United States General Accounting Office

GAO

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

June 2004

DISTRICT OF
COLUMBIA JAIL
Medical Services
Generally Met
Requirements and
Costs Decreased, but
Oversight Is
Incomplete

GAO-04-750

June 2004

DISTRICT OF COLUMBIA JAIL

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

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

GAO is recommending that the
Mayor of the District of Columbia
require the Director of DoC to
(1) develop formal procedures,
including collection of needed data,
for determining whether CCHPS
has met performance standards
linked to monetary damages and
for imposing these damages; and
(2) ensure that CCHPS submits
required quarterly and annual
progress reports describing service
problems and corrective actions. In
reviewing a draft report, DoC did
not comment on our
recommendations, but provided
additional information.
www.gao.gov/cgi-bin/getrpt?GAO-04-750.
To view the full product, including the scope
and methodology, click on the link above.
For more information, contact Marcia Crosse
at (202) 512-7119 or crossem@gao.gov.

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

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

Contents

Letter

1
Results in Brief
Background
CCHPS Provides a Range of Services to Inmates and Has
Established Systems to Monitor Service Quality
DoC Established Several Mechanisms to Oversee CCHPS’s
Delivery of Medical Services
CCHPS Generally Meets Contract Requirements, but DoC’s
Oversight of CCHPS Is Incomplete
Average Per Inmate Medical Cost at Jail Has Decreased
Conclusions
Recommendations for Executive Action
Agency Comments and Our Evaluation

15
19
25
26
27

Appendix I

Scope and Methodology

30

Appendix II

Requirements Linked to Monetary Damages
Provisions in the CCHPS Contract

33

Performance Assessment Instruments Used to
Monitor Services Provided by CCHPS

35

Appendix III

3
5
8
14

Appendix IV

Comments from the District of Columbia Department
of Corrections
41

Appendix V

GAO Contact and Staff Acknowledgments

47

GAO Contact
Acknowledgments

47
47

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GAO-04-750 D.C. Jail Medical Services

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

10
33
36

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

Page ii

21
22
23

GAO-04-750 D.C. Jail Medical Services

Abbreviations
ACA
CCA
CCHPS
CTF
DMH
DoC
DoH
FMCS
FTE
HIV
LPN
MAR
NCCHC
NP
PA
RN

American Correctional Association
Corrections Corporation of America
Center for Correctional Health and Policy Studies, Inc.
Correctional Treatment Facility
District of Columbia Department of Mental Health
District of Columbia Department of Corrections
District of Columbia Department of Health
Family and Medical Counseling Services, Inc.
full-time equivalent
human immunodeficiency virus
licensed practical nurse
medication administration record
National Commission on Correctional Health Care
nurse practitioner
physician assistant
registered nurse

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GAO-04-750 D.C. Jail Medical Services

United States General Accounting Office
Washington, DC 20548

June 30, 2004
The Honorable Tom Davis
Chairman
Committee on Government Reform
House of Representatives
Dear Mr. Chairman:
The District of Columbia Department of Corrections (DoC) is responsible
for providing medical services to inmates of the District of Columbia Jail1
and the Correctional Treatment Facility (CTF), an overflow facility
adjacent to the Jail. From August 1995 until September 2000, medical
services at the Jail were under the control of a court-ordered Receiver
because DoC had not complied with repeated court orders to provide
adequate care to inmates. The Receiver contracted with the Center for
Correctional Health and Policy Studies, Inc. (CCHPS), a private not-forprofit organization, to provide medical services at the Jail beginning in
March 2000.2 When the receivership ended, the court returned
responsibility for the Jail’s medical services to DoC, which continued to
contract with CCHPS. In April 2003, DoC expanded its contract with
CCHPS to include medical services provided to inmates housed at the
CTF.
In June 2000, shortly before the court terminated the receivership, we
testified before the Subcommittee on the District of Columbia on selected
issues related to medical services provided at the Jail.3 In response to
questions about the cost and level of services, we reported that the per
inmate cost of medical services at the Jail exceeded the cost in two other
jurisdictions4 and that there were no specific criteria to determine an

1

The Jail is also known as the Central Detention Facility.

2

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

3
See U.S. General Accounting Office, District of Columbia Receivership: Selected Issues
Related to Medical Services at the D.C. Jail, GAO/T-GGD-00-173 (Washington, D.C.: June
30, 2000).
4

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

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GAO-04-750 D.C. Jail Medical Services

acceptable level of medical services and staffing at the Jail. You asked us
to obtain information on the District of Columbia’s progress in providing
medical services to inmates since the receivership ended and what
mechanisms exist to monitor the quality of these services. We are
reporting on (1) the medical services DoC has contracted with CCHPS to
provide to inmates held at the Jail and the CTF, including CCHPS’s
monitoring of those services; (2) the mechanisms DoC established to
oversee the services provided by CCHPS; (3) CCHPS’s compliance with
the requirements in its contract and DoC’s efforts to ensure CCHPS’s
compliance; and (4) the cost of providing medical services at the Jail from
2000 to 2003 and the current cost of medical services at the Jail and the
CTF.
To examine the medical services provided to inmates, CCHPS’s monitoring
of those services, and DoC’s oversight of CCHPS’s contract compliance,
we analyzed documents and interviewed officials from DoC and CCHPS.
In doing our work, we relied, in part, on reports by a national expert in
correctional health care who was hired by DoC to conduct independent
reviews of CCHPS’s medical services. We interviewed this expert, referred
to as the independent reviewer, and analyzed all of the quarterly reports he
submitted to DoC. In addition, we analyzed a random sample of grievances
submitted by Jail and CTF inmates from April 1, 2003, through October 31,
2003. Although we focused primarily on services provided by CCHPS, we
also reviewed documents and interviewed officials about the medical
services provided to inmates off-site that are not a part of the CCHPS
contract. We also analyzed documents and interviewed officials from other
District of Columbia agencies with responsibilities related to inmate health
care and from national organizations that accredit correctional health care
facilities. In addition, we reviewed our previous work related to medical
services at the Jail. To determine the cost of providing medical services at
the Jail and the CTF, we analyzed documents and interviewed officials
from the District of Columbia Office of Contracting and Procurement;
DoC, including its Office of the Chief Financial Officer; and CCHPS. We
also examined independently audited accounting data from the District of
Columbia Office of Financial Operations and Systems. We determined that
the medical services cost information we used in our analysis was reliable.
The scope of our work included medical services provided to CTF inmates
only since April 2003, when DoC expanded its contract with CCHPS to
include this facility. In reviewing DoC’s activities, we assessed the
agency’s internal controls related to its contract with CCHPS. We did our
work from August 2003 through June 2004 in accordance with generally
accepted government auditing standards. (See app. I for additional details
on our scope and methodology, including our cost calculations.)

