Audit of the Federal Bureau of Prisons
Comprehensive Medical Services Contracts
Awarded to the University of Massachusetts
Medical School

***
22-052

MARCH 2022

EXECUTIVE SUMMARY
Audit of the Federal Bureau of Prisons Comprehensive Medical
Services Contracts Awarded to the University of Massachusetts
Medical School
Objectives

Audit Results

The Department of Justice Office of the Inspector General
conducted an audit of the Federal Bureau of Prisons’ (BOP)
contracts awarded to the University of Massachusetts
Medical School (UMass) to provide comprehensive medical
services at the Federal Correctional Complex located in
Butner, North Carolina (FCC Butner); Federal Medical Center
located in Devens, Massachusetts (FMC Devens); and Federal
Correctional Institution located in Ray Brook, New York (FCI
Ray Brook). The objectives of this audit were to assess the
BOP’s award and administration of the contracts, and
UMass’s compliance with the terms, conditions, laws, and
regulations applicable to the contracts.

Between 2012 and 2014, the BOP awarded three indefinitedelivery/requirements contracts to UMass, which has been
providing comprehensive medical care to BOP since 1999.
The three contracts, which had an estimated total value of
over $304.4 million, were for UMASS to provide
comprehensive medical services (CMS) at FCC Butner, FMC
Devens, and FCI Ray Brook. Each contract period of
performance was 1-year base and four 1-year options. As of
March 2020, all three contracts ended, and the facilities were
using short-term contracting methods to acquire medical
services from UMass.
Acquisition Process

Results in Brief

We found that the BOP did not always complete its
acquisition planning and awarding of follow-on CMS
contracts in a timely manner. We determined the delays in
the CMS acquisition process were related to poor
collaboration and communication among the facilities and
the centralized contracting office, inefficient processes
involving the preparation and approval of the Request for
Contract Action and the completion of proposal technical
evaluations, and a lack of preparing written acquisition plans
and establishing milestones.

We found areas for improvement related to the BOP’s
acquisition process, contract administration, contract
performance oversight, and payment of billings. The
acquisition process weaknesses resulted in extended periods
of time where the BOP acquired medical services without full
and open competition. We also determined that BOP
officials lacked sufficient data to effectively monitor the
contracts, did not maintain adequate documentation for
changes made to contracts, and did not appropriately review
billing documentation prior to payment. In addition, BOP
contract administration staff did not act within their
delegated authority when approving invoices for payment.

Contracting without Full and Open Competition
As a result of the BOP’s inefficient acquisition process, FCC
Butner and FMC Devens purchased medical services for
nearly 2 years without full and open competition. In
addition, we found that the BOP did not adhere to Federal
Acquisition Regulation (FAR) requirements when contracting
without full and open competition, such as including
adequate documentation to support the Contracting
Officer’s determination that prices paid for services were fair
and reasonable.

Further, the BOP did not have a reliable, consistent process
in place to evaluate timeliness or quality of inmate
healthcare. We determined that the BOP could improve its
contract monitoring to enable it to assess these performance
requirements.

Recommendations

Contract Administration

Our report contains 15 recommendations to assist the BOP
in improving its acquisition process for medical services,
contract administration, management of contract
performance, and billing process.

We found the BOP completed contract modifications when
adding services to the contract requirements, but contract
administration staff did not include sufficient documentation

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in the contract file justifying the modifications. We also
found that the BOP did not always properly delegate contract
administration responsibilities to Contracting Officer’s
Representatives (COR). In an instance where a COR was
delegated at FMC Devens, the COR did not maintain a
current COR certification, as required by the FAR.
Contract Performance
Although the BOP told us that it did not identify any significant
problems with UMass’s performance related to the timely
delivery of inmate healthcare and quality of care, we found
that BOP did not have a reliable, consistent process in place to
evaluate either the timeliness of inmate healthcare or the
quality of that care. Specifically, we found that for the
contracts we audited, facility staff did not complete required
tasks to review and evaluate UMass’s performance of the
contract requirements. Also, we found that UMass did not
provide all required on-site clinics consistently throughout the
period of performance of the contracts. In addition, we found
that BOP did not have a reliable, consistent process
throughout all BOP facilities to monitor and analyze wait times
for outside inmate appointments and the causes for cancelled
or rescheduled appointments to ensure inmates receive
timely healthcare.
Billing
Our review of the BOP’s process related to CMS billings
identified several areas where the BOP can and should
improve. Specifically, we found that the BOP did not have a
consistent process to review billings for off-site services to
ensure they were billed at Medicare rates and in some
instances these charges were not verified at all. Also, we
found that the BOP did not always rely on adequate
supporting documentation when reviewing billings and that
invoices were approved for payment by staff who were not
delegated such authority in a COR delegation letter.
Additionally, we found that staff, without the proper
authority, negotiated pricing not covered by the contract
potentially putting the BOP at risk of being subjected to
disputes, claims, or overpaying for medical services. Finally,
we found that FCC Butner paid UMass $169,814 in interest
during fiscal years 2018 and 2019 because it paid invoices
after 30 days, which did not comply with the requirements of
the Prompt Payment Act.

[Status]

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Table of Contents
Introduction ................................................................................................................................................. 1
Background .................................................................................................................................................. 1
The Federal Bureau of Prisons............................................................................................................ 1
FCC Butner ............................................................................................................................................. 2
FMC Devens ........................................................................................................................................... 2
FCI Ray Brook ........................................................................................................................................ 2
University of Massachusetts Medical School .................................................................................... 2
OIG Audit Approach ............................................................................................................................. 3
Audit Results ................................................................................................................................................ 4
Comprehensive Medical Services Acquisition Process........................................................................... 4
Acquisition Process Environment ....................................................................................................... 4
Request for Contract Action and Supporting Documentation ....................................................... 5
Evaluation of Proposals ....................................................................................................................... 6
Establishing and Managing Milestones Throughout the Acquisition Process ............................. 7
Contracting without Full and Open Competition .................................................................................... 7
Other than Full and Open Competition Authority and Required Documentation ...................... 8
Monitoring of Contracting without Full and Open Competition .................................................... 9
Contract Administration ...........................................................................................................................10
Contract Modifications .......................................................................................................................10
Contracting Officer Representative ..................................................................................................11
Contract Performance ..............................................................................................................................12
Inpatient and Outpatient Services....................................................................................................12
Comprehensive Medical Services Costs Billing Process .......................................................................15
Off-site Medical Services Billings ......................................................................................................15
On-site Medical Services Billings ......................................................................................................16
Staff Assigned to Approve Billings ....................................................................................................16
Prompt Payment Act ..........................................................................................................................17
Conclusion and Recommendations .......................................................................................................... 18
APPENDIX 1: Objectives, Scope, and Methodology ................................................................................ 20
Objectives ...................................................................................................................................................20
Scope and Methodology ...........................................................................................................................20

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Statement on Compliance with Generally Accepted Government Auditing Standards............20
Internal Controls .................................................................................................................................20
Compliance with Laws and Regulations ..........................................................................................21
Sample-Based Testing ........................................................................................................................22
Computer-Processed Data ................................................................................................................22
APPENDIX 2: The Federal Bureau of Prisons Response to the Draft Audit Report .............................. 23
APPENDIX 3: Office of the Inspector General Analysis and Summary of Actions Necessary to Close
the Audit Report......................................................................................................................................... 29

iv

Introduction
The Department of Justice Office of the Inspector General has completed an audit of three Federal Bureau of
Prisons’ (BOP) contracts awarded to the University of Massachusetts Medical School (UMass) between 2012 and
2014 to provide comprehensive medical services at the Federal Correctional Complex located in Butner, North
Carolina (FCC Butner); Federal Medical Center located in Devens, Massachusetts (FMC Devens); and Federal
Correctional Institution located in Ray Brook, New York (FCI Ray Brook). The contracts were indefinitedelivery/requirements contracts 1, and each had a 1-year base and four 1-year options. As of March 2020, the
comprehensive medical services contracts at all three facilities expired, and each facility used monthly purchase
orders to acquire medical care for its inmates. The estimated total values of the contracts are presented in the
following table.

Table 1
Comprehensive Medical Services Contracts with UMass

BOP Facility
FMC Butner
FMC Devens
FCI Ray Brook
Total

Estimated Value
$175,515,071
120,742,210
8,166,684
$304,423,965

Note: The estimated value at each facility was calculated using the
original contract award, any changes made throughout the contract,
and amounts from the Justification for Other than Full and Open
Competition.
Source: BOP contract documentation and staff interviews

Background
The Federal Bureau of Prisons
The BOP was established in 1930 to provide more progressive and humane care for federal inmates,
professionalize the prison service, and ensure consistent and centralized administration. As of December 2020,
the BOP was responsible for the custody and care of 152,184 federal inmates. The BOP seeks to protect society
by confining offenders in the controlled environments of prisons and community-based facilities that are safe,
humane, cost-efficient, and appropriately secure. It also seeks to provide cost-effective health care consistent
with community standards by providing essential medical, dental, and mental health services for federal
inmates.
When the BOP's internal resources cannot fully meet inmates' health care needs, the BOP awards contracts to
supplement its in-house medical services. Comprehensive medical services (CMS) contracts are intended to
FAR 16.503 states that an indefinite-delivery/requirements contract is one that provides for filling all actual purchase
requirements of designated Government activities for supplies or services during a specified contract period with deliveries
or performance to be scheduled by placing orders with the contractor.

1

1

provide necessary professional and facility services for inmates both as inpatients and outpatients. The CMS
contractors provide these services at local physician’s offices, hospitals, and other healthcare facilities, as well as
at medical specialty clinics conducted on-site at individual facilities.
The BOP’s Field Acquisition Office (FAO) in Grand Prairie, Texas, is responsible for awarding contracts that
exceed the Simplified Acquisition Threshold, rather than the individual facility awarding such contracts. 2 After
contract award, facility contracting staff are responsible for contract administration and management functions,
while FAO staff provide facilities assistance and guidance.

