Three children died in U.S. Customs and Border Protection’s custody in fiscal year 2019, prompting questions about medical care in the agency’s southwest border facilities.
CBP developed health screening policies and received emergency funds to enhance detainees’ medical care. But CBP hasn’t consistently overseen these policies, so some children were not given health screenings as intended. Further, CBP violated appropriations law by using some of these funds for items such as its canine program. CBP also lacks reliable data on deaths and didn’t report this data to Congress as directed.
We made 10 recommendations to address these issues.
Medical Provider Office at a U.S. Customs and Border Protection Facility
What GAO Found
As of May 2020, U.S. Customs and Border Protection (CBP) within the Department of Homeland Security (DHS) had obligated nearly $87 million of the approximately $112 million it received specifically for consumables and medical care in a 2019 emergency supplemental appropriations act. CBP obligated some of these funds for consumable goods and services, like food and hygiene products, as well as medical care goods and services such as defibrillators, masks, and gloves. However, CBP obligated some of these funds for other purposes in violation of appropriations law. For example, CBP obligated some of these funds for goods and services for its canine program; equipment for facility operations like printers and speakers; transportation items that did not have a primary purpose of medical care like motorcycles and dirt bikes; and facility upgrades and services like sewer system upgrades.
GAO identified two factors that contributed to CBP's violations—insufficient guidance to CBP offices and components before obligations were made, and a lack of oversight roles and responsibilities for reviewing obligations once made.
- After the 2019 emergency supplemental was enacted, CBP did not provide sufficient guidance explaining how offices and components could obligate funds for consumables and medical care and, as a result, some offices and components may not have understood that there were limitations on how they could use those funds. For example, officials from one CBP component stated they believed they could use the consumables and medical care funds for any goods or services they considered to be in the interest of individuals in custody or that would help ensure the efficient processing of individuals.
- Once obligations were made, CBP did not provide oversight across its offices and components, such as by reviewing obligations, to ensure the obligations were consistent with the purpose of the funds.
Until CBP develops and implements additional guidance, and establishes oversight roles and responsibilities, the agency does not have assurance that the remainder of funds appropriated for consumables and medical care—about $25 million as of May 2020—will be obligated consistent with the purpose of the funds.
CBP took various steps to enhance medical care and services for individuals in its custody, including, among other things, increasing its use of contracted medical providers (see figure on the next page), issuing new health screening policies, and requesting the Centers for Disease Control and Prevention assess conditions and make recommendations for the reduction of influenza in its facilities. In particular, in January 2019 CBP issued an interim directive which, among other things, required health interviews and medical assessments for certain individuals in its custody. CBP updated this directive in December 2019 and issued corresponding implementation plans in March 2020.
Contracted Medical Provider Office at a U.S. Customs and Border Protection Facility
GAO identified gaps related to CBPs implementation and oversight of its medical care efforts. For example:
- CBP has not consistently implemented enhanced medical care policies and procedures at southwest border facilities. Through facility visits and analysis of data, GAO found that some locations were not consistently conducting health interviews and medical assessments, as required by the medical directives. Further, while CBP's implementation plans call for oversight of medical efforts, such as metrics to assess compliance, the plans do not include some elements necessary for effective oversight, such as performance targets and roles and responsibilities for corrective actions. Until CBP develops and implements oversight mechanisms that include targets, roles, and responsibilities, the agency is not well-positioned to ensure consistent implementation of medical efforts.
- CBP decided not to implement a recommendation from the Centers for Disease Control and Prevention to offer influenza vaccines to individuals in custody, but did not document how it arrived at this decision. CBP officials stated that vaccinating apprehended individuals for influenza would pose operational, medical, legal, and logistical challenges. CBP officials stated they made this decision in consultation with others in the Department of Homeland Security, and this group continues to meet on public health issues, and will use such meetings to reassess whether to offer influenza vaccines. Documenting what information it uses in reassessing this decision, such as how it weighs the costs and benefits, would help provide CBP, Congress, and the public assurance that the agency has taken all relevant factors into account.