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GAO-04-750 D.C. Jail Medical Services

Results in Brief

DoC has contracted with CCHPS to provide a broad range of medical
services to inmates of the Jail and the CTF, and the types of services
available have changed little since CCHPS began providing care in 2000.
These services include physical and mental health screening when inmates
are admitted; primary care; mental health care; and chronic and specialty
care, such as dental and orthopedic services. CCHPS also assists DoC in
helping inmates obtain services not included in the contract, such as
specialty care and emergency medical services that cannot be offered at
the Jail or the CTF and community-based medical services for inmates
after they are released. CCHPS has established a quality improvement
program to fulfill its obligation to monitor the quality of its services. A key
component of this program is a quarterly analysis of random samples of
inmate medical records; these analyses use standardized performance
assessment instruments to provide CCHPS with quantitative data
measuring how consistently it delivers required services to inmates.
DoC established several mechanisms to oversee CCHPS’s delivery of
medical services to inmates at the Jail and the CTF. DoC’s contract with
CCHPS gives DoC authority to impose monetary damages on CCHPS if it
fails to meet any of 12 requirements specified in the contract, most of
which relate to providing key services to a minimum percentage of
inmates. For example, DoC may impose damages if CCHPS does not
conduct an intake screening within 24 hours for 95 percent of inmates. In
addition, DoC’s contract with CCHPS requires CCHPS to submit quarterly
and annual progress reports that discuss any quality problems and the
actions taken to correct them. DoC’s independent reviewer monitors the
services provided by CCHPS on a quarterly basis. During his reviews, the
independent reviewer uses the same performance assessment instruments
as CCHPS to monitor both CCHPS’s delivery of medical services and the
accuracy of CCHPS’s internal performance analyses. The independent
reviewer does not, however, specifically review CCHPS’s compliance with
the contract requirements associated with monetary damages.
Although available evidence indicates that CCHPS has generally complied
with the terms of its contract, DoC has not exercised sufficient oversight
to provide assurance that problems either are not occurring or are quickly
corrected. The independent reviewer has consistently found that the
medical services CCHPS provides to inmates meet the contract’s
requirements for access to care and quality. In addition, CCHPS has
generally met the contract requirement that it implement a quality
improvement program. For example, CCHPS has regularly used the
performance assessment instruments to monitor its services, and the
independent reviewer has concluded that CCHPS’s assessments with these

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GAO-04-750 D.C. Jail Medical Services

instruments are accurate. However, in a few areas CCHPS has not always
met the contract’s medical services and monitoring requirements. For
example, while CCHPS recently improved its performance in providing
timely follow-up to inmates with abnormal chest x-ray results, the
independent reviewer had repeatedly found problems in this area since
2000. Although the independent reviewer provides DoC with important
information about CCHPS’s performance, other limitations in DoC’s
oversight of CCHPS’s services may hinder the agency’s ability to be
assured of CCHPS’s compliance with the contract. For example, DoC lacks
the necessary data and a formal procedure to determine whether CCHPS
has met contract requirements linked to monetary damages; it also lacks a
procedure to impose damages if they are warranted. In addition, DoC has
not regularly enforced the contract requirement that CCHPS submit
quarterly and annual progress reports describing quality problems and
corrective actions. CCHPS has never submitted the quarterly reports and
has not submitted all the required annual reports.
From 2000 to 2003, the average daily cost of providing medical services to
a Jail inmate decreased by almost one-third, from about $19 a day per
inmate to about $13 a day. This decrease in per inmate costs occurred
because the total cost of providing medical services at the Jail decreased
by about 3 percent during this period, while the average inmate population
rose by about 41 percent. DoC and CCHPS officials told us that they
controlled total costs by various means, including controlling personnel
expenditures. On April 1, 2003, DoC consolidated the services provided to
inmates in the Jail and the CTF under one contract with CCHPS. This
contract revision also introduced a new pricing structure, which simplified
DoC’s administration of the contract. DoC now pays CCHPS on a per
inmate basis, using a rate schedule ranging from $13.00 to $14.75 a day per
inmate, depending on the size of the inmate population. In contract year
2003, which ended March 31, 2004, the total cost of providing medical
services at the Jail and the CTF was about $15.8 million; during that year
17,431 inmates were admitted to the two facilities.
We are recommending that the Mayor require the Director of DoC to
develop formal procedures, including collection of needed data, for
regularly assessing whether CCHPS has met contract requirements linked
to monetary damages and for imposing these damages. We are also
recommending that the Mayor require the Director of DoC to ensure that
CCHPS submits required quarterly and annual progress reports on
identified problems and corrective actions.

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GAO-04-750 D.C. Jail Medical Services

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

Background

The District of Columbia Jail and CTF house inmates awaiting trial or who
have been sentenced for misdemeanors.5 The Jail was opened in 1976, and
from 1985 to July 2002, a court order limited the population to 1,674
inmates. Since July 2002 the population has grown, and during March
2004, the facility had an average daily population of 2,357. In addition to
serving as an overflow facility, the CTF houses pregnant inmates, inmates
with disabilities who need medical services, inmates in witness protection,
and inmates who need to be separated from the general inmate
population. Opened in 1992, the CTF is operated by a private company, the
Corrections Corporation of America (CCA), under a contract with DoC.
During March 2004, the CTF had an average daily population of 1,197.
In 1995, the U.S. District Court for the District of Columbia removed
medical services at the Jail from DoC’s control, placing these services
under the temporary supervision of a court-appointed Receiver. This
removal resulted from the District of Columbia’s failure to address
problems identified in two lawsuits brought against the Jail in 1971 and
1975, which alleged that DoC was failing to provide minimally adequate
medical care for inmates.6 Before it terminated the receivership in 2000,
the Court hired a national expert in correctional health care to conduct an
independent quality review of medical services provided by CCHPS to
inmates at the Jail. DoC subsequently contracted directly with this expert
to help develop a set of performance assessment instruments for

5

While terms of incarceration may vary, under District of Columbia law, convictions for
many misdemeanors can result in incarceration for up to 180 days. See e.g., D.C. Code § 22404; § 22-1510; § 22-3232; § 47-4101. In addition to pretrial detainees and convicted
prisoners, the Jail and the CTF also house inmates waiting for transfer to other correctional
facilities, including Federal Bureau of Prisons facilities, as well as inmates who have been
returned to the District of Columbia area for various reasons, including parole hearings or
court testimonies.
6
See Campbell v. McGruder, 416 F.Supp. (D.D.C. May 24, 1976), 580 F.2d 521 (D.C. Circ.
1978) and Inmates of D.C. Jail v. Jackson, 416 F. Supp 111 (D.D.C. May 24, 1976). The CTF
was not part of these lawsuits.

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GAO-04-750 D.C. Jail Medical Services

reviewing CCHPS’s clinical services and monitoring activities7 and to
conduct quarterly on-site reviews of CCHPS.
DoC has a constitutional obligation to ensure that medical care is provided
to inmates in its custody,8 and DoC’s contract with CCHPS requires
CCHPS to provide comprehensive medical services to all inmates assigned
to the Jail and the CTF and to establish a quality improvement program to
monitor the quality of medical services it provides. In some areas,
particularly the assessment of inmates’ health when they are admitted to
the facilities, the contract lists specific services that CCHPS must provide,
such as certain diagnostic tests. In other areas, such as services for
inmates with chronic conditions, the requirement to provide care is less
detailed. In addition to describing services that CCHPS is required to
provide, the contract states that DoC can impose monetary damages9 on
CCHPS if it does not meet 12 specific requirements. (See app. II for a
description of the contract requirements that are linked to monetary
damages.) Compliance with the requirements is to be determined through
monitoring by DoC or its designee.
The contract with DoC also requires that CCHPS acquire and maintain
accreditation for its medical services. The Jail’s medical services are
accredited by the National Commission on Correctional Health Care
(NCCHC), while the CTF is accredited by the American Correctional
Association (ACA). NCCHC and ACA, both national, not-for-profit
organizations, offer voluntary accreditation processes for medical services
provided in correctional facilities; relatively few jails nationwide are
accredited by these organizations.10 NCCHC accredits only a correctional
facility’s medical services, while ACA accredits all aspects of the
correctional facility, including medical services. Both organizations have