FCC Butner
FCC Butner is comprised of five facilities: a low security facility, two medium-security facilities, a minimum-security
satellite prison camp, and a Federal Medical Center (FMC). Most of the medical services at the complex are
provided at the FMC. The FMC is a full functioning hospital, identified as a Care Level III/IV facility, and provides
all specialty areas of medicine, as well as being the primary referral center for all inmates requiring oncology,
chemotherapy, or radiation therapy. As of July 2020, FCC Butner housed 4,203 inmates.

FMC Devens
FMC Devens is comprised of a federal medical center and an adjacent minimum-security satellite camp, fulfilling
the medical and mental health care needs of male inmates. The FMC, identified as a Care Level IV facility,
provides health care to inmates with serious health issues and is the primary center for providing transplant
services for inmates. As of July 2020, FMC Devens housed 919 inmates.

FCI Ray Brook
FCI Ray Brook is a medium security facility with a detention center and is identified as a Care Level 1 facility with
a generally healthy inmate population. Regardless of this designation, the need for inmate healthcare may arise
at any time and in any level of complexity. As of July 2020, FCI Ray Brook housed 561 inmates.

University of Massachusetts Medical School
UMass, a public institution and the Commonwealth of Massachusetts’ only public medical school, was founded
in 1962 to provide affordable medical education for state residents and to increase the number of primary care
physicians in underserved areas. Currently, it is an academic health science center of 6,180 professionals.
UMass offers services and expertise to help federal and state agencies and other health care organizations create
and apply needed health care solutions. This includes offering innovative options for clinical, financial, and
policy challenges in developing and administering entire programs serving vulnerable populations.
The UMass Health and Criminal Justice Program provides comprehensive, innovative health care solutions and is
responsible for the performance of BOP’s comprehensive medical services contracts awarded to UMass. UMass
has been providing comprehensive medical care to BOP since 1999.

2 As of February 2020, the Simplified Acquisition Threshold is $250,000. Prior to December 12, 2017, the threshold was
$100,000.

2

OIG Audit Approach
The objectives of this audit were to assess the BOP’s award and administration of the contracts and UMass’s
compliance with the terms, conditions, laws, and regulations applicable to the contracts in the areas of: (1)
contractor performance; (2) billings and payments; and (3) contract management, oversight, and monitoring.
In conducting our audit, we tested compliance with what we consider to be the most important conditions of the
contract award. Unless otherwise stated in our report, the criteria we used to evaluate compliance are
contained in the Federal Acquisition Regulation (FAR), and BOP policies and procedures. We interviewed BOP
Central Office and FAO officials. We also interviewed FCC Butner, FMC Devens, and FCI Ray Brook staff from the
Health Services Unit, Business Office, and Contracting who were involved with the UMass contracts.
Additionally, we interviewed key personnel at UMass, including executive management and other officials and
staff.
We also tested the BOP’s procedures for ensuring adequate contract acquisition, administration, and oversight,
and reviewed supporting documentation to ensure compliance with contract requirements. Additionally, we
reviewed the BOP’s contract files to ensure completeness as required by the FAR. Lastly, we tested invoices
billed to the BOP to ensure accuracy and allowability of costs.

3

Audit Results
We found that delays in the CMS acquisition process caused the BOP to acquire medical services for extended
periods of time without full and open competition. We believe these delays can be avoided in the future with
improved collaboration, training, and communication, as well as better monitoring of the acquisition process
using established milestones. Additionally, we found that the BOP did not comply with requirements under the
FAR related to: (1) adequate documentation in the contract file when executing CMS contract modifications, (2)
properly delegating contract administration responsibilities to qualified Contracting Officer’s Representatives
(COR), and (3) delegated CORs maintaining required certifications.
We also determined that improvements can be made to BOP’s management of inpatient and outpatient
services. The improvements relate to ensuring BOP staff that are delegated performance oversight
responsibilities complete their required performance reporting tasks and maintain supporting documentation
for the contractor’s ratings, and ensuring staff are provided guidance and tools for the steps that can be taken
when contract requirements are not fulfilled timely. Further, BOP should implement a reliable, consistent
process throughout all BOP facilities to monitor and analyze wait times for outside inmate appointments and
the causes for cancelled or rescheduled appointments to ensure inmates receive timely and quality healthcare.
Additionally, we found that the BOP did not ensure that the facilities had a consistent process to review off-site
medical services billings for accuracy, that billings for on-site providers had adequate supporting
documentation, that appropriate staff approved billings for payment, and that the facilities complied with
requirements of the Prompt Payment Act. 3

Comprehensive Medical Services Acquisition Process
We found that the BOP has not always been able to complete its acquisition planning and awarding of CMS
contracts in a timely manner. As a result, FCC Butner and FMC Devens acquired medical services for nearly 2
years after existing contracts ended without full and open competition. We determined the delays in the CMS
acquisition process were related to poor communication and collaboration among the individual facilities and
the FAO, inefficient preparation and review of documentation included in the Request for Contract Action (RCA),
technical evaluations of proposals that were frequently postponed due to a lack of guidance and policies to
assist in completing the evaluations, and a lack of preparing acquisition plans including establishing and
monitoring milestones for the acquisition. In addition, we found that a majority of the acquisition process tasks
were the responsibility of Health Services staff within the facilities who had other responsibilities that took
precedence, and that those priorities resulted in some of the delays in the acquisition process.

Acquisition Process Environment
CMS contracts are used by the BOP to provide medical services to inmates that cannot be fulfilled within the
facility using BOP resources such as access to specialists, transplants, and oncology care. CMS contracts are
awarded for a 5-year period of performance and steps must be taken to have the next contract awarded timely
in accordance with BOP policies and the FAR. The acquisition of medical services at the BOP is a shared
responsibility between the FAO and the individual facility where the medical services are necessary. We found
that the facility staff we interviewed for this audit were not always familiar with how to complete required
3

FAR Subpart 32.9

4

acquisition planning tasks. While the FAO staff were continuously engaged in the acquisition of medical services
for individual facilities throughout the BOP, staff at an individual facility only work on these tasks once every 5
years. In addition, most of the facility staff that were responsible for these tasks told us they had not received
training and did not have written policies and procedures specific to their tasks.
Health Services staff at the facilities responsible for acquisition tasks also told us that completing required
documents was difficult due to a lack of understanding in how to prepare the documentation. Also, other
responsibilities within the Health Services Unit, such as providing healthcare to inmates, took precedence over
these tasks. FAO staff told us that they understood facility staff had other priorities; however, there were
significant delays, and the FAO staff rarely elevated such issues to senior management.

Request for Contract Action and Supporting Documentation
The acquisition of CMS begins with the preparation of an RCA that includes documentation required by the BOP,
such as an acquisition plan, government estimate for the cost of the services requested, and a description of the
necessary services. While the BOP Acquisition Policy is silent regarding how long completing and approving the
RCA should take, it does include a minimum adequate acquisition lead time of 1 year to award a CMS contract
from the time an RCA is approved by the FAO.
Although it is the responsibility of a facility’s staff to complete an RCA, FAO staff told us that, given the
complexity of CMS acquisitions, the FAO typically notifies facilities when an RCA is required approximately 18
months prior to the existing CMS contract ending. However, we were told by staff at the three facilities that they
were not notified by the FAO, and instead they initiated the process on their own 12-18 months prior to ongoing
contracts ending. Given that the BOP estimates the minimum amount of time to award a CMS contract after
RCA approval is 1 year, the notification at 18 months would provide 6 months to complete and approve an RCA.
However, we found that the most recent RCAs submitted by FCC Butner and FMC Devens took about 18 months
to approve – three times longer than anticipated.
In our review of the RCA process, we found that there was a significant amount of time spent on completing an
adequate independent government cost estimate, and we believe this was the cause of significant delay.
Government cost estimates provide the anticipated quantity and related cost of services in an acquisition, and
the estimate is prepared by facility staff with first-hand knowledge of a facility’s medical needs. FAO staff told us
they provided facility staff general guidance to prepare cost estimates and approved an RCA once it was
determined to be adequate.
In our review of the government cost estimates associated with recent CMS acquisitions at FCC Butner and FMC
Devens, we found several revisions were made to the estimates, but none of the revisions appeared to be
significant. In some instances, we found that these revisions took several months to be completed and
submitted back to the FAO, and these revisions could have been avoided with a discussion between the FAO
Contracting Officer and facility staff. Additionally, we did not identify specific documented reasons for the
revisions. Facility staff told us that there were instances where FAO staff told them revisions were adequate, but
then would receive the estimate back months later requiring additional changes. Additionally, facility staff told
us they did not have written policies and procedures specific to preparing cost estimates or training to assist
them when completing the cost estimates.

5

Evaluation of Proposals
FAO staff use completed RCAs to solicit proposals from prospective vendors through solicitations that include
evaluation criteria. The proposals are to detail how vendors intend to fulfill the requirements established by the
BOP in the solicitation. The submitted proposals are evaluated by both the FAO and facility staff. FAO staff are
responsible for completing an evaluation of price and past performance for each submitted proposal, while the
facility staff complete a technical evaluation of each proposal. FAO works with the facility to convene an
evaluation panel consisting of two to three Health Services staff and provides the panel with guidelines for
completion of evaluations.
Similar to the completion of RCAs, we found issues with the completion of evaluations for the recent CMS
acquisitions at FCC Butner and FMC Devens that contributed to CMS contract award timeliness issues. We
found that the technical evaluation process for the FMC Devens proposals, replacing the contract ending in
January 2018, was significantly delayed. Although the FAO received potential vendors’ proposals in May 2019,
we found that the proposals were not provided to the technical evaluation panel until October 2019 and the
evaluations were not completed and provided to the FAO until March 2020. We also found no documented
communications between FMC Devens staff and the FAO throughout the evaluation process, and no
documentation in the file regarding the delays.
For the FCC Butner acquisition, we found that the FAO Comprehensive Medical Service Section Chief and
Contracting Officer traveled to the facility to provide in-person guidance for completing the technical evaluations
due to the complexity of the requirements. FCC Butner staff told us that this expedited the process and that,
without FAO assistance, staff would not have known what to do and would have been unable to complete the
evaluations as quickly.
Staff at both facilities responsible for conducting the technical evaluations told us that the evaluation criteria
was generic and vague and did not apply to all the requirements in the solicitation, which made it difficult to
evaluate the proposals. For example, staff at one facility told us that a requirement in the solicitation was to
provide on-site clinics, while the evaluation criteria included determining the distance to and from the service
provider. Because the services were to be offered within the facility and were not to include transportation to
the provider, the evaluation criteria were not applicable.
In addition, we found that conducting technical evaluations was not routine for facility staff, similar to our
finding regarding the completion of RCAs. According to the facility staff, no training specific to completing
technical evaluations had been provided, and there were no written policies and procedures on how to conduct
the evaluations.
At the conclusion of our audit, we discussed with BOP officials the training, support, and guidance concerns
discussed in the above sections and were told that training was in place for those who complete acquisition
tasks, and that FAO was available to provide support to facility staff whenever necessary. However, we asked
but were not provided any additional documentation demonstrating these actions.
Given the challenges facility staff expressed throughout the audit and the timeliness issues related to CMS
acquisitions, we believe the BOP should ensure facility staff are aware of resources available to assist in
completing acquisition tasks and more thoroughly document its training provided to facility staff responsible for
completing acquisition planning tasks. Additionally, we recommend that BOP should obtain feedback regarding
6

training currently provided to its facility staff and enhance its training and resources related to preparing
adequate RCAs and completing technical evaluations.