CBP does not have reliable information on deaths, serious injuries, and suicide attempts and has not consistently reported deaths of individuals in custody to Congress. CBP officials attributed this to several reasons, including that CBP's directive on significant incident reporting does not include a definition of suicide attempts and its automated reporting system does not have categories specific to serious injuries or suicide attempts. Instead, these incidents are classified together with less serious incidents and included as general “injuries or illnesses” in reports to senior leadership. Without additional field guidance and updates to its reporting system, CBP will continue to lack reliable information on the number of incidents that occur in its custody. Further, from fiscal year 2014 through fiscal year 2019, CBP was directed to report on deaths of individuals in its custody to Congress. GAO's review of CBP documentation and reports to Congress showed that 31 individuals died in custody along the southwest border from fiscal years 2014 through 2019, but CBP documented only 20 deaths in its reports. Ensuring that deaths in custody are reported to Congress and documented appropriately would help CBP improve transparency with Congress.
Why GAO Did This Study
Three children died in CBP custody between December 2018 and May 2019, prompting questions about CBP's medical care for those in its custody. In July 2019, an emergency supplemental appropriations act was enacted, providing additional funds to CBP, including funds for consumables and medical care.
GAO was asked to review CBP's medical efforts for individuals in its custody along the southwest border. This report examines (1) the extent to which CBP obligated and oversaw funds for consumables and medical care, (2) steps CBP took to enhance medical care, (3) the extent to which CBP implemented and oversaw its medical care efforts, and (4) the extent to which CBP has reliable information on, and reported, deaths, serious injuries, and suicide attempts of individuals in custody.
To conduct this audit GAO reviewed CBP documentation, including financial reports; directives, policies, and training related to screening individuals for medical issues; and directives and policy documentation on reporting deaths in custody. GAO interviewed CBP officials in headquarters and two field locations, and observed medical efforts in facilities in field locations, selected on the basis of volume of apprehensions.
GAO is making 10 recommendations to CBP, including to:
- develop and implement additional guidance for ensuring supplemental funds are obligated consistent with their purposes;
- establish oversight roles and responsibilities to ensure supplemental funds are obligated consistent with their purposes;
- develop and implement oversight mechanisms for CBP's policies and procedures relating to medical care for individuals in its custody, to include performance targets and roles and responsibilities for taking corrective action, among other things;
- document what information it is using to assess whether to offer the influenza vaccine to individuals in custody;
- provide additional guidance to field personnel to ensure they classify reports on deaths, serious injuries, and suicide attempts in accordance with CBP policy;
- update its internal reporting system to include categories on serious injuries and suicide attempts; and
- ensure reliable information on deaths in custody is reported to Congress and appropriate documentation on such reporting is maintained.
DHS concurred with all 10 recommendations.
Recommendations for Executive Action
|United States Customs and Border Protection||1. The Commissioner of CBP should develop and implement additional guidance for ensuring funds appropriated for specific purposes are obligated consistent with the purpose of the funds. (Recommendation 1)|
|United States Customs and Border Protection||2. The Commissioner of CBP should establish and document oversight roles and responsibilities to ensure funds appropriated for specific purposes are obligated consistent with the purpose of the funds. (Recommendation 2)|
|United States Customs and Border Protection||3. The Commissioner of CBP should develop and implement oversight mechanisms for CBP's implementation of policies and procedures relating to medical care for individuals in its custody to include documentation of expected practices, metrics and corresponding performance targets, and roles and responsibilities for taking corrective action. (Recommendation 3)|
|United States Customs and Border Protection||4. The Commissioner of CBP should document what information it is using to assess whether to offer the influenza vaccine to individuals in custody, including how it weighs costs and benefits. (Recommendation 4)|
|United States Customs and Border Protection||5. The Commissioner of CBP should develop and implement training on recognizing medical distress in children for all CBP officers and Border Patrol agents who may come into contact with children in custody. (Recommendation 5)|
|United States Customs and Border Protection||6. The Commissioner of CBP should ensure that contracting officers for its medical services blanket purchase agreement perform and properly document annual reviews, as required by FAR. (Recommendation 6)|
|United States Customs and Border Protection||7. The Commissioner of CBP should provide additional guidance to field personnel to ensure they classify significant incident reports on deaths, serious injuries, and suicide attempts, in accordance with CBP policy. (Recommendation 7)|
|United States Customs and Border Protection||8. The Commissioner of CBP should update the Significant Incident Reporting System to include categories that align with CBP's directive on the reporting of significant incidents. (Recommendation 8)|
|United States Customs and Border Protection||9. The Commissioner of CBP should provide additional guidance to components on the procedures for reporting deaths in custody to OPR and other entities within CBP. (Recommendation 9)|
|United States Customs and Border Protection||10. The Commissioner of CBP should ensure that timely, reliable information on deaths in custody is reported to Congress, as directed, and maintain documentation on those reports. (Recommendation 10)|