7

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

8

The Eighth Amendment to the Constitution of the United States prohibits “cruel and
unusual punishment.” The U.S. Supreme Court, in Estelle v. Gamble, concluded that
“deliberate indifference to the serious medical needs of prisoners” violates this prohibition.
429 U.S. 97 104 (1976).
9

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

10

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

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GAO-04-750 D.C. Jail Medical Services

developed detailed accreditation standards that include, for example,
specific elements that are required in an inmate’s initial medical
assessment and in a facility’s quality improvement program. The
accreditation process for both organizations includes on-site inspections
of the facility every 3 years and submission of an annual report certifying
that the facility continues to be in compliance with the accreditation
standards. During on-site inspections, inspectors interview staff, review
documentation provided by the facility, and examine a sample of inmate
medical records. NCCHC and ACA inspectors submit their findings to
expert panels, who make the accreditation decisions.
One component of the quality improvement program required by both
NCCHC and ACA is a grievance system that allows inmates an opportunity
to question or complain about their care. Inmates at the Jail or the CTF
who have concerns about medical services can complete a grievance form
and submit it to the warden’s office in their facility. The warden’s staff
records the grievance in their system and then forwards it to CCHPS.
CCHPS’s medical director and quality improvement coordinator review
the grievance and work with the clinicians involved to determine if the
inmate’s complaint is valid and, if so, how it should be addressed. If it is
determined that an inmate needs to receive care, CCHPS schedules an
appointment. After CCHPS has reviewed the grievance, it sends a report to
the warden, who then provides a response to the inmate.
In June 2000, we testified before the House Committee on Government
Reform, Subcommittee on the District of Columbia, about the provision of
medical services at the Jail.11 We reported that the per inmate cost at the
Jail was higher than those at the two other jurisdictions reviewed, and that
services and staffing levels also exceeded those of the other jurisdictions.12
We also found that there were no specific criteria that determine an
acceptable level of medical service and staffing at a jail. Rather, the range
of services was a function of many local factors, including the specific
demands and constraints placed on the facility’s service delivery system.

11

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

12

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

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GAO-04-750 D.C. Jail Medical Services

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

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

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

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

13

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

14

Because tuberculosis occurs more frequently in correctional settings than in the general
population and because of the ease with which it can be transmitted, it is considered a
significant health issue for correctional facilities. Pregnant inmates and inmates who have
been in the Jail or the CTF within the last 6 months and have a record of a normal chest xray do not receive a chest x-ray at intake. Similarly, inmates who have recently been in the
facilities and received a skin test for tuberculosis with normal results are not required to
have another. However, according to CCHPS officials, even if inmates have had a skin test
within 3 to 4 weeks, they often perform another test to ensure that the inmate has not been
exposed to tuberculosis while in the community.
15

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

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GAO-04-750 D.C. Jail Medical Services

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

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GAO-04-750 D.C. Jail Medical Services

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

Type and description of service

Types of service providers

Intake services

Initial medical, mental health, and dental screening on
a
admission to the Jail and referral for additional care if needed

Physicians, physician assistants
(PA), licensed practical nurses
(LPN), phlebotomistsb

Primary
medical care

Sick call and primary care services: assessment of inmates requesting
to be seen by a clinician and possible referral to a physician or specialty
care clinic

Physicians, PAs, nurse practitioners
(NP), registered nurses (RN)

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

Physicians, NPs, PAs

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

NPs, RNs

“Outpatient” mental health services: services provided to inmates in the
general housing population, including group therapy, one-on-one
therapy, and medication management

Psychiatrists, psychologists, social
workers, RNs, LPNs

“Inpatient” mental health services: services provided in two specialized
units of the Jail for inmates with acute or serious chronic mental health
problems; inmates needing inpatient services are housed in these unitsc

Psychiatrists, social workers, RNs,
LPNs; interdisciplinary team also
includes corrections officers and
classification and parole officers

Dental services: basic dental care, including routine and surgical
extractions, fitting dentures, filling cavities, and oral hygiene and
education

Dentists, dental assistants, dental
hygienists

On-site specialty services include cardiology, dermatology, gynecology,
neurology, ophthalmology, orthopedics, general surgery, podiatry, and
pulmonary clinics

Physicians, podiatrists

Infirmary
services

Short-term management of inmates requiring observation or a level of
care that cannot be provided in the general population

Physicians, RNs

Ancillary
services

Includes pharmacy services, laboratory services, and providing
prostheses and glasses

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

Mental health
services

Specialty care

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

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

Phlebotomists are medical technicians who collect blood.

c

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

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

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GAO-04-750 D.C. Jail Medical Services

clinic was deleted from the contract, and more recently CCHPS combined
the ophthalmology and optometry clinics. In addition, CCHPS began
offering endocrinology and infectious disease clinics on-site—even though
they are not required by the contract—to improve inmates’ access to these
services and continuity of care. CCHPS officials had expected the
consolidation of medical services at the Jail and the CTF to result in some
service efficiencies, such as combining the on-site specialty clinics offered
at both facilities; however, CCHPS and DoC officials told us it has not
been feasible to easily move inmates between facilities because of security
issues. CCHPS therefore continues to offer all on-site specialty clinics at
both facilities.
When inmates need medical services that cannot be provided at the Jail or
the CTF, CCHPS refers them to providers in the community. These off-site
services, including emergency care and certain specialty services, are not
part of the CCHPS contract; instead, DoC has an agreement with the
District of Columbia Department of Health (DoH) to provide services to
inmates through Greater Southeast Community Hospital.16 When Greater
Southeast is not able to provide the needed services, it in turn refers the
inmates to other members of the DC Healthcare Alliance and other
community providers.17 DoC pays for all off-site services through an
interagency agreement with DoH;18 in 2003 there were 4,169 appointments
for inmates off-site.
Although DoC’s contract with CCHPS does not specify that CCHPS
provide discharge planning services to inmates,19 NCCHC accreditation

16

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

17

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

18

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

19

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

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GAO-04-750 D.C. Jail Medical Services

standards include discharge planning activities. Both CCHPS and DoC
have made efforts to plan for the release of inmates with medical
,
conditions and to link them to community-based medical services.20 21 For
example, CCHPS’s policies require that inmates receive a 2-week supply of
medications at the time of their release. In addition, CCHPS provides
support to DoC’s collaboration with the District of Columbia Department
of Mental Health (DMH) to help Jail inmates22 obtain access to community
mental health services when they are released.
CCHPS supports DoC’s and DoH’s discharge planning efforts to link
inmates who have certain chronic and communicable diseases, such as
tuberculosis, to community-based medical services. In addition, through a
joint program of DoH’s HIV/AIDS Administration and DoC, Family and
Medical Counseling Services, Inc. (FMCS), a community-based provider,
offers HIV testing and links HIV-positive inmates to services in the
community when they are released.23 CCHPS refers inmates requesting an
HIV test to FMCS and provides FMCS with office space, computers, and
access to the inmate’s electronic medical record in the CCHPS system.24

20
According to DoC officials, their concern about discharge planning has increased as a
result of a July 2000 decision by the Supreme Court of New York. This decision held that
each inmate receiving mental health services during incarceration in New York City was
entitled to receive discharge planning services, so long as the services do not delay or
postpone the inmate’s release date. See Brad H. v. City of New York, 712 N.Y.S.2d 336
(Sup. Ct. 2000), aff’d, 176 N.Y.S2d 852 (App. Div. 2000).
21
DoC and other District agencies bear the cost of these discharge planning services,
although CCHPS provides some on-site support, including access to computers and office
space.
22

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

23

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

24

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

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CCHPS Developed a
System to Monitor Its
Medical Services

