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entitled 'Bureau of Prisons: Timelier Reviews, Plan for Evaluations, 
and Updated Policies Could Improve Inmate Mental Health Services 
Oversight' which was released on July 17, 2013. 

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United States Government Accountability Office: 
GAO: 

Report to Congressional Requesters: 

July 2013: 

Bureau of Prisons: 

Timelier Reviews, Plan for Evaluations, and Updated Policies Could 
Improve Inmate Mental Health Services Oversight: 

GAO-13-1: 

GAO Highlights: 

Highlights of GAO-13-1, a report to congressional requesters, 

Why GAO Did This Study: 

BOP is responsible for the care and custody—-including mental health 
care-—of more than 219,600 federal inmates. BOP identifies and treats 
inmates’ mental health disorders, and has procedures in place to 
assess the provision of mental health services in its 119 facilities, 
and 15 private prisons operating under contract. GAO was requested to 
provide information on BOP’s costs and oversight of inmate mental 
health services. This report addresses: (1) BOP’s costs to provide 
these services; (2) the extent to which BOP assesses whether its 
institutions comply with BOP policies for providing services; and (3) 
the extent to which BOP tracks the costs of providing mental health 
services to inmates in contract facilities, and assesses compliance 
with contract requirements. 

GAO analyzed obligated funds for fiscal years 2008 through 2012 for 
the two BOP divisions responsible for mental health services at BOP 
institutions, examined the most recent review reports for a random 
sample of 47 BOP institutions and all 15 contract facilities, examined 
BOP’s policies, and interviewed BOP officials. 

What GAO Found: 

During a 5-year period-—fiscal years 2008 through 2012-—costs for 
inmate mental health services in institutions run by the Bureau of 
Prisons (BOP) rose in absolute dollar amount, as well as on an annual 
per capita basis. Specifically, mental health services costs rose from 
$123 million in fiscal year 2008 to $146 million in fiscal year 2012, 
with increases generally due to three factors-—inmate population 
increases, general inflationary increases, and increased participation 
rates in psychology treatment programs such as drug abuse treatment 
programs. Additionally, the per capita cost rose from $741 in fiscal 
year 2008 to $821 in fiscal year 2012. It is projected that these 
costs will continue to increase with an estimated per capita cost of 
$876 in fiscal year 2015, due, in part, to increased program funding 
and inflation. 

BOP conducts various internal reviews that assess institutions’ 
compliance with its policies related to mental health services, and it 
also requires institutions to obtain external accreditations. BOP’s 
internal program reviews are on-site audits of a specific program, 
including two that are relevant to mental health services-—psychology 
and health services. Most institutions in GAO’s sample received good 
or superior ratings on their psychology and health services program 
reviews, but these reviews did not always occur within BOP-established 
time frames, generally due to lack of staff availability. When reviews 
were postponed, delays could be lengthy, sometimes exceeding a year, 
even for those institutions with the lowest ratings in previous 
reviews. Moreover, BOP has not evaluated whether most of its 
psychology treatment programs are meeting their established goals and 
has not developed a plan to do so. BOP is developing an approach for 
reporting on the relative reduction in recidivism associated with 
major inmate programs, which may include some psychology treatment 
programs. Using this opportunity to develop a plan for evaluating its 
psychology treatment programs would help ensure that the necessary 
evaluation activities, as well as any needed program changes, are 
completed in a timely manner. Further, BOP’s program statements—-its 
formal policies—-related to mental health services contain outdated 
information. Policy changes are instead communicated to staff through 
memos. By periodically updating its program statements, BOP would be 
better assured that staff have a consistent understanding of its 
policies, and that these policies reflect current mental health care 
practices. 

BOP collects information on the daily cost to house the 13 percent of 
federal inmates in contract facilities, but it does not track the 
specific contractor costs of providing mental health services. The 
performance-based, fixed-price contracts that govern the operation of 
BOP’s contract facilities give flexibility to the contractors to 
decide how to provide mental health services and do not require that 
they report their costs for doing so to BOP. BOP uses several methods 
to assess the contractors’ compliance with contract requirements and 
standards of care. BOP conducts on-site reviews to assess the services 
provided to inmates in contract facilities, including those for mental 
health. BOP uses results from these reviews, as well as reports from 
external accrediting organizations, the presence of on-site monitors, 
and internal reviews conducted by the contract facility, to assess 
contractor compliance and to ensure that the contractor is 
consistently assessing the quality of its operations. 

What GAO Recommends: 

GAO recommends that BOP (1) take steps to prioritize the completion of 
postponed program reviews, (2) develop a plan to evaluate treatment 
programs, and (3) develop and implement updated program statements. 
BOP concurred with the first and third recommendation and partially 
concurred with the second. GAO considered additional information 
provided by BOP about its plan to conduct evaluations and modified 
this recommendation accordingly. 

View [hyperlink, http://www.gao.gov/products/GAO-13-1]. For more 
information, contact David C. Maurer at (202) 512-9627 or 
maurerd@gao.gov, or Debra A. Draper at (202) 512-7114 or 
draperd@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

Mental Health Services Costs Have Increased in BOP-Operated 
Institutions since Fiscal Year 2008 and Are Expected to Continue to 
Increase: 

BOP Assesses Compliance with Its Policies for Inmate Mental Health 
Services, but Reviews Are Not Always Timely; BOP Has Not Evaluated the 
Effectiveness of Most Treatment Programs or Updated Most Policies: 

BOP Does Not Track Contractors' Costs of Providing Inmate Mental 
Health Services but Does Assess Compliance with Requirements and 
Standards of Care: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Bureau of Prisons' Psychology Treatment Programs' 
Descriptions and Numbers of Participants for FY 2008 and 2012: 

Appendix III: Bureau of Prisons (BOP)-Operated Institutions by Mental 
Health Care Levels as of February 2013: 

Appendix IV: Inmate Intake and Mental Health Assessment Process: 

Appendix V: Inmate Diagnoses by Inmate Mental Health Care Level and 
Gender, as of February 9, 2013: 

Appendix VI: Findings from Program Review Reports, Accreditation 
Reports, and Contract Facility Monitoring Review Reports: 

Appendix VII: Bureau of Prisons' Elements of Modified Therapeutic 
Communities: 

Appendix VIII: Bureau of Prisons Program Statements Related to Mental 
Health Services for Inmates: 

Appendix IX: GAO Contacts and Staff Acknowledgments: 

Tables: 

Table 1: Number and Percentage of Federal Inmates in Bureau of Prisons 
(BOP)-Operated Facilities by Designated Inmate Mental Health Care 
Level, as of May 11, 2013: 

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

Table 3: Actual Costs and Percentage Changes of Inmate Mental Health 
Services, and Inmate Populations in Bureau of Prisons (BOP)-Operated 
Institutions: 

Table 4: Projected Costs and Percentage Changes of Inmate Mental 
Health Services, and Projected Inmate Populations in Bureau of Prisons 
(BOP)-Operated Institutions: 

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

Table 6: Institutional Ratings in Psychology Services and Health 
Services Program Review Reports for BOP-Operated Institutions: 

Table 7: Most Common Deficiencies in Psychology Services and Health 
Services Program Reviews Related to Mental Health Services for BOP-
Operated Institutions: 

Table 8: Examples of Deficiencies and Institutional Corrective Actions 
from Psychology Services Program Review Reports for BOP-Operated 
Institutions: 

Table 9: Most Common Deficiencies Cited in Joint Commission Ambulatory 
Care Accreditation Reports for BOP-Operated Institutions: 

Table 10: Most Common Deficiencies in Contract Facility Monitoring 
Reviews That May Be Related to Mental Health Services in Contract 
Facilities: 

Table 11: Most Common Deficiencies in Joint Commission Accreditation 
Reports Related to Mental Health Services in Contract Facilities: 

Figures: 

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

Figure 2: The Bureau of Prisons' Program Review Process: 

Abbreviations: 

ACA: American Correctional Association: 

BOP: Bureau of Prisons: 

BRAVE: Bureau Rehabilitation and Values Enhancement: 

CFM: Contract Facility Monitoring: 

DOJ: Department of Justice: 

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

FCC: Federal Correctional Complex: 

FCI: Federal Correctional Institution: 

FDC: Federal Detention Center: 

FMC: Federal Medical Center: 

FPC: Federal Prison Camp: 

FTC: Federal Transfer Center: 

MCC: Metropolitan Correctional Center: 

MCFP: Medical Center for Federal Prisoners: 

MDC: Metropolitan Detention Center: 

MH: mental health: 

MTC: modified therapeutic community: 

NR DAP: Non-Residential Drug Abuse Treatment Program: 

ORE: Office of Research and Evaluation: 

PA: physician's assistant: 

PDS: Psychology Data System: 

PRG: Program Review Guidelines: 

RDAP: Residential Drug Abuse Program: 

SFF: Secure Female Facility: 

SHU: special housing unit: 

SOTP-NR: Non-Residential Sex Offender Treatment Program: 

SOTP-R: Residential Sex Offender Treatment Program: 

STAGES: Steps Toward Awareness, Growth and Emotional Strength: 

USP: U.S. Penitentiary: 

[End of section] 

GAO:
United States Government Accountability Office: 
441 G St. N.W. 
Washington, DC 20548: 

July 17, 2013: 

The Honorable Elijah E. Cummings: 
Ranking Member: 
Committee on Oversight and Government Reform: 
House of Representatives: 

The Honorable Robert C. "Bobby" Scott: 
Ranking Member: 
Subcommittee on Crime, Terrorism, Homeland Security, and Investigations 
Committee on the Judiciary: 
House of Representatives: 

The Honorable Richard J. Durbin: 
United States Senate: 

The mission of the Department of Justice's (DOJ) Federal Bureau of 
Prisons (BOP) is to protect society by confining offenders in the 
controlled environments of prisons and community-based facilities that 
are safe, humane, cost-efficient, and appropriately secure. As part of 
its duties, BOP is responsible for delivering adequate medical care, 
including mental health services, in a manner consistent with accepted 
community standards for a correctional environment.[Footnote 1] 
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.[Footnote 2] To carry out its 
responsibility for delivering mental health care for inmates, BOP 
provides mental health services primarily through its Correctional 
Programs Division's Psychology Services Branch and its Health Services 
Division. 

As of July 4, 2013, BOP was responsible for overseeing more than 
219,600 federal inmates--most of whom are housed in BOP's 119 
institutions or 15 privately managed facilities with which BOP 
contracts for confinement.[Footnote 3] Studies have shown that 
psychological treatment during incarceration is effective in reducing 
mental illness symptoms and in reducing recidivism.[Footnote 4] 
Moreover, according to an Urban Institute study, public health and 
correctional stakeholders view prisons as an opportunity to affect 
factors that contribute to criminal behavior and the cycle of repeated 
incarceration, such as untreated mental illness.[Footnote 5] There is 
no clear consensus on the rate of mental illness among federal 
prisoners, and estimated rates vary widely. For example, a 2006 Bureau 
of Justice Statistics report stated that about 45 percent of federal 
prisoners suffered from a mental health problem, which the report 
defined as symptoms of a mental health disorder or a mental health 
problem that was diagnosed or treated within the previous 12 months, 
as reported by the inmate.[Footnote 6] Another study of a sampling of 
inmates newly admitted to BOP custody during fiscal years 2002 and 
2003 estimated that 15.2 percent of the inmates were in need of 
psychological services, which the report defined as having received a 
current psychiatric diagnosis, having been prescribed antipsychotic or 
mood-stabilizing medication at any time in the inmate's life, or 
having had an overnight hospital stay for mental health reasons at any 
time in the inmate's life.[Footnote 7] 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.[Footnote 8] 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 
Correctional Association (ACA) and The Joint Commission.[Footnote 9] 
We analyzed 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.[Footnote 10] We used the sample to 
determine the extent to which BOP assesses its institutions in 
accordance with its own policies. We compared BOP's policies for 
inmate mental health care and processes for monitoring the provision 
of inmate mental health care at the institution level with the 
Standards for Internal Control in the Federal Government and risk 
management principles.[Footnote 11] In addition, we analyzed the most 
recent accreditation reports from ACA and The Joint Commission 
conducted for this same sample of BOP-operated institutions.[Footnote 
12] We interviewed officials from BOP's Office of Research and 
Evaluation (ORE), which conducts research and evaluation of BOP 
programs, to determine what evaluations BOP has conducted of its 
psychology treatment programs in the past and what evaluations are 
ongoing or planned. We assessed BOP's evaluation planning against 
standards for project management. We discussed these oversight 
activities with BOP officials responsible for managing the psychology 
treatment programs and conducting program reviews. Additionally, to 
obtain insights into the overall program review process, we observed 
two psychology services on-site program reviews.[Footnote 13] 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.[Footnote 14] 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. 

Background: 

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 levels[Footnote 15]--and about 13 percent, or 
approximately 29,400 inmates, are housed in privately managed contract 
facilities--generally housing low-security inmates.[Footnote 16] BOP 
has eight operational divisions to oversee major BOP program areas, 
including the Correctional Programs Division and the Health Services 
Division, that manage the administration of mental health services. 
[Footnote 17] 

Provision of Mental Health Services in the Federal Prison System: 

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. 

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

[Refer to PDF for image: organization chart] 

Top level: 
Bureau of Prisons Director. 

Second level, reporting to Bureau of Prisons Director: 
Deputy Director. 

