Bureau of Prisons:

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

GAO-13-1: Published: Jul 17, 2013. Publicly Released: Jul 17, 2013.

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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.

Why GAO Did This Study

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

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

What GAO Recommends

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

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.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In July 2013, we reported on the Department of Justice's (DOJ) Federal Bureau of Prisons' (BOP) efforts to provide mental health services to federal inmates. We found, among other things, that BOP conducted internal reviews to assess BOP-operated institutions' compliance with its policies related to mental health services, but that the majority of the reviews we examined did not occur within the BOP-specified time frames. As a result, we recommended that, when program reviews are delayed, BOP ensures that institutions with the lowest ratings on its psychology and health services reviews receive the highest priority for the completion of subsequent reviews. In response to this recommendation, in October 2014 BOP revised its Program Review Schedule Instructions, which are provided to the Program Review Branch (PRB) section chiefs. The instructions provide guidance in preparing the review schedule for the upcoming fiscal year. In the revised instructions, BOP first instructs PRB section chiefs to schedule all reviews one month prior to the actual due date. This will allow for a cushion in case a review is delayed. Further, the instructions state that in the event of a delay due to an assigned examiner not being able to conduct a review as scheduled, another examiner will be selected to conduct the review. Finally, the instructions state that if a review is delayed due to uncontrollable circumstances, Program Review Division (PRD) staff will ensure that the review is scheduled and conducted at the earliest possible time, and that an official schedule change memorandum should be submitted to and approved by the PRD Assistant Director. As a result of these actions, BOP is better positioned to make sure reviews, including reviews for institutions with the lowest ratings, are conducted in a timely manner.

    Recommendation: 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, the Director of BOP should, when program reviews are delayed, ensure institutions with the lowest ratings receive the highest priority for the completion of reviews.

    Agency Affected: Department of Justice: Bureau of Prisons

  2. Status: Open

    Comments: We followed up with the Bureau of Prisons (BOP) and as of October 2014, BOP had taken no action on this recommendation.

    Recommendation: 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, the Director of BOP should 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.

    Agency Affected: Department of Justice: Bureau of Prisons

  3. Status: Open

    Comments: In June 2014, the Bureau of Prisons (BOP) stated that it developed and issued a revised version of the Institution Management of Mentally Ill Inmates program statement on May 1, 2014. The new program statement is titled Treatment and Care of Inmates with Mental Illness. According to BOP officials, the new program statement emphasizes a recovery model of mental health, evidence-based practices, interdisciplinary collaboration, the availability of services across all security levels, and continuity of care as offenders release to their communities. Field staff received training on the revised program statement on May 19, 2014. BOP is also in the process of updating its Psychology Services Manual, which is still being reviewed. BOP developed and implemented one updated program statement and is in the process of updating another. Once both updated program statements have been issued, BOP will be better positioned to ensure consistent adherence to policies and to reduce any confusion that may alter the provision or quality of inmate mental health care.

    Recommendation: To ensure policies related to inmate mental health care accurately reflect current practices, the Director of BOP should develop and implement updated program statements to ensure that these statements reflect currently accepted treatment practices and standards.

    Agency Affected: Department of Justice: Bureau of Prisons

 

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