As part of its contract with DoC, CCHPS is responsible for monitoring the
quality of the medical services it provides to Jail and CTF inmates, and
CCHPS has established a quality improvement program to fulfill this
responsibility. A key component of the program is a quarterly analysis of
random samples of inmate medical records using standardized
performance assessment instruments. These quarterly analyses provide
CCHPS with quantitative data about its performance in certain areas. Each
assessment instrument measures CCHPS’s performance of a specific set of
activities; these activities are generally more detailed than the
requirements described in the contract.25 (See app. III for a summary
description of the instruments.) Using the samples of medical records and
other documentation to complete the performance assessment
instruments, CCHPS clinicians determine how consistently CCHPS
delivers required services to inmates. Currently, there are 23 performance
assessment instruments, 20 of which measure medical services provided
to inmates in various service areas. For example, the intake services
instrument includes a measurement of the percentage of inmates who
received a chest x-ray for tuberculosis within 24 hours of admission. The
remaining 3 instruments measure the extent to which CCHPS has
conducted other components of its quality improvement program, such as
validating that clinical staff are licensed.
In addition to these quarterly analyses of medical services, CCHPS’s
quality improvement program also includes other reviews, such as annual
reviews of urgent care and radiological safety procedures, monthly
reviews of inmate grievances and of any inmate deaths, and ongoing
reviews of infection control activities. The program also requires CCHPS
to conduct at least two in-depth studies a year, each of which focuses on a
specific issue, such as a medical service problem that has been identified
by the quarterly analyses.

25

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

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GAO-04-750 D.C. Jail Medical Services

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

DoC has developed several mechanisms to oversee CCHPS’s delivery of
medical services to inmates and enforce CCHPS’s compliance with the
contract. For example, DoC’s contract with CCHPS gives DoC the
authority to impose monetary damages if CCHPS fails to meet any of 12
requirements specified in the contract, most of which relate to CCHPS’s
performance in providing key medical services. For most of these
requirements, the contract authorizes DoC to impose the damages if
CCHPS fails to deliver the required service to a minimum percentage of
inmates—for example if CCHPS does not conduct an intake screening
within 24 hours for 95 percent of inmates. (See app. II for additional
information on the contract requirements that are linked to monetary
damages.) Some of the requirements relate to CCHPS’s staff, including
ensuring that staff have required licenses and credentials. In addition, the
contract contains a requirement that CCHPS have an infection control
program approved by DoC. DoC, or its designee, is responsible for
determining CCHPS’s compliance with these 12 contract requirements.
To further assist DoC in overseeing CCHPS’s delivery of services, the
contract also stipulates that CCHPS will submit quarterly and annual
progress reports to DoC. These progress reports are to include a
description of quality problems, such as those identified by CCHPS’s
quality improvement program or the independent reviewer, and actions
taken to correct them. DoC also requires CCHPS to maintain accreditation
of its services. In addition, DoC staff responsible for oversight of the
contract are frequently on-site at the Jail and the CTF observing the
contractor, and, as of May 2004, DoC had plans to begin jointly conducting
the quarterly analyses of inmate medical records with CCHPS.26
Furthermore, DoC’s independent reviewer conducts quarterly reviews of
CCHPS’s activities. Each review consists of two principal components.
First, the independent reviewer checks the accuracy of CCHPS’s internal
use of the standardized performance instruments. To do this, he uses the
same performance assessment instruments that CCHPS uses in its quality
improvement program to examine a sample of the analyses CCHPS has
completed, and assesses whether CCHPS accurately characterized the

26

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

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GAO-04-750 D.C. Jail Medical Services

medical records studied.27 Second, in addition to validating CCHPS’s
analyses, the independent reviewer uses the performance instruments to
independently assess the quality of CCHPS’s services by analyzing a
separate random sample of inmate medical records in selected service
areas, such as mental health services.28 While CCHPS uses the
performance assessment instruments as a quality improvement vehicle,
the independent reviewer’s use of these instruments contributes to his
assessment of whether CCHPS is meeting its contractual obligations.
However, the independent reviewer does not specifically evaluate
CCHPS’s compliance with the contract requirements associated with
monetary damages.
As part of his review, the independent reviewer also assesses other
components of CCHPS’s quality improvement program, visits the medical
units at the Jail and the CTF, and interviews CCHPS staff. After conducting
the review, the independent reviewer provides DoC with a written report
describing his general findings, including service areas in which CCHPS
excels or needs to improve. Since August 2000, the independent reviewer
has conducted 14 quarterly on-site reviews of CCHPS.

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

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

27

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

28

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

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GAO-04-750 D.C. Jail Medical Services

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

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

On the basis of his review, the independent reviewer has consistently
reported that CCHPS’s medical services meet the contract’s requirements
for access to care and quality. He has also reported that services meet the
“required constitutional standards of care.” In addition, he told us that, in
his opinion, CCHPS is one of the best correctional health care providers in
the country. According to the independent reviewer, some activities, such
as documenting the administering of medication, have been performed
consistently over the life of the contract. Other activities have improved
over time. For example, in one report, the independent reviewer noted
that CCHPS’s chronic disease guidelines were outdated, but later reported
that CCHPS had appropriately revised the guidelines.
In addition, CCHPS generally meets the contract requirement that it
implement a quality improvement program. CCHPS has used the
performance assessment instruments each quarter to monitor its services,
and the independent reviewer has concluded that CCHPS accurately uses
these instruments to assess its medical services. For example, based on
data from its quarterly analyses, CCHPS identified problems in inmates’
access to dental care. As a result, CCHPS conducted a study to identify
ways to improve access to this service and eventually established a system
that gave higher priority to care for inmates with more serious dental
problems. CCHPS’s subsequent review found that access had improved.
While CCHPS’s medical services and monitoring efforts generally meet the
requirements of the contract, in a few areas CCHPS has not always met
requirements. For example, the contract requires that CCHPS provide
timely follow-up services to inmates with abnormal chest x-ray results.29
Although CCHPS has recently improved its performance, the independent

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

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GAO-04-750 D.C. Jail Medical Services

reviewer had repeatedly found that CCHPS did not always provide timely
follow-up services to these inmates. The independent reviewer also
recently determined that CCHPS is not performing reviews of inmate
deaths. This is an NCCHC requirement, and CCHPS’s quality improvement
program specifies that CCHPS should conduct such reviews monthly.
In addition, CCHPS has not regularly submitted the required quarterly and
annual progress reports providing information on quality problems and its
actions to correct them. CCHPS has never submitted quarterly reports, and
submitted only one annual report. Furthermore, the annual progress
report CCHPS did submit provided only limited information. For example,
it did not discuss CCHPS’s lack of timely follow-up on abnormal x-ray
results, although the independent reviewer had repeatedly identified this
as a problem.
Inmates have expressed concerns about other medical services required
by the contract. Our analysis of a sample of the 369 inmate grievances
submitted from April 2003 through October 2003 found that many
complaints related to inmates’ ability to gain access to requested sick call
and primary care services and to the timely distribution of medications.30
For example, some inmates complained that they had submitted multiple
requests to be seen during sick call and had not yet been seen. CCHPS’s
internal monitoring has also identified problems related to sick call
services, such as inconsistent use of the protocols developed to guide
inmate health assessments.31 In addition, advocacy groups with whom we
spoke expressed concern about distribution of medications on weekends
and to newly admitted inmates.