Establishing and Managing Milestones Throughout the Acquisition Process
As discussed, awarding CMS contracts is a multi-step process lasting 18 months or longer and requires
collaboration between the FAO and the individual facilities. The FAR requires agencies to prepare a written
acquisition plan that includes milestones necessary to award the contract in a timely manner, as well as the
technical, business, management, and other significant considerations of the acquisition. 4 BOP officials told us
that for the CMS acquisitions, milestones were not established or tracked in a written acquisition plan because
the contracts are awarded as firm-fixed and do not require a written acquisition plan in accordance with the
BOP Acquisition Policy and FAR. However, the contract documentation we reviewed identified the CMS contracts
as indefinite delivery/requirements, which is required by the FAR to have a written acquisition plan. Regardless,
due to the timeliness issues identified previously throughout the acquisition process, we believe the BOP should
establish and monitor milestones to ensure CMS contracts are awarded prior to the existing contract ending.
Although the BOP does not require written acquisition plans for CMS acquisitions, BOP maintains contract files
with documents and information related to CMS acquisitions in its electronic contract file system. In our review
of these contract files, we found the files included most of the information required in the written acquisition
plan except milestones for key events throughout the acquisition process. We also found that the BOP’s
electronic system includes a feature to create and monitor milestones, but that this feature was not being
utilized.
Because the BOP did not identify and document acquisition milestones, along with planned and actual
completion dates – including explanations for significant delays, the contract files were not as useful as they
might have been for BOP management to monitor and identify the steps in the process that were prone to
delay. As a result, we recommend the BOP ensure that written acquisition plans, including milestones, are
completed for CMS acquisitions and that the established milestones are monitored and any delays, and
associated causes and steps taken to address the delays, are documented in the contract file.

Contracting without Full and Open Competition
We found that delays in the CMS acquisition process resulted in follow-on contracts not being awarded prior to
existing CMS contracts ending at both FCC Butner and FMC Devens. Due to the continuous need to provide
medical care for inmates, the BOP bridged these gaps by purchasing medical services using short-term purchase
orders. As shown in Table 2, the BOP purchased medical services through short-term purchase orders at FCC
Butner and FMC Devens for approximately $85 million over about 2 years.

4

FAR 7.105

7

Table 2
Short-Term Contracting for Medical Services

BOP Facility
FCC Butner
FMC Devens
Total

Dollar
Amount
$56,466,946
28,329,901
$84,796,846

Number of Monthly
Purchase Orders
25
20

Number of
JOFOCs
6
4

Note: The dollar amount and number of months were calculated from the end of the 6-month
extension exercised after the contracts period of performance ended until March 2020.
Source: BOP Justification for Other than Full and Open Competition (JOFOC) documents

Although not prohibited, contracting without full and open competition carries risks, such as overpaying for
goods and services, and should only be used under certain conditions. Based on our review, we found the BOP
relied on contracting without full and open competition to purchase medical services rather than ensuring
follow-on contracts were awarded timely. As such, to mitigate the associated risks with contracting without full
and open competition, the BOP should have a well-designed process including sufficient documentation of the
Contracting Officer’s determinations and adequate monitoring.

Other than Full and Open Competition Authority and Required Documentation
To authorize the purchase of medical services without full and open competition, contracting staff at FCC Butner
and FMC Devens prepared a written document referred to as a Justification for Other than Full and Open
Competition (JOFOC). 5 The purpose of the JOFOC was to serve as part of the contract file detailing why the
required services were obtained without competition as required by the FAR.
We found that the BOP prepared 10 JOFOCs, 6 at FCC Butner and 4 at FMC Devens, to justify the purchase of
approximately $85 million in medical services without full and open competition between January 2018 and July
2020. We reviewed 5 of the 10 JOFOCs to determine whether BOP included sufficient facts and rationale in the
justification to justify the use of the authority cited. 6 We found that the BOP used the authority of ‘unusual and
compelling urgency’ in all the JOFOCs we reviewed. According to the FAR, this provision should be applied in
situations where: (1) an unusual and compelling urgency precludes full and open competition; and (2) delay in
award of a contract would result in serious injury, financial or other, to the Government. 7 Additionally, the FAR
notes that agencies cannot use contracting without full and open competition due to a lack of advance
planning. 8
We also found that the contract files did not include sufficient information to justify the use of the selected
authority. Specifically, we focused our review on the BOP’s documentation to support the Contracting Officer’s

5

FAR 6.303-1(a)

6

FAR 6.303-2

7

FAR 6.302-2(b)

8

FAR 6.301(c)

8

determination that the anticipated cost was fair and reasonable. We found that, for the JOFOCs reviewed, the
JOFOCs indicated that the Contracting Officer determined the anticipated costs were fair and reasonable;
however, the contract files did not include any supporting documentation or analysis to support that
determination. We found that for some of the JOFOCs reviewed, the anticipated costs were based on the same
rates as the expired contracts, while in other JOFOCs reviewed the rates for some services had increased.
However, we found that both facilities did not have supporting documentation to justify that the increased rates
were fair and reasonable. In one instance, the FMC Devens Contract Specialist requested assistance on rate
determinations from a FAO Contracting Officer and was advised that the increased rates were acceptable; but
FAO did not provide supporting documentation for this determination. Also, we found at FCC Butner that the
Contract Specialist negotiated the increased rates with UMass; however, there was no supporting
documentation included in the contract file for how the rates were determined to be fair and reasonable.
The FAR also limits the duration of when ‘unusual and compelling urgency’ can be used. Specifically, the FAR
requires that the period of performance of a contract awarded using this authority: (i) may not exceed the time
necessary to meet the unusual and compelling requirements of the work to be performed and for the agency to
enter into another contract for the required services using competitive procedures, and (ii) may not exceed 1
year unless the head of the agency determines exceptional circumstances apply. 9
We reviewed the period of performance for all 10 JOFOCs and found that while each was prepared to cover a
period of performance less than 1 year, when added to the previous JOFOC, the period using the authority at
each facility exceeded 1 year. For example, FMC Devens prepared four different JOFOCs, each with a period of
performance of 6 months, or a combined total of 2 years as shown previously in Table 2.
In addition to documentation requirements, when agencies contract for services without full and open
competition, the agency is required to make the justification publicly available with such disclosure being made
within 30 days of the contract award and a posting maintained for a minimum of 30 days. 10 We found that none
of the justifications for FCC Butner and FMC Devens were posted publicly or for the minimum of 30 days.
Contracting staff at FMC Devens told us that they were unaware of this requirement.
As a result of the issues we identified with the contract documentation and authority used by the BOP, we
recommend the BOP review its use of JOFOCs for CMS acquisitions to ensure compliance with regulations and
ensure staff understand the requirements when contracting without full and open competition.

Monitoring of Contracting without Full and Open Competition
The FAR and BOP Acquisition Policy require that all JOFOCs exceeding the Simplified Acquisition Threshold be
approved by the FAO Chief and those that exceed $650,000 receive an additional level of approval from the BOP
Procurement Executive and the BOP Assistant Director for Administration Division who serves as the BOP
Competition Advocate. 11 We determined that the BOP adhered to its approval process for the JOFOCs we

9

FAR 6.302-2(d)

10

FAR 6.305

11

BOP Acquisition Policy 6.304(c) and FAR 6.304(a)(2)

9

reviewed. However, we found that the BOP did not have an adequate process in place to monitor its use of
contracting without full and open competition.
BOP’s Central Office and FAO officials told us that both offices maintained logs of JOFOCs submitted for
approval. We reviewed both logs from October 2017 through February 2020 and found that the FAO logged 134
CMS JOFOCs including 52 over $650,000, while the Central Office log only included 17 CMS JOFOCs. The Central
Office’s Procurement Executive and Competition Advocate told us that they reviewed each JOFOC when it was
submitted, but they only receive those over $650,000 and were unaware of the total number of JOFOCs
prepared related to CMS acquisitions. These officials also told us they were unaware how frequently and for
how long the facilities were contracting without full and open competition.
We believe that BOP’s senior procurement officials lacked sufficient data on the use of contracting without full
and open competition related to medical services. Information providing a more complete picture of this type
of contracting would enable senior management to more effectively identify potential underlying problems in
the CMS acquisition process and ensure contracting without full and open competition is limited to those
circumstances provided by regulation.
As a result of these issues, we recommend the BOP implement a process to properly justify, manage, and
monitor all CMS contracting made without full and open competition.

Contract Administration
We found that the BOP did not adhere to the FAR in several areas related to contract administration of the CMS
contracts. Specifically, we found that the contracting staff at FCC Butner and FMC Devens did not maintain
adequate documentation in the contract files when adding services to the requirements through contract
modifications. Additionally, we found that the BOP did not properly delegate contract administration
responsibilities to CORs. Lastly, we found that the delegated COR at FMC Devens did not maintain a current
certification because the required training was not completed in accordance with DOJ guidelines.

