Mental Health: Federal Procedures to Oversee Protection and Advocacy Programs Could Be Further Improved
Fast Facts
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.
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Highlights
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 The remaining cases were reported as withdrawn by the client, closed due to lack of merit, or not resolved in the individual's favor.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.
Recommendations
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.
Recommendations for Executive Action
| Agency Affected Sort descending | Recommendation | Status |
|---|---|---|
| Substance Abuse and Mental Health Services Administration | 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) |
Closed – Implemented
As of September 2020, 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 provided documentation of a workflow that will allow project officers, team leaders, and branch chiefs to review and approve mid-performance changes made by the programs to priority goals, objectives, and targets. In February 2021, SAMHSA officials confirmed the new features of the system were operational. The agency also provided documentation that it has developed procedures for project officers to review such changes over multiple years.
|
| Substance Abuse and Mental Health Services Administration | 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) |
Closed – Implemented
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.
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