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

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

30
The 369 grievances represent individual grievances. In some instances inmates submitted
multiple grievances. During this period, over 10,000 inmates were admitted to the Jail and
the CTF, and the combined average daily population was 3,169.
31

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

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GAO-04-750 D.C. Jail Medical Services

necessary data and a formal procedure for determining whether CCHPS
has met the requirements; it also lacks a procedure for imposing damages
if they are warranted. To evaluate CCHPS’s compliance with many of the
requirements that are linked to monetary damages, DoC needs data that
indicate the percentage of inmates for whom CCHPS provided the
required service. One potential source for such data is the performance
assessment instruments used by CCHPS and the independent reviewer,
which measure many of the activities included in these contract
requirements.32 However, at present, DoC neither regularly collects data
itself nor requires the independent reviewer or CCHPS to submit data they
collect through their quarterly analyses of services.33 DoC officials also
were not able to provide any documents that articulated how, and how
often, they would evaluate CCHPS’s compliance with the contract
requirements associated with monetary damages, and DoC has not
provided CCHPS with information on the status of its compliance.
Furthermore, if DoC were able to determine that CCHPS was not meeting
a contract requirement, it has not determined whether it would
immediately impose damages on CCHPS or first give CCHPS an
opportunity to correct the problem.
In addition, DoC has generally not enforced the contract requirement that
CCHPS submit quarterly and annual progress reports describing quality
problems and actions taken to correct them. These reports would allow
DoC to obtain information on how CCHPS is addressing compliance or
other performance problems identified by CCHPS’s own monitoring or the
independent reviewer. For example, the independent reviewer has
repeatedly reported that CCHPS did not consistently screen and treat
female inmates for chlamydia and gonorrhea. In addition, while CCHPS
usually responds to inmate grievances in a timely way,34 the independent
reviewer has reported on several occasions that CCHPS does not analyze

32
CCHPS’s analyses produce data on its compliance with 9 of the 12 requirements linked
with monetary damages—all those related to medical services. The independent reviewer’s
analyses do not necessarily produce data on all 9 because he does not specifically review
these 9 service areas and does not review the same service areas during each review.
33

The independent reviewer provided DoC with the data from his quarterly reviews through
March 2001. Since then, he has generally not provided data.
34

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

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GAO-04-750 D.C. Jail Medical Services

grievances in a sufficiently thorough way to identify systemic problems in
CCHPS’s services. Enforcing the requirement that CCHPS submit regular
progress reports would better enable DoC to ensure that CCHPS promptly
corrects such problems.
An area where DoC has been slow to carry out its oversight responsibility
relates to the contract requirement for an infection control plan. To
maintain its NCCHC accreditation, CCHPS must have an infection control
plan, and the April 2003 modification of the contract required that
CCHPS’s plan be approved by DoC. Although CCHPS submitted an
infection control plan to DoC for approval in August 2003, DoC did not
complete its review and approve the plan until June 2004.
In addition to having gaps in its oversight of services provided by CCHPS,
DoC is not providing systematic oversight to ensure that, when CCHPS
refers inmates to off-site services, inmates receive those services
promptly. DoC officials believe the closure of District of Columbia General
Hospital in 2001 and the shift of off-site services to Greater Southeast
Community Hospital have resulted in delays in obtaining off-site care for
inmates, particularly in certain specialty areas, such as orthopedics and
dermatology. The independent reviewer and CCHPS have also expressed
concerns about access to off-site services. CCHPS, which is responsible
for arranging and monitoring off-site appointments, documented earlier
delays in obtaining these appointments, but at the time of our review, it no
longer possessed this documentation. Despite its concerns, DoC has not
systematically documented more recent delays in obtaining off-site
appointments for inmates, is not able to provide any data on the nature or
length of delays, and has no plans to study this issue.35

Average Per Inmate
Medical Cost at Jail
Has Decreased

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

35

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

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GAO-04-750 D.C. Jail Medical Services

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

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

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

36

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

37

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

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GAO-04-750 D.C. Jail Medical Services

Figure 1: Total Annual Cost of Medical Services at the District of Columbia Jail,
2000–2003
Dollars in millions
14

12

11.7a

11.5

11.4

2002b

2003c

10.7
10

8

6

4

2

0
2000b

2001b

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

If adjusted for medical inflation, the total cost for 2000 would have been about $13.2 million. Medical
inflation adjustments were calculated using the medical care component of the Consumer Price Index
for urban consumers.
b

Data for 2000, 2001, and 2002 are from March 12 of the year through March 11 of the following year,
coinciding with the DoC-CCHPS contract year.
c

Data for 2003 are from April 1, 2003, through March 31, 2004, approximating the DoC-CCHPS
contract year and coinciding with the April 1, 2003, contract changes.

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GAO-04-750 D.C. Jail Medical Services

Figure 2: Average Daily Inmate Population at the District of Columbia Jail, 2000–
2003
Number of inmates
2,500

2,342
2,153

2,000
1,662

1,685

2000a

2001a

1,500

1,000

500

0

2002a

2003a

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

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

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

38

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

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GAO-04-750 D.C. Jail Medical Services

Figure 3: Average Daily Cost Per Inmate of Medical Services at the District of
Columbia Jail, 2000–2003
Dollars
24

20

19.33a
17.39

16

14.61
13.32

12

8

4

0

2000b

2001b

2002b

2003c

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

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

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

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

c

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

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

39

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

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GAO-04-750 D.C. Jail Medical Services

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

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

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

40

In March 2000, CCHPS was required by the contract to have 125.2 FTE positions at the
Jail. By April 2003, the contract no longer specified the number of FTE positions CCHPS
had to have.
41

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

42

At the time of the transition from the receivership to the CCHPS contract, members of
Congress expressed concern that CCHPS’s staffing level was very high; however, there is
no single standard for an acceptable level of medical staffing at a jail. NCCHC’s most recent
standards indicate that, despite the general expectation for physician staffing ratios, the
number and type of health care professionals required depends on a variety of factors.
43

Cost data for 2003 are from April 1, 2003, through March 31, 2004, approximating the DoCCCHPS contract year.

44

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

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GAO-04-750 D.C. Jail Medical Services

a per diem rate schedule, which is a sliding scale of prices that declines
slightly as the combined inmate population increases. The schedule starts
at $14.75 per inmate when the inmate population is below 2,200, and
incrementally falls to $13.00 per inmate when the population exceeds
3,200. For example, if the combined population on a particular day were
2,000 inmates, the per diem rate would be $14.75 and the total cost to DoC
for that day would be $29,500. According to DoC officials, the per diem
rate declines when the inmate population rises to reflect economies of
scale. Over the course of 2003, the per diem rate charged to DoC for
services at the jail and the CTF averaged $13.28 per inmate.
The per diem pricing structure has simplified DoC’s contract
administration by generally eliminating the need for a reconciliation
process. Prior to April 2003, the contract required that DoC and CCHPS
complete quarterly reconciliations to determine the difference between
CCHPS’s expected staff costs at the beginning of the contract year and
CCHPS’s actual staff costs during the year.45 These differences resulted
primarily from inmate population changes. However, as DoC and CCHPS
negotiated the final amount of each reconciliation, the process became
increasingly lengthy and several unresolved reconciliations accumulated.
Over the first 3 years of the contract, for example, DoC completed only 4
of the 12 scheduled reconciliations. When the per diem pricing structure
was implemented in 2003, all incomplete reconciliations were resolved in a
final reconciliation settlement.