Contract Modifications
In large, complex, multi-year contracts such as CMS contracts, it is not uncommon for requirements to change,
making it necessary to add or change services that were not anticipated during acquisition planning. These
changes are prepared by the Contracting Officer and called contract modifications. The FAR requires that the
Contracting Officer must include sufficient documentation in the contract file when adding or changing services
through a contract modification. We found 14 of the 27 contract modifications completed for the CMS contracts
at both FCC Butner and FMC Devens were made to add services not originally included in the contract
requirements.
One important item that is required for Contracting Officers to document in the contract file is how the price
was determined to be fair and reasonable when adding services without using competitive procedures. From
our review of the 14 contract modifications that added services, we found that only 2 of the contract
modification files included sufficient documentation to support the Contracting Officer’s determination that the
price for the new services was fair and reasonable. We found that eight of the contract modification files did not
include any documentation to support the Contracting Officer’s determination regarding price, and the
remaining four included insufficient documentation, in our judgement, to adequately support the Contracting
10

Officer’s determination that the prices were fair and reasonable. Specifically, we found that these four contract
modification files did not include enough information to allow for any meaningful review and scrutiny, such as
comparisons to rates for the same specialty in the facility’s locality.
We also found that the BOP added positions and services that, according to BOP officials, the BOP does not
usually include as part of CMS contract requirements. In particular, FAO officials told us that the BOP prefers to
include only professional medical services as requirements of the CMS contracts, and to award separate
contracts for non-professional medical services, such as dental assistants and technicians. We also found that
contract modifications were used to include non-emergent medical transportation services to the CMS contract
requirements. FAO officials told us that Contracting Officers are expected to exercise professional judgment
when completing contract actions and that decisions must be sufficiently documented. FAO officials also told us
that, although the preference is to award these services separately, due to the importance of providing timely
medical care to inmates, adding these services to the CMS contract would be the best option.
Based on the issues we identified with the documentation provided regarding contract modifications, we
recommend the BOP enhance its controls to ensure its contract files comply with regulations for maintaining
documentation related to contract modifications.

Contracting Officer Representative
Contracting Officers are responsible for ensuring performance of all necessary contract actions and contractor
compliance with the terms and conditions of a contract. To assist with the day-to-day administration of a
contract, the Contracting Officer has the authority to designate a COR, and is required to provide a written
delegation letter to officially designate the COR. The delegation letter outlines the COR’s responsibilities under
the contract and the limits of the COR’s authority and must be retained in the contract file and updated as
necessary. Additionally, the FAR specifies that a COR shall be qualified by training and experience
commensurate with the responsibilities delegated, as well as be certified in accordance with the Office of
Management and Budget’s guidance. 12 Due to the complexity of the CMS contracts, the BOP requires the
designee to have a FAC-COR Level II certification. 13
We reviewed the contract files for the three facilities to determine if the BOP properly delegated COR
responsibilities and documented the delegation as required. We found that the BOP did not always properly
delegate its COR designations. Specifically, we found that at FCC Butner, the facility staff member most recently
designated as the COR was no longer employed at the BOP and that an updated appointment letter had not
been issued by the Contracting Officer. Instead, another staff member who previously was appointed as the
COR was responsible for fulfilling the delegated COR responsibilities. We found that FCC Butner officials were
unaware that the COR delegation letter was not current. Although the facility staff member acting as the COR
had previously been appointed as a COR for the CMS contract, without a current and accurate delegation letter
there was the risk that the COR may be unaware of any changes to the contract terms and conditions.

12

FAR 1.602-2(d)

The Federal Acquisition Institute and the Office of Federal Procurement Policy have established the FAC-COR certification
program, which has three levels of certification that allows for appropriate training and experience to manage various
contracts from low-risk simple to high-risk complex.
13

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At FCI Ray Brook, we found that the delegated COR retired in October 2019 and a replacement COR had not
been selected because the facility did not have a FAC-COR Level II certified staff member in the Health Services
unit.
We also found that the COR at FMC Devens did not maintain the FAC-COR Level II certification after June 2019
because continuous learning requirements were not met by the COR. To maintain a FAC-COR Level II, CORs are
required to complete 40 continuous learning points (CLP) hours every 2 years. FAC-COR certification is managed
at the federal agency level and, as such, DOJ identifies the training courses that may be taken to satisfy the
continuous learning requirement. We found that while the COR at FMC Devens had taken the required hours of
training, some of the hours were not eligible to be used for continuous learning purposes according to DOJ’s
policy. We believe that the risk of poor contract administration increases when delegated staff fail to maintain
their certifications.
We recommend that the BOP review and enhance its policies and procedures to ensure that those delegated to
administer CMS contracts are appropriately certified, and that appropriate delegations are in place.

Contract Performance
The CMS contracts we audited required UMass to establish a network of medical specialists to conduct on-site
clinics inside facilities and provide inpatient and outpatient services in a community-based setting, such as at
local physician’s offices, hospitals, and other healthcare facilities. According to the contracts, UMass must
conform to community standards in the delivery of healthcare, which includes providing care in a timely
manner. 14 During our interviews, BOP officials told us that they did not identify any significant issues related to
UMass’s performance of contract requirements. However, we found areas where BOP can improve its oversight
of contract performance requirements, including monitoring the timeliness and quality of inmate care, ensuring
required specialty on-site clinics are provided, and managing and understanding the causes and effects of
appointment cancellations on inmate care.

Inpatient and Outpatient Services
For our audit, we visited FCC Butner, FMC Devens, and FCI Ray Brook and reviewed the contracts awarded to
UMass to provide medical services at the facilities. The FMC at FCC Butner and FMC Devens are two of the BOP’s
six FMCs that are classified as Care Level IV facilities and house inmates with severe health problems and may
require daily nursing care. BOP’s Care Level IV facilities possess the bureau’s most advanced clinical capabilities
and resources.
Based on our review of BOP’s monitoring records and interviews of BOP’s contracting and medical staff, we
determined that BOP was generally satisfied with the quality and quantity of services provided under all three
contracts. While the healthcare provided to the inmates was continuously monitored throughout their medical
evaluations, we found that the BOP did not have a formal process in place to ensure the timeliness of the
healthcare inmates received. For the contracts we audited, we found that the BOP did not utilize any
mechanisms to consistently review and evaluate UMass’s performance of the contract requirements, including
the quality and timeliness of healthcare. At the conclusion of our audit, BOP officials told us this is done using

Community standard refers to the level and type of care that a reasonably competent and skilled health professional, with
a similar background and in the same medical community, would have provided under the circumstances.

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reports generated from the BOP’s electronic medical records system and completion of the Quality Assurance
Surveillance Plan. 15 However, during our audit, we were not provided evidence that these evaluations were
completed for the contracts audited.
We also found that the BOP did not ensure UMass provided all the on-site clinics required by the contracts and it
was therefore necessary for BOP to transport inmates outside facilities for treatment, resulting in avoidable
security risks and additional expenses. Further, we found that the BOP faced challenges in transporting inmates
to off-site appointments which resulted in a frequent need to reschedule appointments that could delay an
inmate’s healthcare. In addition, the BOP did not have systems in place to track and monitor the causes for
rescheduling appointments, including whether the reason for a cancellation was a BOP issue or one that was
out of its control, such as the physician cancelling the appointment. BOP also did not have a process in place to
monitor how long an inmate waited to receive care after a cancelled appointment. Because the BOP did not
have systems to measure or track any of these issues, we believe it is difficult for the BOP to determine whether
inmates are receiving care within the required community standard.
Clinics provided by CMS contractors within BOP facilities are critical for BOP efforts to effectively and efficiently
address the health care needs of its inmates. These clinics also help BOP manage security risks and
cancellations by avoiding transporting inmates to community hospitals and doctors’ offices. The CMS contracts
we audited identified the clinics UMass was expected to provide according to medical specialty. For example, at
both FCC Butner and FMC Devens, the contracts required UMass to provide clinics for specialties such as
cardiology, optometry, vascular surgery, and infectious disease. The CMS contract at FCC Butner also required
UMass to provide after-hour physicians to ensure inmates had around the clock medical care.
From our discussions with BOP and UMass staff and in reviewing documentation, we found that UMass did not
always provide all the medical specialty clinics required by the contracts. Because of this, the BOP was required
to transport inmates to off-site facilities for appointments in specialty areas for which there was no on-site clinic.
Also, we found that even though some specialty areas were included in the contracts, BOP did not enforce the
contract requirements to provide certain on-site clinics because the demand for the specialty area of care was
not sufficient to support the clinic. BOP did not revise or modify the contract requirements in these situations
because of the changing needs of its inmates at the facilities could change in the future. However, in other
circumstances, we found that the BOP identified on-site clinics that were included in the contract requirements,
but UMass was unable to provide physicians to conduct the clinics. For example, at FCC Butner, UMass did not
continuously provide a vascular surgery physician for the required on-site clinic. From September to October
2019, 17 appointments were required to be scheduled off-site for this specialty even though the contract
required an on-site clinic for vascular surgery. When appointments are completed off-site, there is an additional
security risk and other appointments cannot be scheduled due to limited BOP resources for off-site
appointments. Additionally, we found that when required on-site clinics were not provided, the BOP did not
take any further action to promote contract compliance by ensuring that UMass staff the clinics, except to
discuss the status of the vacant clinics at the monthly contractor meetings.
We reviewed the issue of vacant clinics with UMass officials who told us that they are sometimes unable to fill
certain clinics because it is difficult to recruit qualified professionals willing to treat inmates inside BOP facilities.
UMass officials also told us that the BOP includes in its solicitations for CMS contracts certain clinics that are
The Quality Assurance Surveillance Plan is required by FAR Part 46 and includes rating elements such as quality of
goods/services, timeliness of deliveries/performance, business relations, and customer satisfaction.