Third level, reporting to Deputy Director: 
Health Services Division: 
* Psychiatry services; 
* Pharmacy services; 
Correctional Programs Division. 

Fourth level, reporting to Correctional Programs Division: 
Psychology Services Branch: 
* Routine psychological services; 
* Drug abuse treatment programs; 
* Sex offender management programs; 
* Mental health treatment programs. 

Source: Source: GAO analysis of information from the Bureau of Prisons. 

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

[End of figure] 

BOP implemented a mental health care level designation system for both 
institutions and inmates in 2010.[Footnote 18] 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. 

Table 1: Number and Percentage of Federal Inmates in Bureau of Prisons 
(BOP)-Operated Facilities by Designated Inmate Mental Health Care 
Level, as of May 11, 2013: 

Inmate mental health (MH) care level: MH care 1; 
Description: Inmates with no identified mental health problem, as well 
as other inmates with stable mental health conditions requiring 
individual psychological contacts or clinical intervention no more 
than once every 3 to 6 months; 
Number: 155,165; 
Percentage: 92.46%. 

Inmate mental health (MH) care level: MH care 2; 
Description: Inmates require clinical interventions regularly, usually 
quarterly to monthly; 
Number: 5,793; 
Percentage: 3.45%. 

Inmate mental health (MH) care level: MH care 3; 
Description: Inmates require clinical intervention frequently, usually 
weekly over an extended period of time; 
Number: 589; 
Percentage: 0.35%. 

Inmate mental health (MH) care level: MH care 4; 
Description: Inmates require psychiatric hospitalization; 
Number: 857; 
Percentage: 0.51%. 

Inmate mental health (MH) care level: MH screen 1[A]; 
Number: 4,038; 
Percentage: 2.41%. 

Inmate mental health (MH) care level: MH screen 2; 
Number: 1,093; 
Percentage: 0.65%. 

Inmate mental health (MH) care level: MH screen 3; 
Number: 224; 
Percentage: 0.13%. 

Inmate mental health (MH) care level: MH screen 4; 
Number: 61; 
Percentage: 0.04%. 

Total: 
Number: 167,820; 
Percentage: 100%. 

Source: Bureau of Prisons. 

[A] According to BOP officials, "MH screen" is the initial mental 
health designation given to an inmate before the inmate has been 
assessed at the institution where he or she is assigned. Once an 
inmate is assigned and evaluated at the institution, the inmate is 
assigned a "MH care level." The four screening levels match the four 
care levels in the table. 

[End of table] 

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,[Footnote 19] followed by a personality 
disorder diagnosis.[Footnote 20] 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. 

Internal and External Reviews of BOP-Operated Facilities: 

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.[Footnote 21] 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. 

In addition to program reviews, BOP requires all of its institutions, 
as well as its contracted facilities, to be accredited by an external 
organization, ACA. ACA's standards for adult correctional institutions 
include 63 mandatory standards and 458 nonmandatory standards across 
five areas of a correctional institution's operations.[Footnote 22] 
ACA's standards include 7 specifically related to mental health, 4 of 
which are mandatory.[Footnote 23] To be accredited, an institution 
must meet all mandatory standards and 90 percent of applicable 
nonmandatory standards.[Footnote 24] BOP incorporates ACA's standards 
into the PRGs for its own program reviews. As a result of BOP's 
inclusion of ACA's standards in its program reviews, ACA relies 
significantly on findings from BOP's own program review process and 
its confidence in this review process, when it reaccredits BOP-
operated institutions, according to ACA officials. 

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.[Footnote 25] The Joint 
Commission's ambulatory care standards are not specific to mental 
health services, but apply to any type of medical or mental health 
service provided by an institution. For example, one standard requires 
organizations to provide patients with care, treatment, or services 
according to their individualized care plan. BOP's Joint Commission 
accreditation covers services provided by the institution's health 
services unit, including psychiatry and pharmacy services. Certain BOP 
institutions with specialized medical missions also obtain other Joint 
Commission accreditations.[Footnote 26] 

Table 2 provides information on the different types of internal and 
external on-site reviews that BOP institutions undergo, and the 
specific BOP components providing mental health services that each 
review covers. 

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

Review: Psychology Services program review; 
Internally or externally conducted: Internally; 
Time between on-site reviews: Up to 3 years, depending on 
institution's rating[A]; 
BOP components reviewed: Psychology Services, which include substance 
abuse programs and other psychology treatment programs. 

Review: Health Services program review; 
Internally or externally conducted: Internally; 
Time between on-site reviews: Up to 3 years, depending on 
institution's rating[A]; 
BOP components reviewed: Psychiatry and pharmacy services. 

Review: American Correctional Association accreditation; 
Internally or externally conducted: Externally[B]; 
Time between on-site reviews: 3 years; 
BOP components reviewed: Psychology, psychiatry, and pharmacy 
services. 

Review: The Joint Commission accreditation; 
Internally or externally conducted: Externally; 
Time between on-site reviews: 3 years; 
BOP components reviewed: Psychiatry and pharmacy services. 

Source: GAO analysis. 

[A] BOP policy requires subsequent program reviews be conducted every 
3 years for institutions with a good or superior rating, every 2 years 
for institutions with an acceptable rating, and every 18 months for 
institutions with a deficient rating. Institutions receiving an at-
risk rating are reviewed again when the institution requests closure 
on the program review. 

[B] The ACA relies significantly on BOP's own program review process 
when it reaccredits BOP-operated institutions. Reviewers from the ACA 
observe program reviews to determine that the process is sound, but 
may also cite institutions for any deficiencies the reviewers note 
during their observation. 

[End of table] 

Reviews for BOP Contract Facilities: 

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. 

Mental Health Services Costs Have Increased in BOP-Operated 
Institutions since Fiscal Year 2008 and Are Expected to Continue to 
Increase: 

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. 

Mental Health Services Costs Increased from Fiscal Year 2008 through 
Fiscal Year 2012: 

BOP's total mental health services costs increased annually from 
fiscal year 2008 through fiscal year 2012. According to BOP officials, 
mental health services costs include related expenses from both its 
Correctional Programs Division and Health Services Division. As shown 
in table 3, when aggregating these costs, we found that total costs 
increased annually from $123 million in fiscal year 2008 to nearly 
$146 million in fiscal year 2012. 

Table 3: Actual Costs and Percentage Changes of Inmate Mental Health 
Services, and Inmate Populations in Bureau of Prisons (BOP)-Operated 
Institutions: 

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

Correctional Programs Division: Psychology Services[A]; 
Fiscal year 2008: $42.71 million; 
Fiscal year 2009: $44.71 million; 
Fiscal year 2010: $47.26 million; 
Fiscal year 2011: $49.66 million; 
Fiscal year 2012: $51.28 million. 

Correctional Programs Division: Psychology staff training; 
Fiscal year 2008: $0.31 million; 
Fiscal year 2009: $0.80 million; 
Fiscal year 2010: $0.85 million; 
Fiscal year 2011: $0.72 million; 
Fiscal year 2012: $0.64 million. 

Correctional Programs Division: Drug abuse treatment programs; 
Fiscal year 2008: $57.66 million; 
Fiscal year 2009: $60.62 million; 
Fiscal year 2010: $66.22 million; 
Fiscal year 2011: $68.98 million; 
Fiscal year 2012: $71.33 million. 

Correctional Programs Division: Sex Offender Management Programs; 
Fiscal year 2008: $4.74 million; 
Fiscal year 2009: $6.94 million; 
Fiscal year 2010: $6.86 million; 
Fiscal year 2011: $6.61 million; 
Fiscal year 2012: $7.19 million. 

Health Services Division: Psychotropic medication; 
Fiscal year 2008: $11.52 million; 
Fiscal year 2009: $11.58 million; 
Fiscal year 2010: $11.29 million; 
Fiscal year 2011: $9.35 million; 
Fiscal year 2012: $8.49 million. 

Health Services Division: Psychiatrist salaries and benefits; 
Fiscal year 2008: $6.05 million; 
Fiscal year 2009: $6.83 million; 
Fiscal year 2010: $7.17 million; 
Fiscal year 2011: $7.39 million; 
Fiscal year 2012: $6.75 million. 

Total actual costs: 
Fiscal year 2008: $123.00 million; 
Fiscal year 2009: $131.48 million; 
Fiscal year 2010: $139.64 million; 
Fiscal year 2011: $142.71 million; 
Fiscal year 2012: $145.69 million. 

Inmate population at the end of the fiscal year in BOP-operated 
institutions: 
Fiscal year 2008: 165,964; 
Fiscal year 2009: 172,423; 
Fiscal year 2010: 173,289; 
Fiscal year 2011: 177,934; 
Fiscal year 2012: 177,556. 

Total annual cost per capita: 
Fiscal year 2008: $741.11; 
Fiscal year 2009: $762.56; 
Fiscal year 2010: $805.84; 
Fiscal year 2011: $802.05; 
Fiscal year 2012: $820.52. 

Percentage change in per capita cost from prior fiscal year
Fiscal year 2009: 2.89%; 
Fiscal year 2010: 5.68%; 
Fiscal year 2011: -0.47%; 
Fiscal year 2012: 2.30%. 

Source: GAO analysis of BOP data. 

Note: Numbers may not total because of rounding. 

[A] According to BOP officials, Psychology Services costs include all 
expenses related to providing routine psychological treatment to 
inmates in BOP-operated institutions, salaries and expenses for 
psychology staff, and some treatment programs. The costs do not 
include administrative oversight provided by the Central Office, which 
serves as the headquarters of BOP, or regional offices, which oversee 
the operations of the institutions within their respective geographic 
regions. Drug abuse treatment and sex offender management programs are 
not included in psychology services, but are budgeted separately. 

[End of table] 

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).[Footnote 27] 

With respect to costs for psychotropic medication, this was the one 
line item whose related costs showed a downward trend.[Footnote 28] 
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. 

Mental Health Services Costs Are Projected to Grow through Fiscal Year 
2015: 

Including all the same elements in table 3, we projected costs through 
fiscal year 2015, and expect that mental health services costs will 
continue to increase (see table 4). In estimating annual future costs, 
we used fiscal year 2012 as a baseline and discussed with BOP 
officials their projections for underlying factors that would affect 
future changes in costs. Specifically, we used their data for 
anticipated inmate population growth and expected budgetary increases. 
For example, in its fiscal year 2014 budget, BOP requested an 
additional $15 million to expand the RDAP, which, according to BOP 
officials, should enable BOP to reduce the wait list for this program. 
We also applied national inflation factors for the health care 
industry to account for inflationary increases. 

Table 4: Projected Costs and Percentage Changes of Inmate Mental 
Health Services, and Projected Inmate Populations in Bureau of Prisons 
(BOP)-Operated Institutions: 

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

Total projected costs: 
Fiscal year 2013: $149.82 million; 
Fiscal year 2014: $155.86 million; 
Fiscal year 2015: $161.22 million. 

Projected inmate population in BOP-operated institutions: 
Fiscal year 2013: 179,178; 
Fiscal year 2014: 182,124; 
Fiscal year Fiscal year 2015: 184,092. 

Total projected annual cost per capita: 
Fiscal year 2013: $836.15; 
Fiscal year 2014: $855.81; 
Fiscal year 2015: $875.75. 

Percentage change in projected annual per capita cost from prior fiscal 
year: 
Fiscal year 2013: 1.90%; 
Fiscal year 2014: 2.35%; 
Fiscal year 2015: 2.33%. 

Source: GAO analysis of BOP data. 

[End of table] 

BOP Assesses Compliance with Its Policies for Inmate Mental Health 
Services, but Reviews Are Not Always Timely; BOP Has Not Evaluated the 
Effectiveness of Most Treatment Programs or Updated Most Policies: 

BOP conducts various internal reviews to assess BOP-operated 
institutions' compliance with its policies related to mental health 
services, and BOP policy also requires institutions to obtain external 
accreditations. While most BOP-operated institutions received good or 
superior ratings in their psychology and health services program 
reviews, the majority of reviews we examined did not occur within the 
BOP-specified time frames. Additionally, BOP has not evaluated the 
effectiveness of most of its treatment programs and has not developed 
a plan to do so. Finally, BOP's program statements related to mental 
health services, which formally document BOP's policies and 
procedures, contain outdated information. 

BOP Conducts Internal Reviews That Assess Compliance with Policies for 
Mental Health Services, but Most Reviews Do Not Occur on Time: 

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. 

[Side bar] 

Program Reviews: The Bureau of Prisons' Program Review Division 
conducts separate program reviews of each program area at an 
institution. Reviewers assess an institution's performance based on 
Program Review Guidelines and earn one of five ratings--superior, good, 
acceptable, deficient, and at risk. 
Source: GAO analysis of BOP information. 

[End of side bar] 

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 figure 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,[Footnote 29] 
that an institution offers.[Footnote 30] While not generalizable to 
all program reviews, the review teams conducting the two psychology 
services program reviews that we observed followed the applicable PRGs. 

Figure 2: The Bureau of Prisons' Program Review Process: 

[Refer to PDF for image: illustration] 

Bureau of Prisons Program Review Cycle: 

Program Review Division conducts audit; 

Program Review Division issues report on findings: 
If no deficiencies are found, Program Review Division closes audit. 
Otherwise, institution must respond within 30 calendar days of 
report’s date of issuance; 

Institution responds to report with corrective actions for identified 
deficiencies; 

Program Review Division finds corrective actions acceptable[A]: 
Follow-up reviews should be conducted 120-150 calendar days after the 
last day of the program review; 

Institution conducts follow-up review focused on identified 
deficiencies; 

Institution submits to Program Review Division follow-up review 
results and certifies that deficiencies have been resolved; 

Program Review Division closes audit; 

Next review occurs on the following schedule: 

Rating: Superior
Time frame: 3 years. 