Conclusions

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

45

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

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GAO-04-750 D.C. Jail Medical Services

reviewer, it has not taken several other actions that would help it better
oversee the care that inmates receive. For example, DoC has limited its
ability to hold CCHPS accountable for meeting the contract requirements
that are linked to monetary damages. For monetary damages to be a viable
oversight and contract enforcement mechanism, DoC would need to
obtain data that demonstrate whether CCHPS is providing required
services to the minimum percentage of the inmate population stipulated by
the contract. However, DoC has not collected these data. DoC would also
need to develop formal procedures for assessing CCHPS’s compliance
with the requirements and for imposing monetary damages if they are
warranted.
Furthermore, DoC has not enforced the requirement that CCHPS regularly
submit progress reports describing how it is correcting problems
identified through performance monitoring, including any problems that
may place CCHPS out of compliance with the contract. If CCHPS provided
this information, DoC could ensure that CCHPS promptly took corrective
action to respond to problems identified by the independent reviewer or
CCHPS’s own monitoring, such as CCHPS’s failure to promptly follow up
on abnormal chest x-ray results. Having the capacity to enforce the
contract requirements linked with monetary damages and requiring
CCHPS to submit regular progress reports would strengthen DoC’s ability
to ensure that CCHPS provides important medical services to inmates.

Recommendations for
Executive Action
•

•

To help ensure that CCHPS provides required medical services to inmates
of the District of Columbia Jail and the CTF, we recommend that the
Mayor require the Director of DoC to take the following two actions:
Develop formal procedures—including collection of needed data—to
regularly assess whether CCHPS’s performance meets the contract
requirements that are linked to monetary damages and to impose these
damages.
Ensure that CCHPS submits to DoC the required quarterly and annual
progress reports, which should describe identified problems and the
actions CCHPS has taken to correct them.

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GAO-04-750 D.C. Jail Medical Services

Agency Comments
and Our Evaluation

We provided a draft of this report to DoC for comment. In its response
DoC did not comment on our recommendations, but provided additional
information about its contract with CCHPS and medical services for
inmates of the Jail and the CTF. In addition, DoC elaborated on its
oversight of medical services provided by CCHPS. (DoC’s comments are
reprinted in app. IV.)
DoC emphasized in its comments that the independent reviewer acts at the
request and on behalf of the agency. We noted in the draft report that
DoC’s hiring of the independent reviewer was an important step toward
ensuring the quality of CCHPS’s services and described the independent
reviewer’s role in DoC’s oversight of CCHPS. DoC expressed concern that
the issues discussed in the independent reviewer’s reports are intended to
identify opportunities for CCHPS to improve, but that the draft report
portrayed them as problems or deficiencies. While some issues raised by
the independent reviewer could be characterized as opportunities for
service improvement, we found that others indicated performance
shortfalls related to specific contract requirements.
In its comments, DoC discussed our finding that CCHPS has not regularly
submitted the quarterly and annual reports required by the contract; these
reports are to provide DoC with information on problems identified by
CCHPS’s performance monitoring or by the independent reviewer and on
CCHPS’s corrective actions. DoC stated that instead of the quarterly
reports, it relies on certain monthly reports and regular verbal
communication. DoC’s comments describe two types of monthly reports,
one providing various data on off-site services and the other relating to
two performance measures reported to the Office of the Mayor. However,
undocumented verbal communications and these narrowly focused
monthly reports are not a substitute for the quarterly progress reports
called for in the contract and do not enable DoC to ensure that CCHPS is
addressing identified problems. DoC’s comments acknowledge that
CCHPS has not submitted all required annual reports. We do not agree that
the information provided in the December 2002 report on the
reconciliation of CCHPS’s expected and actual costs, which DoC cites in
its comments, provided DoC with the type of information required in the
annual progress reports. For example, this report contains no information
about how CCHPS planned to improve its performance in screening and
treating female inmates for chlamydia and gonorrhea.

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GAO-04-750 D.C. Jail Medical Services

DoC highlighted its role in reducing the cost of medical services provided
to inmates by CCHPS. In the final report we provided additional
information on DoC’s role. DoC also noted that the average daily cost of
services decreased from about $19 to about $13, which we stated in our
draft report, and that this will result in savings over the remaining life of
the contract. However, while the average daily cost per inmate in 2003 was
$13.32, under the current rate schedule, daily per inmate costs may range
from $13.00 when the combined Jail and CTF population exceeds 3,200 to
$14.75 when the inmate population is below 2,200. Therefore, costs over
the remaining life of the contract will depend largely on the inmate
population.
In response to DoC’s comments, we replaced the term “financial penalties”
with “monetary damages.” While the comments state that DoC has other
remedies for contract nonperformance, we believe that the authority to
impose monetary damages is also a useful means of ensuring CCHPS’s
compliance with the contract.
In its comments, DoC described changes in the District’s health care
system that have affected the provision of off-site medical services for
inmates. Because the focus of our report was on services provided by
CCHPS through its contract with DoC, a detailed discussion of these
developments was not within the scope of the report. DoC also stated that
there was a past study on delays in obtaining off-site appointments for
inmates and that there is no need to conduct an additional study. The draft
report did not recommend that DoC conduct an additional study, but
reported that DoC and the independent reviewer have identified problems
with access to off-site services and that DoC has not collected data on
delays.
We incorporated other information provided by DoC in its comments on
our draft report where appropriate.

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

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GAO-04-750 D.C. Jail Medical Services

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

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

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GAO-04-750 D.C. Jail Medical Services

Appendix I: Scope and Methodology

Appendix I: Scope and Methodology

We examined the medical services provided by the Center for Correctional
Health and Policy Studies, Inc. (CCHPS) to inmates at the Jail and the
Correctional Treatment Facility (CTF), including CCHPS’s internal
monitoring; the District of Columbia Department of Corrections’ (DoC)
oversight of those services; CCHPS’s contract compliance; and the cost of
services under the contract. To provide information on CCHPS’s and
DoC’s activities, we reviewed documents and interviewed officials from
those two organizations. DoC documents we reviewed included
contracting documents such as the original request for proposals and
subsequent modifications, reports of inmate population volume, and
specialty clinic utilization statistics. In reviewing DoC’s activities, we
assessed DoC’s internal controls related to the contract with CCHPS.
CCHPS documents we reviewed included policies and procedures, staffing
plans, annual progress reports, and quarterly performance analyses. We
also interviewed the independent reviewer hired by DoC and analyzed the
reviewer’s quarterly reports to examine CCHPS’s medical services and
CCHPS’s quality improvement activities. In addition, we analyzed
documents and interviewed officials from the National Commission on
Correctional Health Care and the American Correctional Association to
obtain information on their correctional health care accreditation
standards, their accreditation review processes, and their findings on DoC
facilities. We also reviewed our previous work on medical services at the
Jail. We reviewed issues related to medical services provided to CTF
inmates only since April 2003, when DoC expanded its contract with
CCHPS to include medical services for inmates at that facility.
To obtain information on inmate complaints about medical services the
contract requires CCHPS to provide and on CCHPS’s responses to these
complaints, we conducted an independent analysis of randomly selected
samples of grievances submitted by inmates at the Jail and the CTF. Of the
201 grievances at the Jail and the 168 grievances at the CTF during the
period April 1, 2003, through October 31, 2003, we randomly selected 75
grievances for each analysis, for a total sample size of 150. DoC was able
to provide us with the detailed information needed for our analysis on 72
of the 75 grievances selected from the Jail and on 72 of the 75 grievances
selected from the CTF. Grievances for which DoC could not provide the
requested information were excluded from each analysis. For both the Jail
and the CTF samples of inmate grievances, we analyzed the timeliness of
CCHPS’s response, the subject of the grievance, and the extent to which
CCHPS’s response addressed the principal areas of concerns cited in the
complaint. The final sample size of 144 grievances produced estimates
about types of grievances and timeliness of responses with a margin of
error of plus or minus 5.0 percent at the 95-percent confidence level.