15

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never requested by the facility throughout the life of the contract. We reviewed the recent solicitation for a
follow-on contract at FCI Ray Brook that required certain clinics even though these clinics had not been provided
by UMass in the preceding 5 years covered by the existing contract. Although this solicitation was beyond the
scope of our audit, the BOP stated that it included these on-site clinics in the solicitation in the event that inmate
needs change at the facilities.
Due to the variety of inmate medical needs, not all healthcare treatments can be provided within a facility. The
CMS contracts contemplate the need for inmates being seen outside the facility in cases where the level of
inmate health care needed exceeds the medical care BOP can provide within the facility, or through available
on-site clinics provided by UMass. In these circumstances, BOP is responsible for transporting these inmates to
area hospitals and doctors’ offices. While BOP officials told us they did not have any concerns regarding
UMass’s scheduling of appointments and the care inmates received outside the facility, they described for us
some challenges that can add to the time inmates wait for treatment outside the facility. These challenges
included limits on staff available to escort inmates and the limited number of trips leaving facilities on a single
day. For example, FCC Butner and FMC Devens officials told us that many off-site appointments were
rescheduled due to emergency medical trips out of the facility that required around the clock correctional staff
coverage and limited how many other trips could be made out of the facility. UMass and BOP officials also told
us that appointments are rescheduled for other unanticipated reasons, such as inmate refusal to attend the
appointment, illness of the inmate, or rescheduling required by the medical provider.
UMass officials also told us that there was a significant amount of time spent by its staff cancelling and
rescheduling inmate appointments. During our audit, we found that the BOP does not adequately track
cancelled or rescheduled inmate appointments, and we were unable to determine what impact these
cancellations and rescheduling had on the delivery of timely medical care to inmates. Due to the lack of reliable
information, we also were unable to verify information provided by UMass regarding the number of cancelled or
rescheduled appointments and the reasons why the appointments were cancelled or rescheduled. The Health
Services staff at FCC Butner and FMC Devens told us that they believed most of the cancelled or rescheduled
appointments were due to emergency medical trips that took precedence over scheduled, routine
appointments, and this resulted in a lack of available BOP correctional officers and vehicles, but we did not
identify documentation that supported this explanation.
While we agree the environment for scheduling and transporting inmates for treatment outside the facility is
challenging, we found that the BOP does not have a process in place to track cancelled or rescheduled inmate
appointments in order to determine wait times, identify causes of cancelling or rescheduling appointments, or
demonstrate that UMass was rescheduling inmate appointments in a timely way following a cancellation.
At the conclusion of our audit, we discussed these issues with BOP officials and were told that inmates
healthcare is consistently monitored, and the timeliness of outside appointments was determined by the
referring physician using community standards. However, as discussed above, we were unable to determine
from BOP records whether delays that resulted when appointments were cancelled and rescheduled impacted
the delivery of inmate healthcare.
To improve compliance with contract terms related to inpatient and outpatient services, we recommend that
BOP ensure that BOP staff delegated performance surveillance responsibilities complete required performance
reporting tasks and maintain supporting documentation for the contractor’s ratings. BOP should also provide

14

facility staff guidance and tools for the steps that can be taken when contract requirements are not fulfilled in a
timely manner.
Additionally, BOP should implement a reliable, consistent process throughout all BOP facilities to monitor and
analyze wait times for outside inmate appointments and the causes for cancelled or rescheduled appointments
in order to ensure that inmates receive timely medical care.

Comprehensive Medical Services Costs Billing Process
From our review of the billing process for medical costs at the three facilities, we identified areas for
improvement, including ensuring billings for off-site medical services using Medicare rates are adequately
reviewed, sufficient documentation is maintained for on-site providers, appropriate delegations for staff who
approve billings for payment, and facilities have procedures in place to avoid the payment of interest.

Off-site Medical Services Billings
Off-site physician services, medical procedures, and hospital services billed by UMass, as well as other CMS
contractors, use Medicare-based rate structures that are often complex. 16 To address the risks associated with
the significant amounts billed by contractors for CMS contracts, and the additional complexities created by the
use of the rate structures, the BOP contracted with a third-party claims adjudication vendor to ensure the
accuracy of claim information, verify that the BOP is not billed for duplicate claims, and verify the local
benchmark Medicare rate structures used in the billings.
In 2017, the OIG issued a report that included a recommendation to the BOP to require CMS contractors to
submit electronic claims, ensure those claims are properly analyzed and maintained by the BOP’s adjudication
vendor, and enforce existing contract language that requires the adjudication vendor to perform fraud analytics
and report any indicators of fraud to the BOP. This recommendation was based on the determination that BOP
medical care claims were processed primarily through paper based manual methods. In response to the OIG’s
recommendation, the BOP awarded a medical claims adjudication services contract, but, as of March 2020, the
BOP had not begun using the adjudication vendor because of technology issues within the BOP.
During our audit, we found that the three facilities each processed its off-site medical services claims in a
different manner. We found that FCC Butner utilized the third-party adjudication vendor until August 2019, but
since that time its medical service claims were not processed through the adjudication vendor. In addition, from
August 2019 to March 2020, UMass billed over $20 million for medical services provided to FCC Butner that were
not reviewed through an adjudication process. Facility staff told us that the invoices were merely reviewed for
mathematical accuracy and to ensure the inmate received the services billed. Based on the volume of medical
services claims, we believe the BOP is at risk of overpaying for medical services incurred by the inmates at FCC
Butner due to the adjudication vendor not being appropriately utilized and the complexities to review Medicare
rates.

16

The contracts in our audit utilize Medicare Part A or B Benchmark pricing for the specific locality with a premium applied.

15

We found the Health Services Unit staff at FMC Devens purchased its own adjudication software that allowed it
to adjudicate the UMass invoices for medical services billed using Medicare rates. The staff told us they
preferred to review invoices rather than using the adjudication vendor.
We found that medical services claims at FCI Ray Brook were only reviewed for mathematical accuracy and that
the inmate received the services billed, and that no verification of the use of Medicare rates was performed.
As a result of the inconsistent review process of medical services billings, we recommend that the BOP
implement specific policies and procedures for reviewing billings submitted using Medicare-based rates, and
that the BOP ensure that facilities utilize the third-party adjudicator vendor.

On-site Medical Services Billings
In a 2007 OIG audit report of the BOP’s CMS contract at FCC Butner, the OIG found that FCC Butner did not
review, or sign timesheets prepared by on-site providers and did not calculate time spent at the facility by these
providers according to the main entrance visitor logs to verify the accuracy of hours billed for on-site providers.
The OIG recommended that the BOP implement controls that require on-site providers to record their arrival
and departure times within their designated work areas each day, and periodically compare the hours reported
in timesheets to the hours recorded on site according to the main entrance logs.
The OIG conducted a follow-up audit in 2013 and reported that in response to the 2007 audit, the BOP
implemented a time clock to improve its controls over the review and payment of hours billed for on-site
providers. However, that audit found the time clock records were at times unavailable or unreliable. In these
instances, the BOP relied on the visitor logs, but stated that the providers did not always record both their
arrival and departure times. The OIG recommended that the BOP revise and take additional steps to enforce its
policy requiring on-site providers to use the time clock.
During this audit, we reviewed FCC Butner’s process to review UMass billings for on-site providers to determine
if the BOP strengthened its process to ensure billings were accurate and properly supported. We reviewed a
sample of invoices to determine if the BOP relied on adequate supporting documentation to approve payments
to UMass. 17 Consistent with the results of the prior audits, we found that the records created using the time
clock were not always complete or legible, and the corresponding supporting documentation in the visitor logs
were also missing or incomplete.
We recommend that the BOP implement Bureau-wide policies and standards for CMS contract billings, to
include appropriate supporting documentation, at all facilities. Also, we recommend that the BOP ensure that
FCC Butner enhance its procedures to ensure complete and accurate recording of on-site provider attendance
to verify related billings.

Staff Assigned to Approve Billings
During our review of the invoice approval process at the three facilities, we identified invoices that were
approved by individuals that were not delegated this authority in the COR delegation letter. We found that at
17 The sampled invoices were selected from UMass on-site providers invoices submitted to FCC Butner for services provided
between January 2017 and December 2019.

16

FCC Butner and FMC Devens, Health Services staff approved invoices for payment who were not delegated this
authority. While these individuals were closely involved with the day-to-day operations of the on-site providers,
they either did not have a FAC-COR certification or were not certified at the level required by the BOP. At FCI Ray
Brook, after the COR retired in October 2019, we found that the Business Administrator or Clinical Director
approved invoices for payment; however, neither were delegated this authority nor had the required FAC-COR
certification.
In addition to improper staff approving invoices for payment, we found that other facility staff were negotiating
pricing for services not covered by a benchmark Medicare rate. For example, we found air ambulance
transportation costs billed to FMC Devens used a rate other than benchmark Medicare because there was not a
rate available for these services. FMC Devens staff told us they used Medicare Part B for its locality with the
contract’s premium applied to agree on an acceptable price with UMass. We were also told that the discussions
for the air ambulance pricing were done between Health Services staff and UMass, and the Contracting Officer
was not involved. The FAR states that only Contracting Officers have the authority to make commitments or
changes that effect price or other terms and conditions of a contract. 18 When staff without the proper authority
negotiate pricing outside the contract terms and conditions, it puts the BOP at risk of being subjected to
disputes, claims, or overpaying for medical services.
As a result of the facilities’ lack of adherence to and understanding of contract administration responsibilities
related to billings, we recommend that the BOP develop and implement policies and procedures emphasizing
responsibilities and authority of staff involved with CMS contracts.

