District of Columbia Jail: Medical Services Generally Met	 
Requirements and Costs Decreased, but Oversight Is Incomplete	 
(30-JUN-04, GAO-04-750).					 
                                                                 
Since the end of a court-ordered receivership overseeing medical 
services at the District of Columbia Jail in September 2000, the 
Department of Corrections (DoC) has contracted with the Center	 
for Correctional Health and Policy Studies, Inc. (CCHPS) to	 
provide inmate medical services. GAO was asked to provide	 
information on (1) the medical services DoC contracted with CCHPS
to provide, including CCHPS's monitoring of its services; (2)	 
mechanisms DoC established to oversee CCHPS's services; (3)	 
CCHPS's contract compliance and DoC's efforts to ensure 	 
compliance; and (4) the cost of medical services. To collect this
information, GAO analyzed documents and interviewed officials	 
from District agencies, CCHPS officials, and an independent	 
reviewer hired by DoC to monitor medical services.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-750 					        
    ACCNO:   A10712						        
  TITLE:     District of Columbia Jail: Medical Services Generally Met
Requirements and Costs Decreased, but Oversight Is Incomplete	 
     DATE:   06/30/2004 
  SUBJECT:   Contract oversight 				 
	     Correctional facilities				 
	     Cost analysis					 
	     Health care costs					 
	     Health care facilities				 
	     Health care services				 
	     Monitoring 					 
	     Municipal governments				 
	     Prisoners						 
	     Service contracts					 

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GAO-04-750

United States General Accounting Office

      GAO Report to the Chairman, Committee on Government Reform, House of
                                Representatives

June 2004

DISTRICT OF COLUMBIA JAIL

 Medical Services Generally Met Requirements and Costs Decreased, but Oversight
                                 Is Incomplete

GAO-04-750

Highlights of GAO-04-750, a report to the Chairman, Committee on
Government Reform, U.S. House of Representatives

Since the end of a court-ordered receivership overseeing medical services
at the District of Columbia Jail in September 2000, the Department of
Corrections (DoC) has contracted with the Center for Correctional Health
and Policy Studies, Inc. (CCHPS) to provide inmate medical services. GAO
was asked to provide information on (1) the medical services DoC
contracted with CCHPS to provide, including CCHPS's monitoring of its
services; (2) mechanisms DoC established to oversee CCHPS's services; (3)
CCHPS's contract compliance and DoC's efforts to ensure compliance; and
(4) the cost of medical services. To collect this information, GAO
analyzed documents and interviewed officials from District agencies, CCHPS
officials, and an independent reviewer hired by DoC to monitor medical
services.

GAO is recommending that the Mayor of the District of Columbia require the
Director of DoC to (1) develop formal procedures, including collection of
needed data, for determining whether CCHPS has met performance standards
linked to monetary damages and for imposing these damages; and (2) ensure
that CCHPS submits required quarterly and annual progress reports
describing service problems and corrective actions. In reviewing a draft
report, DoC did not comment on our recommendations, but provided
additional information.

www.gao.gov/cgi-bin/getrpt?GAO-04-750.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Marcia Crosse at (202)
512-7119 or [email protected].

June 2004

DISTRICT OF COLUMBIA JAIL

Medical Services Generally Met Requirements and Costs Decreased, but Oversight
Is Incomplete

DoC has contracted with CCHPS to provide a broad range of medical services
to inmates at the District of Columbia Jail and the Correctional Treatment
Facility (CTF)-an adjacent overflow facility. Services include health
screenings at intake; primary care services, including care for chronic
conditions; mental health care; and specialty care. In addition, CCHPS
assists DoC in helping inmates obtain services not included in the
contract, such as specialty or emergency services that cannot be offered
on-site. As part of the contract, CCHPS also established a quality
improvement program to monitor its services. A key component of the
program is a quarterly analysis of random samples of inmate medical
records to measure how consistently CCHPS delivers required services.

DoC established several mechanisms to oversee CCHPS's delivery of medical
services to inmates. For example, DoC retained an independent reviewer to
monitor the services provided by CCHPS on a quarterly basis. In addition,
the contract gives DoC authority to impose monetary damages on CCHPS if it
fails to meet any of 12 requirements specified in the contract, most of
which relate to providing key services to a minimum percentage of inmates.
The contract also requires CCHPS to submit quarterly and annual progress
reports describing quality problems identified by the independent reviewer
or its own monitoring and actions taken to correct them.

Although available evidence indicates that CCHPS has generally complied
with the terms of its contract, DoC has not exercised sufficient oversight
to provide assurance that problems are not occurring or are quickly
corrected. The independent reviewer has consistently found that CCHPS's
services meet the contract's overall requirements for access to care and
quality, but has also reported that CCHPS has not always met certain
requirements. For example, while CCHPS recently improved its performance
in providing timely follow-up services to inmates with abnormal chest
x-ray results, the independent reviewer had repeatedly found problems in
this area. DoC has not taken actions that would allow it to be assured of
CCHPS's compliance with contract requirements linked to monetary damages.
The agency has not collected data or developed a formal procedure to
determine whether CCHPS has met the requirements, and it lacks a procedure
to impose damages if warranted. Also, DoC has not regularly enforced the
contract requirement that CCHPS submit quarterly and annual progress
reports describing quality problems and corrective actions, and CCHPS has
often not submitted these reports.

From 2000 to 2003, the average daily cost of providing medical services to
a Jail inmate decreased by almost one-third, from about $19 a day per
inmate to about $13 a day. In 2003, DoC consolidated the services provided
to inmates in the Jail and the CTF under one contract with CCHPS. In that
year, during which 17,431 inmates were admitted to the Jail and the CTF,
the total cost of providing medical services at both facilities was about
$15.8 million.

Contents

  Letter

Results in Brief
Background
CCHPS Provides a Range of Services to Inmates and Has

Established Systems to Monitor Service Quality
DoC Established Several Mechanisms to Oversee CCHPS's
Delivery of Medical Services
CCHPS Generally Meets Contract Requirements, but DoC's

Oversight of CCHPS Is Incomplete
Average Per Inmate Medical Cost at Jail Has Decreased
Conclusions
Recommendations for Executive Action
Agency Comments and Our Evaluation

                                       1

                                      3 5

                                       8

14

15 19 25 26 27

Appendix I Scope and Methodology

Appendix II 	Requirements Linked to Monetary Damages Provisions in the
CCHPS Contract

Appendix III 	Performance Assessment Instruments Used to Monitor Services
Provided by CCHPS

Appendix IV 	Comments from the District of Columbia Department of
Corrections

  Appendix V GAO Contact and Staff Acknowledgments 47

GAO Contact 47
Acknowledgments 47

  Tables

Table 1: Medical Services Provided by CCHPS to Inmates at the Jail and the
CTF, March 2004 10 Table 2: Summary of Contract Requirements with Monetary
Damages Provisions 33 Table 3: Information on Performance Assessment
Instruments Used to Monitor CCHPS's Services 36

  Figures

Figure 1: Total Annual Cost of Medical Services at the District of
Columbia Jail, 2000-2003 21 Figure 2: Average Daily Inmate Population at
the District of Columbia Jail, 2000-2003 22 Figure 3: Average Daily Cost
Per Inmate of Medical Services at the District of Columbia Jail, 2000-2003
23

Abbreviations

ACA American Correctional Association
CCA Corrections Corporation of America
CCHPS Center for Correctional Health and Policy Studies, Inc.
CTF Correctional Treatment Facility
DMH District of Columbia Department of Mental Health
DoC District of Columbia Department of Corrections
DoH District of Columbia Department of Health
FMCS Family and Medical Counseling Services, Inc.
FTE full-time equivalent
HIV human immunodeficiency virus
LPN licensed practical nurse
MAR medication administration record
NCCHC National Commission on Correctional Health Care
NP nurse practitioner
PA physician assistant
RN registered nurse

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separately.

United States General Accounting Office Washington, DC 20548

June 30, 2004

The Honorable Tom Davis
Chairman
Committee on Government Reform
House of Representatives

Dear Mr. Chairman:

The District of Columbia Department of Corrections (DoC) is responsible
for providing medical services to inmates of the District of Columbia
Jail1
and the Correctional Treatment Facility (CTF), an overflow facility
adjacent to the Jail. From August 1995 until September 2000, medical
services at the Jail were under the control of a court-ordered Receiver
because DoC had not complied with repeated court orders to provide
adequate care to inmates. The Receiver contracted with the Center for
Correctional Health and Policy Studies, Inc. (CCHPS), a private not-for
profit organization, to provide medical services at the Jail beginning in
March 2000.2 When the receivership ended, the court returned
responsibility for the Jail's medical services to DoC, which continued to
contract with CCHPS. In April 2003, DoC expanded its contract with
CCHPS to include medical services provided to inmates housed at the
CTF.

In June 2000, shortly before the court terminated the receivership, we
testified before the Subcommittee on the District of Columbia on selected
issues related to medical services provided at the Jail.3 In response to
questions about the cost and level of services, we reported that the per
inmate cost of medical services at the Jail exceeded the cost in two other
jurisdictions4 and that there were no specific criteria to determine an

1The Jail is also known as the Central Detention Facility.

2The contract with CCHPS was renewable annually for up to 4 years after
the initial contract year.

3See U.S. General Accounting Office, District of Columbia Receivership:
Selected Issues Related to Medical Services at the D.C. Jail,
GAO/T-GGD-00-173 (Washington, D.C.: June 30, 2000).

4This earlier report reviewed costs and services in Baltimore and Prince
George's County, Maryland.

acceptable level of medical services and staffing at the Jail. You asked
us to obtain information on the District of Columbia's progress in
providing medical services to inmates since the receivership ended and
what mechanisms exist to monitor the quality of these services. We are
reporting on (1) the medical services DoC has contracted with CCHPS to
provide to inmates held at the Jail and the CTF, including CCHPS's
monitoring of those services; (2) the mechanisms DoC established to
oversee the services provided by CCHPS; (3) CCHPS's compliance with the
requirements in its contract and DoC's efforts to ensure CCHPS's
compliance; and (4) the cost of providing medical services at the Jail
from 2000 to 2003 and the current cost of medical services at the Jail and
the CTF.

