3. INTERNAL CONTROLS OVER IN-HOUSE MEDICAL CARE AT JAILS AND EMERGENCY CARE PROCEDURES IN USMS CELLBLOCKS NEED STRENGTHENING
   
   USMS districts are not adequately monitoring local detention facilities to determine whether federal prisoners are receiving proper health care; and are not effectively initiating health care improvements at local jails providing substandard health care. USMS inspections are cursory, and more in-depth reviews conducted by external groups are not followed up on. Further, we could not determine whether the USMS was in full compliance with USMS policies and procedures governing emergency health care procedures in its own cellblock operations because there was some uncertainty as to what the current policies and procedures were. The overall lack of monitoring and follow-up creates an environment where misjudgments can occur, with health consequences to both the federal prisoner population and USMS personnel.

Background

In-house medical care encompasses health care provided at local jail clinics, as well as limited emergency care provided in USMS cellblock operations. While the USMS has direct control over its own cellblock operations, the USMS must monitor in-house care provided by local jails through its jail inspections program, as well as through external review groups.

Initial medical screening of a federal prisoner occurs at the booking of the individual at a USMS district office, which is often located in the local federal courthouse. At booking, USMS deputies observe the arrestee and fill out a booking sheet documenting the arrestee's responses to a few basic medical questions. The arrestees are kept in the cellblock, while awaiting either a court appearance or transport to a BOP or local jail facility, where medical screening will take place.

Given the short span of time that prisoners usually spend in the cellblock area, medical care is normally not required there. In some cases, however, prisoners awaiting trial may have chronic medical conditions, such as asthma or heart disease that may require medical attention. Emergency medical situations can also occur during a prisoner's cellblock stay.

For basic medical screening and routine medical services for federal prisoners, the USMS relies largely on local and contract jails, as well as the BOP, most of which are equipped with in-house medical clinics within their facilities. The costs of such in-house medical services are usually covered in the per diem rates²⁰ charged to the USMS under the terms of an Intergovernmental Agreement (IGA) in the case of a local jail, or the contracted jail day rate in the case of a private contract facility. Services provided in BOP facilities are done so at no cost to the USMS.

In-house medical services provided by the jails housing federal prisoners can vary substantially. Some local jails may have on-site medical professionals and sophisticated medical facilities, including x-ray and dialysis machines, TB isolation cells, and dental services. Some facilities may even be able to accommodate minor surgical procedures. At the other end of the spectrum are facilities with very limited health care services, where a local deputy or administrative official may ask general medical questions to complete paperwork necessary to process the individual. Prisoners at these facilities must often be transported outside for procedures that are routinely performed at jails with more comprehensive medical services.

Cellblock Medical Care And Emergency Procedures

We toured the cellblocks in the 14 districts we reviewed and interviewed USMS and contract personnel staffing the cellblock operations to determine whether the districts were in compliance with USMS cellblock medical requirements. We had difficulty determining compliance, however, because there was some uncertainty as to what the current policies and procedures were.

In September 2002, the USMS Prisoner Services Division issued, in draft, a policy directive titled, "Prisoner Health and Emergency Care, Minimum Health Standards for Prisoners." The draft was issued in response to a memorandum from the Inspector General to the Director of the USMS, dated May 6, 2002, that detailed the results of an OIG investigation of an alleged denial of treatment to a federal prisoner held in USMS custody.

According to the OIG memorandum, on February 2, 2001, the prisoner in question had sustained multiple facial fractures from an assault by another prisoner while housed at the Maryland Correctional Adjustment Center. The prisoner received only minimal first aid at the facility. Three days after the incident, the prisoner was transported to the USMS office in Baltimore, Maryland, where arrangements were made for transportation to another contract facility in Orange, Virginia. While in USMS custody, the report cited the prisoner's "repeated requests" to USMS personnel for medical treatment. It was not until February 12, 2001, a week and a half later, that the prisoner's injuries were treated.

While USMS employee personnel generally thought that the contract facility bore primary responsibility for rendering medical treatment, USMS personnel conceded that existing USMS regulations were unclear on handling requests for medical treatment. To address this weakness, the Inspector General recommended that the USMS establish clear guidance for USMS personnel on handling prisoners' requests for medical treatment. The USMS responded by issuing the aforementioned September 2002 draft policy on emergency healthcare procedures in the cellblocks.

