Documentation Fraud in the BOP

The OIG released a scathing report against the BOP for their negligence in addressing deaths from causes like suicides and murders among inmates. The focus was on deaths, as it seems to be the primary metric for the Government to monitor: Deaths from overdoses, from errors, from suicides. But death is a funny thing. It’s not a simple outcome that can be traced through cause-and-effect. It’s a tragic ending that arises out of a complex mix of behaviors and systemic influences.

By focusing on deaths, we ignore all the facets of a system that lead to that outcome. As a result, we misplace our priorities. We focus on only the most egregious instances of error or some aberrantly atrocious misconduct. We don’t see the more common errors and mistakes that are far more pervasive in the BOP that, in aggregate, have an equally impactful influence on deaths, particularly fatal overdoses and suicides.

I would know. I was an inmate at a minimum security federal prison for nearly a year: eleven months, one week, and three days to be exact. I saw how inmates were treated at the health clinic. Particularly, I saw how negligent the mental health facilities were at that prison.

You wouldn’t know that based on my documentation: my papers as it’s called, to use prison jargon. Apparently, I was quite active in prison. I learned basic life resuscitation skills and developed techniques to support my post-incarceration return to society, including the successful completion of a course on addiction and substance dependency.

Funny thing is – I can’t recall doing any of that. It’s all fraudulent documentation. None of that happened.

A ghost writer is someone who pens a literary composition under another name. I’m not sure what to call this, but if I had to pick a term, I’d call it: ghost documentation.

It’s rampant throughout prison. Unfortunately, it’s practically the standard of care for prison healthcare. I’ve seen innumerable instances of inmates denied care unless they sign a waiver of liability. I’ve seen inmates receive medical records indicating they were noncompliant with clinical recommendations when in reality they were denied basic care for months.

Just ask any former inmate who spent a decent amount of time in prison. The documentation is flagrantly misleading, and creates a false impression of clinical oversight and continuity of care that just doesn’t exist.

When a physician writes a medical note, he or she is documenting the care provided. Ostensibly, it’s used to chronicle patient improvements over time. In prison, the documentation is designed to avoid legal liability. It’s a subtle difference, but it explains why the solutions proposed by the OIG, which the BOP has apparently agreed to and has begun to implement already – we’ll see – will prove feckless in the end.

Until we address the rampant ghost documentation, the overt instances of fraud, when the alleged care provided is transcribed in a way to avoid liability as opposed to actually heal the patient – and yes, inmates are patients – it doesn’t matter what initiatives are taken to reduce suicides or any other manner of death. This might appear shocking, but it’s obvious to anyone who has been incarcerated. The stories are innumerable. They’re prevalent. I’ve seen far too many to recollect, but the most overt instances are ingrained in my mind.

One inmate was working as a mechanic and had a tool fall on his elbow. He was denied surgical care until he signed a waiver of liability so he couldn’t sue the BOP. This meant he was lying in his cell, incapacitated, for nearly two days before he went to the emergency department and eventually saw a trauma surgeon.

Another inmate, a gay man, was mocked for claiming he was suicidal. For admitting he was experiencing a mental health crisis, he was placed in solitary confinement. And if that wasn’t enough, he was stripped naked – in case he had a weapon somehow concealed under his clothes – and given nothing more than a blanket to cover himself. He was kept like this for nearly two days until he asked to leave.

This isn’t mental health crisis treatment. It’s sanctioned humiliation. Suicidal ideations don’t go away by leaving a patient naked and alone. They’ll eventually reappear. But the documentation will likely state the inmate received acute care and close monitoring. He didn’t. He was stripped naked and left in a room to fester to the point of exhaustion.

After talking to that inmate about that experience, I know for certain that the BOP officers focused more on ensuring he didn’t commit suicide rather than assessing the root causes of his emotions. Never mind why he’s suicidal, let’s just make sure he doesn’t commit suicide on my watch.

This is the problem with the recommendations proposed by the OIG. It’s just protocols and documentation. It doesn’t address the key issue, which is the point of interaction between the on-the-ground correctional officer and the inmate. To understand this, you have to know a bit about the prison culture of correctional officers.

