The United States Marshals Service (USMS) is responsible for providing medical care to the roughly 40,000 prisoners it has in its custody at any given time. Federal prisoners in USMS custody are housed in local jails, contract facilities, and the Federal Bureau of Prisons (BOP) facilities throughout the country while awaiting trial in federal courts. These prisoners remain in USMS custody throughout the trial process, which may run anywhere from several days to several years.

Medical care provided to USMS prisoners falls under one of two categories: 1) in-house medical care, or 2) outside medical care. In-house medical care encompasses health care provided at local jail clinics, and in some instances emergency care provided in USMS cellblock operations. Outside medical care comes into play when a prisoner in USMS custody requires advanced or specialized medical care and must be sent to an outside health care facility. In fiscal year (FY) 2002, the USMS spent approximately $43 million on outside medical services for its prisoners, which included $36 million for medical services and $7 million in related guard costs. In addition to the costs of providing outside medical care, there are associated risks, which include the possibility of: 1) escape; 2) death or injury to an innocent bystander, law enforcement official, or the prisoner; and 3) exposure of the general public to possibly infectious diseases.

The objectives of this audit were to determine whether: 1) the USMS is providing prisoners necessary health care; 2) the USMS is screening and treating prisoners for communicable diseases; 3) prisoner medical costs are necessary and reasonable; and 4) the USMS is providing prisoners secure transport to off-site facilities to receive medical treatment.

The audit's scope encompassed the USMS's management of prisoner medical care during period FY 2000 through FY 2003. Our primary focus was on management of prisoner medical care activities by USMS district offices. In conducting the audit we: 1) researched and reviewed applicable laws, policies, regulations, manuals, and memoranda; 2) interviewed USMS officials at district offices and USMS headquarters; and 3) tested internal controls over prisoner medical care at 14 USMS district offices.¹

To assess USMS efforts at controlling the spread of tuberculosis (TB) among inmates, we interviewed USMS employees manning the cellblock areas to determine whether they were familiar with the symptoms of TB. We also reviewed files of prisoners in USMS custody during our site visits and determined whether TB skin tests were timely completed and documented. In addition, we reviewed USMS efforts to address the control of HIV/AIDS and hepatitis.

In order to determine whether USMS medical procedures were necessary, accurately recorded, and supported by documentation, we tested a statistical sample of outside medical transactions reported in FY 2002 (See Appendix XI). We also interviewed district officials and reviewed randomly selected medical bills to establish if outside medical services were being procured in accordance with federal acquisition regulations.

We judgmentally selected and reviewed the personnel files for contract hospital guards to determine whether the hospital guards utilized by the USMS met the qualification standards for job experience, background, physical fitness, and training. Guards that do not meet these requirements may not perform their job properly and could endanger the lives of the prisoner, themselves, and the general public.

In addition, we interviewed the Contracting Officer's Technical Representative (COTR) for each district's hospital guard contract to determine whether the COTRs were qualified for their position and to determine if they were effectively monitoring the contractor's performance.

Finally, we reviewed USMS jail inspection reports and interviewed jail inspectors to evaluate USMS efforts to ensure that federal prisoners receive adequate health care at the hundreds of detention facilities contracted by the USMS to house federal prisoners awaiting trial.

I. Summary of Audit Findings

The USMS is not properly managing its prisoner medical care. Our audit determined that USMS district offices often ignore essential internal controls and procedures designed to ensure that basic and emergency health care is properly administered and necessary outside medical care is efficiently and safely provided. We also found that by failing to fully comply with statutory cost saving measures, the USMS is paying out millions more than necessary for prisoner medical care on an annual basis. Specifically, the audit determined that:

• USMS districts are not adequately tracking and monitoring communicable diseases, such as TB, hepatitis, and HIV/AIDS.

• The USMS is not obtaining the lowest medical rates allowed by federal legislation, and as a result is paying out an estimated $7 million annually in excess fees for outside medical care.

• USMS districts are not maintaining personnel documentation or providing training needed to ensure that contract hospital guards are fully qualified to perform their duties.

• USMS districts are not properly reviewing the performance and billings of hospital guard contractors.

• USMS districts are not providing adequate emergency response to prisoners housed in their cellblocks. Uncertainty exists at the district level as to what the current policies are governing health and emergency care in cellblocks.

• USMS districts are not taking the necessary actions needed to ensure that federal prisoners housed in local detention facilities are receiving standard basic health care. ²

• USMS districts are not following financial control procedures established to ensure that outside medical payments are: 1) valid and legitimate, 2) necessary according to USMS guidelines, 3) accurate and at the lowest cost, and 4) not duplicated.

• USMS districts are obtaining outside medical services in violation of Federal Acquisition Regulations.

II. Background

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. While awaiting either a court appearance or transport to a federal Bureau of Prisons (BOP) or local jail facility where medical screening will take place, the arrestees are kept in the cellblock. The term "cellblock" refers to a secure area in the USMS office intended to temporarily house prisoners awaiting court proceedings or transport.