To examine the medical services provided to inmates, CCHPS's monitoring of
those services, and DoC's oversight of CCHPS's contract compliance, we
analyzed documents and interviewed officials from DoC and CCHPS. In doing
our work, we relied, in part, on reports by a national expert in
correctional health care who was hired by DoC to conduct independent
reviews of CCHPS's medical services. We interviewed this expert, referred
to as the independent reviewer, and analyzed all of the quarterly reports
he submitted to DoC. In addition, we analyzed a random sample of
grievances submitted by Jail and CTF inmates from April 1, 2003, through
October 31, 2003. Although we focused primarily on services provided by
CCHPS, we also reviewed documents and interviewed officials about the
medical services provided to inmates off-site that are not a part of the
CCHPS contract. We also analyzed documents and interviewed officials from
other District of Columbia agencies with responsibilities related to
inmate health care and from national organizations that accredit
correctional health care facilities. In addition, we reviewed our previous
work related to medical services at the Jail. To determine the cost of
providing medical services at the Jail and the CTF, we analyzed documents
and interviewed officials from the District of Columbia Office of
Contracting and Procurement; DoC, including its Office of the Chief
Financial Officer; and CCHPS. We also examined independently audited
accounting data from the District of Columbia Office of Financial
Operations and Systems. We determined that the medical services cost
information we used in our analysis was reliable. The scope of our work
included medical services provided to CTF inmates only since April 2003,
when DoC expanded its contract with CCHPS to include this facility. In
reviewing DoC's activities, we assessed the agency's internal controls
related to its contract with CCHPS. We did our work from August 2003
through June 2004 in accordance with generally accepted government
auditing standards. (See app. I for additional details on our scope and
methodology, including our cost calculations.)

  Results in Brief

DoC has contracted with CCHPS to provide a broad range of medical services
to inmates of the Jail and the CTF, and the types of services available
have changed little since CCHPS began providing care in 2000. These
services include physical and mental health screening when inmates are
admitted; primary care; mental health care; and chronic and specialty
care, such as dental and orthopedic services. CCHPS also assists DoC in
helping inmates obtain services not included in the contract, such as
specialty care and emergency medical services that cannot be offered at
the Jail or the CTF and community-based medical services for inmates after
they are released. CCHPS has established a quality improvement program to
fulfill its obligation to monitor the quality of its services. A key
component of this program is a quarterly analysis of random samples of
inmate medical records; these analyses use standardized performance
assessment instruments to provide CCHPS with quantitative data measuring
how consistently it delivers required services to inmates.

DoC established several mechanisms to oversee CCHPS's delivery of medical
services to inmates at the Jail and the CTF. DoC's contract with CCHPS
gives DoC authority to impose monetary damages on CCHPS if it fails to
meet any of 12 requirements specified in the contract, most of which
relate to providing key services to a minimum percentage of inmates. For
example, DoC may impose damages if CCHPS does not conduct an intake
screening within 24 hours for 95 percent of inmates. In addition, DoC's
contract with CCHPS requires CCHPS to submit quarterly and annual progress
reports that discuss any quality problems and the actions taken to correct
them. DoC's independent reviewer monitors the services provided by CCHPS
on a quarterly basis. During his reviews, the independent reviewer uses
the same performance assessment instruments as CCHPS to monitor both
CCHPS's delivery of medical services and the accuracy of CCHPS's internal
performance analyses. The independent reviewer does not, however,
specifically review CCHPS's compliance with the contract requirements
associated with monetary damages.

Although available evidence indicates that CCHPS has generally complied
with the terms of its contract, DoC has not exercised sufficient oversight
to provide assurance that problems either are not occurring or are quickly
corrected. The independent reviewer has consistently found that the
medical services CCHPS provides to inmates meet the contract's
requirements for access to care and quality. In addition, CCHPS has
generally met the contract requirement that it implement a quality
improvement program. For example, CCHPS has regularly used the performance
assessment instruments to monitor its services, and the independent
reviewer has concluded that CCHPS's assessments with these

instruments are accurate. However, in a few areas CCHPS has not always met
the contract's medical services and monitoring requirements. For example,
while CCHPS recently improved its performance in providing timely
follow-up to inmates with abnormal chest x-ray results, the independent
reviewer had repeatedly found problems in this area since 2000. Although
the independent reviewer provides DoC with important information about
CCHPS's performance, other limitations in DoC's oversight of CCHPS's
services may hinder the agency's ability to be assured of CCHPS's
compliance with the contract. For example, DoC lacks the necessary data
and a formal procedure to determine whether CCHPS has met contract
requirements linked to monetary damages; it also lacks a procedure to
impose damages if they are warranted. In addition, DoC has not regularly
enforced the contract requirement that CCHPS submit quarterly and annual
progress reports describing quality problems and corrective actions. CCHPS
has never submitted the quarterly reports and has not submitted all the
required annual reports.

From 2000 to 2003, the average daily cost of providing medical services to
a Jail inmate decreased by almost one-third, from about $19 a day per
inmate to about $13 a day. This decrease in per inmate costs occurred
because the total cost of providing medical services at the Jail decreased
by about 3 percent during this period, while the average inmate population
rose by about 41 percent. DoC and CCHPS officials told us that they
controlled total costs by various means, including controlling personnel
expenditures. On April 1, 2003, DoC consolidated the services provided to
inmates in the Jail and the CTF under one contract with CCHPS. This
contract revision also introduced a new pricing structure, which
simplified DoC's administration of the contract. DoC now pays CCHPS on a
per inmate basis, using a rate schedule ranging from $13.00 to $14.75 a
day per inmate, depending on the size of the inmate population. In
contract year 2003, which ended March 31, 2004, the total cost of
providing medical services at the Jail and the CTF was about $15.8
million; during that year 17,431 inmates were admitted to the two
facilities.

We are recommending that the Mayor require the Director of DoC to develop
formal procedures, including collection of needed data, for regularly
assessing whether CCHPS has met contract requirements linked to monetary
damages and for imposing these damages. We are also recommending that the
Mayor require the Director of DoC to ensure that CCHPS submits required
quarterly and annual progress reports on identified problems and
corrective actions.

Background

We provided a draft of this report to DoC for comment. In its response,
DoC did not comment on our recommendations, but provided additional
information about its contract with CCHPS and medical services for inmates
of the Jail and the CTF. In addition, DoC elaborated on its oversight of
the medical services provided by CCHPS.

The District of Columbia Jail and CTF house inmates awaiting trial or who
have been sentenced for misdemeanors.5 The Jail was opened in 1976, and
from 1985 to July 2002, a court order limited the population to 1,674
inmates. Since July 2002 the population has grown, and during March 2004,
the facility had an average daily population of 2,357. In addition to
serving as an overflow facility, the CTF houses pregnant inmates, inmates
with disabilities who need medical services, inmates in witness
protection, and inmates who need to be separated from the general inmate
population. Opened in 1992, the CTF is operated by a private company, the
Corrections Corporation of America (CCA), under a contract with DoC.
During March 2004, the CTF had an average daily population of 1,197.

In 1995, the U.S. District Court for the District of Columbia removed
medical services at the Jail from DoC's control, placing these services
under the temporary supervision of a court-appointed Receiver. This
removal resulted from the District of Columbia's failure to address
problems identified in two lawsuits brought against the Jail in 1971 and
1975, which alleged that DoC was failing to provide minimally adequate
medical care for inmates.6 Before it terminated the receivership in 2000,
the Court hired a national expert in correctional health care to conduct
an independent quality review of medical services provided by CCHPS to
inmates at the Jail. DoC subsequently contracted directly with this expert
to help develop a set of performance assessment instruments for

5While terms of incarceration may vary, under District of Columbia law,
convictions for many misdemeanors can result in incarceration for up to
180 days. See e.g., D.C. Code S: 22404; S: 22-1510; S: 22-3232; S:
47-4101. In addition to pretrial detainees and convicted prisoners, the
Jail and the CTF also house inmates waiting for transfer to other
correctional facilities, including Federal Bureau of Prisons facilities,
as well as inmates who have been returned to the District of Columbia area
for various reasons, including parole hearings or court testimonies.

6See Campbell v. McGruder, 416 F.Supp. (D.D.C. May 24, 1976), 580 F.2d 521
(D.C. Circ. 1978) and Inmates of D.C. Jail v. Jackson, 416 F. Supp 111
(D.D.C. May 24, 1976). The CTF was not part of these lawsuits.

reviewing CCHPS's clinical services and monitoring activities7 and to
conduct quarterly on-site reviews of CCHPS.

DoC has a constitutional obligation to ensure that medical care is
provided to inmates in its custody,8 and DoC's contract with CCHPS
requires CCHPS to provide comprehensive medical services to all inmates
assigned to the Jail and the CTF and to establish a quality improvement
program to monitor the quality of medical services it provides. In some
areas, particularly the assessment of inmates' health when they are
admitted to the facilities, the contract lists specific services that
CCHPS must provide, such as certain diagnostic tests. In other areas, such
as services for inmates with chronic conditions, the requirement to
provide care is less detailed. In addition to describing services that
CCHPS is required to provide, the contract states that DoC can impose
monetary damages9 on CCHPS if it does not meet 12 specific requirements.
(See app. II for a description of the contract requirements that are
linked to monetary damages.) Compliance with the requirements is to be
determined through monitoring by DoC or its designee.

The contract with DoC also requires that CCHPS acquire and maintain
accreditation for its medical services. The Jail's medical services are
accredited by the National Commission on Correctional Health Care (NCCHC),
while the CTF is accredited by the American Correctional Association
(ACA). NCCHC and ACA, both national, not-for-profit organizations, offer
voluntary accreditation processes for medical services provided in
correctional facilities; relatively few jails nationwide are accredited by
these organizations.10 NCCHC accredits only a correctional facility's
medical services, while ACA accredits all aspects of the correctional
facility, including medical services. Both organizations have

7The instruments were developed jointly by the independent reviewer,
CCHPS, and DoC.

8The Eighth Amendment to the Constitution of the United States prohibits
"cruel and unusual punishment." The U.S. Supreme Court, in Estelle v.
Gamble, concluded that "deliberate indifference to the serious medical
needs of prisoners" violates this prohibition. 429 U.S. 97 104 (1976).

9Monetary damages, also referred to as liquidated damages, are amounts
stipulated in a contract that a contractor agrees to pay for failing to
comply with contractual requirements, such as requirements that work be
completed by a certain time.

10There are currently over 3,000 jails nationwide. According to NCCHC, as
of March 2004, approximately 232 jails had been accredited through its
voluntary program. As of November 2003, approximately 165 jails had been
or were in the process of becoming accredited by ACA's voluntary program.

developed detailed accreditation standards that include, for example,
specific elements that are required in an inmate's initial medical
assessment and in a facility's quality improvement program. The
accreditation process for both organizations includes on-site inspections
of the facility every 3 years and submission of an annual report
certifying that the facility continues to be in compliance with the
accreditation standards. During on-site inspections, inspectors interview
staff, review documentation provided by the facility, and examine a sample
of inmate medical records. NCCHC and ACA inspectors submit their findings
to expert panels, who make the accreditation decisions.

