing structure was implemented in 2003, all incomplete reconciliations were resolved in a final reconciliation settlement. DoC has provided a broad range of medical services to inmates at the Jail and the CTF since the receivership ended in September 2000. CCHPS’s medical services have generally met the contract’s requirements for access to care and quality, and CCHPS has demonstrated a commitment to providing inmates with the services they need by adding on-site specialty clinics to improve access and continuity of care. CCHPS also regularly and accurately monitors its services to ensure that it is providing appropriate care. However, CCHPS has not always met all contract requirements for service delivery and quality improvement activities. Although DoC has taken an important step toward ensuring the quality of services that CCHPS provides to inmates by retaining the independent reviewer, it has not taken several other actions that would help it better oversee the care that inmates receive. For example, DoC has limited its ability to hold CCHPS accountable for meeting the contract requirements that are linked to monetary damages. For monetary damages to be a viable oversight and contract enforcement mechanism, DoC would need to obtain data that demonstrate whether CCHPS is providing required services to the minimum percentage of the inmate population stipulated by the contract. However, DoC has not collected these data. DoC would also need to develop formal procedures for assessing CCHPS’s compliance with the requirements and for imposing monetary damages if they are warranted. Furthermore, DoC has not enforced the requirement that CCHPS regularly submit progress reports describing how it is correcting problems identified through performance monitoring, including any problems that may place CCHPS out of compliance with the contract. If CCHPS provided this information, DoC could ensure that CCHPS promptly took corrective action to respond to problems identified by the independent reviewer or CCHPS’s own monitoring, such as CCHPS’s failure to promptly follow up on abnormal chest x-ray results. Having the capacity to enforce the contract requirements linked with monetary damages and requiring CCHPS to submit regular progress reports would strengthen DoC’s ability to ensure that CCHPS provides important medical services to inmates. To help ensure that CCHPS provides required medical services to inmates of the District of Columbia Jail and the CTF, we recommend that the Mayor require the Director of DoC to take the following two actions: Develop formal procedures—including collection of needed data—to regularly assess whether CCHPS’s performance meets the contract requirements that are linked to monetary damages and to impose these damages. Ensure that CCHPS submits to DoC the required quarterly and annual progress reports, which should describe identified problems and the actions CCHPS has taken to correct them. We provided a draft of this report to DoC for comment. In its response DoC did not comment on our recommendations, but provided additional information about its contract with CCHPS and medical services for inmates of the Jail and the CTF. In addition, DoC elaborated on its oversight of medical services provided by CCHPS. (DoC’s comments are reprinted in app. IV.) DoC emphasized in its comments that the independent reviewer acts at the request and on behalf of the agency. We noted in the draft report that DoC’s hiring of the independent reviewer was an important step toward ensuring the quality of CCHPS’s services and described the independent reviewer’s role in DoC’s oversight of CCHPS. DoC expressed concern that the issues discussed in the independent reviewer’s reports are intended to identify opportunities for CCHPS to improve, but that the draft report portrayed them as problems or deficiencies. While some issues raised by the independent reviewer could be characterized as opportunities for service improvement, we found that others indicated performance shortfalls related to specific contract requirements. In its comments, DoC discussed our finding that CCHPS has not regularly submitted the quarterly and annual reports required by the contract; these reports are to provide DoC with information on problems identified by CCHPS’s performance monitoring or by the independent reviewer and on CCHPS’s corrective actions. DoC stated that instead of the quarterly reports, it relies on certain monthly reports and regular verbal communication. DoC’s comments describe two types of monthly reports, one providing various data on off-site services and the other relating to two performance measures reported to the Office of the Mayor. However, undocumented verbal communications and these narrowly focused monthly reports are not a substitute for the quarterly progress reports called for in the contract and do not enable DoC to ensure that CCHPS is addressing identified problems. DoC’s comments acknowledge that CCHPS has not submitted all required annual reports. We do not agree that the information provided in the December 2002 report on the reconciliation of CCHPS’s expected and actual costs, which DoC cites in its comments, provided DoC with the type of information required in the annual progress reports. For example, this report contains no information about how CCHPS planned to improve its performance in screening and treating female inmates for chlamydia and gonorrhea. DoC highlighted its role in reducing the cost of medical services provided to inmates by CCHPS. In the final report we provided additional information on DoC’s role. DoC also noted that the average daily cost of services decreased from about $19 to about $13, which we stated in our draft report, and that this will result in savings over the remaining life of the contract. However, while the average daily cost per inmate in 2003 was $13.32, under the current rate schedule, daily per inmate costs may range from $13.00 when the combined Jail and CTF population exceeds 3,200 to $14.75 when the inmate population is below 2,200. Therefore, costs over the remaining life of the contract will depend largely on the inmate population. In response to DoC’s comments, we replaced the term “financial penalties” with “monetary