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United States Marshals Service's Prisoner Medical Care

Report No. 04-14
February 2004
Office of the Inspector General

Findings and Recommendations


    Management of contract guard operations relative to prisoner medical care was characterized by inadequate training, breaches in policy, and lapses in internal controls. We noted problems in nearly all areas of contract guard activity, ranging from lack of documentation to overpayments. More importantly, the ill-managed contract guard operations have created an environment in which the USMS cannot effectively control the risks inherent to transporting federal prisoners to and from off-site health care facilities.

A critical factor in providing outside medical treatment to federal prisoners is the secure transport to and from health care facilities and guarding of prisoners during the period of treatment. Typically, the USMS does not utilize deputy marshals for such activity, but instead employs contract guards.31 Of the $43 million in prisoner medical care expenditures in FY 2002, $7.4 million or 17 percent went to providing security for prisoners receiving outside medical care. Security in this case refers to the hiring of contract guards for the transportation and guarding of prisoners requiring external medical treatment. Contract guards for hospital transport were used in 12 of the 14 districts we reviewed.

There are inherent risks associated with the transportation and guarding of federal prisoners while in public, the most serious of which is death or injury to an innocent bystander. The most effective way to minimize those risks is to eliminate or reduce the need for outside medical services. In New York, for example, the USMS has benefited from an interagency agreement with Veterans Administration (VA) hospitals in Manhattan and Brooklyn in which VA doctors make site visits to BOP facilities, thus reducing the need for outside medical services. Such arrangements notwithstanding, the need for outside medical care exists, and to address the associated risks the USMS has established policies and procedures related to contract guards that govern: 1) the transporting of prisoners, 2) personnel qualifications, 3) work experience, 4) training, and 5) fitness for duty. For these specific policies and procedures, see Appendix V.

Although contractors provide the hospital guards, the district is responsible for: 1) determining the placement of prisoners under the supervision of contracted guards, 2) determining the number of contracted guards required for a detail, 3) ensuring that the qualification of the contracted guards meet established standards, and that 4) ensuring that contracted guards are properly trained to properly perform their assigned duties and responsibilities.

Our review of USMS district compliance with the established controls indicated that many districts were not in compliance with USMS policies and procedures regarding prisoner transportation and hospital guard duty. Often the district offices were not certain if company contract guards met USMS standards. Some district offices did not retain documentation to verify whether contract guards met all of the qualifications and training requirements stated in the USMS policy and procedures manual.

In some instances, the lack of documentation was due to deficiencies in the contracts themselves. We noted that some contracting documents did not contain a clause requiring the contractor to provide the district office with documentation that all USMS requirements are met, and in some instances the contract did not state that personnel qualifications had to be met at all. A discussion of specific areas with regard to both personal service contracts and guard company contracts follows.

Contract Personnel Records

Personal Service Contracts

USMS policies and procedures require that district offices obtain the following background information for individuals employed to work as hospital guards: 1) valid driver's license, 2) background check, 3) fingerprints, and 4) firearms qualification.

USMS policy requires that these documents be maintained on file to ensure that hospital guards: 1) safely perform their duties, 2) have no criminal background, and 3) can legally transport prisoners. However, our review of personal service contract files revealed that USMS district offices are not properly maintaining personnel information, as illustrated in the table below:

District Firearms
Background Check Driver's
Arizona None None 60% None
DC District Court None 100% 20% None
Kansas 100% 100% 100% 100%
Eastern New York None None 20% None
Western New York 100% N/A 100% 100%
South Carolina 40% 10% 10% None
Southern Texas 100% None 100% None
Western Texas 100% None 80% None
Source: District contract personnel records

Officials at the Eastern District of New York acknowledged that their personal contract guard files were incomplete, and that they were in the process of improving their personnel records. Officials from the Southern and Western Districts of Texas and the District of Arizona all stated that it was their understanding that personnel information was not required for sworn officers and that the guards' primary law enforcement employer had the information on file.

USMS policy does allow for a firearms qualification exemption if the contract guard is a sworn law enforcement officer. However, we found that some guards were retired officers and that many of the guards who were sworn officers had not submitted a USM Form 234 (affidavit of affirmation), as required under USMS policy.32

Guard Company Contracts

As with personal service contracts, the USMS requires that contract guards hired through guard company contracts meet the minimum standards related to experience, fitness, weapons qualifications, physical fitness, criminal background, and training. Of the seven districts reviewed that utilized company hospital guards, our review of personnel files revealed that:

  • Contract guard personnel files at three of the districts did not contain fingerprints.
  • Contract guard personnel records at two of the districts did not contain information related to the guards' previous experience or qualifications.
  • Two districts did not have personnel records on any of the individuals performing hospital guard duties.
  • One district was obtaining guard services without a contract.