One component of the quality improvement program required by both NCCHC
and ACA is a grievance system that allows inmates an opportunity to
question or complain about their care. Inmates at the Jail or the CTF who
have concerns about medical services can complete a grievance form and
submit it to the warden's office in their facility. The warden's staff
records the grievance in their system and then forwards it to CCHPS.
CCHPS's medical director and quality improvement coordinator review the
grievance and work with the clinicians involved to determine if the
inmate's complaint is valid and, if so, how it should be addressed. If it
is determined that an inmate needs to receive care, CCHPS schedules an
appointment. After CCHPS has reviewed the grievance, it sends a report to
the warden, who then provides a response to the inmate.

In June 2000, we testified before the House Committee on Government
Reform, Subcommittee on the District of Columbia, about the provision of
medical services at the Jail.11 We reported that the per inmate cost at
the Jail was higher than those at the two other jurisdictions reviewed,
and that services and staffing levels also exceeded those of the other
jurisdictions.12 We also found that there were no specific criteria that
determine an acceptable level of medical service and staffing at a jail.
Rather, the range of services was a function of many local factors,
including the specific demands and constraints placed on the facility's
service delivery system.

11This testimony focused only on the medical services receivership and the
contract with CCHPS as it pertained to the Jail, and did not consider any
issues related to the CTF. See GAO/T-GGD-00-173.

12We also reported that these services and staffing levels appeared to
stem from courtordered requirements.

  CCHPS Provides a Range of Services to Inmates and Has Established Systems to
  Monitor Service Quality

As required by the contract, CCHPS provides a broad range of medical
services to Jail and CTF inmates, and the types of services CCHPS provides
at the Jail have not changed significantly over the life of the contract.
In addition, CCHPS assists DoC in helping inmates obtain services beyond
those included in CCHPS's contract, such as emergency and specialty care
that cannot be provided at the Jail or the CTF. CCHPS also assists DoC in
its efforts to work with other District of Columbia agencies and community
providers to link soon-to-be-released inmates in need of medical services
with services in the community. As part of its contract with DoC, CCHPS
has also developed a system to monitor the quality of the medical services
it provides to inmates. A key component of this program is quarterly
analyses of random samples of inmate medical records to measure how
consistently CCHPS delivers required services to inmates.

    CCHPS Provides Screening and Treatment Services Required in Its Contract and
    Assists DoC in Obtaining Additional Services

As required by the contract, CCHPS provides a broad range of medical
services to Jail and CTF inmates, including primary care services such as
sick call13 and chronic care; mental health care; and specialty care, such
as dental and orthopedic services. (See table 1 for a description of these
services.) At intake, all inmates receive a health assessment-referred to
as an intake screening-that screens for physical and mental health
conditions. The inmates receive a physical examination and are asked about
current and past health problems, substance abuse, and medication use. In
addition, they receive a chest x-ray and skin test to identify possible
tuberculosis.14 As part of the mental health screening, inmates are asked
a series of questions.15 If inmates respond positively to any of these

13Sick call services consist of clinical services provided to inmates who
have requested routine or nonemergency medical care. Inmates submit a form
requesting to be seen during sick call and are scheduled to be seen by a
nurse in sick call rooms located in the Jail's housing units. Inmates in
the CTF are seen in a centralized location in the medical unit.

14Because tuberculosis occurs more frequently in correctional settings
than in the general population and because of the ease with which it can
be transmitted, it is considered a significant health issue for
correctional facilities. Pregnant inmates and inmates who have been in the
Jail or the CTF within the last 6 months and have a record of a normal
chest xray do not receive a chest x-ray at intake. Similarly, inmates who
have recently been in the facilities and received a skin test for
tuberculosis with normal results are not required to have another.
However, according to CCHPS officials, even if inmates have had a skin
test within 3 to 4 weeks, they often perform another test to ensure that
the inmate has not been exposed to tuberculosis while in the community.

15These pertain to whether the inmate currently uses or has ever used
mental health services, has experienced a recent significant loss, has
ever attempted suicide or selfinjury, has a position of respect in the
community, or is charged with a high-profile crime.

questions, or if they are a juvenile or in jail for the first time, they
are referred for a comprehensive mental health assessment. Based on the
findings of the intake screening, inmates in need of medical care may
receive treatment in a chronic or specialty care clinic, receive therapy
for mental health problems, or be placed in one of two specialized mental
health units. According to CCHPS officials, in 2002 they conducted an
average of 1,654 intake screenings each month. About 20 percent of these
inmates were referred to a chronic care clinic, and about 34 percent were
referred for further mental health assessment.

Table 1: Medical Services Provided by CCHPS to Inmates at the Jail and the
CTF, March 2004

Service area Type and description of service

Types of service providers

Intake services	Initial medical, mental health, and dental screening on
admission to the Jail and referral for additional care if neededa
Physicians, physician assistants (PA), licensed practical nurses (LPN),
phlebotomistsb Primary

     Sick call and primary care services: assessment of inmates requesting

medical care to be seen by a clinician and possible referral to a
physician or specialty care clinic Physicians, PAs, nurse practitioners
(NP), registered nurses (RN)

Chronic care services: ongoing management of chronic diseases, Physicians,
NPs, PAs
primarily asthma, diabetes, epilepsy and other seizure disorders,
hypertension, and human immunodeficiency virus (HIV) and other
infectious diseases

Halfway house services: assessment and coordination of care for NPs, RNs
inmates at one halfway house

Mental health services "Outpatient" mental health services: services
provided to inmates in the general housing population, including group
therapy, one-on-one therapy, and medication management Psychiatrists,
psychologists, social workers, RNs, LPNs

    "Inpatient" mental health services: services provided in two specialized

units of the Jail for inmates with acute or serious chronic mental health
problems; inmates needing inpatient services are housed in these unitsc
Psychiatrists, social workers, RNs, LPNs; interdisciplinary team also
includes corrections officers and classification and parole officers
Infirmary services Short-term management of inmates requiring observation
or a level of care that cannot be provided in the general population

Specialty care Dental services: basic dental care,        Dentists, dental 
                    including routine and surgical         assistants, dental 
                    extractions, fitting dentures,                            
                  filling cavities, and oral hygiene        hygienists
                                  and                 
                               education              
                  On-site specialty services include                          
                       cardiology, dermatology,       
                              gynecology,             Physicians, podiatrists
                       neurology, ophthalmology,      
                     orthopedics, general surgery,    
                             podiatry, and            
                           pulmonary clinics          

                                Physicians, RNs

Ancillary

         Includes pharmacy services, laboratory services, and providing

services

                             prostheses and glasses

Pharmacists, pharmacy technicians, radiology technicians, dieticians,
offsite providers related to laboratory services, glasses, etc.

Source: GAO analysis of documents from the Center for Correctional Health
and Policy Studies, Inc., and the District of Columbia Department of
Corrections.

aAll inmates are admitted to the Jail and the CTF through the Jail's
Receiving and Discharge Unit, so all intake screening takes place in the
Jail.

bPhlebotomists are medical technicians who collect blood.

cThere are no inpatient mental health units in the CTF, so inmates in the
CTF in need of inpatient services are transferred to the Jail's inpatient
units.

There have been no significant changes in the types of medical services
provided by CCHPS since the start of its contract with DoC. However, there
have been some minor changes, including modifications to on-site specialty
clinics. For example, in 2001, the requirement for an oral surgery

clinic was deleted from the contract, and more recently CCHPS combined the
ophthalmology and optometry clinics. In addition, CCHPS began offering
endocrinology and infectious disease clinics on-site-even though they are
not required by the contract-to improve inmates' access to these services
and continuity of care. CCHPS officials had expected the consolidation of
medical services at the Jail and the CTF to result in some service
efficiencies, such as combining the on-site specialty clinics offered at
both facilities; however, CCHPS and DoC officials told us it has not been
feasible to easily move inmates between facilities because of security
issues. CCHPS therefore continues to offer all on-site specialty clinics
at both facilities.

When inmates need medical services that cannot be provided at the Jail or
the CTF, CCHPS refers them to providers in the community. These off-site
services, including emergency care and certain specialty services, are not
part of the CCHPS contract; instead, DoC has an agreement with the
District of Columbia Department of Health (DoH) to provide services to
inmates through Greater Southeast Community Hospital.16 When Greater
Southeast is not able to provide the needed services, it in turn refers
the inmates to other members of the DC Healthcare Alliance and other
community providers.17 DoC pays for all off-site services through an
interagency agreement with DoH;18 in 2003 there were 4,169 appointments
for inmates off-site.

Although DoC's contract with CCHPS does not specify that CCHPS provide
discharge planning services to inmates,19 NCCHC accreditation

16Specialty services that are provided off-site include certain diagnostic
tests and surgeries. While these services are not part of CCHPS's
contract, CCHPS has a utilization management nurse located at Greater
Southeast to assist in managing off-site hospital and specialty services.

17Until 2001, medical services for certain District residents, including
inmates, were offered through the not-for-profit Public Benefits
Corporation and District of Columbia General Hospital. In 2001, the Public
Benefits Corporation was abolished and most services at District of
Columbia General Hospital were discontinued. The District and Greater
Southeast entered into a contract to form the DC Healthcare Alliance to
provide medical services to uninsured or underinsured District residents,
as well as inmates. The Alliance, which is overseen by DoH, is composed of
Greater Southeast and other local health care providers subcontracted to
Greater Southeast.

18DoC transfers funds to DoH, which in turn arranges payment to service
providers through its contract with Greater Southeast and the Alliance.

19Discharge planning refers to the process of providing
soon-to-be-released inmates with medications and assistance in obtaining
follow-up medical services when they are released.

standards include discharge planning activities. Both CCHPS and DoC have
made efforts to plan for the release of inmates with medical conditions
and to link them to community-based medical services.20,21 For example,
CCHPS's policies require that inmates receive a 2-week supply of
medications at the time of their release. In addition, CCHPS provides
support to DoC's collaboration with the District of Columbia Department of
Mental Health (DMH) to help Jail inmates22 obtain access to community
mental health services when they are released.