damages.” While the comments state that DoC has other remedies for contract nonperformance, we believe that the authority to impose monetary damages is also a useful means of ensuring CCHPS’s compliance with the contract. In its comments, DoC described changes in the District’s health care system that have affected the provision of off-site medical services for inmates. Because the focus of our report was on services provided by CCHPS through its contract with DoC, a detailed discussion of these developments was not within the scope of the report. DoC also stated that there was a past study on delays in obtaining off-site appointments for inmates and that there is no need to conduct an additional study. The draft report did not recommend that DoC conduct an additional study, but reported that DoC and the independent reviewer have identified problems with access to off-site services and that DoC has not collected data on delays. We incorporated other information provided by DoC in its comments on our draft report where appropriate. As agreed with your office, unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days after its issue date. At that time, we will send copies to the DoC Director, interested congressional committees, and other parties. We will also make copies available to others on request. In addition, the report will be available at no charge on the GAO Web site at http://www.gao.gov. If you or your staff have any questions about this report, please call me at (202) 512-7119. Another contact and key contributors are listed in appendix V. We examined the medical services provided by the Center for Correctional Health and Policy Studies, Inc. (CCHPS) to inmates at the Jail and the Correctional Treatment Facility (CTF), including CCHPS’s internal monitoring; the District of Columbia Department of Corrections’ (DoC) oversight of those services; CCHPS’s contract compliance; and the cost of services under the contract. To provide information on CCHPS’s and DoC’s activities, we reviewed documents and interviewed officials from those two organizations. DoC documents we reviewed included contracting documents such as the original request for proposals and subsequent modifications, reports of inmate population volume, and specialty clinic utilization statistics. In reviewing DoC’s activities, we assessed DoC’s internal controls related to the contract with CCHPS. CCHPS documents we reviewed included policies and procedures, staffing plans, annual progress reports, and quarterly performance analyses. We also interviewed the independent reviewer hired by DoC and analyzed the reviewer’s quarterly reports to examine CCHPS’s medical services and CCHPS’s quality improvement activities. In addition, we analyzed documents and interviewed officials from the National Commission on Correctional Health Care and the American Correctional Association to obtain information on their correctional health care accreditation standards, their accreditation review processes, and their findings on DoC facilities. We also reviewed our previous work on medical services at the Jail. We reviewed issues related to medical services provided to CTF inmates only since April 2003, when DoC expanded its contract with CCHPS to include medical services for inmates at that facility. To obtain information on inmate complaints about medical services the contract requires CCHPS to provide and on CCHPS’s responses to these complaints, we conducted an independent analysis of randomly selected samples of grievances submitted by inmates at the Jail and the CTF. Of the 201 grievances at the Jail and the 168 grievances at the CTF during the period April 1, 2003, through October 31, 2003, we randomly selected 75 grievances for each analysis, for a total sample size of 150. DoC was able to provide us with the detailed information needed for our analysis on 72 of the 75 grievances selected from the Jail and on 72 of the 75 grievances selected from the CTF. Grievances for which DoC could not provide the requested information were excluded from each analysis. For both the Jail and the CTF samples of inmate grievances, we analyzed the timeliness of CCHPS’s response, the subject of the grievance, and the extent to which CCHPS’s response addressed the principal areas of concerns cited in the complaint. The final sample size of 144 grievances produced estimates about types of grievances and timeliness of responses with a margin of error of plus or minus 5.0 percent at the 95-percent confidence level. Although we focused principally on medical services provided by CCHPS under its contract with DoC, we also obtained information about inmate services that are not part of the CCHPS contract—such as off-site services—by reviewing documents and interviewing officials from CCHPS, DoC, and the District of Columbia Department of Health (DoH). Documents we reviewed included contracts between DoH and community providers and utilization data on off-site services provided to inmates. We also interviewed officials from the District of Columbia Department of Mental Health, a community health care provider, and groups providing legal services to inmates. To calculate the total annual and average per inmate costs of the medical services that CCHPS provided, we reviewed documents such as DoC’s budget records, purchase order summaries, contract pricing modifications, and CCHPS invoices. We interviewed officials from the District of Columbia Office of Contracting and Procurement; DoC, including its Office of the Chief Financial Officer; and CCHPS. We also examined independently audited accounting data from the District of Columbia Office of Financial Operations and Systems. We determined that the medical services cost information we reviewed was reliable, based on documentation provided by the District of Columbia Office of Financial Operations and Systems stating that the source of the data was the System of Accounting and Reporting, the District of Columbia’s official accounting records, which is subject to an independent audit each year. We made certain assumptions to define four comparable 12-month periods that approximated the DoC-CCHPS contract year. Although there are slight differences between the time periods defined for total