Given the short span of time that prisoners usually spend in the cellblock area, medical care is normally not required. 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 jails, contract jails, and BOP facilities, 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 rates charged to the USMS under the terms of an Intergovernmental Service Agreement (IGA),³ in the case of a local jail, or the contracted jail day rate, in the case of a private contract facility. Medical services provided to USMS prisoners in BOP facilities are provided 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, equipped with 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 the facility for procedures that are routinely performed at jails with more comprehensive medical services.

III. Management of Outside Medical Care

The USMS is incurring millions of dollars in unnecessary costs for outside medical care because it is not re-pricing medical billings at the lowest rate afforded by federal legislation. The USMS currently has a contract with Healthnet, Inc., to re-price all outside medical billings at the Medicare rate. The re-pricing of medical bills from the vendor's full price at the Medicare rate saved the agency approximately $20.2 million in its first full year of implementation. However, effective November 29, 1999, Public Law 106-113, which amended Title 18 USC Section 4006, requires the USMS to pay prisoner medical claims at the Medicare or Medicaid rates, whichever is less. Based on a recent study that showed that Medicaid rates averaged 81 percent of Medicare rates, we estimated that the USMS spent about $7 million more on outside medical services in FY 2002 than necessary. The USMS is currently negotiating for a national health care contract that, if fully implemented, will incorporate Medicaid rates into the re-pricing process.

Internal controls over outside medical care at the USMS district offices reviewed were inconsistent and in some cases non-existent. We noted weaknesses in the internal control structure throughout the process, from procurement through payment. Districts were not reconciling invoices with pre-authorizations, in some cases because there were no pre-authorizations with which to reconcile. In tests of procedures, at least 3 percent of medical procedures were determined to be unnecessary. In most instances the unnecessary procedures resulted because districts were not proactively involved in the pre-authorization process, allowing the BOP or local detention facility to dictate whether outside medical treatment was required without notifying the USMS.⁴ Often the district office was unaware of the medical treatment or hospitalization until a bill was received.

USMS prisoner case files were not complete with regard to required medical documentation, and in some districts were non-existent. Medical procedures were not consistently entered into the Prisoner Tracking System (PTS). Financial transactions were not classified consistently in the Financial Management System (FMS). Violations of the Federal Acquisition Regulations were commonplace. Based on our audit testing we determined that 84 of the 164 payment transactions that exceeded $2,500 were not in full compliance with federal procurement regulations because the medical service providers did not have binding written agreements with the USMS.

IV. In-House Medical Care

We found that USMS districts were not adequately monitoring local detention facilities to determine whether federal prisoners were receiving proper health care. In addition, USMS districts were not effectively initiating health care improvements at local jails that provided substandard health care. USMS inspections were cursory and often were not forwarded to headquarters, as required. The inspection reports annually submitted to district officials did not provide enough detailed information, such as observations, interviews, documents reviewed, to support general findings that the health care provided by the jail met 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. In addition, jail inspector duty for deputy marshals is collateral to their normal law enforcement responsibilities. The auditors noted that 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.

Further, inspections by the USMS conflicted with reviews conducted by other groups. In one instance, we noted that USMS district officials had performed an inspection and issued a clean report on a contract facility at the same time that the Department's Civil Division was issuing its own report detailing numerous constitutional rights violations, many related to medical care.

V. Communicable Diseases

USMS tracking and monitoring of communicable diseases, such as TB, hepatitis, and HIV/AIDS, was not consistent from district to district, and in some districts was not done at all. Current USMS policy concerning communicable diseases addresses TB only. However, we found little evidence that districts were acting in accordance with that policy. Many districts were not performing initial intake screening of prisoners for TB, and many did not maintain information on prisoners' TB status. In general, USMS districts rely on local jails to test and monitor TB status. This is problematic because local jails do not always test for TB and are not always timely when they do test.

We found documentation on prisoners' TB status almost non-existent. The USM Form-553, used to document TB clearance, was either entirely missing from case files, if there were case files, or the form did not contain TB results. Documentation in the PTS was also sparse to non-existent. Only 2 of the 14 districts reviewed were utilizing the PTS, and these districts were doing so only partially. One of those districts had entered only 9 of the 25 inmates selected into the PTS, and the other had entered only one prisoner out of the 25 selected.

We asked each of the districts reviewed to provide us a list of prisoners currently in USMS custody who had been diagnosed with active TB. Of the 14 districts, 6 districts could not provide a list of prisoners with active TB, 3 districts were able to provide a list, and 5 of the districts stated that they had not processed any prisoners with active TB during the review period. However, we later determined that one of the districts claiming not to have processed any prisoners with active TB had paid for treatment of active TB for a USMS prisoner in FY 2002. This lack of awareness was not totally unexpected, given the scarcity of TB-related information in the prisoner files and the PTS. It is, nevertheless, a cause for concern given that prisoners who are suspected of or have been diagnosed with active TB are not to be produced for court or transported (other than to an appropriate local medical facility) by USMS personnel until the prisoner has received the appropriate medical care and is medically cleared by a health professional.

In one incident, a prisoner was released on bond prior to his TB test results being received. Subsequent receipt of the prisoner's chest x-ray results confirmed that he had active TB. In another incident, a deputy marshal was unknowingly exposed to TB when he had escorted a prisoner that, unbeknownst to him, had been diagnosed with active TB. According to the deputy, he was not advised of the prisoner's condition until after he had transported the prisoner. The deputy later tested positive for TB and had to be treated.