CCHPS supports DoC's and DoH's discharge planning efforts to link inmates
who have certain chronic and communicable diseases, such as tuberculosis,
to community-based medical services. In addition, through a joint program
of DoH's HIV/AIDS Administration and DoC, Family and Medical Counseling
Services, Inc. (FMCS), a community-based provider, offers HIV testing and
links HIV-positive inmates to services in the community when they are
released.23 CCHPS refers inmates requesting an HIV test to FMCS and
provides FMCS with office space, computers, and access to the inmate's
electronic medical record in the CCHPS system.24

20According to DoC officials, their concern about discharge planning has
increased as a result of a July 2000 decision by the Supreme Court of New
York. This decision held that each inmate receiving mental health services
during incarceration in New York City was entitled to receive discharge
planning services, so long as the services do not delay or postpone the
inmate's release date. See Brad H. v. City of New York, 712 N.Y.S.2d 336
(Sup. Ct. 2000), aff'd, 176 N.Y.S2d 852 (App. Div. 2000).

21DoC and other District agencies bear the cost of these discharge
planning services, although CCHPS provides some on-site support, including
access to computers and office space.

22A DMH staff member works on-site at the Jail to provide assistance to
inmates. Because of resource limitations, this DMH staff member currently
works only with Jail inmates unless contacted by CTF staff about a
specific CTF inmate. However, DMH officials told us that they hope to
eventually expand discharge planning services to CTF inmates with mental
health problems.

23FMCS also offers inmates pre-and post-test counseling and prevention
information.

24Under the Health Insurance Portability and Accountability Act privacy
rule, CCHPS's disclosure of an inmate's personally identifiable health
information to an outside health care provider is allowed where necessary
for treatment, payment, or health care operations. See 45 C.F.R. S:S:
164.502(a)(1)(ii) and 164.506 (2003).

    CCHPS Developed a System to Monitor Its Medical Services

As part of its contract with DoC, CCHPS is responsible for monitoring the
quality of the medical services it provides to Jail and CTF inmates, and
CCHPS has established a quality improvement program to fulfill this
responsibility. A key component of the program is a quarterly analysis of
random samples of inmate medical records using standardized performance
assessment instruments. These quarterly analyses provide CCHPS with
quantitative data about its performance in certain areas. Each assessment
instrument measures CCHPS's performance of a specific set of activities;
these activities are generally more detailed than the requirements
described in the contract.25 (See app. III for a summary description of
the instruments.) Using the samples of medical records and other
documentation to complete the performance assessment instruments, CCHPS
clinicians determine how consistently CCHPS delivers required services to
inmates. Currently, there are 23 performance assessment instruments, 20 of
which measure medical services provided to inmates in various service
areas. For example, the intake services instrument includes a measurement
of the percentage of inmates who received a chest x-ray for tuberculosis
within 24 hours of admission. The remaining 3 instruments measure the
extent to which CCHPS has conducted other components of its quality
improvement program, such as validating that clinical staff are licensed.

In addition to these quarterly analyses of medical services, CCHPS's
quality improvement program also includes other reviews, such as annual
reviews of urgent care and radiological safety procedures, monthly reviews
of inmate grievances and of any inmate deaths, and ongoing reviews of
infection control activities. The program also requires CCHPS to conduct
at least two in-depth studies a year, each of which focuses on a specific
issue, such as a medical service problem that has been identified by the
quarterly analyses.

25As of May 2004, CCHPS and DoC were in the process of reviewing and
revising these performance assessment instruments.

  DoC Established Several Mechanisms to Oversee CCHPS's Delivery of Medical
  Services

DoC has developed several mechanisms to oversee CCHPS's delivery of
medical services to inmates and enforce CCHPS's compliance with the
contract. For example, DoC's contract with CCHPS gives DoC the authority
to impose monetary damages if CCHPS fails to meet any of 12 requirements
specified in the contract, most of which relate to CCHPS's performance in
providing key medical services. For most of these requirements, the
contract authorizes DoC to impose the damages if CCHPS fails to deliver
the required service to a minimum percentage of inmates-for example if
CCHPS does not conduct an intake screening within 24 hours for 95 percent
of inmates. (See app. II for additional information on the contract
requirements that are linked to monetary damages.) Some of the
requirements relate to CCHPS's staff, including ensuring that staff have
required licenses and credentials. In addition, the contract contains a
requirement that CCHPS have an infection control program approved by DoC.
DoC, or its designee, is responsible for determining CCHPS's compliance
with these 12 contract requirements.

To further assist DoC in overseeing CCHPS's delivery of services, the
contract also stipulates that CCHPS will submit quarterly and annual
progress reports to DoC. These progress reports are to include a
description of quality problems, such as those identified by CCHPS's
quality improvement program or the independent reviewer, and actions taken
to correct them. DoC also requires CCHPS to maintain accreditation of its
services. In addition, DoC staff responsible for oversight of the contract
are frequently on-site at the Jail and the CTF observing the contractor,
and, as of May 2004, DoC had plans to begin jointly conducting the
quarterly analyses of inmate medical records with CCHPS.26

Furthermore, DoC's independent reviewer conducts quarterly reviews of
CCHPS's activities. Each review consists of two principal components.
First, the independent reviewer checks the accuracy of CCHPS's internal
use of the standardized performance instruments. To do this, he uses the
same performance assessment instruments that CCHPS uses in its quality
improvement program to examine a sample of the analyses CCHPS has
completed, and assesses whether CCHPS accurately characterized the

26In the past, DoC conducted occasional reviews of CCHPS's services using
the same performance assessment instruments as CCHPS.

medical records studied.27 Second, in addition to validating CCHPS's
analyses, the independent reviewer uses the performance instruments to
independently assess the quality of CCHPS's services by analyzing a
separate random sample of inmate medical records in selected service
areas, such as mental health services.28 While CCHPS uses the performance
assessment instruments as a quality improvement vehicle, the independent
reviewer's use of these instruments contributes to his assessment of
whether CCHPS is meeting its contractual obligations. However, the
independent reviewer does not specifically evaluate CCHPS's compliance
with the contract requirements associated with monetary damages.

As part of his review, the independent reviewer also assesses other
components of CCHPS's quality improvement program, visits the medical
units at the Jail and the CTF, and interviews CCHPS staff. After
conducting the review, the independent reviewer provides DoC with a
written report describing his general findings, including service areas in
which CCHPS excels or needs to improve. Since August 2000, the independent
reviewer has conducted 14 quarterly on-site reviews of CCHPS.

Most available evidence indicates that CCHPS has generally complied with
the contract, but DoC has not exercised sufficient oversight to be assured
that problems are not occurring or are quickly corrected. The independent
reviewer has reported that CCHPS's services meet the contract's
requirements for access to care and quality. In addition, CCHPS has
generally met the contract requirement that it implement a quality
improvement program. However, in a few areas, CCHPS has not always met the
contract's requirements, such as submitting required quarterly and annual
progress reports describing quality problems and actions taken to correct
them. Although the independent reviewer provides important information
about CCHPS's performance, limitations in DoC's oversight of CCHPS may
hinder the agency's ability to be assured of CCHPS's compliance with the
contract. For example, DoC has not enforced the

  CCHPS Generally Meets Contract Requirements, but DoC's Oversight of CCHPS Is
  Incomplete

27His assessments cover a selection of service areas included in the 23
instruments. As he has become more confident of the accuracy of CCHPS's
monitoring, he has reduced the number of service areas he includes in his
reviews, and may validate only one or two areas during a review.

28These service areas can be areas of his own choosing or areas DoC has
asked him to review.

contract requirement that CCHPS provide it with quarterly and annual
progress reports. Furthermore, although DoC has authority to impose
monetary damages on CCHPS if it does not meet certain requirements
included in the contract, DoC has not collected data needed to impose
these damages or developed formal procedures for determining whether CCHPS
has met these requirements and for imposing damages if CCHPS has not met
them.

    CCHPS Generally Provides Required Medical Services and Internal Monitoring,
    but a Few Gaps Remain

On the basis of his review, the independent reviewer has consistently
reported that CCHPS's medical services meet the contract's requirements
for access to care and quality. He has also reported that services meet
the "required constitutional standards of care." In addition, he told us
that, in his opinion, CCHPS is one of the best correctional health care
providers in the country. According to the independent reviewer, some
activities, such as documenting the administering of medication, have been
performed consistently over the life of the contract. Other activities
have improved over time. For example, in one report, the independent
reviewer noted that CCHPS's chronic disease guidelines were outdated, but
later reported that CCHPS had appropriately revised the guidelines.

In addition, CCHPS generally meets the contract requirement that it
implement a quality improvement program. CCHPS has used the performance
assessment instruments each quarter to monitor its services, and the
independent reviewer has concluded that CCHPS accurately uses these
instruments to assess its medical services. For example, based on data
from its quarterly analyses, CCHPS identified problems in inmates' access
to dental care. As a result, CCHPS conducted a study to identify ways to
improve access to this service and eventually established a system that
gave higher priority to care for inmates with more serious dental
problems. CCHPS's subsequent review found that access had improved.

While CCHPS's medical services and monitoring efforts generally meet the
requirements of the contract, in a few areas CCHPS has not always met
requirements. For example, the contract requires that CCHPS provide timely
follow-up services to inmates with abnormal chest x-ray results.29
Although CCHPS has recently improved its performance, the independent

29The contract requires CCHPS to provide inmates with a chest x-ray at
intake to screen for tuberculosis, to review the results of the x-ray
within 72 hours, and to provide appropriate referral for follow-up or
additional evaluation if needed.

reviewer had repeatedly found that CCHPS did not always provide timely
follow-up services to these inmates. The independent reviewer also
recently determined that CCHPS is not performing reviews of inmate deaths.
This is an NCCHC requirement, and CCHPS's quality improvement program
specifies that CCHPS should conduct such reviews monthly.

In addition, CCHPS has not regularly submitted the required quarterly and
annual progress reports providing information on quality problems and its
actions to correct them. CCHPS has never submitted quarterly reports, and
submitted only one annual report. Furthermore, the annual progress report
CCHPS did submit provided only limited information. For example, it did
not discuss CCHPS's lack of timely follow-up on abnormal x-ray results,
although the independent reviewer had repeatedly identified this as a
problem.

Inmates have expressed concerns about other medical services required by
the contract. Our analysis of a sample of the 369 inmate grievances
submitted from April 2003 through October 2003 found that many complaints
related to inmates' ability to gain access to requested sick call and
primary care services and to the timely distribution of medications.30 For
example, some inmates complained that they had submitted multiple requests
to be seen during sick call and had not yet been seen. CCHPS's internal
monitoring has also identified problems related to sick call services,
such as inconsistent use of the protocols developed to guide inmate health
assessments.31 In addition, advocacy groups with whom we spoke expressed
concern about distribution of medications on weekends and to newly
admitted inmates.