Prompt Payment Act
FAR Subpart 32.9 requires agencies to establish policies and procedures to ensure compliance with the Prompt
Payment Act, which states that the due date for making invoice payments is the later of (1) the 30th day after the
designated billing office receives a proper invoice from the contractor; or (2) the 30th day after government
acceptance of the services provided.
We requested the amount of interest paid to UMass related to the Prompt Payment Act from FCC Butner and
FMC Devens for the contracts we reviewed. We found that in fiscal years 2018 and 2019, FCC Butner paid
UMass $169,814 in interest because FCC Butner took longer than 30 days to pay the related invoices.
Specifically, FCC Butner officials told us that more than 90 percent of the interest paid, $159,148, was related to
delays in processing invoices during the federal government shutdown in December 2018 and January 2019.
Although FCC Butner attributed the payment of interest costs to the federal government shutdown, we found
that for the same period, FMC Devens paid just $306 in interest to UMass. FMC Devens officials told us the
interest paid was related to payments made after 30 days caused by issues with its accounting system.
We recommend that the BOP develop contingency plans to ensure invoices are paid timely in accordance with
the Prompt Payment Act to avoid interest payments during disruptions to normal operations caused by
extraordinary circumstances such as a government shutdown.

18

FAR 1.602-2

17

Conclusion and Recommendations
As a result of our audit, we determined that the BOP did not adequately monitor and manage its acquisition of
follow-on contracts for comprehensive medical services (CMS). Consequently, the BOP relied on contracting for
medical services without full and open competition rather than ensuring follow-on contracts were awarded
timely. We determined that in order to more effectively manage the potential risks related to contracting
without full and open competition, the BOP should focus on improving the efficiency of its process for acquiring
CMS. Additionally, BOP senior executives should closely monitor contracting activities at its facilities for the
potential of overusing contracting without full and open competition.
We also identified issues with the BOP’s administration and management of the CMS contracts. Specifically, we
found that the BOP did not comply with requirements under the FAR related to: (1) maintaining adequate
documentation in the CMS contract files, (2) properly delegating contract administration responsibilities to
qualified Contracting Officer’s Representatives (COR), (3) ensuring delegated CORs maintained required
certifications, and (4) the Prompt Payment Act. Additionally, the BOP did not have a consistent process in place
to ensure billings were adequately supported, reviewed for accuracy, and approved by the appropriate staff.
We believe the BOP should enhance its support and management of its staff to improve its contract
administration processes to ensure compliance with regulations and contract terms and conditions.
Finally, BOP officials told us that they did not identify any significant issues related to performance of the
contract requirements by UMass. However, we determined that BOP could improve its oversight of the quality
and timeliness of healthcare provided by ensuring staff delegated performance surveillance responsibilities
complete required reporting tasks and maintain supporting documentation for the contractor’s ratings. We also
determined that BOP should provide staff guidance and tools for the steps that can be taken when contract
requirements are not fulfilled in a timely manner. Further, BOP should implement a reliable process throughout
all BOP facilities to monitor and analyze the wait times for outside inmate appointments and the causes for
cancelled or rescheduled appointments to ensure inmates receive timely healthcare.
We recommend that the BOP:
1. Ensure facility staff are aware of resources available to assist in the acquisition process and more
thoroughly document its training provided to facility staff responsible for completing acquisition
planning tasks.
2. Obtain feedback regarding training currently provided to its facility staff and enhance its training and
resources related to preparing adequate RCAs and completing technical evaluations.
3. Ensure that written acquisition plans, including milestones, are completed for CMS acquisitions and
ensure that the established milestones are monitored and any delays, and associated causes and steps
taken to address the delays, are documented in the contract file.
4. Review its use of JOFOCs for CMS acquisitions to ensure compliance with regulations and ensure staff
understand the requirements when contracting without full and open competition.

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5. Implement a process to properly justify, manage, and monitor all CMS contracting made without full and
open competition.
6. Enhance its controls to ensure its contract files comply with regulations for maintaining documentation
related to contract modifications.
7. Review and enhance its policies and procedures to ensure that those delegated to administer CMS
contracts are appropriately certified, and that appropriate delegations are in place.
8. Ensure that BOP staff delegated performance surveillance responsibilities complete required
performance reporting tasks and maintain supporting documentation for the contractor’s ratings.
9. Provide facility staff guidance and tools for the steps that can be taken when contract requirements are
not fulfilled in a timely manner.
10. Implement a reliable, consistent process throughout all BOP facilities to monitor and analyze wait times
for outside inmate appointments and the causes for cancelled or rescheduled appointments in order to
ensure that inmates receive timely medical care.
11. Implement specific policies and procedures for reviewing billings submitted using Medicare-based rates,
and that the BOP ensure that facilities utilize the third-party adjudicator vendor.
12. Implement Bureau-wide policies and standards for CMS contract billings, to include appropriate
supporting documentation, at all facilities.
13. Ensure that FCC Butner enhance its procedures to ensure complete and accurate recording of on-site
provider attendance to verify related billings.
14. Develop and implement policies and procedures emphasizing responsibilities and authority of staff
involved with CMS contracts.
15. Develop contingency plans to ensure invoices are paid timely in accordance with the Prompt Payment
Act to avoid interest payments during disruptions to normal operations caused by extraordinary
circumstances such as a government shutdown.

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APPENDIX 1: Objectives, Scope, and Methodology
Objectives
The objectives of this audit were to assess the BOP’s award and administration of the contracts, and UMass’
compliance with the terms, conditions, laws, and regulations applicable to the contracts in the areas of: (1)
contractor performance; (2) billings and payments; and (3) contract management, oversight, and monitoring.

Scope and Methodology
The scope of our audit focused on comprehensive medical services provided at FCC Butner, FMC Devens, and
FCI Ray Brook by UMass. In 2012, the BOP awarded Contract Numbers DJBP010600000057 and
DJBP010600000061 with a total value of almost $106.5 million to provide comprehensive medical services at FCC
Butner. As of March 2020, FCC Butner’s estimated contract value increased to approximately $175.5 million. In
2013, the BOP awarded Contract Number DJBP020500000016 with a value a little over $85 million to provide
comprehensive medical services at FMC Devens and as of July 2020 the estimated value was almost $121 million.
In 2014, the BOP awarded Contract Number DJBP021200000035 with a value of almost $8 million to provide
comprehensive medical services at FCI Ray Brook and this increased slightly to an estimated value of almost
$8.2 million.
To accomplish the audit objectives, we interviewed BOP employees, including senior officials from the BOP’s
Central Office and the Field Acquisition Office, as well as Contract Specialists at the Field Acquisition Office and
staff from the Business Office, Contracting, and Health Services at FCC Butner, FMC Devens, and FCI Ray Brook.
We also interviewed UMass senior officials, financial, and program staff with BOP contract responsibilities.
Additionally, we reviewed BOP’s contract documentation and relevant policies, procedures, and guidance related
to contracting and inmate medical care, including the BOP Acquisition Policy. Further, we conducted fieldwork
at the FAO, FCC Butner, FMC Devens, and FCI Ray Brook.

Statement on Compliance with Generally Accepted Government Auditing Standards
We conducted this performance audit in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to
provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the
evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Internal Controls
In this audit, we performed testing of internal controls significant within the context of our audit objectives. We
did not evaluate the internal controls of the BOP and UMass to provide assurance on its internal control
structure as a whole. BOP and UMass management is responsible for the establishment and maintenance of
internal controls in accordance with OMB Circular A-123. Because we do not express an opinion on the BOP’s
and UMass’ internal control structure as a whole, we offer this statement solely for the information and use of
the BOP and UMass. 19

19

This restriction is not intended to limit the distribution of this report, which is a matter of public record.

20

In planning and performing our audit, we identified the following internal control components and underlying
internal control principles as significant to the audit objectives:
Internal Control Components & Principles Significant to the Audit Objectives
Control Environment Principles
The oversight body and management should demonstrate a commitment to integrity and ethical
values.
The oversight body should oversee the entity’s internal control system.
Management should establish an organizational structure, assign responsibility, and delegate authority
to achieve the entity’s objectives.
Management should demonstrate a commitment to recruit, develop, and retain competent individuals.
Management should evaluate performance and hold individuals accountable for their internal control
responsibilities.
Risk Assessment Principles
Management should identify, analyze, and respond to risks related to achieving the defined objectives.
Management should consider the potential for fraud when identifying, analyzing, and responding to
risks.
Control Activity Principles
Management should design control activities to achieve objectives and respond to risks.
Management should design the entity’s information system and related control activities to achieve
objectives and respond to risks.
Management should implement control activities through policies.
Information & Communication Principles
Management should use quality information to achieve the entity’s objectives.
Monitoring Principles
Management should establish and operate monitoring activities to monitor the internal control system
and evaluate the results.

We assessed the design, implementation, and operating effectiveness of these internal controls and identified
deficiencies that we believe could affect the BOP’s ability to effectively and efficiently operate, to correctly state
financial and performance information, and to ensure compliance with laws and regulations. The internal
control deficiencies we found are discussed in the Audit Results section of this report. However, because our
review was limited to aspects of these internal control components and underlying principles, it may not have
disclosed all internal control deficiencies that may have existed at the time of this audit.

Compliance with Laws and Regulations
In this audit we also tested, as appropriate given our audit objectives and scope, selected transactions, records,
procedures, and practices, to obtain reasonable assurance that BOP’s and UMass’ management complied with
federal laws and regulations for which non-compliance, in our judgment, could have a material effect on the
results of our audit. Our audit included examining, on a test basis, the BOP’s and UMass’ compliance with the
following laws and regulations that could have a material effect on BOP’s or UMass’s operations:


FAR Subpart 1.602 - Responsibilities

21



FAR Subpart 6.3 – Other than Full and Open Competition



FAR Subpart 7.1 – Acquisition Plans



FAR Subpart 32.9 – Prompt Payment

This testing included interviewing BOP and UMass personnel, analyzing contract files and data, and reviewing
invoices and supporting documentation. As noted in the Audit Results section of this report, we found the BOP
did not comply with federal regulations related to acquisition and procurement, contract administration, and
billings and payments.

Sample-Based Testing
To accomplish our audit objectives, we performed sample-based testing for invoices and contract
documentation. In this effort, we employed a judgmental sampling design to obtain broad exposure to
numerous facets of the areas we reviewed. This non-statistical sample design did not allow projection of the
test results to the universe from which the samples were selected.

Computer-Processed Data
During our audit, we obtained information from the BOP’s Bureau Electronic Medical Records System, CPARs,
and UMass’ HealthAxis system. We did not test the reliability of those systems as a whole, therefore any
findings identified involving information from those systems were verified with documentation from other
sources.