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GAO-04-750 D.C. Jail Medical Services

Appendix I: Scope and Methodology

Although we focused principally on medical services provided by CCHPS
under its contract with DoC, we also obtained information about inmate
services that are not part of the CCHPS contract—such as off-site
services—by reviewing documents and interviewing officials from CCHPS,
DoC, and the District of Columbia Department of Health (DoH).
Documents we reviewed included contracts between DoH and community
providers and utilization data on off-site services provided to inmates. We
also interviewed officials from the District of Columbia Department of
Mental Health, a community health care provider, and groups providing
legal services to inmates.
To calculate the total annual and average per inmate costs of the medical
services that CCHPS provided, we reviewed documents such as DoC’s
budget records, purchase order summaries, contract pricing
modifications, and CCHPS invoices. We interviewed officials from the
District of Columbia Office of Contracting and Procurement; DoC,
including its Office of the Chief Financial Officer; and CCHPS. We also
examined independently audited accounting data from the District of
Columbia Office of Financial Operations and Systems. We determined that
the medical services cost information we reviewed was reliable, based on
documentation provided by the District of Columbia Office of Financial
Operations and Systems stating that the source of the data was the System
of Accounting and Reporting, the District of Columbia’s official accounting
records, which is subject to an independent audit each year. We made
certain assumptions to define four comparable 12-month periods that
approximated the DoC-CCHPS contract year. Although there are slight
differences between the time periods defined for total costs and inmate
population averages, the length of each period was 1 year. Total cost data
for 2000, 2001, and 2002 are from March 12 of each year through March 11
of the following year, coinciding with the DoC-CCHPS contract year, while
inmate population data for 2000, 2001, and 2002 are from April 1 of each
year through March 31 of the following year, approximating the DoCCCHPS contract year. Total cost and inmate population data for 2003 are
from April 1, 2003, through March 31, 2004, approximating the DoCCCHPS contract year. We calculated the average daily inmate population
for each annual period by first calculating an average daily population for
each of the 12 months within the period, and then averaging the monthly
averages.
We applied an accrual methodology to calculate the total costs associated
with each annual period. The DoC-CCHPS contract during the years 2000
through 2002 specified a fixed contract price at the beginning of each year,
subject to reconciliations during the year. Reconciliations conducted

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GAO-04-750 D.C. Jail Medical Services

Appendix I: Scope and Methodology

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

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GAO-04-750 D.C. Jail Medical Services

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

Appendix II: Requirements Linked to
Monetary Damages Provisions in the CCHPS
Contract
The contract between DoC and CCHPS contains certain requirements that
CCHPS must meet. If these requirements are not met, DoC has the
authority to impose specified monetary damages on CCHPS. Table 2
summarizes the requirements linked with monetary damages.
Table 2: Summary of Contract Requirements with Monetary Damages Provisions

Medical services

Infection control

Monetary damages may be imposed if:

Damages calculation method

Less than 95 percent of Jail intake health screenings are completed within
24 hours.

$200 times the number of
occurrences during the period
a
being measured

Less than 95 percent of eligible inmates’ tuberculosis skin tests are placed
and read within the prescribed time frame. For this item “eligible inmates”
are inmates in the Jail or the CTF more than 96 hours.

$200 times the number of
occurrences during the period
a
being measured

Less than 95 percent of eligible inmates with positive tuberculosis skin tests
receive timely follow-up. For this item “eligible inmates” are inmates in the
Jail or the CTF more than 30 days.

$100 times the number of
occurrences during the period
a
being measured

More than 10 percent of the eligible inmates known to have an abnormal
blood pressure do not have a plan to control blood pressure levels
documented in the medical record within 14 days. For this item “eligible
inmates” are inmates in the Jail or the CTF more than 15 days.

$100 times the number of
occurrences above the 10-percent
threshold during the period being
measureda

More than 15 percent of the eligible inmates known to have human
immunodeficiency virus (HIV) have a clinical status warranting treatment for
prevention of pneumonia, and are not receiving it within 2 weeks of
identification of the need for treatment. For this item “eligible inmates” are
inmates in the Jail or the CTF more than 15 days.

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

More than 15 percent of the eligible diabetics tested as part of an audit are
b
found to have a Hemoglobin A1c level greater than 7 percent and there is
no documented clinical strategy to improve the outcome. For this item
“eligible inmates” are inmates in the Jail or the CTF more than 15 days who
are known to have diabetes.

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

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

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

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

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

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GAO-04-750 D.C. Jail Medical Services

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

Staffing

Monetary damages may be imposed if:

Damages calculation method

The contractor does not maintain valid and current licenses and
certifications as required for all health care providers.

$500 times the number of
occurrences per day for each
healthcare provider, calculated
from the date of the finding

The contractor does not have evidence of annual tuberculosis screening
None identified
and hepatitis B immunization for all health care staff. The contractor’s direct
patient care personnel fail to maintain current cardiopulmonary resuscitation
certification.
The contractor leaves vacant a principal leadership positionc for greater than One and one-half the salary rate
60 days. If a qualified individual is performing the functions of a principal
per hour plus fringe hourly rate
leadership position, this position is not considered vacant.
defined in the contractd times the
number of required hours the
position is left vacant after 60 days
The contractor leaves vacant any required position as accepted by DoC in
the contract for greater than 120 days.

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

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

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

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

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

d

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

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GAO-04-750 D.C. Jail Medical Services

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

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

1

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

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GAO-04-750 D.C. Jail Medical Services

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

Table 3: Information on Performance Assessment Instruments Used to Monitor CCHPS’s Services
Service area/type

Measure

Sample used

Source of sample

Intake services
Intake evaluation

•

•

•
•

Performed complete health assessment by
20 randomly selected
licensed physician, physician assistant (PA), or
inmate medical
nurse practitioner (NP) at intake to the Jail,
recordsa
including a physical and oral examination and
review of bodily systems, such as the
cardiovascular system; a medical and substance
abuse history; check of vital signs (breathing rate,
pulse, temperature); and analysis of a urine sample
Placed tuberculosis skin test, if applicable, and
read within 48-72 hours; performed chest x-ray, if
applicable, within 24 hours
Documented syphilis lab test result
Conducted further mental health evaluation within
24 hours, if indicated by positive response to
screening questions asked at intake

General inmate
population

•

Performed pregnancy test

10 randomly selected
Female inmate
inmate medical records population

•

At intake or within the past 3 months, conducted
measurement of the amount of air an inmate can
push out of his/her lungs

10 randomly selected
inmate medical
recordsb

•

Followed chronic disease guideline; assessment
included degree to which disease has been
controlled and strategy to improve outcome if
degree of control is fair or poor or if patient’s status
c
has worsened
Measured blood sugar levels on intake

First 5 of the 10
randomly selected
inmate medical records
reviewed above

Primary medical care
Asthma care

Diabetes care

•

10 randomly selected
inmate medical
recordsb

Inmates with asthma

General inmate
population

•

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

10 randomly selected
Inmates with diabetes
diabetic inmate medical
records

•

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

First 5 of the 10
randomly selected
diabetic inmate medical
records reviewed
above

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GAO-04-750 D.C. Jail Medical Services

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

Service area/type

Measure
Tested for level of certain white blood cells with
CD4 markerd and HIV viral count within 40 days or
within the past 3 months
• Offered treatment for prevention of pneumonia
within 2 weeks if level of certain white blood cells
with CD4 marker is low
• Considered or ordered anti-HIV drugs within 2
weeks if level of certain white blood cells with CD4
marker is moderately low
• Followed chronic disease guideline; assessment
included degree to which disease has been
controlled and strategy to improve outcome if
degree of control is fair or poor or if patient’s status
has worsenedc
• Vaccinated against pneumococcal infection
including pneumonia
• Administered influenza vaccine during flu season,
October – February.