    DoC's Oversight Limitations Reduce Its Assurance That CCHPS Complies with
    Contract

Although the independent reviewer provides important information about
CCHPS's services, DoC has other weaknesses in its oversight of CCHPS that
reduce its ability to be assured that CCHPS is complying with the contract
and that problems are not occurring. DoC has never used its authority to
impose monetary damages on CCHPS for failing to meet certain contract
requirements. This is in part because it lacks the

30The 369 grievances represent individual grievances. In some instances
inmates submitted multiple grievances. During this period, over 10,000
inmates were admitted to the Jail and the CTF, and the combined average
daily population was 3,169.

31CCHPS has developed a set of nursing sick call protocols to guide nurses
providing sick call services.

necessary data and a formal procedure for determining whether CCHPS has
met the requirements; it also lacks a procedure for imposing damages if
they are warranted. To evaluate CCHPS's compliance with many of the
requirements that are linked to monetary damages, DoC needs data that
indicate the percentage of inmates for whom CCHPS provided the required
service. One potential source for such data is the performance assessment
instruments used by CCHPS and the independent reviewer, which measure many
of the activities included in these contract requirements.32 However, at
present, DoC neither regularly collects data itself nor requires the
independent reviewer or CCHPS to submit data they collect through their
quarterly analyses of services.33 DoC officials also were not able to
provide any documents that articulated how, and how often, they would
evaluate CCHPS's compliance with the contract requirements associated with
monetary damages, and DoC has not provided CCHPS with information on the
status of its compliance. Furthermore, if DoC were able to determine that
CCHPS was not meeting a contract requirement, it has not determined
whether it would immediately impose damages on CCHPS or first give CCHPS
an opportunity to correct the problem.

In addition, DoC has generally not enforced the contract requirement that
CCHPS submit quarterly and annual progress reports describing quality
problems and actions taken to correct them. These reports would allow DoC
to obtain information on how CCHPS is addressing compliance or other
performance problems identified by CCHPS's own monitoring or the
independent reviewer. For example, the independent reviewer has repeatedly
reported that CCHPS did not consistently screen and treat female inmates
for chlamydia and gonorrhea. In addition, while CCHPS usually responds to
inmate grievances in a timely way,34 the independent reviewer has reported
on several occasions that CCHPS does not analyze

32CCHPS's analyses produce data on its compliance with 9 of the 12
requirements linked with monetary damages-all those related to medical
services. The independent reviewer's analyses do not necessarily produce
data on all 9 because he does not specifically review these 9 service
areas and does not review the same service areas during each review.

33The independent reviewer provided DoC with the data from his quarterly
reviews through March 2001. Since then, he has generally not provided
data.

34CCHPS's policies and procedures state that the elapsed time from when
CCHPS receives a grievance to when it issues a written response should be
10 days or less. In almost threefourths of the cases we reviewed, CCHPS
met this standard. According to the written responses we reviewed, many
inmates had already received care by the time CCHPS wrote its response.

grievances in a sufficiently thorough way to identify systemic problems in
CCHPS's services. Enforcing the requirement that CCHPS submit regular
progress reports would better enable DoC to ensure that CCHPS promptly
corrects such problems.

An area where DoC has been slow to carry out its oversight responsibility
relates to the contract requirement for an infection control plan. To
maintain its NCCHC accreditation, CCHPS must have an infection control
plan, and the April 2003 modification of the contract required that
CCHPS's plan be approved by DoC. Although CCHPS submitted an infection
control plan to DoC for approval in August 2003, DoC did not complete its
review and approve the plan until June 2004.

In addition to having gaps in its oversight of services provided by CCHPS,
DoC is not providing systematic oversight to ensure that, when CCHPS
refers inmates to off-site services, inmates receive those services
promptly. DoC officials believe the closure of District of Columbia
General Hospital in 2001 and the shift of off-site services to Greater
Southeast Community Hospital have resulted in delays in obtaining off-site
care for inmates, particularly in certain specialty areas, such as
orthopedics and dermatology. The independent reviewer and CCHPS have also
expressed concerns about access to off-site services. CCHPS, which is
responsible for arranging and monitoring off-site appointments, documented
earlier delays in obtaining these appointments, but at the time of our
review, it no longer possessed this documentation. Despite its concerns,
DoC has not systematically documented more recent delays in obtaining
off-site appointments for inmates, is not able to provide any data on the
nature or length of delays, and has no plans to study this issue.35

From 2000 to 2003, DoC's average daily cost of providing medical services
to an inmate at the Jail decreased by almost one-third. This resulted from
a decrease in the total cost of providing medical services to inmates
despite an increase in the inmate population. DoC and CCHPS officials told
us they controlled costs in various ways, including reducing personnel
expenditures. In 2003, DoC consolidated the services provided to inmates
in the Jail and the CTF under one CCHPS contract and introduced a daily
per inmate pricing structure, known as per diem pricing. The total cost to

35DoC uses data provided by CCHPS to track utilization of off-site
services, but does not obtain or collect information related to the
timeliness of those services.

  Average Per Inmate Medical Cost at Jail Has Decreased

provide medical services to inmates at the Jail and the CTF in 2003 was
about $15.8 million, an average of $13.28 per inmate.

    Cost of Medical Services at Jail Decreased, Despite Growth of Inmate
    Population

From initiation of the CCHPS contract in 2000 to 2003, the average daily
per inmate cost of medical services at the Jail36 decreased by almost
onethird, from about $19 a day to about $13 a day. The average decrease
resulted from a decline in the total cost of services, combined with a
rise in the inmate population. During this period, the total cost of
providing medical services at the Jail decreased from about $11.7 million
to about $11.4 million,37 about 3 percent. (See fig. 1.) At the same time,
the average daily population in the Jail increased by about 680 inmates,
about 41 percent. (See fig. 2.) In fiscal year 1999, the last full year in
which the Receiver directly provided medical services at the Jail, the
total cost was about $12.6 million and the average per inmate cost was
about $21 a day.

36Although DoC consolidated medical services for the Jail and the CTF
under a single contract in April 2003, we were able to identify the cost
attributable to the Jail for the entire year. See app. I for additional
information on our cost and population calculations for each annual
period.

37Adjusted for medical inflation, the total cost would have decreased by
about $1.8 million from 2000 to 2003. Medical inflation adjustments were
calculated using the medical care component of the Consumer Price Index
for urban consumers.

Figure 1: Total Annual Cost of Medical Services at the District of
Columbia Jail, 2000-2003

Dollars in millions 14

12 11.7a

10

8

6

4

2

0 2000b 2001b 2002b 2003c

Sources: GAO analysis of data from the District of Columbia Department of
Corrections, Department of Financial Operations and Systems, and the
Center for Correctional Health and Policy Studies, Inc.

aIf adjusted for medical inflation, the total cost for 2000 would have
been about $13.2 million. Medical

inflation adjustments were calculated using the medical care component of
the Consumer Price Index

for urban consumers.

bData for 2000, 2001, and 2002 are from March 12 of the year through March
11 of the following year,

coinciding with the DoC-CCHPS contract year.

cData for 2003 are from April 1, 2003, through March 31, 2004,
approximating the DoC-CCHPS

contract year and coinciding with the April 1, 2003, contract changes.

Figure 2: Average Daily Inmate Population at the District of Columbia
Jail, 2000- 2003

Number of inmates 2,500

                                     2,342

2,000

1,500

1,000

500

0 2000a 2001a 2002a 2003a

Source: GAO analysis of data from the District of Columbia Department of
Corrections.

aData for 2000, 2001, 2002, and 2003 are from April 1 of each year through
March 31 of the following year, approximating the DoC-CCHPS contract year.

As a result of the combination of decreased cost and increased inmate
population, DoC's average daily cost of providing medical services to an
inmate at the Jail since CCHPS began providing services fell by almost
one-third from 2000 to 2003.38 (See fig. 3.)

38We calculated the average daily cost per inmate by dividing the total
cost for the period by the average inmate population for the period, and
then dividing by the number of days in the period.

Figure 3: Average Daily Cost Per Inmate of Medical Services at the
District of Columbia Jail, 2000-2003

Dollars

19.33a

                            2000b 2001b 2002b 2003c

Sources: GAO analysis of data from the District of Columbia Department of
Corrections, Department of Financial Operations and Systems, and the
Center for Correctional Health and Policy Studies, Inc.

Note: Average daily cost per inmate is calculated by dividing the total
cost for the period by the average inmate population for the period, and
then dividing by the number of days in the period.

aIf adjusted for medical inflation, the total cost for 2000 would have
been about $13.2 million, resulting in an average daily cost per inmate
for 2000 of about $22. Medical inflation adjustments were calculated using
the medical care component of the Consumer Price Index for urban
consumers.

bAverage daily cost per inmate for 2000, 2001, and 2002 is based on
population data from April 1 of each year through March 31 of the
following year, approximating the DoC-CCHPS contract year. It is also
based on total cost data from March 12 of each year through March 11 of
the following year, coinciding with the DoC-CCHPS contract year.

cAverage daily cost per inmate for 2003 is based on total cost and
population data from April 1, 2003, through March 31, 2004, approximating
the DoC-CCHPS contract year.

DoC and CCHPS officials told us that they were able to reduce the total
cost of providing medical services at the Jail through various means. For
example, in 2003, DoC officials stopped paying CCHPS a management fee. DoC
also negotiated with CCHPS officials to reduce employee salaries and
fringe benefits, and CCHPS made more efficient use of its staff.39 For
example, CCHPS was able to eliminate unnecessary testing done at intake,
such as conducting repeat chest x-rays for recently returned inmates,
which allowed CCHPS to increase staff time available for providing other

39Personnel expenditures represent about three-fourths of CCHPS's costs.

services. In addition, CCHPS officials told us they have selectively
replaced higher salaried staff with lower salaried staff; in one case they
changed a vacated pharmacist position to a pharmacy technician position.

CCHPS also controlled personnel expenditures by reducing the overall
number of staff at the Jail, while still meeting NCCHC standards for
physician staffing levels. When the contract began in March 2000, CCHPS
had about 125 full-time equivalent (FTE) positions at the Jail,40 and
there were about 18 Jail inmates for each clinical staff member. As of
April 2003, CCHPS's FTEs at the Jail had decreased to about 114, and the
number of inmates for each clinical staff member had risen to about 27.41
NCCHC requires jails to maintain one physician on-site for 3.5 hours a
week for every 100 inmates, and as of April 2003, CCHPS exceeded this
standard by having one physician on-site for about 4.3 hours a week for
every 100 inmates.42 Until April 2003, DoC established required staffing
levels for CCHPS as a part of its contract, but the contract now allows
CCHPS, with DoC's approval, to adjust staffing levels in response to
inmate population changes.