While much of what the draft policy addressed was already contained in USMS Policy 99-47 on cellblock operations, there were several important changes in guidance provided to cellblock personnel. Under the current policy, for instance, all medication held by prisoners except nitroglycerin for heart patients must be taken away and secured when entering the cellblock. The draft policy would allow inhalers for asthma patients, as well as nitroglycerin for heart patients into the cellblock. In addition, all emergency care incidents must be documented on a Form USM-210 Field Report under the draft policy, whereas no requirement exists under the current policy.

As of the last day of fieldwork on October 28, 2003, the September 2002 draft policy remained in draft, awaiting the USMS general counsel's approval. However, we noted during the survey phase of our audit in a site visit to the Eastern District of California that the draft policy had been disseminated and implemented. In contrast, several of the 14 districts reviewed during the verification phase of our audit were not aware of the draft policy's existence. An administrative officer in one district said that she had no record of the policy, and that it was her understanding that the policy was still a "work in progress." Contrary to what we found in the Eastern District of California, a chief deputy in another district explained that a draft policy would never be sent to the field for dissemination.

USMS officials at our exit conference explained the policy was still in draft, awaiting the USMS general counsel's approval, which begs the question as to why a policy still in draft had been implemented in at least one district. These inconsistencies notwithstanding, the delays in implementation of the draft policy raises a concern given that the policy in question was created in response to perceived failures on part of USMS management to establish clear guidance for the appropriate action to prevent serious injury or death to prisoners in custody.

Serious injury or deaths in cellblock, while rare, do occur. For example, in February 1999, a federal prisoner died while being transported from the cellblock at the federal courthouse in Tucson, Arizona. The autopsy indicated that the prisoner had acute appendicitis. The prisoner and several of his inmates had notified the cellblock officers that the prisoner was ill and was requesting treatment. The prisoner complained of chills, stomach pain, and the inability to urinate. Rather than being given immediate medical treatment, the prisoner was told he would have to wait until he could receive treatment at the local contract facility.

By the time the van arrived, the prisoner had lapsed into unconsciousness. Despite his condition, he was loaded, unconscious, into the van. En route to the detention center the prisoner stopped breathing and was at that point taken to a local hospital, where he died. The family of the prisoner was paid $150,000 by the U.S. government in a court settlement arising from the incident.

Subsequent to this event, the USMS issued Policy 99-47 Cellblock Operations, which addressed, among other things, emergency medical care procedures. However, even if the policy had been in place before the appendicitis incident, we are not confident that it would have made a difference because there was no specific guidance given or training provided to assist USMS personnel in determining when a condition requires hospitalization.

The American Correctional Association (ACA) standards address emergency care response in jails and detention facilities.²¹ The ACA standards require a four-minute response time for prisoner medical emergencies. Further, the standards require jail personnel to be trained to recognize signs and symptoms of conditions requiring emergency medical care, and the methods of obtaining medical assistance.

Cellblock Equipment

In addition to testing compliance with the primary policies and procedures, we tested for compliance with peripheral policies regarding cellblock equipment. The results were as follows:

• Automated External Defibrillator
  
  The USMS's Automated External Defibrillators²² (AED) First Responder Policy Directive requires that deputy marshals working in district offices be certified in both Cardio Pulmonary Resuscitation (CPR) and AED procedures.²³ The AED program is administered by the USMS but serves the federal court system by protecting court personnel, civilians, and prisoners alike. The USMS policy specifies that two operational employees at each district be trained as AED instructors. The instructors are in turn responsible for training additional staff. Also, the staff is required to be certified in CPR before receiving AED training.²⁴
  
  Our review determined that only six of the districts reviewed had provided the required AED annual training and certification to their deputies during 2002. Five of the districts that had not provided training stated that they had plans to begin training in the near future. However, delays in training and certifying district personnel in these life-saving skills could lead to the improper use of the AED and to possible tragic consequences for a heart attack victim.

• Medical Assistance Signage
  
  USMS policy requires that at least one sign be posted in each cellblock advising prisoners how to request emergency medical assistance. We found that 3 of 14 districts did not have signs posted. Without these signs, prisoners may not know that medical assistance is available, and as a result may not notify cellblock personnel as soon as symptoms appear.

• Prisoner Refusal of Medical Care
  
  USMS policy states: "If a prisoner refuses transportation and/or medical assistance after complaining of illness or injury, the prisoner will be required to sign a USM-210 acknowledging a desire not to receive medical assistance."
  
  Our review determined that many USMS employees manning the district cellblocks were unaware of USMS prisoner medical procedures that require prisoners who refuse medical treatment to sign a written waiver.