Rating: Good
Time frame: 3 years. 

Rating: Acceptable
Time frame: 2 years. 

Rating: Deficient
Time frame: 18 months. 

Rating: At-risk
Time frame: When institution requests closure of program review. 

Source: GAO analysis of information from the Bureau of Prisons. 

[End of figure] 

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,[Footnote 31] and a variety of issues related to suicide risk 
assessments, suicide watch logs, and follow-up care after a suicide 
watch.[Footnote 32] 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, 
[Footnote 33] including about 23 percent that were more than 6 months 
late, based on the institution's prior ratings.[Footnote 34] (See 
table 5.) For example, one institution that had received an acceptable 
rating--and therefore should have been reviewed 24 months later--did 
not get reviewed again for more than 38 months. Among the 47 health 
services program review reports that we examined, about 70 percent did 
not occur within BOP's established time frames, including 6 percent 
that occurred more than 6 months late.[Footnote 35] According to BOP 
officials, institutions that do not receive timely program reviews are 
required to use their staff to conduct an internal operational review 
using the relevant PRGs,[Footnote 36] 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. 

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

Psychology Services: 
Review conducted on time (confidence interval): 34% (23.4-45.7%); 
Less than 3 months late (confidence interval): 23% (14.9-34.0%); 
3 to 6 months late (confidence interval): 19% (10.6-29.8%); 
More than 6 months late (confidence interval): 23% (14.9-34.0%). 

Health Services: 
Review conducted on time (confidence interval): 30% (20.2-41.5%); 
Less than 3 months late (confidence interval): 51% (41.5-64.9%); 
3 to 6 months late (confidence interval): 13% (5.3-20.2%); 
More than 6 months late (confidence interval): 6% (3.2-14.9%). 

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

Notes: Numbers may not add to 100 percent because of rounding. We 
reviewed the most recent health and psychology services program review 
reports for 47 institutions and calculated the time elapsed between 
that review and the previous review. The 95 percent confidence 
intervals for the estimates are shown in parentheses. 

[End of table] 

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.[Footnote 37] Additionally, the Assistant Director for the 
Program Review Division approves any deviation in schedule.[Footnote 
38] 

Although it is important that BOP officials review and approve 
postponements of program reviews, when reviews are postponed the 
delays can be lengthy, even for institutions with the lowest ratings. 
For example, BOP officials told us that to reduce travel costs, they 
delayed the review of an institution rated acceptable by 14 months to 
combine its review with that of another nearby institution's review. 
Of the 11 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.[Footnote 39] Therefore, when 
scheduling postponed reviews, proper risk management would call for 
BOP to give highest priority to those institutions with the lowest 
ratings. Because delays in program reviews may hamper BOP's ability to 
adequately monitor inmate care, it is important for BOP to minimize 
delays, especially for the lowest-rated institutions. Furthermore, 
with BOP's inmate population expected to increase through 2020, 
[Footnote 40] it will be even more important for BOP to ensure that it 
conducts timely program reviews to identify potential problems with 
access to care or compliance with its treatment policies that growing 
institutional crowding might exacerbate. 

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.[Footnote 41] 

Additional Psychology Services Branch Reviews: 

[Side bar] 

Certification of Use of Modified Therapeutic Community Model: The 
Psychology Services Branch certifies new RDAPs and Challenge programs 
within six months of the treatment program becoming operational to 
ensure that the institution is adhering to the modified therapeutic 
community model of treatment. This model stresses values and behaviors 
that are needed in the outside community, such as responsibility to 
self and others, and thinking and acting in accordance with the norms 
of the community. 
Source: GAO analysis of BOP information. 

[End of side bar] 

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.[Footnote 42] The branch conducts the certification 
reviews to ensure that the program adheres to the 10 elements of a 
modified therapeutic community (MTC), the treatment model BOP uses for 
residential psychology treatment programs. (See app. VII for 
additional information on the elements of a MTC.) Psychology Services 
officials told us they would like to expand the certification process 
to all eight residential treatment programs, but expansion was 
contingent on securing additional funds for travel because the 
certification reviews are done at the program location. 

[Side bar] 

Remote Reviews: The Psychology Services Branch considers remote reviews 
to be a mechanism for the central office to provide ongoing technical 
assistance to institutions. Headquarters staff conduct the reviews and 
send the results to the institution. 
Source: Bureau of Prisons. 
Psychology Services officials. 

[End of side bar] 

The Psychology Services Branch is planning to implement remote reviews 
of treatment programs and has begun to implement remote reviews of 
clinical services. In March 2013, officials from Psychology Services 
told us they plan to implement procedures in 2013 for annual remote 
reviews for 9 of BOP's 10 residential and nonresidential treatment 
programs.[Footnote 43] Staff plan to conduct these reviews from BOP's 
headquarters using electronic medical records; the reviews are 
expected to focus on areas such as staff utilization, treatment 
planning and services, and documentation quality. The Psychology 
Services Branch has also started to conduct remote reviews of selected 
clinical services provided. In early 2013, the Psychology Services 
Branch conducted a remote review of the mental health classification 
at each institution for inmates whose mental health care level did not 
appear to align with the level of care the inmate was 
receiving.[Footnote 44] Psychology Services officials also plan to 
conduct remote reviews of suicide risk assessments to evaluate whether 
the assessments are well reasoned and, for at-risk inmates, treatment 
began when the inmate was on suicide watch. 

External Accreditation Reviews Assess Whether BOP Is Meeting 
Established Standards of Care: 

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.[Footnote 45] All of The Joint 
Commission's standards are mandatory. If, during the on-site review, 
examiners find insufficient compliance with a standard, the 
institution must submit documentation to The Joint Commission that it 
has resolved the issue prior to being granted full accreditation. 

We reviewed the most recent ACA and ambulatory care Joint Commission 
accreditation reports for our sample of 47 institutions.[Footnote 46] 
We found limited findings related to mental health care in both the 
ACA and Joint Commission accreditation reports, meaning that the 
institutions generally were complying with applicable standards. 
Findings from our analysis are detailed in appendix VI. 

We also reviewed the accreditation reports of the four BOP-operated 
institutions that have Joint Commission accreditations for behavioral 
health care. All four institutions received full accreditation. One of 
the institutions had no findings, and for two institutions, The Joint 
Commission examiners found that the suicide risk screenings did not 
specify the inmate's protective factors, which are factors that 
decrease an inmate's risk of suicide. 

BOP Has Not Evaluated Most of Its Psychology Treatment Programs and 
Has Not Yet Developed a Plan To Do So: 

[Side bar] 

Evaluations: An evaluation determines whether a program is meeting its 
intended outcomes. Intended outcomes of psychology treatment programs 
could include lower recidivism rates, lower rates of misconduct, or 
better management of mental illness symptoms. 
Source: GAO analysis of Bureau of Prisons information. 

[End of side bar] 

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.[Footnote 47] ORE completed its 
review of RDAP in 2000 and the Bureau Rehabilitation and Values 
Enhancement (BRAVE) Program in 2001 and found positive results. 
[Footnote 48] For example, inmates who participated in RDAP had less 
recidivism after 3 years of release than inmates who did not go 
through the program.[Footnote 49] 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. 
[Footnote 50] 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 of the Second Chance Act of 
2007, 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). [Footnote 51] 
After we provided a draft of this report to DOJ for comment, BOP 
officials told us they have begun to develop an approach to complete 
the first report pursuant to the Second Chance Act of 2997, 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. 

Given the reporting requirement in the Second Chance Act of 2007 and 
the lack of clarity regarding how BOP intends to meet this reporting 
requirement, it is important that BOP to 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.[Footnote 52] With a plan, BOP 
could have greater assurance that the activities necessary to conduct 
the evaluations of the psychology treatment programs, as well as any 
needed program changes that may be identified during those 
evaluations, would be completed in a timely manner. 

BOP Program Statements Related to Mental Health Services Contain 
Outdated Information: 

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 
appendix VIII).[Footnote 53] 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.[Footnote 54] 
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. 

BOP Does Not Track Contractors' Costs of Providing Inmate Mental 
Health Services but Does Assess Compliance with Requirements and 
Standards of Care: 

BOP does not track its contractors' costs of providing mental health 
services to the 13 percent of BOP inmates housed in privately managed 
facilities. The performance-based,[Footnote 55] fixed-price contracts 
that govern the operation of BOP's privately managed facilities give 
flexibility to the contractors to decide how to provide mental health 
services. Nevertheless, BOP assesses the contractors' compliance with 
contract requirements and accreditation standards related to mental 
health through Contract Facility Monitoring (CFM) reviews, external 
accreditation reviews, and other reviews. 

BOP Does Not Track Contractors' Cost of Providing Inmate Mental Health 
Services in Contract Facilities: 

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.[Footnote 56] 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.[Footnote 57] 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[Footnote 58]--said that they track mental health services 
costs internally and take them into account when calculating the per 
diem inmate cost they use when bidding for BOP contracts.[Footnote 59] 
Additionally, two of the primary contractors told us that they 
subcontract for health services, including mental health services, and 
do not know the subcontractors' specific cost for providing mental 
health services. We spoke with one subcontractor that told us it 
tracks these costs internally. We requested this cost information from 
that subcontractor and two of the three primary contractors we spoke 
with, but were unable to obtain this information because the 
contractors consider it proprietary and confidential.[Footnote 60] 

BOP Assesses Compliance with Mental Health Requirements and Standards 
in Several Ways: 

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's Contract Facility Monitoring Reviews: 

BOP conducts annual on-site CFM reviews at each contract facility, the 
objective of which is to assess whether the contract facilities are 
meeting performance outcomes outlined in the contract. Following a CFM 
review, BOP issues a report to the facility noting deficiencies and 
findings from the review. 

With respect to mental health, each contract requires that "all 
inmates are [to be] screened for mental health, substance abuse, and 
other behavioral problems and receive appropriate intervention, 
treatment, and programs to promote a healthy, safe, and secure 
environment." According to BOP, this language is more generic than 
prescriptive because of the contracts' performance-based nature. The 
contract also specifies that private facilities must obtain and 
maintain ACA and Joint Commission accreditation. BOP officials told us 
that while BOP gives contractors discretion in deciding how to deliver 
mental health services--and does not dictate adherence to BOP's mental 
health policies--they believe that requiring contractors to achieve 
and sustain the same accreditations as BOP institutions helps ensure a 
high level of service. 

BOP developed a Quality Assurance Plan that sets out the areas that 
BOP is to assess during the CFM reviews. The plan includes auditing 
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.[Footnote 61] 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. 

External Accreditation Reviews by ACA and Joint Commission: 

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.[Footnote 62] Our review of the most recent Joint 
Commission accreditation reports found that 6 of the 13 contract 
facilities were fully in compliance with the ambulatory care standards 
we determined were related to mental health services--a small subset 
of the 192 standards by which they are assessed. The Joint Commission 
found the remaining 7 facilities to be either partially or 
insufficiently compliant with these standards.[Footnote 63] 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. 
[Footnote 64] These compliance issues related to: inmate assessments 
not including information on addictions other than alcohol or drugs; 
inmate treatment plans not including goals and metrics to measure an 
inmate's progress; and the lack of documentation of an assessment of 
clinical competence for staff being hired.[Footnote 65] For more 
information on the specific ambulatory care and behavioral health 
standards for which the contract facilities were not in compliance, 
see appendix VI. 

Contractor Internal Assessments and Quality Control Plans: 

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.[Footnote 
66] 

According to BOP officials, the contractors' Quality Control Plans are 
much more detailed than BOP's Quality Assurance Plan because the 
contractors are monitoring many more areas than BOP does in order to 
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. 

Conclusions: 

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 report pursuant to the Second Chance Act 
of 2007, it would be beneficial for BOP to develop a plan that 
identifies the resources necessary and target time frames to carry out 
future evaluations of its 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. 

Recommendations for Executive Action: 

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. 

Agency Comments and Our Evaluation: 

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 
[hyperlink, 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. 

Signed by: 

David C. Maurer, Director: 
Homeland Security and Justice Team: 

Signed by: 

Debra A. Draper, Director: 
Health Care Team: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

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.[Footnote 67] 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. 

To address the question on the extent to which BOP assesses whether 
BOP-operated institutions comply with BOP policies for providing 
inmate mental health services, we reviewed all relevant policies and 
program statements related to mental health services provided to 
inmates. Program statements outline BOP's formal policies and 
procedures. We also met with BOP officials responsible for oversight 
in the Psychology Services Branch, Health Services Division, and 
Program Review Division to understand each unit's oversight activities 
and how the units communicate with each other and with institution 
staff. We compared BOP's policies for inmate mental health care and 
processes for monitoring the provision of inmate mental health care at 
the institution level with the Standards for Internal Control in the 
Federal Government and risk management principles.[Footnote 68] We 
conducted site visits to two institutions because they serve inmate 
populations with significant mental health care needs--one institution 
with several psychology treatment programs and another with a level 4 
mental health care designation.[Footnote 69] During each of these site 
visits, we discussed with institution staff the programming provided 
to inmates with mental health conditions and the institution's 
experience with BOP oversight activities. Although not generalizable, 
the visits provided important insights into the services 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 timeframe of our 
study. While the observations from these visits are not generalizable 
to all BOP institutions or to all program reviews, the visits provided 
important 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.[Footnote 70] 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.[Footnote 71] 

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.[Footnote 72] 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.[Footnote 73] For our review of 
the ambulatory care accreditation reports, we focused on findings 
related to psychiatry and pharmacy care, as these were the areas 
covered by the review most applicable to inmate mental health care. 
The Joint Commission's accreditation is for those services provided by 
the institution's health services unit and does not include psychology 
services. Because of the level of detail presented in the reports, 
findings related to pharmacy care are not specific to the 
administration of psychotropic drugs. We also reviewed the findings 
from The Joint Commission's behavioral health accreditation reports 
for the four BOP institutions with behavioral health accreditations. 