No formal USMS policies currently exist at the national level for tracking and monitoring cases of hepatitis and HIV/AIDS. We found that district offices, for the most part, had not taken any steps to fill the policy vacuum at the national level regarding hepatitis and HIV/AIDS. When asked, district officials stated that there were no local policies or that they were not aware of them if there were. Not surprisingly, there was little consistency from district to district in the handling of hepatitis and HIV/AIDS cases. Seven of the districts were documenting the health status for HIV/AIDS and hepatitis for prisoners on USMS forms, six of which entered information into the PTS.

VI. Prisoners are Transported and Guarded by Contract Personnel

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. Contract guards were used in 12 of the 14 districts we reviewed.

Management of contract guard operations relative to prisoner medical care was characterized by inadequate training, breaches in policy, and lapses in internal controls. The problems occurred 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 in transporting federal prisoners to and from off-site health care facilities.

We found that districts were not keeping complete personnel files documenting the guards' experience and other qualifications. Furthermore, several districts reviewed by the audit team did not require that these individuals complete any of the USMS's required training courses.

The USMS is not placing a high priority on monitoring and evaluating the performance of their hospital guard contracts. The U.S. Marshal usually assigns deputies collateral duty as COTR. The COTR is the on-site contract administrator and is responsible for monitoring the contract to ensure that contract performance requirements are being met. We interviewed COTRs to evaluate their knowledge of contractor performance and found that many COTRs lacked a proper knowledge of the hospital guard contract they were managing. We further ascertained that most COTRs had not submitted formal evaluations of the contract to district management.

We noted at least one instance where a guard's failure to follow standard procedure allowed a prisoner 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.

As a result, 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 together, open the hospital room window and lower himself to the ground to make his escape. Following his escape, the prisoner hijacked a woman driving her car. He was subsequently apprehended and later died in custody from advanced TB.

VII. Office of Program Review

The internal review function within the USMS falls under the jurisdiction of the Management and Budget Division, specifically the Office of Program Review. On April 19, 2000, the USMS Deputy Director issued a memorandum directing the Program Review Office to suspend its reviews of USMS district operations. Historically, this had been Program Review's primary area of responsibility, with staff completing about 30 reviews annually. The reviews are comprehensive in scope and cover nearly all aspects of district operations, including activities related to prisoner medical care, such as: 1) prisoner transport, 2) contract and IGA billings, and 3) judicial security. The inspection reports, signed by the USMS Director, contain findings and recommendations, and require a formal resolution process, documenting that necessary corrective actions were taken. The district reviews were initially suspended as a short-term measure to deal with staffing shortages in the field, which required that Program Review staff be detailed to district offices in need of administrative support. However, as of the last day of our fieldwork on October 28, 2003, district review activity remained on hold. According to USMS officials, the reason for the continued suspension is that the USMS plans to reorganize its internal review function will remain on hold pending completion of the reorganization.

In the three years since the suspension of these district reviews, the Office has existed in a state of limbo. The staff is now restricted to performing property management reviews, and does so only on a special request basis. Staffing levels at the Eastern office have been reduced from six to two analysts. The staff assigned to the Western office in Denver, Colorado has been reduced from six analysts to four, the remainder of which has been detailed to the Witness Security Program. The Central office in Houston, Texas has been closed.

VIII. OIG Recommendations

Our report contains 12 recommendations to help improve USMS efforts to manage prisoner medical care. These include recommending that the USMS:

• Effectively track and monitor USMS prisoners diagnosed with active TB.

• Implement a policy for tracking and monitoring of HIV/AIDS and hepatitis cases.

• Strengthen the jail inspection program.

• Ensure that deputy marshals are in compliance with cellblock health care policy and that they receive annual Cardio Pulmonary Resuscitation (CPR) and Automated Electronic Defibrillator (AED) training in order to maintain certification.

• Complete on-going effort to negotiate a national managed health care contract for prisoner medical services that remedy non-compliance with Title 18 USC and will effectively streamline the process.

• Enforce current USMS policy regarding the use of prisoners' private insurance, where practicable, to cover the costs of outside medical care.

• Ensure that guard contracts are effectively monitored.

• Ensure that districts adhere to established procedures for authorizing, recording and tracking outside medical procedures.

• Re-institute internal operational reviews of USMS district offices.

1. The 14 USMS districts were: District of Arizona, Central District of California, Southern District of California, District of Columbia District Court, Middle District of Florida, Northern District of Illinois, District of Kansas, District of New Mexico, Eastern District of New York, Western District of New York, Eastern District of Pennsylvania, District of South Carolina, Western District of Texas, and Southern District of Texas.
2. American Correctional Association (ACA) has established criteria defining standard basic prisoner health care.
3. The Intergovernmental Agreement states that a negotiated daily rate per prisoner will be paid by the USMS to the jail.
4. District officials stated that the BOP often does not request or seek authorization from the USMS when obtaining outside medical treatment for federal prisoners in USMS custody.