    Cost in 2003 Reflected Addition of the CTF and Change to a Per Diem Pricing
    Structure

In 2003, the total cost for medical services in the Jail and the CTF was
about $15.8 million;43 over the course of that year 17,431 inmates were
admitted to both facilities.44 In the same year, DoC consolidated medical
services for CTF inmates into the contract for services for Jail inmates.
It also introduced a daily per inmate pricing structure-known as per diem
pricing-to calculate the rates paid to CCHPS. This pricing structure uses

40In March 2000, CCHPS was required by the contract to have 125.2 FTE
positions at the Jail. By April 2003, the contract no longer specified the
number of FTE positions CCHPS had to have.

41In April 2003, there were also 51.7 FTEs at the CTF.

42At the time of the transition from the receivership to the CCHPS
contract, members of Congress expressed concern that CCHPS's staffing
level was very high; however, there is no single standard for an
acceptable level of medical staffing at a jail. NCCHC's most recent
standards indicate that, despite the general expectation for physician
staffing ratios, the number and type of health care professionals required
depends on a variety of factors.

43Cost data for 2003 are from April 1, 2003, through March 31, 2004,
approximating the DoC-CCHPS contract year.

44In 2003, the combined average daily population of the Jail and the CTF
was 3,257. These data are from April 1, 2003, through March 31, 2004,
approximating the DoC-CCHPS contract year.

a per diem rate schedule, which is a sliding scale of prices that declines
slightly as the combined inmate population increases. The schedule starts
at $14.75 per inmate when the inmate population is below 2,200, and
incrementally falls to $13.00 per inmate when the population exceeds
3,200. For example, if the combined population on a particular day were
2,000 inmates, the per diem rate would be $14.75 and the total cost to DoC
for that day would be $29,500. According to DoC officials, the per diem
rate declines when the inmate population rises to reflect economies of
scale. Over the course of 2003, the per diem rate charged to DoC for
services at the jail and the CTF averaged $13.28 per inmate.

The per diem pricing structure has simplified DoC's contract
administration by generally eliminating the need for a reconciliation
process. Prior to April 2003, the contract required that DoC and CCHPS
complete quarterly reconciliations to determine the difference between
CCHPS's expected staff costs at the beginning of the contract year and
CCHPS's actual staff costs during the year.45 These differences resulted
primarily from inmate population changes. However, as DoC and CCHPS
negotiated the final amount of each reconciliation, the process became
increasingly lengthy and several unresolved reconciliations accumulated.
Over the first 3 years of the contract, for example, DoC completed only 4
of the 12 scheduled reconciliations. When the per diem pricing structure
was implemented in 2003, all incomplete reconciliations were resolved in a
final reconciliation settlement.

DoC has provided a broad range of medical services to inmates at the Jail
and the CTF since the receivership ended in September 2000. CCHPS's
medical services have generally met the contract's requirements for access
to care and quality, and CCHPS has demonstrated a commitment to providing
inmates with the services they need by adding on-site specialty clinics to
improve access and continuity of care. CCHPS also regularly and accurately
monitors its services to ensure that it is providing appropriate care.
However, CCHPS has not always met all contract requirements for service
delivery and quality improvement activities.

Although DoC has taken an important step toward ensuring the quality of
services that CCHPS provides to inmates by retaining the independent

Conclusions

45The new per diem pricing system retains two reconciliations each year
for pharmaceutical supplies due to the high variability of pharmaceutical
costs.

reviewer, it has not taken several other actions that would help it better
oversee the care that inmates receive. For example, DoC has limited its
ability to hold CCHPS accountable for meeting the contract requirements
that are linked to monetary damages. For monetary damages to be a viable
oversight and contract enforcement mechanism, DoC would need to obtain
data that demonstrate whether CCHPS is providing required services to the
minimum percentage of the inmate population stipulated by the contract.
However, DoC has not collected these data. DoC would also need to develop
formal procedures for assessing CCHPS's compliance with the requirements
and for imposing monetary damages if they are warranted.

Furthermore, DoC has not enforced the requirement that CCHPS regularly
submit progress reports describing how it is correcting problems
identified through performance monitoring, including any problems that may
place CCHPS out of compliance with the contract. If CCHPS provided this
information, DoC could ensure that CCHPS promptly took corrective action
to respond to problems identified by the independent reviewer or CCHPS's
own monitoring, such as CCHPS's failure to promptly follow up on abnormal
chest x-ray results. Having the capacity to enforce the contract
requirements linked with monetary damages and requiring CCHPS to submit
regular progress reports would strengthen DoC's ability to ensure that
CCHPS provides important medical services to inmates.

Recommendations for 	To help ensure that CCHPS provides required medical
services to inmates of the District of Columbia Jail and the CTF, we
recommend that the

                                Executive Action

      Mayor require the Director of DoC to take the following two actions:

o  	Develop formal procedures-including collection of needed data-to
regularly assess whether CCHPS's performance meets the contract
requirements that are linked to monetary damages and to impose these
damages.

o  	Ensure that CCHPS submits to DoC the required quarterly and annual
progress reports, which should describe identified problems and the
actions CCHPS has taken to correct them.

  Agency Comments
  and Our Evaluation

We provided a draft of this report to DoC for comment. In its response DoC
did not comment on our recommendations, but provided additional
information about its contract with CCHPS and medical services for inmates
of the Jail and the CTF. In addition, DoC elaborated on its oversight of
medical services provided by CCHPS. (DoC's comments are reprinted in app.
IV.)

DoC emphasized in its comments that the independent reviewer acts at the
request and on behalf of the agency. We noted in the draft report that
DoC's hiring of the independent reviewer was an important step toward
ensuring the quality of CCHPS's services and described the independent
reviewer's role in DoC's oversight of CCHPS. DoC expressed concern that
the issues discussed in the independent reviewer's reports are intended to
identify opportunities for CCHPS to improve, but that the draft report
portrayed them as problems or deficiencies. While some issues raised by
the independent reviewer could be characterized as opportunities for
service improvement, we found that others indicated performance shortfalls
related to specific contract requirements.

In its comments, DoC discussed our finding that CCHPS has not regularly
submitted the quarterly and annual reports required by the contract; these
reports are to provide DoC with information on problems identified by
CCHPS's performance monitoring or by the independent reviewer and on
CCHPS's corrective actions. DoC stated that instead of the quarterly
reports, it relies on certain monthly reports and regular verbal
communication. DoC's comments describe two types of monthly reports, one
providing various data on off-site services and the other relating to two
performance measures reported to the Office of the Mayor. However,
undocumented verbal communications and these narrowly focused monthly
reports are not a substitute for the quarterly progress reports called for
in the contract and do not enable DoC to ensure that CCHPS is addressing
identified problems. DoC's comments acknowledge that CCHPS has not
submitted all required annual reports. We do not agree that the
information provided in the December 2002 report on the reconciliation of
CCHPS's expected and actual costs, which DoC cites in its comments,
provided DoC with the type of information required in the annual progress
reports. For example, this report contains no information about how CCHPS
planned to improve its performance in screening and treating female
inmates for chlamydia and gonorrhea.

DoC highlighted its role in reducing the cost of medical services provided
to inmates by CCHPS. In the final report we provided additional
information on DoC's role. DoC also noted that the average daily cost of
services decreased from about $19 to about $13, which we stated in our
draft report, and that this will result in savings over the remaining life
of the contract. However, while the average daily cost per inmate in 2003
was $13.32, under the current rate schedule, daily per inmate costs may
range from $13.00 when the combined Jail and CTF population exceeds 3,200
to $14.75 when the inmate population is below 2,200. Therefore, costs over
the remaining life of the contract will depend largely on the inmate
population.

In response to DoC's comments, we replaced the term "financial penalties"
with "monetary damages." While the comments state that DoC has other
remedies for contract nonperformance, we believe that the authority to
impose monetary damages is also a useful means of ensuring CCHPS's
compliance with the contract.

In its comments, DoC described changes in the District's health care
system that have affected the provision of off-site medical services for
inmates. Because the focus of our report was on services provided by CCHPS
through its contract with DoC, a detailed discussion of these developments
was not within the scope of the report. DoC also stated that there was a
past study on delays in obtaining off-site appointments for inmates and
that there is no need to conduct an additional study. The draft report did
not recommend that DoC conduct an additional study, but reported that DoC
and the independent reviewer have identified problems with access to
off-site services and that DoC has not collected data on delays.

We incorporated other information provided by DoC in its comments on our
draft report where appropriate.

As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its issue date. At that time, we will send copies to the DoC
Director, interested congressional committees, and other parties. We will
also make copies available to others on request. In addition, the report
will be available at no charge on the GAO Web site at http://www.gao.gov.
If you

  or your staff have any questions about this report, please call me at (202)
    512-7119. Another contact and key contributors are listed in appendix V.

Sincerely yours,

Marcia Crosse Director, Health Care-Public Health and Military Health Care
Issues

                       Appendix I: Scope and Methodology

We examined the medical services provided by the Center for Correctional
Health and Policy Studies, Inc. (CCHPS) to inmates at the Jail and the
Correctional Treatment Facility (CTF), including CCHPS's internal
monitoring; the District of Columbia Department of Corrections' (DoC)
oversight of those services; CCHPS's contract compliance; and the cost of
services under the contract. To provide information on CCHPS's and DoC's
activities, we reviewed documents and interviewed officials from those two
organizations. DoC documents we reviewed included contracting documents
such as the original request for proposals and subsequent modifications,
reports of inmate population volume, and specialty clinic utilization
statistics. In reviewing DoC's activities, we assessed DoC's internal
controls related to the contract with CCHPS. CCHPS documents we reviewed
included policies and procedures, staffing plans, annual progress reports,
and quarterly performance analyses. We also interviewed the independent
reviewer hired by DoC and analyzed the reviewer's quarterly reports to
examine CCHPS's medical services and CCHPS's quality improvement
activities. In addition, we analyzed documents and interviewed officials
from the National Commission on Correctional Health Care and the American
Correctional Association to obtain information on their correctional
health care accreditation standards, their accreditation review processes,
and their findings on DoC facilities. We also reviewed our previous work
on medical services at the Jail. We reviewed issues related to medical
services provided to CTF inmates only since April 2003, when DoC expanded
its contract with CCHPS to include medical services for inmates at that
facility.