costs and inmate population averages, the length of each period was 1 year. Total cost data for 2000, 2001, and 2002 are from March 12 of each year through March 11 of the following year, coinciding with the DoC-CCHPS contract year, while inmate population data for 2000, 2001, and 2002 are from April 1 of each year through March 31 of the following year, approximating the DoC- CCHPS contract year. Total cost and inmate population data for 2003 are from April 1, 2003, through March 31, 2004, approximating the DoC- CCHPS contract year. We calculated the average daily inmate population for each annual period by first calculating an average daily population for each of the 12 months within the period, and then averaging the monthly averages. We applied an accrual methodology to calculate the total costs associated with each annual period. The DoC-CCHPS contract during the years 2000 through 2002 specified a fixed contract price at the beginning of each year, subject to reconciliations during the year. Reconciliations conducted during contract years often resulted in adjustments to DoC payments in a subsequent contract year. By applying an accrual method, we attributed reconciliation costs to the years from which they originated rather than the years in which they were paid. We performed our work from August 2003 through June 2004 in accordance with generally accepted government auditing standards. The contract between DoC and CCHPS contains certain requirements that CCHPS must meet. If these requirements are not met, DoC has the authority to impose specified monetary damages on CCHPS. Table 2 summarizes the requirements linked with monetary damages. In 2000, DoC, CCHPS, and the independent reviewer hired by DoC to monitor CCHPS’s medical services developed performance assessment instruments to allow them to determine how consistently CCHPS delivered required medical services to inmates and whether it conducted activities included in its quality improvement program. Table 3 describes the measures included in the performance assessment instruments, as well as the samples measured and the sources of the samples. When reviewing services, the person conducting the assessment determines whether each bulleted measure has been met. In addition to the person named above, key contributors to this report were Emily Gamble Gardiner, Marc Feuerberg, Krister Friday, and Anne Montgomery.

Summary: Since the end of a court-ordered receivership overseeing medical services at the District of Columbia Jail in September 2000, the Department of Corrections (DoC) has contracted with the Center for Correctional Health and Policy Studies, Inc. (CCHPS) to provide inmate medical services. GAO was asked to provide information on (1) the medical services DoC contracted with CCHPS to provide, including CCHPS's monitoring of its services; (2) mechanisms DoC established to oversee CCHPS's services; (3) CCHPS's contract compliance and DoC's efforts to ensure compliance; and (4) the cost of medical services. To collect this information, GAO analyzed documents and interviewed officials from District agencies, CCHPS officials, and an independent reviewer hired by DoC to monitor medical services. DoC has contracted with CCHPS to provide a broad range of medical services to inmates at the District of Columbia Jail and the Correctional Treatment Facility (CTF)--an adjacent overflow facility. Services include health screenings at intake; primary care services, including care for chronic conditions; mental health care; and specialty care. In addition, CCHPS assists DoC in helping inmates obtain services not included in the contract, such as specialty or emergency services that cannot be offered on-site. As part of the contract, CCHPS also established a quality improvement program to monitor its services. A key component of the program is a quarterly analysis of random samples of inmate medical records to measure how consistently CCHPS delivers required services. DoC established several mechanisms to oversee CCHPS's delivery of medical services to inmates. For example, DoC retained an independent reviewer to monitor the services provided by CCHPS on a quarterly basis. In addition, the contract gives DoC authority to impose monetary damages on CCHPS if it fails to meet any of 12 requirements specified in the contract, most of which relate to providing key services to a minimum percentage of inmates. The contract also requires CCHPS to submit quarterly and annual progress reports describing quality problems identified by the independent reviewer or its own monitoring and actions taken to correct them. Although available evidence indicates that CCHPS has generally complied with the terms of its contract, DoC has not exercised sufficient oversight to provide assurance that problems are not occurring or are quickly corrected. The independent reviewer has consistently found that CCHPS's services meet the contract's overall requirements for access to care and quality, but has also reported that CCHPS has not always met certain requirements. For example, while CCHPS recently improved its performance in providing timely follow-up services to inmates with abnormal chest x-ray results, the independent reviewer had repeatedly found problems in this area. DoC has not taken actions that would allow it to be assured of CCHPS's compliance with contract requirements linked to monetary damages. The agency has not collected data or developed a formal procedure to determine whether CCHPS has met the requirements, and it lacks a procedure to impose damages if warranted. Also, DoC has not regularly enforced the contract requirement that CCHPS submit quarterly and annual progress reports describing quality problems and corrective actions, and CCHPS has often not submitted these reports. From 2000 to 2003, the average daily cost of providing medical services to a Jail inmate decreased by almost one-third, from about $19 a day per inmate to about $13 a day. In 2003, DoC consolidated the services provided to inmates in the Jail and the CTF under one contract with CCHPS. In that year, during which 17,431 inmates were admitted to the Jail and the CTF, the total cost of providing medical services at both facilities was about $15.8 million.