It’s a two tier caste system. The lower tier, the foot soldiers, are the correctional officers who patrol the prison wards and interact most closely with the inmates. They’re typically poorly educated, local to the area, and former military personnel who landed in the BOP through their military and regional connections. The higher level guards, the ones who become wardens, assistant wardens, and other administrative bureaucrats, transmigrated from urban regions or more centralized administrative hubs of the BOP. They’re out in the boondocks of federal prison to do a few years of field work before they receive another promotion and relocate back to Washington, DC or find work at a government contracting facility somewhere in Virginia.

The latter types are the ones who draft these reports. They’re disconnected from the day to day lives of inmates. To know what’s really going on, you have to ask the lower level correctional officers. But they won’t talk. They’ll just continue documenting whatever minimizes their legal liability, regardless of what actually transpired.

Let me give you the most glaring example of this disconnect. The report cites a major concern of contraband, such as knives and drugs. It mentions how contraband could be a potential risk factor for deaths. But it doesn’t acknowledge how contraband enters prisons. It’s all ushered in through the willful blind eye of the correctional officers patrolling the wards. Nothing gets in without their tacit approval. I’ve seen it. Clearly those who drafted the report haven’t spent a single night in federal prison. Why would they cite contraband as a risk factor for deaths but not discuss how it gets in? The report continues like this for nearly hundred pages: Words without meaning and action plans without any context of what prison is really like.

Let’s look closely at one of the recommendations to understand the vast emptiness this report.

Recommendation 1

Develop strategies to ensure that staff assigns accurate, consistent, and timely Mental Health Care Level designations to inmates.

Status: Resolved.

BOP Response: The BOP concurred with this recommendation and stated that it will continue to enhance current strategies to ensure that employees assign accurate, consistent, and timely MHCL designations to inmates. The BOP stated that it is already implementing several strategies to accomplish this important goal.

The BOP stated that institution Chief Psychologists should review documentation of subordinate psychologists, including documentation related to changes in MHCLs and that, during institution Care Coordination and Reentry Team meetings, professionals from multiple disciplines (e.g., Psychology Services, Health Services, Unit Team, Custody, Social Work) discuss numerous factors impacting inmate treatment, including the accuracy of MHCLs.

The recommendation cited above doesn’t delve into how those mental health determinations are made, just that they’ll be made and documented. But how those designations are made matters most of all. It’s empty pageantry disguised as a solution.

Correctional officers will simply document these reports in a way to minimize their work load and minimize the clinical requirements of the inmates. Nothing will truly improve. In fact, these recommendations will increase the documentation burden of correctional officers and, as a result, further the documentation divide between what is written and what actually happened. With increased legal liability comes increased misrepresentation.

Until we address the rampant documentation fraud that transpires in federal prisons, we won’t have any meaningful resolution.

There’s a simple solution to this. Allow for the direct engagement of inmates with mental health counselors or services without the oversight of the BOP. As it stands, all protocols and recommendations requires the input of BOP correctional officers. That’s the point at which the documentation fraud takes place. And from there, all other initiatives, no matter how well conceived, won’t work because the point of care, the most critical time for clinical intervention, has been rendered moot.

On Table 1, the report discusses the checks and balances required to properly document an inmate death. Yes, the preliminary cause of death has to be reported within 24 hours. That seems like a good thing. In fact, the BOP is smart to set up a system that disseminates reports within the internal chain of command and externally.

But the protocols state that the report has to be drafted by the on-site officer and makes no mentioning of input from the inmates themselves. This means the care coordination is wholly dependent on how a non-clinically trained correctional officer at the point of care perceives the situation.

It’s a shame because the protocol is quite robust. The warden has to acknowledge the cause of death within 30 days and any documentation has to be reviewed by an external clinical officer of the BOP within 90 days. That’s warp speed for prisons. But it’s not going to work because the protocol hinges on what the correctional officer documents.

That’s the moment that needs to be properly accounted for. Instead, everything is built on a system of documentation that begins afterwards. This is liability first medicine. It doesn’t work for patients in the larger world of healthcare, so why would it work for incarcerated patients?

The most this report will do is add another coating of documentation to a system already laden with documentation fraud. The new filings required because of this report will be nothing more than empty words posing as solutions to a problem we’re not actually solving. We’ll pretend we’re addressing inmate deaths, but the suicides, overdoses, and murders will continue. And then, years from now, we’ll question why our solutions aren’t working.

That’s because deaths aren’t the problem. The system of documentation fraud in the BOP is the issue.