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. 
[Footnote 74] 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,[Footnote 
75] 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 timeframe 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. 

[End of section] 

Appendix II: Bureau of Prisons' Psychology Treatment Programs' 
Descriptions and Numbers of Participants for FY 2008 and 2012: 

Program name: Non-Residential Drug Abuse Treatment Program (NR DAP); 
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; 
Fiscal year: 2008; 
Number of inmate participants: 13,361; 
Number of inmates on waiting list at the end of the fiscal year: 2,392.
Fiscal year: 2012; 
Number of inmate participants: 20,141; 
Number of inmates on waiting list at the end of the fiscal year: 9,825. 

Program name: Residential Drug Abuse Treatment Program (RDAP); 
Program description: 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; 
Fiscal year: 2008; 
Number of inmate participants: 14,721; 
Number of inmates on waiting list at the end of the fiscal year: 6,980.
Fiscal year: 2012; 
Number of inmate participants: 14,482; 
Number of inmates on waiting list at the end of the fiscal year: 4,807. 

Program name: Challenge Program; 
Program description: 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; 
Fiscal year: 2008; 
Number of inmate participants: 1,613; 
Number of inmates on waiting list at the end of the fiscal year: 284.
Fiscal year: 2012; 
Number of inmate participants: 2,139; 
Number of inmates on waiting list at the end of the fiscal year: 482. 

Program name: Bureau Rehabilitation and Values Enhancement (BRAVE) 
Program; 
Program description: 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; 
Fiscal year: 2008; 
Number of inmate participants: 255; 
Number of inmates on waiting list at the end of the fiscal year: 38.
Fiscal year: 2012; 
Number of inmate participants: 199; 
Number of inmates on waiting list at the end of the fiscal year: 24. 

Program name: Habilitation Program; 
Program description: 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; 
Fiscal year: 2008; 
Number of inmate participants: 29; 
Number of inmates on waiting list at the end of the fiscal year: 4.
Fiscal year: 2012; 
Number of inmate participants: 19; 
Number of inmates on waiting list at the end of the fiscal year: 1. 

Program name: Skills Program; 
Program description: 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; 
Fiscal year: 2008; 
Number of inmate participants: 72; 
Number of inmates on waiting list at the end of the fiscal year: 2. 

Fiscal year: 2012; 
Number of inmate participants: 40; 
Number of inmates on waiting list at the end of the fiscal year: 9. 

Program name: Steps Toward Awareness, Growth and Emotional Strength 
(STAGES) Program[A]; 
Program description: 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; 
Fiscal year: 2008; 
Number of inmate participants: [Empty]; 
Number of inmates on waiting list at the end of the fiscal year: 
[Empty].
Fiscal year: 2012; 
Number of inmate participants: 17; 
Number of inmates on waiting list at the end of the fiscal year: 2. 

Program name: Step-Down Unit Programs; 
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; 
Fiscal year: 2008; 
Number of inmate participants: NA; 
Number of inmates on waiting list at the end of the fiscal year: NA.
Fiscal year: 2012; 
Number of inmate participants: 90; 
Number of inmates on waiting list at the end of the fiscal year: 9. 

Program name: Resolve Program; 
Program description: The Resolve Program is a trauma treatment program 
for female inmates. The Resolve Program consists of two components: a 
psycho-educational workshop and a non-residential program for inmates 
with trauma-related disorders; 
Fiscal year: 2008; 
Number of inmate participants: 208; 
Number of inmates on waiting list at the end of the fiscal year: 589.
Fiscal year: 2012; 
Number of inmate participants: 2,358; 
Number of inmates on waiting list at the end of the fiscal year: 1,636. 

Program name: Sex Offender Management Programs[B]; 
Fiscal year: 2008; 
Number of inmate participants: 373; 
Number of inmates on waiting list at the end of the fiscal year: 381.
Fiscal year: 2012; 
Number of inmate participants: 740; 
Number of inmates on waiting list at the end of the fiscal year: 1,776. 

Program name: Sex Offender Management Programs[B]; 
* Non-Residential Sex Offender Treatment Program (SOTP-NR); 
Program description: 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. 

Program name: Sex Offender Management Programs[B]; 
* Residential Sex Offender Treatment Program (SOTP-R); 
Program description: 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. 

Program name: Sex Offender Management Programs[B]; 
Commitment and Treatment Program[C]; 
Program description: The Commitment and Treatment Program is a civil 
commitment program for persons certified as sexually dangerous 
persons. It is a civil commitment program is for the confinement and 
treatment of persons deemed sexually dangerous by the court. The 
program was established in response to requirements from the Adam 
Walsh Child Protection and Safety Act of 2006[D]; 
Fiscal year: 2008; 
Number of inmate participants: [Empty]; 
Number of inmates on waiting list at the end of the fiscal year: 
[Empty]; 
Fiscal year: 2012; 
Number of inmate participants: 23; 
Number of inmates on waiting list at the end of the fiscal year: No 
waiting list. 

Source: GAO analysis of BOP information. 

Notes: Participation is defined as the number of unique inmates who 
participated in the program at any time during the fiscal year. 

[Empty] = program not operating. 

NA= Not available: 

[A] The STAGES Program was activated in fiscal year 2012. 

[B] The number of inmates participating in the Sex Offender Management 
Programs includes those inmates participating in both SOTP-NR and SOTP-
R. 

[C] Participation in the Commitment and Treatment Program is defined as 
the number of new participants each year. Therefore, the numbers 
represent the number of new inmates admitted each year and do not 
reflect the total number of inmates in the program for each fiscal 
year. 

[D] Pub. L. No. 109-248, 120 Stat. 587 (2006). 

[End of table] 

Appendix III: Bureau of Prisons (BOP)-Operated Institutions by Mental 
Health Care Levels as of February 2013: 

Mental health (MH) care level: MH care 1[A]; 

Institution name: Atwater USP; 
Institution location: Atwater, CA. 

Institution name: Bennettsville FCI; 
Institution location: Bennettsville, SC. 

Institution name: Berlin FCI; 
Institution location: Berlin, NH. 

Institution name: Big Sandy USP; 
Institution location: Inez, KY. 

Institution name: Herlong FCI; 
Institution location: Herlong, CA. 

Institution name: Lee USP; 
Institution location: Pennington Gap, VA. 

Institution name: Manchester FCI; 
Institution location: Manchester, KY. 

Institution name: McDowell FCI; 
Institution location: Welch, WV. 

Institution name: McKean FCI; 
Institution location: Lewis Run, PA. 

Institution name: Oxford FCI; 
Institution location: Oxford, WI. 

Institution name: Pollock FCC; 
Institution location: Pollock, LA. 

Institution name: Ray Brook FCI; 
Institution location: Ray Brook, NY. 

Institution name: Safford FCI; 
Institution location: Safford, AZ. 

Institution name: Sandstone FCI; 
Institution location: Sandstone, MN. 

Institution name: Three Rivers FCI; 
Institution location: Three Rivers, TX. 

Institution name: Yankton FPC; 
Institution location: Yankton, SD. 

Institution name: Yazoo City FCC; 
Institution location: Yazoo City, MS. 

Mental health (MH) care level: MH care 2[B]; 

Institution name: Aliceville FCI; 
Institution location: Aliceville, AL. 

Institution name: Ashland FCI; 
Institution location: Ashland, KY. 

Institution name: Bastrop FCI; 
Institution location: Bastrop, TX. 

Institution name: Beaumont FCC; 
Institution location: Beaumont, TX. 

Institution name: Beckley FCI; 
Institution location: Beaver, WV. 

Institution name: Big Spring FCI; 
Institution location: Big Spring, TX. 

Institution name: Brooklyn MDC; 
Institution location: Brooklyn, NY. 

Institution name: Bryan FPC; 
Institution location: Bryan, TX. 

Institution name: Butner Low FCI; 
Institution location: Butner, NC. 

Institution name: Butner Medium II FCI; 
Institution location: Butner, NC. 

Institution name: Canaan USP; 
Institution location: Waymart, PA. 

Institution name: Chicago MCC; 
Institution location: Chicago, IL. 

Institution name: Cumberland FCI; 
Institution location: Cumberland, MD. 

Institution name: Duluth FPC; 
Institution location: Duluth, MN. 

Institution name: Edgefield FCI; 
Institution location: Edgefield, SC. 

Institution name: El Reno FCI; 
Institution location: El Reno, OK. 

Institution name: Elkton FCI; 
Institution location: Lisbon, OH. 

Institution name: Englewood FCI; 
Institution location: Littleton, CO. 

Institution name: Estill FCI; 
Institution location: Estill, SC. 

Institution name: Florence FCC; 
Institution location: Florence, CO. 

Institution name: Forrest City FCC; 
Institution location: Forrest City, AR. 

Institution name: Fort Dix FCI; 
Institution location: Fort Dix, NJ. 

Institution name: Gilmer FCI; 
Institution location: Glenville, WV. 

Institution name: Guaynabo MDC; 
Institution location: Guaynabo, PR. 

Institution name: Honolulu FDC; 
Institution location: Honolulu, HI. 

Institution name: Houston FDC; 
Institution location: Houston, TX. 

Institution name: Jesup FCI; 
Institution location: Jesup, GA. 

Institution name: La Tuna FCI; 
Institution location: Anthony, TX. 

Institution name: Leavenworth USP; 
Institution location: Leavenworth, KS. 

Institution name: Lewisburg USP; 
Institution location: Lewisburg, PA. 

Institution name: Lompoc FCC; 
Institution location: Lompoc, CA. 

Institution name: Loretto FCI; 
Institution location: Loretto, PA. 

Institution name: Los Angeles MDC; 
Institution location: Los Angeles, CA. 

Institution name: Marion USP; 
Institution location: Marion, IL. 

Institution name: McCreary USP; 
Institution location: Pine Knot, KY. 

Institution name: Memphis FCI; 
Institution location: Memphis, TN. 

Institution name: Mendota FCI; 
Institution location: Mendota, CA. 

Institution name: Miami FCI; 
Institution location: Miami, FL. 

Institution name: Miami FDC; 
Institution location: Miami, FL. 

Institution name: Milan FCI; 
Institution location: Milan, MI. 

Institution name: Montgomery FPC; 
Institution location: Montgomery, AL. 

Institution name: Morgantown FCI; 
Institution location: Morgantown, WV. 

Institution name: New York MCC; 
Institution location: New York, NY. 

Institution name: Oakdale FCC; 
Institution location: Oakdale, LA. 

Institution name: Oklahoma City FTC; 
Institution location: Oklahoma City, OK. 

Institution name: Otisville FCI; 
Institution location: Otisville, NY. 

Institution name: Pekin FCI; 
Institution location: Pekin, IL. 

Institution name: Pensacola FPC; 
Institution location: Pensacola, FL. 

Institution name: Petersburg FCC; 
Institution location: Hopewell, VA. 

Institution name: Philadelphia FDC; 
Institution location: Philadelphia, PA. 

Institution name: Phoenix FCI; 
Institution location: Phoenix, AZ. 

Institution name: San Diego MCC; 
Institution location: San Diego, CA. 

Institution name: Schuylkill FCI; 
Institution location: Minersville, PA. 

Institution name: Seagoville FCI; 
Institution location: Seagoville, TX. 

Institution name: SeaTac FDC; 
Institution location: Seattle, WA. 

Institution name: Sheridan FCI; 
Institution location: Sheridan, OR. 

Institution name: Talladega FCI; 
Institution location: Talladega, AL. 

Institution name: Tallahassee FCI; 
Institution location: Tallahassee, FL. 

Institution name: Texarkana FCI; 
Institution location: Texarkana, TX. 

Institution name: Victorville FCC; 
Institution location: Victorville, CA. 

Institution name: Williamsburg FCI; 
Institution location: Salters, SC. 

Mental health (MH) care level: MH care 3[C]; 

Institution name: Alderson FPC; 
Institution location: Alderson, WV. 

Institution name: Allenwood FCC; 
Institution location: White Deer, PA. 

Institution name: Atlanta USP; 
Institution location: Atlanta, GA. 

Institution name: Butner Medium I FCI; 
Institution location: Butner, NC. 

Institution name: Carswell FMC; 
Institution location: Fort Worth, TX. 

Institution name: Coleman FCC; 
Institution location: Sumterville, FL. 

Institution name: Danbury FCI; 
Institution location: Danbury, CT. 

Institution name: Devens FMC; 
Institution location: Ayer, MA. 

Institution name: Dublin FCI; 
Institution location: Dublin, CA. 

Institution name: Fairton FCI; 
Institution location: Fairton, NJ. 

Institution name: Fort Worth FCI; 
Institution location: Fort Worth, TX. 

Institution name: Greenville FCI; 
Institution location: Greenville, IL. 