To obtain information on inmate complaints about medical services the
contract requires CCHPS to provide and on CCHPS's responses to these
complaints, we conducted an independent analysis of randomly selected
samples of grievances submitted by inmates at the Jail and the CTF. Of the
201 grievances at the Jail and the 168 grievances at the CTF during the
period April 1, 2003, through October 31, 2003, we randomly selected 75
grievances for each analysis, for a total sample size of 150. DoC was able
to provide us with the detailed information needed for our analysis on 72
of the 75 grievances selected from the Jail and on 72 of the 75 grievances
selected from the CTF. Grievances for which DoC could not provide the
requested information were excluded from each analysis. For both the Jail
and the CTF samples of inmate grievances, we analyzed the timeliness of
CCHPS's response, the subject of the grievance, and the extent to which
CCHPS's response addressed the principal areas of concerns cited in the
complaint. The final sample size of 144 grievances produced estimates
about types of grievances and timeliness of responses with a margin of
error of plus or minus 5.0 percent at the 95-percent confidence level.

Appendix I: Scope and Methodology

Although we focused principally on medical services provided by CCHPS
under its contract with DoC, we also obtained information about inmate
services that are not part of the CCHPS contract-such as off-site
services-by reviewing documents and interviewing officials from CCHPS,
DoC, and the District of Columbia Department of Health (DoH). Documents we
reviewed included contracts between DoH and community providers and
utilization data on off-site services provided to inmates. We also
interviewed officials from the District of Columbia Department of Mental
Health, a community health care provider, and groups providing legal
services to inmates.

To calculate the total annual and average per inmate costs of the medical
services that CCHPS provided, we reviewed documents such as DoC's budget
records, purchase order summaries, contract pricing modifications, and
CCHPS invoices. We interviewed officials from the District of Columbia
Office of Contracting and Procurement; DoC, including its Office of the
Chief Financial Officer; and CCHPS. We also examined independently audited
accounting data from the District of Columbia Office of Financial
Operations and Systems. We determined that the medical services cost
information we reviewed was reliable, based on documentation provided by
the District of Columbia Office of Financial Operations and Systems
stating that the source of the data was the System of Accounting and
Reporting, the District of Columbia's official accounting records, which
is subject to an independent audit each year. We made certain assumptions
to define four comparable 12-month periods that approximated the DoC-CCHPS
contract year. Although there are slight differences between the time
periods defined for total costs and inmate population averages, the length
of each period was 1 year. Total cost data for 2000, 2001, and 2002 are
from March 12 of each year through March 11 of the following year,
coinciding with the DoC-CCHPS contract year, while inmate population data
for 2000, 2001, and 2002 are from April 1 of each year through March 31 of
the following year, approximating the DoC-CCHPS contract year. Total cost
and inmate population data for 2003 are from April 1, 2003, through March
31, 2004, approximating the DoC-CCHPS contract year. We calculated the
average daily inmate population for each annual period by first
calculating an average daily population for each of the 12 months within
the period, and then averaging the monthly averages.

We applied an accrual methodology to calculate the total costs associated
with each annual period. The DoC-CCHPS contract during the years 2000
through 2002 specified a fixed contract price at the beginning of each
year, subject to reconciliations during the year. Reconciliations
conducted

Appendix I: Scope and Methodology

during contract years often resulted in adjustments to DoC payments in a
subsequent contract year. By applying an accrual method, we attributed
reconciliation costs to the years from which they originated rather than
the years in which they were paid. We performed our work from August 2003
through June 2004 in accordance with generally accepted government
auditing standards.

Appendix II: Requirements Linked to Monetary Damages Provisions in the CCHPS
Contract

The contract between DoC and CCHPS contains certain requirements that
CCHPS must meet. If these requirements are not met, DoC has the authority
to impose specified monetary damages on CCHPS. Table 2 summarizes the
requirements linked with monetary damages.

Table 2: Summary of Contract Requirements with Monetary Damages Provisions

Monetary damages may be imposed if: Damages calculation method

Medical services Less than 95 percent of Jail intake health screenings are
completed within $200 times the number of 24 hours. occurrences during the
period being measureda

Less than 95 percent of eligible inmates' tuberculosis skin tests are
placed $200 times the number of and read within the prescribed time frame.
For this item "eligible inmates" occurrences during the period are inmates
in the Jail or the CTF more than 96 hours. being measureda

Less than 95 percent of eligible inmates with positive tuberculosis skin
tests $100 times the number of receive timely follow-up. For this item
"eligible inmates" are inmates in the occurrences during the period Jail
or the CTF more than 30 days. being measureda

More than 10 percent of the eligible inmates known to have an abnormal
$100 times the number of blood pressure do not have a plan to control
blood pressure levels occurrences above the 10-percent documented in the
medical record within 14 days. For this item "eligible threshold during
the period being inmates" are inmates in the Jail or the CTF more than 15
days. measureda

More than 15 percent of the eligible inmates known to have human $100
times the number of immunodeficiency virus (HIV) have a clinical status
warranting treatment for occurrences above the 15-percent prevention of
pneumonia, and are not receiving it within 2 weeks of threshold during the
period being identification of the need for treatment. For this item
"eligible inmates" are measureda inmates in the Jail or the CTF more than
15 days.

More than 15 percent of the eligible diabetics tested as part of an audit
are found to have a Hemoglobin A1cb level greater than 7 percent and there
is no documented clinical strategy to improve the outcome. For this item
"eligible inmates" are inmates in the Jail or the CTF more than 15 days
who are known to have diabetes.

Less than 95 percent of eligible inmates with chronic illness
(hypertension, diabetes, HIV, asthma, seizures) are followed clinically
according to the chronic care guidelines and seen at least every 90 days.

Infection control 	The contractor does not maintain a DoC-approved
infection control plan within 1 month of the contract award.

$100 times the number of occurrences above the 15-percent threshold during
the period being measureda

$100 times the number of days for each inmate not followed in the chronic
care clinic

$500 times the number of days the approved infection control plan is not
in effect

Appendix II: Requirements Linked to Monetary Damages Provisions in the
CCHPS Contract

Monetary damages may be imposed if: Damages calculation method

Staffing The contractor does not maintain valid  $500 times the number of  
            and current licenses and                
              certifications as required for all      occurrences per day for 
                    health care providers.                               each 
                                                         healthcare provider, 
                                                                   calculated 
                                                      from the date of the    
                                                             finding          

The contractor does not have evidence of annual tuberculosis screening and
hepatitis B immunization for all health care staff. The contractor's
direct patient care personnel fail to maintain current cardiopulmonary
resuscitation certification.

The contractor leaves vacant a principal leadership positionc for greater
than 60 days. If a qualified individual is performing the functions of a
principal leadership position, this position is not considered vacant.

The contractor leaves vacant any required position as accepted by DoC in
the contract for greater than 120 days.

None identified

One and one-half the salary rate per hour plus fringe hourly rate defined
in the contractd times the number of required hours the position is left
vacant after 60 days

One and one-half the salary rate per hour plus fringe hourly rate defined
in the contractd times the number of required hours the position is left
vacant after 120 days

Source: GAO analysis of the District of Columbia Department of Corrections
documents.

aThe contract states that these damages will not exceed a 30-day period.
However, DoC officials were not able to explain whether this means that
the period being measured is not to exceed 30 days or that the damages
cannot be imposed for a period exceeding 30 days.

bHemoglobin A1c is a blood sugar average used to determine how well
diabetes is being controlled. The contract defines a normal hemoglobin A1c
level as less than 6.8 percent.

cPrincipal leadership position is defined as the medical director, mental
health director, health services administrator, executive administrator,
or director of nursing.

dAccording to DoC officials, the hourly rates are defined using the most
recent wage rates specified in the contract.

Appendix III: Performance Assessment Instruments Used to Monitor Services
Provided by CCHPS

In 2000, DoC, CCHPS, and the independent reviewer hired by DoC to monitor
CCHPS's medical services developed performance assessment instruments to
allow them to determine how consistently CCHPS delivered required medical
services to inmates and whether it conducted activities included in its
quality improvement program.1 Table 3 describes the measures included in
the performance assessment instruments, as well as the samples measured
and the sources of the samples. When reviewing services, the person
conducting the assessment determines whether each bulleted measure has
been met.

1As of May 2004, CCHPS and DoC were in the process of reviewing and
revising these performance assessment instruments.

Appendix III: Performance Assessment Instruments Used to Monitor Services
                               Provided by CCHPS

Table 3: Information on Performance Assessment Instruments Used to Monitor
CCHPS's Services

             Service area/type Measure Sample used Source of sample

Intake services

Intake evaluation  o  	Performed complete health assessment by licensed
physician, physician assistant (PA), or nurse practitioner (NP) at intake
to the Jail, including a physical and oral examination and review of
bodily systems, such as the cardiovascular system; a medical and substance
abuse history; check of vital signs (breathing rate, pulse, temperature);
and analysis of a urine sample

o  	Placed tuberculosis skin test, if applicable, and read within 48-72
hours; performed chest x-ray, if applicable, within 24 hours

o  Documented syphilis lab test result

o  	Conducted further mental health evaluation within 24 hours, if
indicated by positive response to screening questions asked at intake 20
randomly selected General inmate inmate medical population recordsa

o  	Performed pregnancy test 10 randomly selected Female inmate inmate
medical records population

Primary medical care
Asthma care  o  At intake or within the past 3 months, conducted

                    10 randomly selected Inmates with asthma

measurement of the amount of air an inmate can push out of his/her lungs

inmate medical recordsb

o  	Followed chronic disease guideline; assessment First 5 of the 10
included degree to which disease has been randomly selected controlled and
strategy to improve outcome if inmate medical records degree of control is
fair or poor or if patient's status reviewed above has worsenedc

  Diabetes care  o  Measured blood sugar levels on intake 10 randomly selected

inmate medical

recordsb

General inmate population

o  Performed blood test that measures average blood

                   10 randomly selected Inmates with diabetes

sugar over a period of time (Hemoglobin A1c), and if test indicated
diabetes, a clinical strategy for treating the inmate was documented in
medical record within 40 days of admission to facility or within past 3
months diabetic inmate medical records

o  	Followed chronic disease guideline; assessment First 5 of the 10
included degree to which disease has been randomly selected controlled and
strategy to improve outcome if diabetic inmate medical degree of control
is fair or poor or if patient's status records reviewed has worsenedc
above

Appendix III: Performance Assessment Instruments Used to Monitor Services
Provided by CCHPS

             Service area/type Measure Sample used Source of sample

Human Immunodeficiency Virus (HIV) care

o  	Tested for level of certain white blood cells with CD4 markerd and HIV
viral count within 40 days or within the past 3 months

o  	Offered treatment for prevention of pneumonia within 2 weeks if level
of certain white blood cells with CD4 marker is low

o  	Considered or ordered anti-HIV drugs within 2 weeks if level of
certain white blood cells with CD4 marker is moderately low

o  	Followed chronic disease guideline; assessment included degree to
which disease has been controlled and strategy to improve outcome if
degree of control is fair or poor or if patient's status has worsenedc

o  	Vaccinated against pneumococcal infection including pneumonia

o  	Administered influenza vaccine during flu season, October - February.