The USMS requires that the districts document the qualifications and background of all individuals contracted to guard and transport federal prisoners. These controls have been established to ensure that guard personnel are capable of properly performing their duties.

By not complying with these policies the districts increase the risk of hiring an individual who lacks the proper qualifications and experience or has a criminal background, which in turn increases the risk that incidents resulting in injury or death may occur.


USMS policy requires that personal service guards receive specific training within 30 days of providing service in addition to annual refresher training thereafter. The policy permits that past or current agency training may be used in lieu of USMS training but must be annotated on the Affirmation of Qualifications statement in the guard's contract file.33

Contract hospital guards are required to: 1) view a video on TB, 2) become familiar with USMS policies and procedures, 3) know how to apply and remove restraints and conduct searches, 4) review and agree to comply with the USMS use of force policy and must certify to their knowledge of the policy, and 5) review USMS Policy Directive 99-18(1) regarding professional standards of conduct and certify to their knowledge of the policy.

We reviewed the training provided to contract hospital guards at 12 of 14 the district offices.34 We noted that 8 of the 12 districts using contract guards kept no records on hospital guard training. The following table summarizes the results of our review.

District Company
Contract Guards
Contract Guards
Training Training
Arizona None35 None
Central California Yes36 N/A37
DC District Court N/A None
Northern Illinois None N/A
Kansas N/A None
Eastern New York N/A None
Western New York N/A Yes
Eastern Pennsylvania None N/A
South Carolina None None
Southern Texas N/A Partial38
Western Texas N/A None
Southern California Yes N/A
Source: District contract personnel records

The District of South Carolina was somewhat unusual in that guard personnel files contained letters signed by the U.S. Marshal stating that the hospital contract guards had met USMS experience qualifications and did not require additional training. Based on our review and interviews with district officials, we concluded that despite USMS policy requiring training for hospital guards, the U.S. Marshal made a decision to not provide training for their personal contract guards. We also concluded that this decision was based on the Marshal's determination that if a personal contract guard had met the experience requirements, then the USMS training requirements were not applicable. While this may have been done in good faith and based on confidence in the contract personnel, a decision to circumvent internal controls increases the risk that an incident will occur that may jeopardize public safety.

Prisoner Escape

We encountered such an incident in our review of the district office in Southern California when a prisoner with active TB managed to escape from his hospital room. The prisoner, who was hospitalized for treatment of active TB, was placed in a non-secured section of the hospital because the secured wing was full. The unsecured hospital room had no observation port in the door and had windows to the outside that could be opened. Further, because the prisoner had active TB, the contract guard did not stay in the room with the patient. Consequently, the contract guard failed to maintain regular visual contact, in violation of USMS procedures. In this instance, the prisoner was out of the guard's sight for a long enough period to put on his street clothes (which he should not have had), tie several bed sheets, open the window and lower himself to the ground to make his escape. Following his escape, the prisoner hijacked a woman driving her car. He was eventually apprehended and later died in custody from advanced TB.

The woman filed a lawsuit against the hospital and the USMS and the USMS was found not to be liable. While the incident ended without serious physical injury to the innocent bystander, the escape of a violent felon with a highly contagious disease into the community could have had far more serious consequences.

Alleged Prisoner Abuse

In another incident, this one in the Northern District of Illinois, a prisoner undergoing dialysis treatment alleged that two contract guards engaged in misconduct, stating that while in a hospital bed watching TV he was beaten by a guard for changing the channel. According to the prisoner, the guard warned him "not to change the TV channel or he would kick his ass." The prisoner stated that he hit the nurses call button, and when she arrived the guard told the nurse that the prisoner had been acting up.

On a separate occasion, the prisoner complained about another contract guard handcuffing him in a manner that was very painful because he was undergoing dialysis. He stated that while the jail guards had handcuffed him in a manner that was not painful, the contract hospital guards handcuffed him in a manner to induce severe pain. He added that when he refused to be handcuffed in such a manner the contract guard made disparaging remarks about the prisoner's mother.

District officials stated that they contacted the contractor and asked that they suspend the two accused guards until an investigation could be completed. Further information obtained by the audit team indicated that the accused guards were suspended temporarily, but there was no evidence that the USMS followed through with an investigation into the prisoner's complaint.

Contract Monitoring

At the heart of the aforementioned problems is the issue of contract monitoring. In most cases, the responsibility for monitoring contract performance rests with the Contracting Officer's Technical Representative (COTR).39 An active and well-trained COTR is central to the effective management of any contract operation.

USMS policy requires that district office employees meet specific requirements to qualify as a COTR.40 We interviewed the COTR at each of the six districts with guard company contracts to evaluate their knowledge of contractor performance requirements, such as guard training and guard qualifications. We also asked to review annual written evaluations of the contractors' performance to determine if the evaluations were comprehensive and submitted timely.

