Mental Health:

Federal Procedures to Oversee Protection and Advocacy Programs Could Be Further Improved

GAO-18-450: Published: May 24, 2018. Publicly Released: May 24, 2018.

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Individuals with mental illness are a vulnerable population. To investigate potential abuse or neglect, the Department of Health and Human Services provides grants for state-based Protection and Advocacy for Individuals with Mental Illness programs. In 2016, it gave $36 million to 57 programs.

We found that the programs reported a range of positive outcomes, including a high percentage of cases resolved in the individual's favor.

We also identified needed improvements to HHS's oversight procedures, including a need to track long-term performance changes and be more timely in completing program reviews, and recommended HHS address these gaps.

 

Photograph of hands.

Photograph of hands.

Multimedia:

Additional Materials:

Contact:

Katherine Iritani
(202) 512-7114
iritanik@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

What GAO Found

The eight selected state Protection and Advocacy for Individuals with Mental Illness (PAIMI) programs GAO reviewed reported a range of positive outcomes from their work on behalf of individuals with mental illness. For example, in fiscal year (FY) 2016, the selected programs reported resolving in the individual's favor 1,772 out of 2,390 cases (74 percent) related to complaints of alleged abuse, neglect, and rights violations. The remaining cases were reported as withdrawn by the client, closed due to lack of merit, or not resolved in the individual's favor. These programs also reported concluding a variety of broader, system-level activities—referred to as systemic activities—intended to benefit groups of individuals with mental illness. These systemic activities resulted in, for example, changes to procedures in mental health institutions and correctional facilities.

Selected Outcomes Reported by Eight Protection and Advocacy for Individuals with Mental Illness Programs, Fiscal Year 2016

Type of activity

Outcome

Individual cases  

Closed in favor of individual

   Rights violations

1,122

   Neglect

341

   Abuse

309

Total

1,772

Systemic activities

Concluded successfully

   Facility monitoring

263

   Investigations

46

   Group advocacy (non-litigation)

29

   Other

29

Total

367

Source: GAO analysis of 2016 Substance Abuse and Mental Health Services Administration data. | GAO-18-450

The Substance Abuse and Mental Health Services Administration (SAMHSA), which oversees the state PAIMI programs, has a variety of procedures in place to monitor performance and compliance. However, two areas warrant additional attention, as follows:

SAMHSA has not consistently examined changes to performance benchmarks—the goals, objectives, and targets that PAIMI programs set annually for their planned work. Programs are permitted to modify these benchmarks, and GAO found that four had done so. A new SAMHSA system implemented in 2017 could improve recording of benchmark changes, but SAMHSA lacks procedures to examine changes across years, which could help identify performance concerns.

SAMHSA often failed to complete its periodic, in-depth reviews of programs and to provide findings of identified deficiencies to PAIMI programs on a timely basis. SAMHSA has plans to improve the efficiency of its review process. However, it is unclear the extent to which these plans will resolve the timeliness issues, which could delay resolution of any issues found in the reviews.

Why GAO Did This Study

PAIMI grant awards, established by Congress in 1986 and totaling $36 million in 2016, are administered by SAMHSA to support state protection and advocacy programs. PAIMI programs protect and advocate for the rights of individuals with significant mental illness by investigating reports of incidents of abuse and neglect of such individuals in facilities such as hospitals, and in the community, among other activities.

The 21st Century Cures Act included a provision for GAO to review the PAIMI programs and their compliance with federal statutory and regulatory requirements. This report examines (1) the outcomes reported by PAIMI programs in selected states, and (2) SAMHSA's oversight of state PAIMI programs, including their compliance with federal requirements. GAO reviewed FY 2015 and 2016 PAIMI program documentation for eight of 57 programs selected for variation in funding amount, geographic location, and other factors. GAO also reviewed relevant SAMHSA policies and procedures and assessed them against federal standards for internal control.

What GAO Recommends

GAO recommends that SAMHSA take steps to ensure that changes to performance benchmarks are examined over time, and to ensure onsite reviews are completed—and findings are provided to state programs—in a timely manner. The Department of Health and Human Services concurred with GAO's recommendations.

For more information, contact Katherine Iritani at (202) 512-7114 or iritanik@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: As of October 2019, HHS reported that the Substance Abuse and Mental Health Services Administration (SAMHSA) would add new additional features to its web-based system for overseeing the mental health protection and advocacy programs, with an implementation target date of October 2020. The agency described one new feature as a tracking tool to monitor program requests to revise priority goals, objectives, and targets over multiple years. In the meantime, SAMHSA has developed a manual tracking tool for its project officers to use until the electronic tool is in place. Another new feature is a workflow that will allow project officers, team leaders, and branch chiefs to review and approve changes made by the programs. However, SAMHSA has not yet provided documentation of the latter feature to demonstrate that it has developed procedures for project officers to review the changes over multiple years. Therefore, the agency lacks assurances that its project officers will consistently examine whether a particular program is regularly making changes to benchmarks that may be indicative of a potential performance problem. We will review the web-based tracking tool when available and continue to monitor SAMHSA's efforts to develop procedures for examining changes to benchmarks over multiple years.

    Recommendation: The Assistant Secretary for Mental Health and Substance Use should establish procedures to better ensure that mid-performance changes to program priority goals, objectives, and targets are examined across multiple years. (Recommendation 1)

    Agency Affected: Department of Health and Human Services: Public Health Service: Substance Abuse and Mental Health Services Administration

  2. Status: Closed - Implemented

    Comments: In July 2018, HHS reported that the Substance Abuse and Mental Health Services Administration (SAMHSA) had instituted a new process requiring onsite performance monitoring findings be delivered within 90 days of the site visit, with the fiscal portion of the report following. The agency also reiterated that SAMHSA has streamlined its report. In June 2019, HHS indicated that SAMHSA continues to monitor these new procedures and they will be monitored to ensure timely submissions. In October 2019, SAMHSA provided documentation that onsite monitoring findings were reported back to programs visited during fiscal year 2019 within the 90-day timeframe.

    Recommendation: The Assistant Secretary for Mental Health and Substance Use should take steps, including the steps it has planned, to ensure onsite reviews are completed and findings are provided to programs on a timely basis. (Recommendation 2)

    Agency Affected: Department of Health and Human Services: Public Health Service: Substance Abuse and Mental Health Services Administration

 

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