22

APPENDIX 2: The Federal Bureau of Prisons Response to the Draft
Audit Report
U.S. Department of Justice
Federal Bureau of Prisons

Wa!ihi11gto11, D .C. 20534

Office ofrhe Director

January 19,

2 0 22

MEMORANDUM FOR
GENERAL

ASSISTANT
AUDIT

FROM:

M. D.

SUBJECT :

Response
of Inspector General ' s (OIG)
Draft Report: Audit of the Federal Bureau of
Prisons' Comprehensive Medical Services Contracts
Awarded to the University of Massachusetts Medical
School

The Bureau of Prisons (BOP) appreciates the opportunity to provide
a formal response to the Office of the Inspector General ' s above
referenced r eport.
The BOP has completed our review, and offer the
following comments regarding the recommendations . As a general
comment , the BOP notes that while it concurs with the
recommendations as indicated below , it already has systems and
mechanisms in place to address many of the identified concerns .
These are described in further detail below.
Ensure facility staff are aware of resources
available to assist in the acquisition process and more thoroughly
documented its training provided to facility staff responsible for
completing acquisition planning tasks.

Recommendation One:

The BOP concurs with this recommendat i on .
Procurement professionals are required to complete acquisition
related training which includes available r esources externally and
within the BOP to assist with the acquisition process . Training is
recorded and included in the procurement staff electronic training
file.
The National Acquisition Branch provides Acquisition
Training for Program Offices .
Additionally , the Health Services
Division hosts biennial leadership training with the procurement

BOP's Response:

23

training provided by the Field Acquisitions Office (FAO} and the
Commercial Law Branch (CLB} within the Office of General Counsel
(OGC}. All training is documented within the individual staff
training records maintained by the Human Resources Management
Division (HRMD} .
Obta i n feedback regarding training currently
provided to its facility staff and enhance its training and
resources related to preparing adequate RCAs and completing
technical evaluations.

Recommendation Two:

The BOP concurs with this recommendation with
regards to institution staff . With the aforementioned training in
recommendation one , the Health Services Division obtains training
evaluations f r om each staff member attending leadership training
and utilizes this information to enhance future training and
resource needs, specifical ly those involving RCAs and techni cal
evaluations. The BOP plans to continue this evaluation feedback
loop process for the purpose of enhancing future training needs
within the procurement , RCA, and technical evaluation areas.

BOP' s Response:

Ensure that written acquisition plans ,
including milestones, are completed for CMS acquisitions a nd ensure
that the established milestones are monitored and any delays, and
associated causes and steps taken to address delays, a r e documented
in the contract file .

Recommendation Three:

The BOP concurs with this recommendation .
Acqui sition plans/procurement history and milestones documents are
included in al l Comprehensive Medical Section (CMS} procurement
f i les . Additionally, milestones are captured in Content Manager .
All procurement actions are moni t ored any delays are noted
according in the mi l estones.

BOP's Response:

Review its use of JOFOCS for CMS acquisitions
to ensure compliance with regul ations and ensu re staff understand
the requi r ements when c ontracting without full and open
competition .

Recommendation Four:

The BOP concurs wi th this recommendat i on. We will
revi ew the use of J OFOCS and ensure staff understand c ompliance
with regul ations.

BOP's Response:

Implement a process to properly justify,
manage, and monitor all CMS contracting made wit hout f u ll and open
competitio n.

Recommendation Five:

Page 2 o f 6

24

BOP's Response:
The BOP concurs with th i s recommendation.
In
accordance with FAR 13.104, Promoting Competition , procurement
staff must promote competition to the maximum. The BOP will
continue to review and monitor CMS contract files to ensure
procurement action includes documentation of full and open
competition.
Reconunendation Six:
Enhance its controls to ensure it s contract
files comply with r egulations for maintaining documentation related
t o contract modif ica tions.
BOP' s Response:
The BOP concurs with this recommendat i on .
Controls are established by regulation and policy . All Federal
Acquisition Cert i fication in Contracting (FAC-C)
Certified/Warranted Cont racting staff are required to comply the
requirements of the Federal Acquisition Regulat i on , Justice
Acquisition Regulation and the Bureau of Pr isons Acquisition
Policy , which states Contracting staff shall documents the file
related to contract modifications .
Recommendation Seven:
Review and enhance i ts pol i cies and
procedures to ensure that those de legated to admi n i ster CMS
contracts are appropriately certified, and that appropriate
delegations are in place.
BOP's Response: The BOP concurs with this recommendation.
Policies and procedures exist requ iring that a ll Admi nistrative
Contracting Officer s (ACO) delegated the authority to admini ster
CMS contracts are properly certified and maintain active FAC-C
Certification and BOP Warrants . Contracting professionals are
certified in accordance with the FAC - C standards . All award
notices ident i fy the ACO .
Recommendation Eight:
Ensure that BOP staff delegated performance
surveillance responsibilities complete required performance
reporting tasks and ma i ntain supporting documentat i on for the
contractor's ratings .
BOP's Response: The BOP concurs with this recommendation .
In
accordance FAR 42.1502 Policy (Past Performance) and the Contactor
Performance Assessment Reporting (CPAR) System , programming staff
and procurement staff shall prepare at least annually a past
performance evaluation at the time the work under a contract is
complete . The eva l uation for contractors remains i ndefinitely on
file in the CPAR automated platform. Staff designated as
contracting officer representatives (CORs) for technical report on
contractor's performance work closely with procurement staff to

Page 3 of 6

25

ensure all reporting is complete and submitted timely through the
CPAR System.
Recommendation Nine:
Provide facility staff guidance and tools for
steps that can be taken when contract requirements are not
fulfilled in a timely manner.
BOP's Response: The BOP concurs with this recommendation.
Procurement professionals are required to complete acquisition
related training which includes available resources externally and
within the Agency to assist with the acquisition process. Training
is recorded and included in the procurement staff electronic
training file.
The Nati onal Acquisition Branch provides
Acquisition Training for Program Offices . Additionally, the Health
Se rvices Division hosts biennial leadership training with the
procurement training provided by the FAO and the CLB within the
Office of General Counsel. All training is documented within the
individual staff training records maintained by the Human Resources
Management Division.
Recommendation Ten:
Implement a reliable, cons istent process
throughout all BOP facilities to monitor wait times outside inmate
appointments and the causes for cancelled or rescheduled
appointments in order to ensure that inmates receive timely medical
care.
BOP's Response:
The BOP concurs with this recommendation. The BOP
monitors wait times for outside medica l appointments through the
electronic health record (EHR), specifically through the
consultation queue of the EHR. The consultation queue of the EHR,
identifies that time frame clinically indicated for the
consultation to be scheduled, the actual date the consultation is
scheduled through the comprehensive medical provider, and a
verification of when results are received/recorded from the
completed consultation . Health Services Administrators review this
consultation queue frequently and specifically during each
utilization review committee (URC).
Identified discrepancies for
canceled or rescheduled appointments are documented within the EHR
with updates to applicable consultations as appropriate .
Recommendation Eleven:
Implement spe cific policies and procedures
for reviewing billing submitted using Medicare-based rates, and
that t he BOP ensure that facilities utilize the third-party
adjudication vendor .
BOP's Response:
The BOP concurs with this recommendation. The BOP
has a third-party bill adjudicator platform. All active CMS

Page 4 of 6

26

contracts will be modified as vendors complete their test trials
with the Bil l Adjudicat or . All new CMS requirements i nclude the
Bill Adjudicator language i n the sol i citati on once awa r ded the
execution of bill adjudication is immediately implemented .
Implement Bureau- wide policies and
standards for CMS contract billings , to include appropriate
support i ng documentation , at all facilities.

Recommendation Twelve:

The BOP concurs with th i s recommendation. All CMS
contracts include FAR 52.212- 4(g) which provides a detailed outline
of the information required on all invoices. Additional l y, the CMS
perf ormance work statement Output #3 "Submit Properly Priced
invoices £or services renderedn identifi es in detail the
i nformat i on required when submitting invoices/medica l claims .

BOP ' s Response:

Ensure that FCC Butner enhance its
procedures to ensure complete and accurate recording of on- site
provider attendance to verify r elated b illings .

Recommendation Thirteen :

The BOP concurs with this recommendation .
Butner
wil l enhance i t s procedures to ensure complete and accurate
recording of on-site p rovider attendance to verify related bil l ings
by re- educat ing contractor staff regarding the requirement to
complete and s i gn the Contractor/Vis i tor Log Book at the entrance
of each institution when entering and exiting the respective
institution . They will also be reminded of the requirement to
punch in and out us i ng the time clock at each inst i tution . In the
event the time c l ock is malfunctioning, the contractor will write
in his/her time, which will be verified using the sign in/sign out
time from the Contractor/Visitor Log Book. When the time cards are
copied for b i lling purposes, staff wi ll ensure the copies are
legible and re- copy/adjust the copier settings if necessary.

BOP' s Response:

Develop and implement policies and
procedures emphasizing responsibilities and authority of staff
involved with CMS contracts .

Recommendation Fourteen:

The BOP concurs with this recommendation .
Procurement staff are aware of the policies , procedures and
responsibilities involving CMS contracts. Health Services
Admini strators work closely with procurement staff and participate
in training for CMS specific policies, procedures , and
responsibilities.

BOP ' s Response:

Develop contingency plans to ensure
invoices are paid timely in accordance with the Prompt Payment Act

Recommendation Fifteen:

Page 5 of 6

27

to avoid interest payments during disruptions to normal operations
caused by extraordinary circumstances such as a government
shutdown.
The BOP does not concur with this recommendation
to the extent that it could create a conflict with t he Antideficiency Act. All applicable contracts executed by the BOP
include FAR Clause 52.232-19 Availability of Funds for Next Fiscal
Year, and the Government's obligation for performance of the
contract beyond the date is contingent upon the availability of
appropriated funds from which payment for contract purposes can be
made. Additionally, the Anti-deficiency Act restricts the Federal
Government's ability to obligate funds in adva nce o f an
appropriation or beyond appropriation levels.