10 randomly selected Inmates with HIV
inmate medical
recordsb

Hypertension care  o  Noted blood pressure reading at intake 	10 randomly
selected General inmate inmate medical population recordsb

o  	Initiated treatment, or plan to treat, within 14 days 10 randomly
selected Inmates with high of identification of high blood pressure
medical records of blood pressure

inmates with high blood

pressure

o  	Followed chronic disease guideline; assessment included degree to
which disease has been controlled and strategy to improve outcome if
degree of control is fair or poor or if patient's status has worsenedc
First 5 of the 10 randomly selected medical records of inmates with high
blood pressure reviewed above

                           Positive tuberculosis skin

o  Clinical evaluation of inmate and treatment decision

10 randomly selected Inmates with positive tuberculosis skin testsmade within 14
                                     daysc

test cases inmate medical recordse Nursing sick call performance

o  	Assessment of inmate's condition appropriate to chief complaintf

o  	Recorded relevant vital signs, such as breathing rate, pulse, and
temperaturef

2 inmate medical records from each of 18 inmate housing unitsg Sick call
requests from inmates

f

o  Treatment plan appropriate to condition

                             Mental Health Services

Chronic mental health care  o  	Psychiatric progress evaluations conducted
by 10 randomly selected Inmates in male psychiatrist every 2 weeks inmate
medical records inpatient mental

o  	Inmate's interdisciplinary treatment plan reviewed health housing
units by staff within 4 weeks

Appendix III: Performance Assessment Instruments Used to Monitor Services
Provided by CCHPS

             Service area/type Measure Sample used Source of sample

Acute mental health care  o  	Initial mental health assessment done by
clinical 10 randomly selected Inmates in male staff within 7 working days
inmate medical records inpatient mental

o  	Initial psychiatric evaluation done by psychiatrist health housing
units within 24 hours

o  	Subsequent psychiatric progress evaluations by psychiatrist every week

o  	Developed interdisciplinary treatment plan within 5 working days

o  	Inmate's interdisciplinary treatment plan reviewed within 4 weeks

Abnormal Involuntary  o  Documented testing (AIMS test) to determine 10
inmate records from Pharmacy list of Movement Scale (AIMS) possible side
effects of antipsychotic drugs within male inpatient mental inmates taking
testing 30 days of intake or within past 6 months health housing unit and
antipsychotic drugs

10 inmate medical records from general population

                      hDiagnosis consistent                                   
     Appropriate   o       with use of       10 randomly   
medication for          medication          selected     Pharmacy list of
    mental health                           inmate medical     inmates taking 
      treatment                                    records            certain 
                                                           medications, e.g., 
                                                           for                
                                                             schizophrenia    

Level of certain drugs for  o  Reported level of medications every 3
months 10 randomly selected Pharmacy list of bipolar disorder (depakote  o
Physician review of medication levels with inmate medical records inmates
receiving

and lithium) appropriate response noted in medical recordsh depakote and
lithium

Specialty care

Urgent care  o           Care timelyf          10 urgent care Inmates seen 
performance                                    visitsi                  in 
                o   Documented appropriate vital                 urgent care  
                           signs, such as                        
                    fbreathing rate, pulse, and                  
                            temperature                          
                o    Appropriate assessment of                   
                       condition and plan to                     
                               treatf                            

Specialty clinic services  o  	Progress note in medical record reflects
need for 5 randomly selected Inmates seen in consultation inmate medical
records specialty clinic

o  	Consultation ordered by physician, PA, or NP from each specialty
clinicj

o  Consultation accomplished within 30 days of order

o  	Documentation of appropriate follow-up consistent with consultant's
recommendation or rationale for not following consultant's recommendation

Communicable disease  o  Screened female inmates for gonorrhea and 10
randomly selected General inmate treatment chlamydia within 14 days of
admission to the facility inmate medical records population

o  	Patients with positive test for syphilis received 10 randomly selected
Inmates identified as appropriate treatment (based on federal guidelines)
inmate medical records positive for gonorrhea, within 5 days of receiving
laboratory reportc

for each disease chlamydia, or syphillis

o  	Patients with positive test for gonorrhea received appropriate
treatment (based on federal guidelines) within 3 days of receiving
laboratory reportc

o  	Patients with positive test for chlamydia received appropriate
treatment (based on federal guidelines) within 3 days of receiving
laboratory reportc

Appendix III: Performance Assessment Instruments Used to Monitor Services
Provided by CCHPS

Service area/type Measure Sample used Source of sample

Dental care  o  Timeliness of treatment appropriate to condition: 10
randomly selected Inmates seen in

Trauma/symptoms of infection or intense pain - inmate medical records
dental clinic within 24 hours

Any other acute condition - within 7 days

o  	Documentation that oral health education materials were provided to
patients

o  	Clear and complete documentation of visits and procedures, including
medical history

Ancillary services

Chest X-ray reporting and

o  Timely reporting of chest x-ray results, appropriate

                  10 randomly selected Log of all x-rays taken

clinician acknowledgment of results, and appropriate follow-up of abnormal
chest x-ray results within 48 hoursc follow-up

                             inmate medical records

o  Timely reporting of x-ray results, appropriate

     Nonchest X-ray reporting 10 randomly selected Log of all x-rays taken

clinician acknowledgment of results, and appropriate follow-up of abnormal
x-ray results within 48 hours of when the x-ray is performedc and
follow-up

inmate medical records Laboratory servicesk  o  Report laboratory results within
                       24 hours, as 10 randomly selected

No source identified in performance assessment instruments

appropriate

o  	Clinical acknowledgment of laboratory results and appropriate clinical
responsec

                             inmate medical records

     Medication    o  Number of omissions in inmate records 5 MARs MARs books 
administration                    in the                 books  
records (MAR)l        medication administration books           
                   o    Number of cases in which inmates           
                                     refused                       
                      medications on three consecutive             
                      occasions noted                              
                        in the medication administration           
                                      books                        
                   o  Number of cases in which inmates who         
                                     refused                       
                        medications on three consecutive           
                                    occasions                      
                        received appropriate follow-up m           

Quality improvement activities
Credentialing  o  Validated current license for physician, PA, and NP

                              10 randomly selected

Nursing files, dental files, mental health files, and combined
physician/PA/NP files staff and U.S. Drug Enforcement Administration
registration for physician and NP staff

o  Validated current license - nursing staff

o  Validated current license - dental staff

o  Validated current license - mental health staff clinician files from
each provider type, and from the combined physician/PA/NP staff

 Complaints and grievances  o  Analyzed trends in terms of numbers and category

All medical grievances 	CCHPS log of inmate grievances

distribution of complaints and grievances

o  	Percentage of complaints and grievances appropriately addressed within
14 days

Appendix III: Performance Assessment Instruments Used to Monitor Services
Provided by CCHPS

             Service area/type Measure Sample used Source of sample

Quality improvement program

o  Annual work plan

o  	Activities reviewed include management of communicable diseases,
pharmacy and therapeutics, reviews of inmate deaths, clinical guidelines,
and adherence to standards. In addition, there is regular performance
measurement of access to and availability, continuity, and coordination of
care; complaints about care; and acute, chronic, and communicable disease
care. Focus studies should be performed where problems exist. Barriers to
care should be identified and interventions should be designed to reduce
the barriers. Remeasurement should occur to document meaningful
improvement.

                         Not applicable Not applicable

Source: GAO analysis of the Center for Correctional Health and Policy
Studies, Inc. information.

aThis sample is limited to the first eight if all eight have been done
appropriately. The sample is chosen from the 2-week period beginning 4
weeks prior to the review.

bThe sample is chosen from the inmates seen within the 3 months prior to
the review.

cPerformance assessment requires clinical judgment by physician, PA, or
NP.

dCD4 cells are a type of white blood cell that fights infection. HIV
destroys CD4 cells, which weakens the immune system.

eThe sample is chosen from the inmates seen within the month prior to the
review.

fPerformance assessment requires clinical judgment by physician, PA, NP,
or registered nurse (RN).

gThe sample covers 3 days within the 2-week period prior to the review.

hPerformance assessment requires clinical judgment by physician.

iThe sample is chosen from 3 days within the 3-week period prior to the
review.

jThis sample is composed of five records from each specialty clinic within
the 3 months prior to the review. The specialty clinics are the
cardiology, dermatology, eye, gynecology, neurology, orthopedics,
podiatry, and pulmonary clinics.

kBecause of problems, such as difficulty linking CCHPS's computerized
inmate medical records to laboratory results, these measures have not been
used in recent reviews, and are being reviewed.

lMARs are written records of medications ordered for and distributed to
inmates. MARs for each inmate are placed in larger "books," separated by
housing unit and organized alphabetically by inmate, which are then taken
to the housing units when medications are distributed. RNs distributing
medications to inmates are required to note on the MAR that the inmate
received the medication, or to provide information on why the medication
was not given to the inmate.

mInmates who refuse three or more consecutive doses of medication or
refuse to take medications consistently are referred to their primary
provider for evaluation.

Appendix IV: Comments from the District of Columbia Department of Corrections

Appendix IV: Comments from the District of Columbia Department of
Corrections

Appendix IV: Comments from the District of Columbia Department of
Corrections

Appendix IV: Comments from the District of Columbia Department of
Corrections

Appendix IV: Comments from the District of Columbia Department of
Corrections

Appendix IV: Comments from the District of Columbia Department of
Corrections

Appendix V: GAO Contact and Staff Acknowledgments

GAO Contact Helene F. Toiv, (202) 512-7162

Acknowledgments 	In addition to the person named above, key contributors
to this report were Emily Gamble Gardiner, Marc Feuerberg, Krister Friday,
and Anne Montgomery.

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