Institution name: Hazelton USP/SFF; 
Institution location: Bruceton Mills, WV. 

Institution name: Lexington FMC; 
Institution location: Lexington, KY. 

Institution name: Marianna FCI; 
Institution location: Marianna, FL. 

Institution name: Terminal Island FCI; 
Institution location: San Pedro, CA. 

Institution name: Terre Haute FCC; 
Institution location: Terre Haute, IN. 

Institution name: Tucson FCC; 
Institution location: Tucson, AZ. 

Institution name: Waseca FCI; I
Institution location: Waseca, MN. 

Mental health (MH) care level: MH care 4[D]; 

Institution name: Butner FMC; 
Institution location: Butner, NC. 

Institution name: Carswell FMC; 
Institution location: Fort Worth, TX. 

Institution name: Devens FMC; 
Institution location: Ayer, MA. 

Institution name: Rochester FMC; 
Institution location: Rochester, MN. 

Institution name: Springfield MCFP; 
Institution location: Springfield, MO. 

Legend: 

FCC refers to Federal Correctional Complex:
FCI refers to Federal Correctional Institution:
FDC refers to Federal Detention Center:
FMC refers to Federal Medical Center:
FPC refers to Federal Prison Camp:
FTC refers to Federal Transfer Center:
MCC refers to Metropolitan Correctional Center:
MCFP refers to Medical Center for Federal Prisoners:
MDC refers to Metropolitan Detention Center:
SFF refers to Secure Female Facility:
USP refers to U.S. Penitentiary: 

Source: Bureau of Prisons. 

Notes: Butner is an FCC consisting of four facilities with different MH 
care levels--two that are MH care level 2, on that is a MH care level 
3, and one that is a MH care level 4--therefore in this table Butner is 
listed four times. Carswell and Devens are each a single institution 
but are rated as both MH care levers 3 and 4, and are therefore each 
listed twice in this table. There are 14 FCCs--Allenwood, Beaumont, 
Butner, Coleman, Florence, Forrest City, Lompoc, Oakdale, Petersburg, 
Pollock, Terre Haute, Tucson, Victorville, and Yazoo City. Each FCC 
represents more than one institution. 

[A] All MH care level 1 institutions are classified as care level 1 for 
both medical and mental health needs. Inmates in these facilities tend 
to have minimal treatment needs. 

[B] MH care level 2 institutions have Psychology Services staffing that 
serves inmates classified as care level 2 who require a moderate level 
of intervention. 

[C] MH care level 3 inmates--who require significant mental health 
interventions but not inpatient treatment--are served by institutions 
with enhanced staff specifically designated to address these needs. 
This enhanced staffing may involve a fully staffed residential 
treatment program, such as the STAGES Program, or a care level 3 
psychologist with an outpatient caseload of care level 3 mental health 
cases. Therefore, entire institutions are not designated as care level 
3 for mental health; rather, specific programs/psychologists are 
designated to provide services for care level 3 mental health cases. 
(STAGES is a residential program that provides treatment to male mental 
health care level 3 inmates with a primary diagnosis of borderline 
personality disorder. Individuals with borderline personality disorder 
have long-term patterns of unstable or turbulent emotions that often 
result in impulsive actions and chaotic relationships with other 
people. 

[D] MH care level 4 institutions are classified as care level 4 for 
both medical and mental health needs. Inmates in these facilities have 
acute needs that require inpatient treatment. 

[End of table] 

[End of section] 

Appendix IV: Inmate Intake and Mental Health Assessment Process: 

Figure: [Refer to PDF for image: process illustration] 

All individuals entering a Bureau of Prisons facility undergo a 
medical screening by a physician's assistant (PA) within 24 hours. 

The inmate screening looks for mental health issues such as prior 
treatment for mental illness, suicidal behavior, and psychotic 
symptoms. If the PA suspects that the inmate has a mental health 
issue, he or she will refer the inmate to Psychology Services staff. 

Inmates designated to FCIs, USPs, FMCs, FPCs, and work cadre inmates 
at MCCs and MDCs: 

* Inmate completes a Psychology Services Inmate Questionnaire; 

* Psychology Services staff reviews the questionnaire and conducts a 
clinical interview with the inmate; 

* If deemed necessary by the psychologist, the inmate will be 
psychologically tested. 

[First 3 steps within 14 days of arrival] 

* Psychology staff complete a screening report in the Psychology Data 
System (PDS) for inclusion in the inmate's central file; 
Within 30 days of arrival for newly committed inmates; 
Within 45 days for inmates transferred from one facility to another 
(including contract facilities). 

Pretrial or presentence detainees housed in MCCs, MDCs, and Jail Units: 

* Inmate completes a Psychology Services Inmate Questionnaire within 
24 hours of arrival; 

* Psychology Services staff reviews the questionnaire and conduct 
follow-up services if certain issues, such as suicidal thoughts, are 
identified in the inmate's questionnaire responses or if the inmate 
requests to be seen by a Psychology Services staff member. 
Inmates who express having suicidal thoughts are referred to the 
institution's Suicide Prevention Program Coordinator; 

* Within 30 days of arrival, if psychology staff conducts follow-up 
services, they complete a screening report in PDS and forward a copy 
to the inmate's pretrial information packet and central file. 

Inmates in holdover status en route to a different institution: 

* If PA identifies a mental health issue, the inmate is referred to 
Psychology Services for an evaluation. 

* Psychologist conducts the evaluation and documents the problem and 
recommended corrective actions in PDS. 

Legend: 
FCI: Federal Correctional Institution; 
USP: United States Penitentiary; 
FMC: Federal Medical Center; 
MCC: Metropolitan Correctional Center; 
MDC: Metropolitan Detention Center; 
FPC: Federal Prison Camp. 

Source: GAO analysis of information from the Bureau of Prisons. 

[End of figure] 

Appendix V: Inmate Diagnoses by Inmate Mental Health Care Level and 
Gender, as of February 9, 2013: 

Male inmates: 

Class of mental disorder: Total number of male inmates; 
Inmate mental health care level 1[A]: 144,700; 
Inmate mental health care level 2: 4,541; 
Inmate mental health care level 3: 432; 
Inmate mental health care level 4[B]: 809. 

Class of mental disorder: Anxiety disorders[C]; 
Inmate mental health care level 1[A]: 1,128; 
Inmate mental health care level 2: 538; 
Inmate mental health care level 3: 54; 
Inmate mental health care level 4[B]: 17. 

Class of mental disorder: Mood disorders[D]; 
Inmate mental health care level 1[A]: 2,801; 
Inmate mental health care level 2: 2,001; 
Inmate mental health care level 3: 162; 
Inmate mental health care level 4[B]: 62. 

Class of mental disorder: Personality disorders[E]; 
Inmate mental health care level 1[A]: 2,360; 
Inmate mental health care level 2: 1,055; 
Inmate mental health care level 3: 232; 
Inmate mental health care level 4[B]: 168. 

Class of mental disorder: Schizophrenia and other psychotic 
disorders[F]; 
Inmate mental health care level 1[A]: 251; 
Inmate mental health care level 2: 1,115; 
Inmate mental health care level 3: 244; 
Inmate mental health care level 4[B]: 402. 

Class of mental disorder: Somatoform disorders[G]; 
Inmate mental health care level 1[A]: 3; 
Inmate mental health care level 2: 1; 
Inmate mental health care level 3: 1; 
Inmate mental health care level 4[B]: 2. 

Class of mental disorder: Other disorders not used in mental health 
care level designations[H]; 
Inmate mental health care level 1[A]: 34,538; 
Inmate mental health care level 2: 2,180; 
Inmate mental health care level 3: 284; 
Inmate mental health care level 4[B]: 282. 

Female inmates: 

Class of mental disorder: Total number of female inmates; 
Inmate mental health care level 1[A]: 10,449; 
Inmate mental health care level 2: 991; 
Inmate mental health care level 3: 124; 
Inmate mental health care level 4[B]: 46. 

Class of mental disorder: Anxiety disorders[C]; 
Inmate mental health care level 1[A]: 573; 
Inmate mental health care level 2: 320; 
Inmate mental health care level 3: 36; 
Inmate mental health care level 4[B]: 4. 

Class of mental disorder: Mood disorders[D]; 
Inmate mental health care level 1[A]: 671; 
Inmate mental health care level 2: 540; 
Inmate mental health care level 3: 77; 
Inmate mental health care level 4[B]: 9. 

Class of mental disorder: Personality disorders[E]; 
Inmate mental health care level 1[A]: 260; 
Inmate mental health care level 2: 240; 
Inmate mental health care level 3: 84; 
Inmate mental health care level 4[B]: 9. 

Class of mental disorder: Schizophrenia and other psychotic 
disorders[F]; 
Inmate mental health care level 1[A]: 11; 
Inmate mental health care level 2: 70; 
Inmate mental health care level 3: 45; 
Inmate mental health care level 4[B]: 25. 

Class of mental disorder: Somatoform disorders[G]; 
Inmate mental health care level 1[A]: 0; 
Inmate mental health care level 2: 1; 
Inmate mental health care level 3: 0; 
Inmate mental health care level 4[B]: 0. 

Class of mental disorder: Other disorders not used in mental health 
care level designations[H]; 
Inmate mental health care level 1[A]: 3,820; 
Inmate mental health care level 2: 583; 
Inmate mental health care level 3: 82; 
Inmate mental health care level 4[B]: 22. 

Source: GAO analysis of data from the Bureau of Prisons. 

Notes: Inmates with multiple diagnoses are included under all 
applicable classes of disorders. Therefore, the numbers of inmates in 
the classes cannot be totaled. Classes of mental disorders are from the 
Diagnostic and Statistical Manual, Version IV-TR (DSM-IV-TR), which is 
the standard classification system of mental disorders used by mental 
health practitioners in the United States. The specified classes of 
mental disorders are those that BOP uses to determine an inmate's 
mental health care level assignment. Diagnosis information was drawn 
from records that explain an inmate's mental health care level or from 
open treatment plans. 

[A] Mental health care level 1 includes inmates without mental health 
problems and inmates with diagnosed mental health conditions who do not 
need to be seen more than once every 3 months. According to BOP, 
120,023 male inmates and 7,144 female inmates at mental health care 
level 1 did not have a diagnosed mental health disorder as of February 
2013. 

[B] According to the Bureau of Prisons, a precise number of diagnoses 
at mental health care level 4 is not available because those inmates 
directly designated to medical referral centers may not have diagnostic 
information in the Psychology Data System, BOP's electronic medical 
record system for psychological services, because paper charts are 
still in use at these facilities. Additionally, diagnoses may be 
pending if inmates are undergoing forensic evaluations, which are 
evaluations for a court. 

[C] Anxiety disorders include generalized anxiety disorder, panic 
disorder, post-traumatic stress disorder, obsessive compulsive 
disorder, and specific phobias. 

[D] Mood disorders include major depressive disorder, dysthmia (chronic 
low-level depression), and bipolar disorders. 

[E] BOP excludes consideration of antisocial personality disorder in 
designating an inmate to a mental health care level. A personality 
disorder is an enduring pattern of inner experience and behavior that 
deviates markedly from the expectations of the individual's culture, is 
pervasive and inflexible, has an onset in adolescence or early 
adulthood, is stable over time, and leads to distress or impairment. 
Borderline personality disorder is a personality disorder in which 
individuals have long-term patterns of unstable or turbulent emotions 
that often result in impulsive actions and chaotic relationships with 
other people. 

[F] Other psychotic disorders include schizoaffective disorder (a 
mental condition that causes both a loss of contact with reality and 
mood problems), delusional disorder, and brief psychotic disorder. 

[G] The common feature of the somatoform disorders is the presence of 
physical symptoms that suggest a general medical condition but are not 
fully explained by a general medical condition, by the direct effects 
of a substance, or by another mental disorder (e.g., panic disorder). 

[H] This category represents diagnoses for all mental health disorders 
that are not used to designate an inmate to a mental health care level. 
The largest category is for substance abuse disorders. 

[End of table] 

[End of section] 

Appendix VI: Findings from Program Review Reports, Accreditation 
Reports, and Contract Facility Monitoring Review Reports: 

Results from Analysis of Psychology Services and Health Services 
Program Review Reports: 

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.[Footnote 76] Table 7 provides 
information on the rating levels garnered by the institutions. 

Table 6: Institutional Ratings in Psychology Services and Health 
Services Program Review Reports for BOP-Operated Institutions: 

Psychology Services program reviews: 

Rating: Superior; 
Percentage (number of institutions): 44.7% (21); 
Confidence interval: 34.0%-56.4%. 

Rating: Good; 
Percentage (number of institutions): 44.7% (21); 
Confidence interval: 34.0%-56.4%. 

Rating: Acceptable; 
Percentage (number of institutions): 10.6% (5); 
Confidence interval: 5.3%-20.2%. 

Rating: Deficient; 
Percentage (number of institutions): 0% (0); 
Confidence interval: 0%-5.3%. 

Rating: At risk; 
Percentage (number of institutions): 0% (0); 
Confidence interval: 0%-5.3%. 

Health Services program reviews: 

Rating: Superior; 
Percentage (number of institutions): 23.4% (11); 
Confidence interval: 14.9%-34.0%. 

Rating: Good; 
Percentage (number of institutions): 53.2% (25); 
Confidence interval: 41.5%-64.9%. 

Rating: Acceptable; 
Percentage (number of institutions): 21.3% (10); 
Confidence interval: 12.8%-31.9%. 

