When originally established under the PAIMI Act, state PAIMI  programs were required to investigate reports of potential abuse and  neglect of individuals with significant mental illness residing in institutional  facilities and to protect and advocate the rights of these individuals. They may  also conduct broader system-level protection and advocacy activities,  such as facility monitoring, intended to benefit larger groups of individuals  with significant mental illness. These systemic activities, as we refer to  them in this report, include efforts to drive changes in policies and  practices of the state’s mental health agency, treatment facilities, and  other systems, such as school systems, that impact people with  significant mental illness. SAMHSA has procedures for the scope and  time frame of the reviews. Selected State PAIMI Programs Reported Achievements in Ending and Preventing Abuse, Neglect, and Rights Violations of Those with Significant Mental Illness

The eight selected state PAIMI programs reported favorably resolving a  majority of individuals’ cases related to alleged abuse, neglect, or rights  violations. In addition, these selected programs reported concluding a  variety of systemic activities, with a significant focus on monitoring and  addressing issues of abuse or neglect at facilities. The remaining 26 percent of  cases were reported as withdrawn by the client, closed due to lack of  merit, or were not resolved in the individual’s favor. 1). SAMHSA Has Controls in Place to Oversee Program Compliance with PAIMI Requirements, but Oversight of Program Effectiveness Is More Limited

		SAMHSA Has Controls in Place to Monitor Compliance with Program Requirements

SAMHSA has controls in place for monitoring the PAIMI programs’  compliance with statutory and regulatory requirements through its  ongoing and periodic in-depth monitoring activities. In our review of fiscal year 2015 and 2016 documentation, we found  evidence that the application and performance report review process  helped identify and resolve a range of potential compliance issues. As a result, SAMHSA also placed the Puerto  Rico PAIMI program in restricted status. SAMHSA Has Not Consistently Examined Changes to Program Benchmarks or Completed and Provided Onsite Review Findings in a Timely Manner

We identified two weaknesses that could be limiting SAMHSA’s oversight  of program effectiveness. Inconsistent Recording of Changes to Performance Benchmarks and Lack of Procedures for Examining Changes across Years

We found that SAMHSA did not always record changes programs made  to their performance benchmarks and did not have procedures for  examining benchmark changes over time. However, these changes were not recorded by SAMHSA  reviewers in the review checklists. Although SAMHSA has plans to make reviews  more efficient and to add resources, it is unclear to what extent these  steps will resolve the lack of timeliness. Recommendations for Executive Action

We are making the following two recommendations to SAMHSA:  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)
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. Appendix I: Protection and Advocacy for Individuals with Mental Illness (PAIMI) Grants by Program, Fiscal Year 2016

Appendix II: Selected State PAIMI Program Priority Goal Categories in Fiscal Year 2016

State Protection and Advocacy for Individuals with Mental Illness (PAIMI)  programs determine their priority goals each fiscal year to prioritize the  work they hope to accomplish.
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 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.
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.

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.