Local Jailhouse Medical Care

To assess the quality of care provided to federal prisoners at local jails, the USMS has a jail inspection program. Current USMS jail inspection guidelines include standards established by the ACA. USMS deputy marshals, as a collateral duty, conduct these jail inspections and submit the reports to the district office. The reports rate the jails compliance with ACA standards and list any medical care deficiencies noted at the jail, with comments on plans or actions to be initiated or undertaken by the district to correct substandard conditions.²⁵

However, we noted that the inspection reports annually submitted to district officials are cursory and did not provide enough detailed information (such as observations, interviews, and documents reviewed) to support general findings that the health care provided by the jail meets the required standards. Further, in three of the districts reviewed, deputy marshals who had not received any training in jail inspections were performing the inspections. Finally, jail inspector duty for deputy marshals is collateral to their normal law enforcement responsibilities. Deputies assigned to perform jail inspections were not specifically rated on their performance evaluations for the quality or timeliness of their jail inspection work.

Our audit questioned not only the quality of the USMS jail inspections, but also their timeliness, as many reports were not being submitted annually as required by USMS policy and procedures. In FY 2002, 8 of the 14 districts reviewed did not complete annual evaluations of the prisoner medical care provided by all their major use detention facilities. The following table lists the results of our jail inspection audit testing by district office.

There also appeared to be little evidence of any follow-up on the inspection reports. The lack of follow-up included external inspections, as illustrated in the discussion below concerning the Department of Justice (DOJ) Civil Rights Division's review of the Nassau County Correction Center (NCCC) in New York

Nassau County Correction Center

On April 19, 1999, the DOJ notified Nassau County of its intent to investigate the NCCC to determine whether its conditions violated inmates' constitutional rights. The DOJ conducted the investigation pursuant to the Civil Rights of Institutionalized Persons Act 42, U.S.C.A. 1997. On September 11, 2000, the DOJ issued its letter of findings containing evidence that the NCCC had, through deliberate indifference to inmates' serious medical needs, subjected its inmates to conditions that violated their constitutional rights and caused them grievous harm.

The parties subsequently entered into a settlement agreement to litigation. The following is a partial list of some of the actions that the NCCC was required to take to improve prisoner health care:

• Security personnel trained in first response to medical emergency situations.

• Medical director must be a qualified and licensed physician.

• 24-hour on-site full-time physician.

• The medical contractor must provide and maintain monthly reports of medical staff positions and vacancies.

• Intake screening to be performed on the prisoner's day of arrival.

• Blood tests for syphilis.

• Pneumococal and influenza vaccinations provided.

• Hepatitis C treated in accordance with CDC guidelines.

• Full health assessment within (7) days of arrival if history and visual indicate good health.

• Sick call five days a week.

• Establish sick call policies.

• No inmate shall be disciplined for accessing health care.

• Chronic disease registry (list of prisoners with chronic diseases).

• Written chronic disease treatment guidelines.

• Only trained and qualified medical staff shall administer medications.

• Drug profile system - listing adverse reactions.

• Seven day supply of medications for released prisoners.

• Policies and procedures for maintaining health records.

• NCCC shall develop and implement written guidelines for female medical care including routine screening for pregnancy, sexually transmitted disease, HIV counseling, and routine gynecological and obstetric care.

USMS policy requires that a written report must be prepared by the district office and submitted to the Prisoner Services Division following the issuance of any court order related to the conditions of confinement at a detention facility used by the district. However, a report on the NCCC court settlement was not submitted to the PSD.

Further, the USMS entered into an IGA with the NCCC in May 2000, shortly after the DOJ investigation had begun, and completed its own inspection in September 2000 at the same time the DOJ was releasing its list of findings. The USMS inspection listed no deficiencies.

The most recent USMS jail inspection of the NCCC was completed on January 22, 2003. That inspection report listed the jail as partially compliant in medical, dental, and mental health appraisals. The inspector's only comments in the January 2003 report were: 1) the facility performs a full medical and mental health screening upon arrival; 2) dental inspections were performed within 14 days of arrival, but only to look for any major dental problems; and 3) full dental inspections were not completed within the first 14 days.

We interviewed district personnel supervising prisoner operations and found that while they were aware of the NCCC litigation, including the settlement agreement, they were largely indifferent towards the issues brought up by it. Our review determined that the inspector did not properly address the DOJ investigative findings or settlement agreement requirements in either the September 2000 or January 2003 inspection reports.