Rating: Deficient; 
Percentage (number of institutions): 2.13% (1); 
Confidence interval: 1.1%-8.5%. 

Rating: At risk; 
Percentage (number of institutions): 0% (0); 
Confidence interval: 0%-5.3%. 

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

Note: We reviewed the most recent report for a random sample of 47 of 
the 94 institutions that had been operating long enough to receive a 
program review. For purposes of this report, we use the term 
institutions to refer to both single institutions and a complex of two 
or more institutions that are reviewed as a single unit for purposes of 
program reviews. The estimates shown in this table are generalizable to 
the population. The confidence intervals shown in the table were 
calculated at the 95 percent level of confidence. According to BOP, a 
superior rating indicates the program is performing all vital functions 
and a history of strong internal controls exists, resulting in zero or 
very minimal deficiencies. A good rating demonstrates the program's 
vital function areas are sound and internal controls are strong. 
Institutions with an acceptable rating may have deficiencies, but they 
do not detract from the adequate accomplishment of the vital functions. 
A deficient rating demonstrates that one or more vital functions of the 
program are not being performed at an acceptable level and internal 
controls are weak. An at risk-rating demonstrates that the program is 
impaired to the point that it is not accomplishing its overall mission 
and internal controls do not demonstrate substantial continued 
compliance. 

[End of table] 

We also analyzed the most frequently cited deficiencies identified in 
the psychology services and health services reports that we reviewed. 
Among the findings from the psychology services program review 
reports, 10 institutions had a deficiency related to care provided to 
inmates in a residential treatment program. Table 8 shows the most 
frequently cited deficiencies in the psychology services and health 
services program review reports that we reviewed. The table also 
includes examples of deficiencies in each category. 

Table 7: Most Common Deficiencies in Psychology Services and Health 
Services Program Reviews Related to Mental Health Services for BOP-
Operated Institutions: 

Psychology services program review deficiencies: 

Issues related to care provided to inmates in residential treatment 
programs; 
Number of institutions with deficiency: 10; 
Examples of deficiencies cited at BOP institutions: 
* Inmates who completed the Residential Drug Abuse Treatment Program 
(RDAP) were not always enrolled in follow-up services in a timely 
manner; 
* Not all of the inmates in the Challenge Program had treatment plans 
that were individualized and had goals commensurate with the inmate's 
treatment needs; 
* Treatment plans for RDAP inmates are not completed in a timely 
fashion. 

Issues related to suicide risk assessments, suicide watch, or post 
suicide watch care; 
Number of institutions with deficiency: 10; 
Examples of deficiencies cited at BOP institutions: 
* Not all inmates removed from suicide watch received follow-up 
consistent with the clinician's plan; 
* Not all inmates placed on suicide watch have documentation of a 
daily visit by a psychologist in the suicide watch logs or the 
Psychology Data System (PDS); 
* Not all suicide risk assessments were entered into PDS within 24 
hours of the referral. 

Issues related to the care provided to inmates in nonresidential 
treatment programs; 
Number of institutions with deficiency: 9; 
Examples of deficiencies cited at BOP institutions: 
* Not all inmates who have successfully completed nonresidential 
treatment have received a program completion award; 
* Not all treatment plans for inmates participating in nonresidential 
drug treatment are completed in a timely fashion; 
* The identification, referral, and interview process, which informs 
the chief psychologist of female inmates recommended for trauma 
education, is inadequate. 

Health services program review deficiencies: 

Issues related to documentation of diagnosis information; 
Number of institutions with deficiency: 12; 
Examples of deficiencies cited at BOP institutions: 
* Inmates in mental health chronic care clinics do not always have 
Diagnostic and Statistical Manual of Mental Disorders, Version-Fourth 
Edition (DSM-IV) axis codes documented on the problem list and follow-
up chronic care clinic visits, as necessary[A]; 
* Initial psychiatric visits did not always have all DSM-IV axes 
documented and addressed appropriately[B]. 

Issues with the management and administration of medication; 
Number of institutions with deficiency: 6; 
Examples of deficiencies cited at BOP institutions: 
* Management and administration of pharmaceuticals (medications) were 
not always in accordance with policy; 
* Providers with prescribing authority do not reevaluate a 
prescription prior to its renewal, and a medication was prescribed 
without proper diagnosis; 
* Medications were prescribed when not clinically indicated. Also, a 
prescription was renewed without reevaluation. 

Issues related to the administration and storage of controlled 
substances; 
Number of institutions with deficiency: 6; 
Examples of deficiencies cited at BOP institutions: 
* Medication Administration Records are not always completed for 
inmates on controlled substances; 
* Medication orders for controlled substances were reordered without 
the proper ongoing documentation; 
* Not all orders for controlled substances were cosigned by a 
physician on his/her next work day. 

Issues related to the safe storage of needles and syringes; 
Number of institutions with deficiency: 5; 
Examples of deficiencies cited at BOP institutions: 
* Not all needles and syringes in the main stock were inventoried and 
stored correctly; 
* Not all syringes, including prefilled needles and syringes, were 
inventoried and stored correctly. 

Source: GAO analysis of Psychology Services and Health Services program 
review reports. 

Notes: We reviewed the most recent Health Services and Psychology 
Services program review reports for a random sample of 47 of the 94 
institutions that had been operating long enough to receive a program 
review. For purposes of this report, we use the term institution to 
refer to both single institutions and a complex of two or more 
institutions that are reviewed as a single unit for purposes of program 
reviews. These results are not generalizable to the population of BOP 
institutions. 

[A] The Diagnostic and Statistical Manual of Mental Disorders, Version 
IV, is the standard classification system for mental disorders used by 
mental health practitioners. 

[B] The DSM-IV is organized into a five-part axis system, with each 
axis representing a part of a patient's overall assessment. 

[End of table] 

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. 

Table 8: Examples of Deficiencies and Institutional Corrective Actions 
from Psychology Services Program Review Reports for BOP-Operated 
Institutions: 

Deficiency: Not all 60-day progress reviews for inmates participating 
in RDAP are completed in a timely manner; 
Example of an institution's corrective action plan: The institution 
responded that it developed and implemented a timetable for conducting 
60-day reviews. 

Deficiency: A review of 10 treatment plans revealed the following: (1) 
Three were missing signatures. (2) Four inmates did not receive 
treatment in accordance with the treatment plan. Goals for treatment 
were not always referenced in the notes. (3) Four were not updated as 
needed. (4) Two were not closed out at the completion of treatment; 
Example of an institution's corrective action plan: The institution 
responded that all signed treatment plans will be scanned into the 
Psychology Data System (PDS) for easy review and access. When entering 
PDS notes on inmates with treatment plans, the notes will be directly 
related to the inmate's treatment plan goals. All treatment plans will 
be reviewed and updated at least annually. PDS rosters will be run on a 
monthly basis to guarantee that all treatment plans of departed inmates 
have been closed. 

Deficiency: Not all inmates received appropriate follow-up after crisis 
intervention; 
Example of an institution's corrective action plan: The institution 
responded that the chief psychologist now requires immediate 
notification of any instance of crisis intervention to ensure 
documentation is appropriate. In addition, a PDS roster of crisis 
intervention contacts is run at least monthly to ensure follow-up, if 
warranted, has been conducted as stipulated. 

Deficiency: Inmates with PSY ALERT codes are not being cleared for 
release to the general population[A]; 
Example of an institution's corrective action plan: The institution 
responded that a new tracking mechanism has been developed and is 
currently being utilized to identify all inmates who arrive with a PSY 
ALERT code. This tracking mechanism incorporates a roster that will be 
run on a daily basis to identify inmates in the pipeline who are PSY 
ALERT. All inmates with this code will be screened by a psychologist 
prior to their release to the general population. This screening will 
be reported in PDS under the heading "Psychology Alert screening." 

Deficiency: Not all inmates housed in special housing units (SHU) for 
30 days or more received a timely 30-day SHU review by a psychologist; 
Example of an institution's corrective action plan: The Institution 
responded that the system of control previously utilized was abandoned 
and a new system established. Currently, inmates housed in SHUs are 
being tracked on a 28-day rotation with all inmates receiving a SHU 
review contact on the first day of the week in which their review is 
due. 

Source: GAO analysis of psychology services program review reports. 

Notes: We did not analyze corrective action plans associated with 
deficiencies identified in health services program review reports 
because most of those deficiencies were not related to mental health 
care. 

[A] Inmates with a PSY ALERT code are not to be released into the 
general population until they have been assessed by a psychologist. 

[End of table] 

Results from Analysis of ACA and Joint Commission Accreditation 
Reports for BOP-Operated Institutions: 

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.[Footnote 77] 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. 

Table 9: Most Common Deficiencies Cited in Joint Commission Ambulatory 
Care Accreditation Reports for BOP-Operated Institutions: 

Psychiatry: 

Provider certification; 
Number of BOP institutions with partial or insufficient compliance 
with standard[A]: 1; 
Examples of observations at BOP institutions resulting in findings of 
partial or insufficient compliance: 
* A psychiatrist's board certification had expired and the institution 
had not verified that the psychiatrist had a current certification.[B] 

Pharmacy: 

Safe management of high-alert and hazardous medications[C]; 
Number of BOP institutions with partial or insufficient compliance with 
standard[A]: 5; 
Examples of observations at BOP institutions resulting in findings of 
partial or insufficient compliance: 
* The institution did not have an institution-specific list of high-
alert and hazardous medications; 
* Two high-concentration medications were not included on the 
institution's list of high-alert medications. 

Use of look-alike/sound-alike medications[D]; 
Number of BOP institutions with partial or insufficient compliance 
with standard[A]: 5; 
Examples of observations at BOP institutions resulting in findings of 
partial or insufficient compliance: 
* Not all look-alike/sound-alike medications had a high-alert label; 
* While the institution had developed a list of sound-alike 
medications and implemented a process for risk reduction for those 
medications, the institution had not implemented a list or process for 
reducing the possibility of look-alike errors for injectable 
medications. 

Safe storage of medication; 
Number of BOP institutions with partial or insufficient compliance 
with standard[A]: 5; 
Examples of observations at BOP institutions resulting in findings of 
partial or insufficient compliance: 
* The temperature ranges for a medication refrigerator were found to 
be out of range, and the institution did not take action to change the 
refrigerator's temperature or move the medications stored in the 
refrigerator; 
* Medications that had expired were still available for use. 

Source: GAO analysis of Joint Commission accreditation reports. 

[A] If an institution is found to be in partial or insufficient 
compliance with any Joint Commission standard, the institution must 
submit evidence of compliance with the standard before an accreditation 
decision is made. 

[B] According to an official from BOP's Office of Quality Management, 
BOP policy does not require psychiatrists to be board certified. 

[C] High-alert medications are those medications involved in a high 
percentage of errors or unexpected occurrences involving death or 
serious injury, as well as medications that carry an increased risk for 
abuse or other adverse outcomes. 

[D] Look-alike drugs are two drugs in which the names of the drugs can 
be confused with each other and result in medication errors. Sound-
alike drugs are two drugs that, when their names are spoken, can be 
confused with each other and result in medication errors. 

[End of table] 

Findings from the BOP and Accreditation Review Reports for Contract 
Facilities: 

In our review of each of the recent Contract Facility Monitoring (CFM) 
reports for the 15 private facilities, we found four main policy areas 
where deficiencies that could be related to mental health care were 
cited at more than 1 facility--Inmate Classification and Program 
Review, Health Information Management, Patient Care, and Medical 
Designation and Referral Services for Federal Inmates (see table 11). 
We determined that these deficiencies may be related to mental health 
because they can involve mental health professionals, such as 
psychiatrists, psychologists or licensed professional counselors; 
pharmacy care, which can include psychotropic medications; or health 
information that may include information on mental health. 

Table 10: Most Common Deficiencies in Contract Facility Monitoring 
Reviews That May Be Related to Mental Health Services in Contract 
Facilities: 

Contract facility monitoring review policy area: 

Inmate classification and program review; 
Number of institutions with deficiency: 7; 
Examples of deficiencies cited in each category: 
* Program needs of the inmates need to be identified in program review 
reports, measured in terms to demonstrate an inmate's progress through 
treatment, and reviewed at the treatment team meetings. Inmate program 
needs could include mental health treatment programs that would be 
discussed with mental health staff at treatment team meetings. 

Health information management; 
Number of institutions with deficiency: 5; 
Examples of deficiencies cited in each category: 
* Information that may include mental health information is missing 
from inmate health records; 
* Errors in inmate health records, which may include mental health 
information, were inadequately corrected. 

Patient care; 
Number of institutions with deficiency: 3; 
Examples of deficiencies cited in each category: 
* Patient care records for inmates seeking mental health clinic 
evaluations were incomplete. 

Medical designation and referral services for federal inmates; 
Number of institutions with deficiency: 2; 
Examples of deficiencies cited in each category: 
* Forms containing important medical information, which may include 
mental health information, for inmates in transit from one institution 
to another were not always written in lay terms for correctional staff 
to understand. 

Source: GAO analysis of Contract Facility Monitoring Review reports. 

[End of table] 

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.[Footnote 78] 

Table 11: Most Common Deficiencies in Joint Commission Accreditation 
Reports Related to Mental Health Services in Contract Facilities: 

The Joint Commission deficiency category: 

1. Medication management; 
Type of accreditation: Ambulatory care; 
Examples of deficiencies cited in each category: 
* Medications were mislabeled or stored improperly; 
* A list of look-alike/sound-alike medications was not developed. 