We determined that most of the COTRs lacked a proper knowledge of the hospital experience, billing procedures and rates, problems and complaints, and, in general, the guard contract they were managing. We further determined that most COTRs had not submitted formal evaluations of the contract to district management.

While most of the COTRs had received the required training, only one of those we interviewed indicated active involvement in monitoring of the contract. This was not a wholly unexpected outcome, as the COTR function in the USMS is a collateral duty, often performed by deputy marshals with a full workload and little background experience in contracts.

An example of the limited oversight provided at the district level was seen in the Northern District of Illinois, which had been utilizing the Magic Security, Inc., over a four-year period to both transfer and guard federal prisoners receiving outside medical treatment.

Our review of the district office determined the following regarding the contractor:

  • We determined that the district had made overpayments in excess of $211,411 over a two-year period on the guard company contract. We reviewed several invoices from FY 2002 and determined that the rates listed on the invoice were consistently above the negotiated rate on the most current contract.41

    In addition, we detected several contractor errors in the summary total of billing sheets listing the number of guard hours and transports provided. We noted that the district office did review the billings as evidenced by numerous corrections. However, based on the large number of undetected errors we determined that the district office was not adequately reviewing the invoices and billing sheets.
  • The guard company had used their own vehicles to transport federal prisoners to medical appointments. Our audit indicated that the district had not inspected the vehicles to ensure that they met USMS security specifications.
  • The district did not retain documentation demonstrating that the contract guard personnel met USMS standards.
  • Contract personnel were not provided the training required by USMS policies.
  • The contractor was in Chapter 11 bankruptcy at the time of our review, but had not notified the district office of its financial condition.
  • USMS guard identification badges were not being returned to the USMS after contractor employees separated from the contractor.
  • The district did not perform periodic formal written evaluations of the guard contractor. Contractor officials stated that they have never been reviewed by the USMS.


Overall, contract guard management at the district offices was characterized by a lack of documentation and verification stemming from an absence of strong oversight on the part of the district COTRs. District offices were not verifying whether guard companies were providing hospital guards that met USMS personnel requirements. These lapses in oversight increase the risk of hiring unqualified or incompetent guards, which could ultimately result in incidents of escape and injury or death to an innocent bystander, law enforcement official, or the prisoner.


We recommend the USMS:

  1. Ensure that guard contracts are effectively monitored by:

    1. requiring that the COTR submit comprehensive guard contractor evaluations every six months. These evaluations should be thorough and should require documentation that supports the determinations and findings of the COTR.

    1. requiring that the COTR submit to the contracting officer, along with the contractor evaluation, a list of the district's active contract guards. This list should include identifying information, prior experience, and training.

    1. requiring that COTR evaluation elements be included in the personnel ratings of USMS employees assigned as COTRs.

  1. The USMS procures contract guards through one of two means: 1) contract guard companies, or 2) personal service contracts. In contrast to formal guard company contracts, which involve competitive bidding and generally run for five years, personal service contracts, as the name denotes, are contracts with individuals and bear more of a resemblance to a temporary worker than a contract employee. For the most part, these involve off-duty or former law enforcement officers whose duties include guarding prisoners in USMS holding cells and transporting prisoners in need of medical treatment to and from hospital facilities.
  2. USMS policy states that active sworn law enforcement officers are exempt from USMS firearms qualifications if they certify in the affirmation of work qualifications for contract guards that they are currently qualified and authorized to carry their duty firearm. In addition, they must have been qualified by their agency within the past 12 months and must re-qualify at least annually thereafter.
  3. Signed document listing the guard's qualifications including experience, training, background and fitness for duty.
  4. Two districts did not utilize contract guards (personal or company).
  5. "None" indicates the auditors found no documentation in the files related to guard training.
  6. "Yes" indicates that the district had documentation indicating that the guards had received the required training.
  7. "N/A" indicates the district did not use that type of contract guard.
  8. "Partial" indicates the district had some documentation indicating guard training but the files were incomplete.
  9. Contracting officers may appoint individuals selected by the district office to act as authorized representatives in the monitoring and administration of a contract. Such officials are designated in the contract as the COTR.
  10. COTRs must attend and successfully complete a 16-hour basic COTR course and obtain a minimum of 3 hours training specifically in procurement ethics. Once the COTR signs a certification for procurement officials required by the Procurement Integrity Act, the contracting officer designates in writing that the COTR can act as an authorized representative to monitor contract performance and deliveries in accordance with the contract requirements and certify satisfactory delivery of supplies or services before contractor invoices are paid.
  11. When we informed the USMS of the overpayments, district officials stated that because the USMS had other contracts with Magic Security there would be a financial audit of all their contracts.