Sample used

Source of sample

10 randomly selected
inmate medical
recordsb

Inmates with HIV

Noted blood pressure reading at intake

10 randomly selected
inmate medical
recordsb

General inmate
population

•

Initiated treatment, or plan to treat, within 14 days
of identification of high blood pressure

10 randomly selected
Inmates with high
medical records of
blood pressure
inmates with high blood
pressure

•

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

First 5 of the 10
randomly selected
medical records of
inmates with high blood
pressure reviewed
above

Positive tuberculosis skin
test cases

•

Nursing sick call
performance

•

Clinical evaluation of inmate and treatment decision 10 randomly selected
made within 14 daysc
inmate medical
recordse
Assessment of inmate’s condition appropriate to
2 inmate medical
chief complaintf
records from each of
18 inmate housing
Recorded relevant vital signs, such as breathing
f
unitsg
rate, pulse, and temperature

Human Immunodeficiency
Virus (HIV) care

•

Hypertension care

•

•
•

Treatment plan appropriate to conditionf

•

Psychiatric progress evaluations conducted by
psychiatrist every 2 weeks
Inmate’s interdisciplinary treatment plan reviewed
by staff within 4 weeks

Inmates with positive
tuberculosis skin tests
Sick call requests
from inmates

Mental Health Services
Chronic mental health care

•

Page 37

10 randomly selected
Inmates in male
inmate medical records inpatient mental
health housing units

GAO-04-750 D.C. Jail Medical Services

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

Service area/type
Acute mental health care

Abnormal Involuntary
Movement Scale (AIMS)
testing

Measure
Initial mental health assessment done by clinical
staff within 7 working days
• Initial psychiatric evaluation done by psychiatrist
within 24 hours
• Subsequent psychiatric progress evaluations by
psychiatrist every week
• Developed interdisciplinary treatment plan within 5
working days
• Inmate’s interdisciplinary treatment plan reviewed
within 4 weeks
• Documented testing (AIMS test) to determine
possible side effects of antipsychotic drugs within
30 days of intake or within past 6 months
•

Sample used

Source of sample

10 randomly selected
Inmates in male
inmate medical records inpatient mental
health housing units

10 inmate records from Pharmacy list of
male inpatient mental
inmates taking
health housing unit and antipsychotic drugs
10 inmate medical
records from general
population

Appropriate medication for
mental health treatment

•

Diagnosis consistent with use of medicationh

10 randomly selected
Pharmacy list of
inmate medical records inmates taking certain
medications, e.g., for
schizophrenia

Level of certain drugs for
bipolar disorder (depakote
and lithium)

•

Reported level of medications every 3 months
Physician review of medication levels with
h
appropriate response noted in medical records

10 randomly selected
Pharmacy list of
inmate medical records inmates receiving
depakote and lithium

Care timelyf
Documented appropriate vital signs, such as
f
breathing rate, pulse, and temperature
Appropriate assessment of condition and plan to
treatf

10 urgent care visitsi

Progress note in medical record reflects need for
consultation
Consultation ordered by physician, PA, or NP
Consultation accomplished within 30 days of order
Documentation of appropriate follow-up consistent
with consultant’s recommendation or rationale for
not following consultant’s recommendation

5 randomly selected
Inmates seen in
inmate medical records specialty clinic
from each specialty
clinicj

•

Specialty care
Urgent care performance

•
•
•

Specialty clinic services

•
•
•
•

Communicable disease
treatment

•

•

•

•

Screened female inmates for gonorrhea and
10 randomly selected
chlamydia within 14 days of admission to the facility inmate medical records
Patients with positive test for syphilis received
10 randomly selected
appropriate treatment (based on federal guidelines) inmate medical records
c
within 5 days of receiving laboratory report
for each disease
Patients with positive test for gonorrhea received
appropriate treatment (based on federal guidelines)
within 3 days of receiving laboratory reportc
Patients with positive test for chlamydia received
appropriate treatment (based on federal guidelines)
c
within 3 days of receiving laboratory report

Page 38

Inmates seen in
urgent care

General inmate
population
Inmates identified as
positive for gonorrhea,
chlamydia, or syphillis

GAO-04-750 D.C. Jail Medical Services

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

Service area/type
Dental care

Measure
Timeliness of treatment appropriate to condition:

•

Trauma/symptoms of infection or intense pain –
within 24 hours
•
•

Sample used

Source of sample

10 randomly selected
Inmates seen in
inmate medical records dental clinic

Any other acute condition – within 7 days
Documentation that oral health education materials
were provided to patients
Clear and complete documentation of visits and
procedures, including medical history

Ancillary services
Chest X-ray reporting and
follow-up

•

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

10 randomly selected
Log of all x-rays taken
inmate medical records

Nonchest X-ray reporting
and follow-up

•

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

10 randomly selected
Log of all x-rays taken
inmate medical records

Laboratory servicesk

•

Report laboratory results within 24 hours, as
appropriate
Clinical acknowledgment of laboratory results and
appropriate clinical responsec

10 randomly selected
No source identified in
inmate medical records performance
assessment
instruments

Number of omissions in inmate records in the
medication administration books
Number of cases in which inmates refused
medications on three consecutive occasions noted
in the medication administration books
Number of cases in which inmates who refused
medications on three consecutive occasions
received appropriate follow-upm

5 MARs books

MARs books

10 randomly selected
clinician files from each
provider type, and from
the combined
physician/PA/NP staff

Nursing files, dental
files, mental health
files, and combined
physician/PA/NP files

All medical grievances

CCHPS log of inmate
grievances

•

Medication administration
l
records (MAR)

•
•

•

Quality improvement activities
• Validated current license for physician, PA, and NP
Credentialing
staff and U.S. Drug Enforcement Administration
registration for physician and NP staff
• Validated current license – nursing staff
• Validated current license – dental staff
• Validated current license – mental health staff
Complaints and grievances • Analyzed trends in terms of numbers and category
distribution of complaints and grievances
• Percentage of complaints and grievances
appropriately addressed within 14 days

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GAO-04-750 D.C. Jail Medical Services

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

Service area/type
Quality improvement
program

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

Sample used

Source of sample

Not applicable

Not applicable

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

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

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

c

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

d

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

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

f

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

g

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

h

Performance assessment requires clinical judgment by physician.

i

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

j

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

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

l

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

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

Page 40

GAO-04-750 D.C. Jail Medical Services

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

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

Page 41

GAO-04-750 D.C. Jail Medical Services

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

Page 42

GAO-04-750 D.C. Jail Medical Services

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

Page 43

GAO-04-750 D.C. Jail Medical Services

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

Page 44

GAO-04-750 D.C. Jail Medical Services

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

Page 45

GAO-04-750 D.C. Jail Medical Services

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

Page 46

GAO-04-750 D.C. Jail Medical Services

Appendix V: GAO Contact and Staff
Acknowledgments

Appendix V: GAO Contact and Staff
Acknowledgments
GAO Contact

Helene F. Toiv, (202) 512-7162

Acknowledgments

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

(290315)

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GAO-04-750 D.C. Jail Medical Services

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