2. Documentation of the competency of medical and behavioral health 
staff; 
Type of accreditation: Ambulatory care/behavioral health care; 
Examples of deficiencies cited in each category: 
* The initial assessment of staff clinical competence was not 
documented; 
* An assessment of clinical competency was not documented for staff 
during performance reviews; 
* No primary source verification of the education of the clinical 
psychologist. 

3. Inmate assessments; 
Type of accreditation: Behavioral health care; 
Examples of deficiencies cited in each category: 
* Inmate assessments did not include information on addictions other 
than alcohol or drugs. 

4. Inmate treatment plans; 
Type of accreditation: Behavioral health care; 
Examples of deficiencies cited in each category: 
* Inmate treatment plans did not include goals and metrics to measure 
an inmate's progress. 

Source: GAO analysis of Joint Commission Accreditation reports. 

[End of table] 

[End of section] 

Appendix VII: Bureau of Prisons' Elements of Modified Therapeutic 
Communities: 

Element of a modified therapeutic community: Community as method; 
Examples of standards contained in each element: 
* 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. 

Element of a modified therapeutic community: Unit appearance; 
Examples of standards contained in each element: 
* 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. 

Element of a modified therapeutic community: Rules and norms; 
Examples of standards contained in each element: 
* 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. 

Element of a modified therapeutic community: Staff roles; 
Examples of standards contained in each element: 
* 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. 

Element of a modified therapeutic community: Supervision and training; 
Examples of standards contained in each element: 
* 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. 

Element of a modified therapeutic community: Transition; 
Examples of standards contained in each element: 
* 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: Community activities; 
Examples of standards contained in each element: 
* 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. 

Element of a modified therapeutic community: Treatment phase through 
journals; 
Examples of standards contained in each element: 
* 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. 

Element of a modified therapeutic community: Small therapy groups; 
Examples of standards contained in each element: 
* 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. 

Element of a modified therapeutic community: Community jobs; 
Examples of standards contained in each element: 
* Community jobs are described, posted, and selected based on 
therapeutic need; 
* Participants are able to describe their jobs and how they relate to 
the modified therapeutic community and recovery; 
* Staff monitor job assignments and work groups in the community and 
use incentives and sanctions to promote positive behavior and reduce 
negative behavior. 

Source: GAO analysis of Bureau of Prisons information. 

Notes: The Residential Drug Abuse Treatment Program targets inmates at 
the end of their sentence who volunteer for drug abuse treatment and 
have a verifiable and diagnosable substance abuse condition. The 
Challenge Program is a residential program designed to facilitate 
favorable institutional adjustment and successful reintegration into 
the community for high-security inmates with a history of substance 
abuse or a major mental illness. 

[End of table] 

[End of section] 

Appendix VIII: Bureau of Prisons (BOP) Program Statements Related to 
Mental Health Services for Inmates: 

BOP program statement: Psychology Services Manual; 
Description: Establishes operational policy, procedures, and 
guidelines for the delivery of psychological services within BOP; 
Date program statement was last updated: March 7, 1995. 

BOP program statement: Institution Management of Mentally Ill Inmates; 
Description: Establishes policy, procedures, standards, and guidelines 
for managing mentally ill inmates in all regular (i.e., non-medical) 
correctional institutions; 
Date program statement was last updated: March 31, 1995. 

BOP program statement: Psychiatric Services; 
Description: Establishes policy, procedures, and guidelines related to 
the identification of inmates in need of psychiatric services, 
psychiatric diagnostic and treatment services, and continuity of 
psychiatric care; 
Date program statement was last updated: January 15, 2005. 

BOP program statement: Suicide Prevention Program; 
Description: Establishes the components of a suicide prevention 
program that should be in place at each institution; 
Date program statement was last updated: April 5, 2007. 

BOP program statement: Forensic and Other Mental Health Evaluations; 
Description: Describes the procedures BOP shall follow to prepare a 
psychological or psychiatric evaluation on an inmate committed to its 
custody; 
Date program statement was last updated: April 16, 2008. 

BOP program statement: Psychology Treatment Programs; 
Description: Establishes policy, procedures, and guidelines for the 
delivery of psychology treatment programs; 
Date program statement was last updated: March 16, 2009. 

BOP program statement: Psychiatric Evaluation and Treatment; 
Description: Describes procedures for voluntary and involuntary 
psychiatric evaluation, hospitalization, care, and treatment, in a 
suitable facility, for persons in BOP custody; 
Date program statement was last updated: July 13, 2011. 

BOP program statement: Sex Offender Programs; 
Description: Establishes procedures and guidelines for Sex Offender 
Treatment and Management Services in BOP; 
Date program statement was last updated: February 15, 2013. 

Source: GAO analysis of BOP program statements. 

[End of table] 

[End of section] 

Appendix IX: GAO Contacts and Staff Acknowledgments: 

GAO Contacts: 

David C. Maurer, (202) 512-9627 or maurerd@gao.gov: 

Debra A. Draper, (202) 512-7114 or draperd@gao.gov: 

Staff Acknowledgments: 

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. 

[End of section] 

Footnotes: 

[1] For the purposes of this review, we are defining mental health 
services as (1) psychiatric and psychological treatments provided to 
inmates, such as group and individual psychotherapy sessions, crisis 
intervention and counseling, and clinical case management; (2) 
psychology treatment programs--typically involving standard protocols 
that apply to all participants--including residential and 
nonresidential drug treatment programs, sex offender management 
programs, and other specialized mental health treatment programs; and 
(3) psychotropic medication used for the purposes of treating mental 
illness. 

[2] For example, in May 2011, the United States Supreme Court held in 
the case of Brown, Governor of California v. Plata, 131 S.Ct. 1910, 
that to remedy the violation of a federal right, specifically the 
severe and unlawful mistreatment of prisoners through grossly 
inadequate provision of medical and mental health care, it was 
necessary to institute a court-mandated prison population limit. The 
court recognized that for years the medical and mental health care 
provided by California's prisons had fallen short of minimum 
constitutional requirements and had failed to meet prisoners' basic 
health needs. Adequate medical and mental health care must meet 
minimum constitutional requirements and meet prisoners' basic health 
needs. 

[3] Privately managed contract facilities house low-security, 
specialized populations such as sentenced criminal aliens. A criminal 
alien is a noncitizen in the United States, who may be present on a 
lawful basis or not, who has been convicted of a crime. During the 
course of our review, BOP had 15 contract facilities, which we 
included in our study; however, as of May 31, 2013, the contract for 1 
facility was terminated and therefore as of this date BOP had 14 
contract facilities. 

[4] According to BOP guidance, mental illness includes: anxiety 
disorders (such as post-traumatic stress disorder), mood disorders 
(such as depression), psychotic disorders (such as schizophrenia), 
somatization disorders (which are a psychiatric condition in which the 
sufferer experiences multiple physical symptoms that are not explained 
by disease), eating disorders, and personality disorders (excluding 
antisocial personality disorder) that involve a rigid and unhealthy 
pattern of thinking and behaving. 

[5] Urban Institute, Opportunities for Cost Savings in Corrections 
Without Sacrificing Service Quality: Inmate Health Care (Washington, 
D.C.: February, 2013). 

[6] Bureau of Justice Statistics, Bureau of Justice Statistics Special 
Report: Mental Health Problems of Prison and Jail Inmates (September 
2006). The Bureau of Justice Statistics is a DOJ agency that collects, 
analyzes, publishes, and disseminates information on crime, criminal 
offenders, victims of crimes, and the operation of the justice systems 
at all levels of government. 

[7] Philip R. Magaletta, Pamela M. Diamond, Erik Faust, Dawn M. 
Daggett, and Scott D. Camp, "Estimating the Mental Illness Component 
of Service Need in Corrections: Results From the Mental Health 
Prevalence Project," Criminal Justice and Behavior, vol. 36, no. 3 
(March 2009), 229-244. The authors of this study excluded from their 
definition the most severely disturbed inmates who are housed in 
medical facilities and those who receive psychological services as a 
result of policy, such as those placed in segregated housing units. 
Segregated housing units are units within an institution where 
prisoners are kept apart from the general population in highly 
restrictive conditions for administrative reasons, such as pending 
transfer to another prison, or disciplinary reasons, such as violating 
prison rules. 

[8] We limited our projections to 3 years as projections that are 
further into the future are less reliable. 

[9] ACA's mission includes the development and promotion of effective 
standards for the care, custody, training, and treatment of offenders. 
The Joint Commission accredits and certifies health care organizations 
and programs in the United States. 

[10] In some cases, a number of institutions belong to a Federal 
Correctional Complex (FCC). At FCCs, institutions with different 
missions and security levels are located in proximity to one another. 
For an FCC, BOP performs one program review for the entire complex and 
not for the individual institutions that make up the complex. For 
purposes of this report, we use the term institution to refer to 
either a single institution or a complex of institutions that is 
considered a single unit for program review purposes. Therefore, BOP 
conducted 94 program reviews for the 116 institutions that were 
operating long enough to have a program review as of August 2012. 
Three additional institutions were not operating long enough to 
undergo a program review as of August 31, 2012. Program reviews begin 
at an institution 18 to 24 months after the institution opens. 

[11] GAO, Standards for Internal Control in the Federal Government, 
[hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1] 
(Washington, D.C.: November 1999), and Project Management Institute, A 
Guide to the Project Management Body of Knowledge (PMBOK® Guide), 5th 
ed. (Newtown Square, PA: 2013). A Guide to the Project Management Body 
of Knowledge provides standards for project managers. 

[12] As with program reviews, a single accreditation report may cover 
either a single institution or a complex with multiple institutions. 
For the 47 institutions in our sample, we analyzed 37 Joint Commission 
accreditation reports because not all BOP institutions are required to 
obtain Joint Commission accreditation. 

[13] We chose the two institutions because they provided different 
levels of care, and their program reviews were being conducted within 
the timeframe of our study. While the observations from these visits 
are not generalizable to all BOP institutions or to all program 
reviews, the visits provided important perspectives about the program 
review process. 

[14] During the course of our review, the contract for one contract 
facility was terminated on May 31, 2013; the private firm that managed 
this facility declined to provide its views. 

[15] There are four security level designations for institutions that 
house males--minimum, low, medium, and high--and three for 
institutions that house females--minimum, low, and high. The security 
level designation of a facility depends on the level of security and 
staff supervision that the institution is able to provide, such as the 
presence of security towers, perimeter barriers, the type of inmate 
housing, and inmate-to-staff ratio. BOP also has administrative 
facilities that house inmates of all security levels. 

[16] In addition to the federal institutions and contract facilities, 
BOP also houses about 13,300, or 6 percent, of inmates that fall under 
community corrections management, which includes 185 residential 
reentry centers and in-home detention. Residential reentry centers 
provide a structured, supervised environment and counseling, job 
placement, and other services to facilitate inmates' reentry to the 
community after a period of incarceration. We did not review mental 
health services provided in residential reentry centers because they 
were outside the scope of our work. 

[17] In addition to Correctional Programs and Health Services, the 
other program divisions are Administration; Human Resource Management; 
Industries, Education, and Vocational Training; Information, Policy, 
and Public Affairs; Office of General Counsel; and Program Review. 

[18] BOP also has a separate medical care level designation system, 
which it implemented in 2004. 

[19] Psychotic disorders other than schizophrenia include 
schizoaffective disorder (a mental condition that causes both a loss 
of contact with reality and mood problems), delusional disorder, and 
brief psychotic disorder. 

[20] A personality disorder is an enduring pattern of inner experience 
and behavior that deviates markedly from the expectations of the 
individual's culture, is pervasive and inflexible, has an onset in 
adolescence or early adulthood, persists over time, and leads to 
distress or impairment. BOP excludes consideration of antisocial 
personality disorder in designating an inmate to a mental health care 
level because, according to BOP officials, such a large proportion of 
BOP's inmate population could be diagnosed with antisocial personality 
disorder. Another type of personality disorder is borderline 
personality disorder. Individuals with borderline personality disorder 
have long-term patterns of unstable or turbulent emotions that often 
result in impulsive actions and chaotic relationships with other 
people. 

[21] According to BOP, a superior rating indicates the program is 
performing all vital functions and a history of strong internal 
controls exists resulting in zero or very minimal deficiencies. A good 
rating demonstrates the program's vital function areas are sound and 
internal controls are strong. An acceptable rating is the baseline 
rating, and each program is assumed to be performing at this level at 
the beginning of the review. BOP policy states that institutions with 
an acceptable rating may have deficiencies, but they do not detract 
from the adequate accomplishment of the vital functions. A deficient 
rating demonstrates that one or more vital functions of the program 
are not being performed at an acceptable level and internal controls 
are weak. An at-risk rating demonstrates that the program is impaired 
to the point that it is not accomplishing its overall mission and 
internal controls do not demonstrate substantial continued compliance. 

[22] The five areas are administration and management, physical plant, 
institutional operations, institutional services, and inmate programs. 

[23] For example, one standard requires institutions to have a mental 
health program that includes, among other services, screening for 
mental health problems on intake, outpatient services, crisis 
intervention, and stabilization of the mentally ill. 

[24] Standards are not applicable if the institution does not serve 
the specific population covered by the standard or does not have a 
specific program covered by the standard. For instance, all standards 
relating specifically to the treatment of female inmates are not 
applicable to an institution that houses only male inmates. 