BOP's Response:

Page 6 of 6

28

APPENDIX 3: Office of the Inspector General Analysis and
Summary of Actions Necessary to Close the Audit Report
The OIG provided a draft of this audit report to the Federal Bureau of Prisons (BOP) and the University of
Massachusetts Medical School (UMass) for review and official comment. The BOP’s response is incorporated in
Appendix 2 of this final report. UMass elected not to provide a written response to the draft audit report. In
response to our draft audit report, the BOP concurred with our recommendations and discussed the actions it
will implement in response to our findings. As a result, the status of the audit report is resolved. The following
provides the OIG analysis of the response and summary of actions necessary to close the report.
Recommendations for the BOP:
1. Ensure facility staff are aware of resources available to assist in the acquisition process and more
thoroughly document its training provided to facility staff responsible for completing acquisition
planning tasks.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that
procurement professionals are required to complete acquisition related training which includes
available resources externally and within the BOP to assist with the acquisition process, and that training
is recorded in the staff’s electronic training file maintained by the Human Resources Management
Division. The BOP further stated that its National Acquisition Branch provides acquisition training to its
program offices as well as the Field Acquisition Office and the Commercial Law Branch for the Health
Services Division.
This recommendation can be closed when we receive evidence that facility staff responsible for
acquisition tasks have received training and are aware of resources available related to the acquisition
process.
2. Obtain feedback regarding training currently provided to its facility staff and enhance its training and
resources related to preparing adequate RCAs and completing technical evaluations.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that the
Health Services Division obtains training evaluations for the training referenced in the above
recommendation and utilizes this information to enhance future training and resource needs,
specifically those involving RCAs and technical evaluations. In addition, the BOP stated it will continue
the evaluation feedback process to enhance future training needs within procurement, RCA, and
technical evaluation areas.
This recommendation can be closed when we receive evidence that staff feedback was solicited and
considered when making enhancements to the training program to address issues identified in our audit
related to the acquisition process, RCAs, and technical evaluations.

29

3. Ensure that written acquisition plans, including milestones, are completed for CMS acquisitions and
ensure that the established milestones are monitored and any delays, and associated causes and steps
taken to address delays, are documented in the contract file.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that
acquisitions plans (procurement history) and milestones documents are included in the procurement
files and the milestones are captured in its electronic contract file system. The BOP further stated that
all procurement actions are monitored, and any delays are noted according in the milestones.
This recommendation can be closed when we receive evidence that written acquisition plans, including
milestones, are completed for CMS acquisitions and that sufficient documentation is maintained in the
procurement files for any delays.
4. Review its use of JOFOCs for CMS acquisitions to ensure compliance with regulations and ensure staff
understand the requirements when contracting without full and open competition.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that it will
review the use of JOFOCs and ensure its staff understands regulations associated with contracting
without full and open competition.
This recommendation can be closed when we receive a description of the JOFOC review process and the
results of the BOP’s review of its use of JOFOCs for CMS acquisitions to ensure compliance with
regulations, and that staff understand requirements when contracting without full and open
competition.
5. Implement a process to properly justify, manage, and monitor all CMS contracting made without full and
open competition.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that it will
continue to review and monitor CMS contract files to ensure procurement action includes
documentation of full and open competition.
This recommendation can be closed when we receive evidence that BOP implemented a process to
ensure all CMS contracting made without full and open competition is properly justified, managed, and
monitored.
6. Enhance its controls to ensure its contract files comply with regulations for maintaining documentation
related to contract modifications.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that all
warranted contracting staff are required to comply with the requirements of FAR, Justice Acquisition
Regulation, and the Bureau of Prisons Acquisition Policy, which states Contracting staff shall document
the file related to contract modifications.

30

This recommendation can be closed when we receive evidence that the BOP enhanced its controls to
ensure its contract files comply with regulations for maintaining documentation related to contract
modifications.
7. Review and enhance its policies and procedures to ensure that those delegated to administer CMS
contracts are appropriately certified, and that appropriate delegations are in place.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that policies
and procedures exist requiring that all Administrative Contracting Officers delegated the authority to
administer CMS contracts are properly certified and maintain active certifications and warrants. The
BOP further stated that Contracting professionals are certified in accordance with FAC-C standards and
that all award notices identify the Administrative Contracting Officer.
This recommendation can be closed when we receive evidence that the BOP reviewed and enhanced its
policies and procedures to ensure staff are properly delegated CMS contract administration
responsibilities and staff are appropriately certified.
8. Ensure that BOP staff delegated performance surveillance responsibilities complete required
performance reporting tasks and maintain supporting documentation for the contractor’s ratings.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that program
and procurement staff shall prepare, at least annually, a past performance evaluation at the time work
under a contract is complete, and this is to be maintained in the Contractor Performance Assessment
Reporting system. Further, the BOP stated that staff designated as Contracting Officer Representatives
work closely with procurement staff to ensure all reporting is complete and submitted timely through
the electronic system.
This recommendation can be closed when we receive evidence that the BOP completed all required
performance monitoring and reporting tasks and maintain supporting documentation for the
contractor’s ratings.
9. Provide facility staff guidance and tools for steps that can be taken when contract requirements are not
fulfilled in a timely manner.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that
procurement professionals are required to complete acquisition-related training, which includes
resources available externally and internally, and the training is recorded in its staff’s electronic training
record. The BOP further stated that the Health Services Division hosts biennial leadership training with
the procurement training provided by the FAO and the Commercial Law Branch within the Office of
General Counsel.
This recommendation can be closed when we receive evidence that the BOP provided facility staff
guidance and tools for steps that can be taken when contract requirements are not fulfilled in a timely
manner.

31

10. Implement a reliable, consistent process throughout all BOP facilities to monitor wait times outside
inmate appointments and the causes for cancelled or rescheduled appointments in order to ensure that
inmates receive timely medical care.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that it
monitors wait times for outside medical appointments through the consultation queue in the electronic
health record which identifies the timeframe clinically indicated for the consultation to be scheduled, the
actual date consultation is scheduled through the comprehensive medical provider, and a verification of
when results are received/recorded from the completed consultation. The BOP further states that
Health Services Administrators review this consultation queue frequently and specifically during each
utilization review committee. The BOP also stated that discrepancies for cancelled or rescheduled
appointments are documented within the electronic health record.
This recommendation can be closed when we receive evidence that the BOP implemented a reliable,
consistent process BOP-wide to monitor wait times and the causes for cancelled or rescheduled
appointments.
11. Implement specific policies and procedures for reviewing billing submitted using Medicare-based rates,
and that the BOP ensure that facilities utilize the third-party adjudication vendor.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that it has a
third-party bill adjudicator platform, and that all CMS contracts will be modified as vendors complete
testing with the third party. Further, the BOP stated that all new CMS solicitations include the bill
adjudicator language and, once the contract is awarded, the execution of bill adjudication is
implemented.
This recommendation can be closed when we receive evidence that the BOP implemented policies and
procedures, BOP-wide, for reviewing billing submitted using Medicare-based rates, and that all facilities
are using the third-party bill adjudicator.
12. Implement Bureau-wide policies and standards for CMS contract billings, to include appropriate
supporting documentation, at all facilities.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that all CMS
contracts include FAR 52.212-4(g), which provides a detailed outline of the information required on all
invoices, and the performance work statement identifies, in detail, the information required when
submitting invoices/medical clams.
This recommendation can be closed when we receive evidence that the BOP implemented policies and
standards BOP-wide for CMS contract billings to ensure appropriate supporting documentation is
received and maintained with the invoices.

32

13. Ensure that FCC Butner enhance its procedures to ensure complete and accurate recording of on-site
provider attendance to verify related billings.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that FCC
Butner will enhance its procedures to ensure complete and accurate recording of on-site provider
attendance to verify billings and re-educate contractor staff on the requirements to complete the
Contractor/Visitor Log at the entrance. Also, the BOP stated that it will remind contractor staff of the
requirement to punch in and out using the timeclock and of procedures if the timeclock is not
functioning properly. Additionally, if the timeclock is malfunctioning, the contractor will write their time
on the timecard to be verified to the Contractor/Visitor Log. Further, the BOP stated that staff will
ensure that when timecards are copied for billing purposes that the copies are legible and re-copy if
necessary.
This recommendation can be closed when we receive evidence that the BOP enhanced its procedures to
ensure complete and accurate recording of on-site provider attendance at FCC Butner.
14. Develop and implement policies and procedures emphasizing responsibilities and authority of staff
involved with CMS contracts.
Resolved. The BOP concurred with our recommendation. The BOP stated in its response that
procurement staff are aware of policies, procedures, and responsibilities involving CMS contracts and
that Health Services staff work closely with procurement staff and participate in CMS specific policies,
procedures, and responsibilities.
This recommendation can be closed when we receive evidence that the BOP developed and
implemented policies and procedures emphasizing responsibilities and authority of staff involved with
CMS contracts.
15. Develop contingency plans to ensure invoices are paid timely in accordance with the Prompt Payment
Act to avoid interest payments during disruptions to normal operations caused by extraordinary
circumstances such as a government shutdown.
Resolved. In its response, the BOP stated it did not concur with our recommendation to the extent that
it could create a conflict with the Anti-Deficiency Act. The OIG agrees that the BOP should not violate the
Anti-Deficiency Act, and our recommendation does not suggest that. We discussed this with BOP
officials who stated that the BOP concurs with the recommendation notwithstanding the potential
conflict that could be created with the Anti-Deficiency Act. Specifically, the BOP stated in its response
that the Anti-Deficiency Act restricts the BOP’s ability to obligate funds in advance of an appropriation.
Outside of this potential conflict, BOP officials stated that they agreed that BOP should pay its invoices
and would work to develop contingency plans as outlined in the recommendation.
This recommendation can be closed when we receive evidence that the BOP developed contingency
plans to ensure invoices are paid timely in accordance with the Prompt Payment Act during disruptions
to normal operations caused by extraordinary circumstances, and that the BOP provide clarification
regarding circumstances when a payment should not occur due to a conflict with the Anti-Deficiency Act.
33