Conditions of Confinement Reviews

In FY 2000, the DOJ initiated a program to assess the conditions of confinement at 40 of the largest non-federal institutions housing federal prisoners. The review process is referred to as the Conditions of Confinement Reviews (CCR) Program. The purpose of the program is to ensure that non-federal facilities housing federal detainees: 1) are safe, 2) are humane, 3) protect detainee statutory rights, and 4) protect detainees' constitutional rights. The impetus for the program arose from the DOJ's Strategic Goals, one being to protect American society by providing for the safe, secure and humane confinement of persons in federal custody.

Toward that end, in June 2000 the DOJ contracted with PriceWaterhouseCoopers, LLP (PwC) to implement a program to review the conditions of confinement for federal prisoners and detainees in non-federal jails and prisons. The criteria for the assessments were comprised of 59 core standards developed by the DOJ to determine whether detention facilities are safe, humane, and protect individual rights.

As was the case with the DOJ's review of the NCCC, we noted that the USMS had not taken steps to ensure that local jails initiated corrective actions on medical deficiencies reported in the CCRs of federal prisoners detained at local detention facilities.

The following table lists the CCRs completed on detention facilities utilized by the USMS districts reviewed in this audit. The table also shows the health care related findings at each facility and whether the district took sufficient action with these facilities to improve the stated conditions.

Seven districts had contracts or IGAs with detention centers that had received CCRs. As indicated in the above table, six of the detention centers had significant health care issues.

The USMS PSD or contracting division requested a response and corrective action plan for each CCR finding from the detention center. We observed that in one case, the findings were responded to only in an advisory capacity. The detention administrator stated in his reply that he totally disagreed with some findings and other findings could only be corrected if the USMS increased its per diem rate.

Although we did observe that some detention centers submitted corrective action plans, we saw no evidence that the affected district took any action to ensure the plan was fully implemented. District officials told us that they either did not know a CCR had been performed or were unaware that the detention center had submitted a corrective action plan. One official stated that the district would not get involved unless directed by USMS Headquarters.

Conclusion

USMS internal controls over monitoring of in-house medical care at jail facilities need strengthening and revision to ensure that adequate health care is provided to federal prisoners in USMS custody. In the case of local jails, a lack of proper and thorough jail monitoring and adequate follow-up by the districts does not provide assurance that USMS prisoners are receiving proper and adequate health care services. Similarly, lack of compliance with established cellblock policies and procedures substantially increases the possibility of prisoner injury or death, and leaves the government open to successful litigation.

Recommendations

We recommend the USMS:

5. Require that a management plan be created that ensures that deputy marshals are in compliance with cellblock health care policy and that they receive annual CPR and AED training in order to maintain certification.

6. Strengthen the jail inspection program by:
   
   
   1. Ensuring that districts comply with USMS policy requiring an annual jail inspection. The PSD should maintain an IGA database which includes the date of the latest inspection.
   
   
   2. Ensuring that district employees assigned as jail inspectors attend inspection training, including refresher courses, that contains a module on prisoner medical care. Employees conducting jail inspections should receive performance evaluations that include jail inspections as a rating element.
   
   
   3. Requiring U.S. Marshals to review and improve their current jail inspection requirements. The reports for prisoner medical services should be more detailed and include supporting documents. The assessment tools provided in the CCRs should serve as a guide in improving the reports.
   
   
   4. Requiring districts to follow up on all CCR findings at least three years after the review has been completed. USMS inspection reports conducted on jail facilities that have submitted corrective action plans should include certification by the jail inspector that the jail is in compliance with the plan.

20. The Intergovernmental Agreement states that a negotiated daily rate per prisoner will be paid by the USMS to the jail.
21. The ACA is a professional membership organization dedicated to the improvement of corrections and the development and training of correctional professionals. The ACA's membership consists of individuals and organizations involved in all facets of corrections, including adult institutions and jails, community corrections, juvenile justice, institutions of higher learning, and probation and parole.
22. Defibrillators are devices that deliver an electric shock to a person experiencing a cardiac arrest. The defibrillator sends an electric message by means of a shock to the heart to resume contracting. Studies indicate that with each minute that passes without any intervention, the chances for recovery are diminished by 10 percent for the person experiencing cardiac arrest.
23. CPR and AED certification must be renewed annually.
24. CPR must be administered at the same time electric shocks are being given so that the victim is oxygenated.
25. In addition, a pilot program initiated in 1994 enabled USMS districts to utilize State inspection reports in lieu of reports prepared by the districts. As with the USMS inspection report, deficiencies noted in the state report are to be discussed with facility administrators to correct the condition.
26. Inspection report was submitted without the health care section completed.