[25] According to BOP officials, medical care level 1 institutions are 
not required to be accredited for ambulatory care by The Joint 
Commission. 

[26] Four BOP institutions--Federal Medical Center Rochester, U.S. 
Medical Center Springfield, Federal Medical Center Devens, and 
Metropolitan Correctional Center in New York--also have behavioral 
health accreditations because they have inpatient psychiatric units or 
a treatment program for individuals addicted to pain-relieving drugs, 
such as oxycodone or morphine. Two additional institutions--Federal 
Correctional Complex Butner and Federal Medical Center Carswell--have 
psychiatric units within inpatient hospital facilities that are also 
accredited under The Joint Commission's hospital standards. 

[27] Pursuant to 18 U.S.C. § 3621(e), BOP is required to make 
available appropriate substance abuse treatment for each prisoner the 
BOP determines has a treatable condition of substance addiction or 
abuse, including the provision of residential substance abuse 
treatment for all eligible prisoners (and make arrangements for 
appropriate aftercare), subject to the availability of appropriations. 

[28] The cost data for psychotropic medications may not be exact 
because some psychotropic medications can be used to treat certain non-
mental health conditions and some non-psychotropic medications can be 
used to treat certain mental health conditions. For example, 
antihistamines used to treat allergies are considered psychotropic 
medications. 

[29] RDAP targets inmates who volunteer for drug abuse treatment and 
have a verifiable and diagnosable substance abuse disorder. 

[30] The psychology services PRGs do not contain program review steps 
related to sexual offender treatment programs because BOP issued the 
related program statement in February 2013, and had not yet developed 
PRG steps related to these programs. According to BOP officials, they 
anticipate that a meeting to develop PRGs related to these programs 
will occur in May 2013. 

[31] An example of a deficiency related to care provided in a 
residential treatment unit was that not all inmates who completed RDAP 
were enrolled in follow-up services in a timely manner. Inmates who 
complete the residential portion of RDAP are to receive follow-up 
services in their institution or in the community at a residential 
reentry center. 

[32] A suicide risk assessment is a psychologist's assessment of an 
inmate's potential for suicide. Suicide watch logs are documentation 
of observations of an inmate's behavior while the inmate is on suicide 
watch. After each suicide watch, a psychologist completes a report 
that documents the guidelines for the inmate's follow-up care. 

[33] The estimate is 66.0 percent. The differences in the reported 
estimates are due to rounding error. The associated 95 percent 
confidence interval is (54.3, 76.6). 

[34] The estimate is 23.4 percent. The associated 95 percent 
confidence interval is (14.9, 34.0). 

[35] For the estimate of 70 percent, the confidence interval is 54.3 
to 76.6 percent; and for the estimate of 6 percent , the confidence 
interval is 3.2 to 14.9 percent. 

[36] BOP requires all institutions to conduct their own internal 
audits in each program area. These reviews, called operational 
reviews, use the same PRGs that are used by Program Review staff 
during their reviews. Operational reviews are expected to be conducted 
10 to 14 months from the week of the previous program review. For 
those institutions with a good or superior rating, an additional 
operational program review should be conducted 22 to 26 months from 
the week of the previous program review. In addition, according to BOP 
officials, if a program review is delayed, the institution is still 
required to conduct an annual operational review. 

[37] BOP requires institutions to conduct their own internal audits in 
each program area. These reviews, called operational reviews, use the 
same PRGs that are used by Program Review staff during program 
reviews. Operational reviews should be conducted 10 to 14 months from 
the week of the previous program review. For those institutions with a 
good or superior rating, an additional operational program review 
should be conducted 22 to 26 months from the week of the previous 
program review. In addition, according to BOP officials, if a program 
review is delayed, the institution is required to conduct an internal 
operational review annually. 

[38] We found that institutions were generally following the time 
frames specified in BOP policy with regard to the submission of 
corrective action plans. Among the 35 institutions that were required 
to submit corrective action plans in response to a psychology services 
program review, 33 submitted the plans within BOP's established time 
frame of 30 days. The remaining 2 submitted their corrective action 
plans within 10 additional days. 

[39] Project Management Institute, A Guide to the Project Management 
Body of Knowledge (PMBOK® Guide), Fifth Edition. We have used A Guide 
to the Project Management Body of Knowledge as criteria in previous 
reports, including Nonproliferation and Disarmament Fund: State Should 
Better Assure the Effective Use of Program Authorities, [hyperlink, 
http://www.gao.gov/products/GAO-13-83]. 

[40] GAO, Bureau of Prisons: Growing Inmate Crowding Negatively 
Affects Inmates, Staff, and Infrastructure, [hyperlink, 
http://www.gao.gov/products/GAO-12-743] (Washington, D.C.: Sept. 12, 
2012). 

[41] According to BOP guidance, a psychologist or psychiatrist should 
meet with all inmates classified as mental health care level 3 more 
frequently than monthly. 

[42] 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. 

[43] 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. 

[44] For each institution, headquarters staff did a reclassification 
of one or two of the inmates who were receiving a level of care higher 
than their mental health care level designation indicated. 
Headquarters staff then sent these one or two examples of 
reclassification, along with a list of all inmates who may require 
reclassification at the institution, to the institution for further 
review. 

[45] The other three mandatory standards relate to the required 
elements of an institution's mental health program, mental health 
screenings for inmates transferred from another institution within the 
same system, and suicide prevention plans. The three non-mandatory 
mental health standards relate to providers' credentials, the 
timeliness of certain mental health evaluations, and the placement of 
inmates with severe mental illness or developmental disorders. 

[46] 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. 

[47] GAO, Designing Evaluations, 2012 Revision, [hyperlink, 
http://www.gao.gov/products/GAO-12-208G] (Washington, D.C.: Jan. 2012). 

[48] The BRAVE program, which addresses institutional adjustment, 
antisocial attitudes and behaviors, and motivation to change, is for 
inmates 32 years old and younger serving sentences of at least 60 
months. 

[49] Specifically, 44.3 percent of male inmates who completed RDAP 
were likely to be rearrested or have their supervision revoked because 
of a violation of their conditions of supervision within 3 years after 
release to supervision in the community. In comparison, 52.5 percent 
of inmates who did not receive treatment were rearrested or had their 
supervision revoked within 3 years. For women, 24.5 percent of those 
who completed RDAP were likely to be rearrested or have their 
supervision revoked within 3 years after release, compared with 29.7 
percent of the untreated women. Among female inmates, the effect of 
treatment was not statistically significant. See Federal Bureau of 
Prisons, Office of Research and Evaluation, TRIAD Drug Treatment 
Evaluation Project Final Report of Three-Year Outcomes: Part 1 
(Washington, D.C.: 2000). 

[50] The Sex Offender Treatment Program is a high-intensity 12-to 18-
month program designed for high-risk sexual offenders. 

[51] Pub. L. No. 110-199, § 231 122 Stat. 657, 683-86 (2008). 
Subsequent to the Second Chance Act of 2007, BOP was appropriated $2.6 
million to conduct the activities to provide the report. 

[52] Project Management Institute, A Guide to the Project Management 
Body of Knowledge (PMBOK® Guide), Fifth Edition. 

[53] The two program statements that have not been updated since 1995 
are the program statement that serves as the Psychology Services 
Manual, which establishes policies, procedures, and guidelines for the 
provision of psychology services throughout BOP, and the program 
statement on institution management of mentally ill inmates, which 
establishes policies, procedures, and guidelines for the management of 
mentally ill inmates at regular (i.e., nonmedical) correctional 
institutions. 

[54] [hyperlink, http://www.gao.gov/products/GAO/AIMD-00-21.3.1]. 

[55] According to BOP, performance-based contracts generally establish 
the performance standards for the contractor, including those related 
to mental health services, and it is up to the individual contractors 
to determine how they will meet those standards. BOP's fixed-priced 
contracts only require the contractors to provide BOP with their costs 
on a per inmate per day basis. 

[56] This daily rate covers all the costs the facility incurs to house 
the inmate, including for mental health services. BOP inmates housed 
in contract facilities are designated as a low security level, and 
most have a mental health care level designation of 1 or 2. 

[57] Pursuant to the contract and the Federal Acquisition Regulation, 
48 C.F. R. § 52.246-4, if any of the services do not conform with 
contract requirements and the defects in services cannot be corrected 
by performance, the government may reduce the contract price to 
reflect the reduced value of the services performed. 

[58] One of the contractor companies operates several private 
facilities, but for two of those facilities it acts as a subcontractor 
to operate the facility. Throughout this report we will refer to this 
company as a primary contractor. 

[59] We did not speak to one primary contractor that manages 1 of 
BOP's 15 contract facilities: the contractor declined to participate 
in interviews because the contract was terminated as of May 31, 2013. 

[60] We did not request cost information from one contractor because a 
subcontractor provides mental health services in its BOP contract 
facilities; this subcontractor is not the same subcontractor we 
interviewed. 

[61] In conducting our analysis, we determined that a deficiency was 
related to mental health if it involved psychology, psychiatry, or 
pharmacy care, as these areas have relevance to the provision of 
mental health services. 

[62] This contract facility had since submitted its corrective action 
plan to ACA and was granted reaccreditation. 

[63] According to The Joint Commission, a facility is found to be 
partially compliant if it has two occurrences of noncompliance with 
the standard's area during the review. A facility is found to be 
insufficiently compliant with the standards if it has three or more 
occurrences of noncompliance in the standard's area during the review. 
As a part of the scoring, The Joint Commission considers the potential 
risk to patient care or safety for noncompliance. 

[64] The ambulatory care accreditation covers the broad categories of 
surgical, medical/dental, and diagnostic/therapeutic services, and 
represents a variety of settings, including outpatient hospitals and 
prisons. The behavioral health accreditation focuses on organizations 
that provide services to persons with intellectual and developmental 
disabilities, as well as mental health and chemical dependency 
services. 

[65] As of April 2013, all 7 of the facilities that had been found to 
be either partially or insufficiently compliant with Joint Commission 
standards have since submitted their corrective action plans to The 
Joint Commission and were granted reaccreditation. 

[66] According to the contractor, it wanted to have more specific time 
frames because it relies more on master's-level clinicians than on the 
doctoral-level clinicians more prevalent at BOP institutions. 

[67] IHS Global Insight is a firm that provides comprehensive economic 
and financial information on countries, regions, and industries. 

[68] GAO, Standards for Internal Control in the Federal Government, 
[hyperlink, http://www.gao.gov/products/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. 

[69] 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. 

[70] In some cases, a number of institutions belong to a Federal 
Correctional Complex (FCC). At FCCs, multiple institutions with 
different missions and security levels are located in proximity to one 
another. For an FCC, BOP performs one program review for the entire 
complex, and not for the individual institutions that make up the 
complex. For purposes of this report, we use the term institution to 
refer to either a single institution or a complex of institutions that 
is considered a single unit for program review purposes. Therefore, 
BOP conducted 94 program reviews for the 116 institutions that had 
been operating long enough to undergo a program review as of August 
31, 2012. Three additional institutions were not operating long enough 
to undergo a program review as of August 31, 2012. Program reviews 
begin at an institution 18 to 24 months after the institution opens. 

[71] The hypergeometric distribution is used when sampling without 
replacement from a small population whose elements can be classified 
into two mutually exclusive categories (i.e., Yes/No). 

[72] ACA's mission includes the development and promotion of effective 
standards for the care, custody, training, and treatment of offenders. 
The Joint Commission accredits and certifies health care organizations 
and programs in the United States. 

[73] As with program reviews, a single accreditation report may cover 
either a single institution or a complex with multiple institutions. 
For the 47 institutions in our sample, we analyzed 37 Joint Commission 
accreditation reports. Nine of the 47 institutions were medical care 
Level 1 institutions and therefore are not required to be accredited 
by The Joint Commission. An additional institution changed from a 
Level 1 to a Level 2 institution and had not gone through 
accreditation. Level 1 institutions serve the healthiest inmates. 

[74] Executive Office of the President, Office of Management and 
Budget, Office of Federal Procurement Policy, Memorandum for Chief 
Acquisition Officers and Senior Procurement Executives: Increasing 
Competition and Structuring Contracts for the Best Results 
(Washington, D.C.: Oct. 27, 2009). 

[75] One of the contractor companies operates several private 
facilities, and for one of those facilities it has a subcontract from 
the primary contractor to operate the facility. Throughout this report 
we refer to this company as a primary contractor. 

[76] The associated 95 percent confidence interval for 89.4 percent is 
(79.8, 94.7), and for 76.6 percent is (66.0, 85.1). 

[77] Four BOP institutions--Federal Medical Center Rochester, U.S. 
Medical Center Springfield, Federal Medical Center Devens, and 
Metropolitan Correctional Center in New York--also have behavioral 
health accreditations because they have inpatient psychiatric units or 
a treatment program for individuals addicted to pain relieving drugs, 
such as oxycodone or morphine. Two additional institutions--Federal 
Correctional Complex Butner and Federal Medical Center Carswell--have 
psychiatric units within inpatient hospital facilities that are also 
accredited under The Joint Commission's hospital standards. 

[78] The ambulatory care accreditation covers the broad categories of 
surgical, medical/dental, and diagnostic/therapeutic services, and 
represents a variety of settings, including outpatient hospitals and 
prisons. The behavioral health accreditation focuses on organizations 
that provide services to persons with intellectual and developmental 
disabilities, as well as mental health and chemical dependency 
services. 

[End of section] 

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