Background Mental health disorders affect millions of adults and children in the United  States and can range in severity. In 2016, an estimated 4.2 percent of the  adult population—more than 10.4 million individuals—were considered to  have a serious mental illness based on federal survey data. Individuals  with mental illness may reside and receive care in a variety of settings,  including inpatient institutional settings, such as public or private  hospitals, other residential treatment facilities, or community-based  settings. 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.  Examples of institutional facilities covered under the PAIMI Act include  hospitals, nursing homes, and correctional facilities. In 2000, the PAIMI  Act was amended to allow certain PAIMI programs to also assist eligible  individuals who live in community settings, including their own homes,  although programs must still prioritize services for eligible individuals  residing in institutional settings. For example, state PAIMI programs  assist individuals with abuse, neglect, and rights violation cases in school  settings. Key State PAIMI Program  Requirements and  Activities State PAIMI programs are administered by either state agencies or non- profit organizations that have been designated by the governor of each  state to operate a protection and advocacy system. The state PAIMI  programs are allotted federal grants through a formula that is based  equally on (1) the population in each state, and (2) the population in each  state weighted by its relative per capita income. In 2016, state PAIMI  program grants ranged from $229,300 to $3,133,536. (See appendix I for  allotment by program.) To receive a PAIMI grant, each protection and  advocacy organization must submit an annual application, and the PAIMI  programs they operate must meet applicable statutory and regulatory  requirements. (See table 1.) Approved state PAIMI programs use their grants to protect and advocate  for individual clients, such as investigating specific complaints. 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. (See table 2.) Each state PAIMI program, with input from the advisory council and  governing authority, sets priority goals and short-term, measurable  objectives and targets annually as performance benchmarks for the work  it plans to conduct. Programs can also revise these benchmarks during  the year to align with changing needs. For example, the types of  individual cases programs accept and work on may depend on the types  of complaints that are received, which may vary over time. SAMHSA Oversight of  State PAIMI Programs SAMHSA administers the PAIMI grants and is responsible for oversight  and monitoring of the state PAIMI programs. To oversee the state  PAIMI programs, SAMHSA conducts both ongoing reviews of the annual  application and performance information submitted by the programs, and  periodic, in-depth reviews: Ongoing monitoring activities. PAIMI grant applications are  effective for 4-year periods, but programs submit additional grant  applications annually to update certain information, such as the  program budget and goals. SAMHSA awards PAIMI grants based on  criteria such as whether the grantee submitted a statement of annual  program priorities, including quantifiable targets and measurable  outcomes. In addition to the application, programs must submit key  data annually in a program performance report. The performance  report must describe a program’s individual and systemic activities,  accomplishments, and expenditures during the most recent fiscal year  and must include a section prepared by the advisory council. The  performance report requires programs to report on both standard  measures required of all programs and on progress towards the  program-specific priority goals, objectives, and targets. SAMHSA  reviews information submitted by the programs annually through  grants applications and performance reports, including completing a  review checklist and following up with programs with questions. Periodic monitoring. SAMHSA conducts four to five onsite  monitoring reviews of state PAIMI programs each year, which officials  told us means a given program would be reviewed approximately  every 10 years. Programs are reviewed on a rotating basis, but some  may be reviewed more frequently if concerns have been identified,  according to officials. The onsite monitoring process, which includes  an onsite visit and review of program documentation, is intended to  monitor program compliance and provide guidance on improving  program effectiveness. 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. Through their work with  individuals and completion of systemic activities, the selected programs  reported meeting a majority of their priority goals and objectives. Outcomes of Individual  Cases Selected programs reported favorably resolving about 74 percent of  individual cases related to alleged abuse, neglect, or rights violations in  fiscal year 2016, on average (see table 3). 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. Across the  programs there was variation in the percentage of cases resolved  favorably, with two of the selected programs reporting half, or less than  half, of their cases resolved favorably, and one program reporting nearly  100 percent of cases closed favorably. SAMHSA officials and NDRN staff  cited a number of factors that could contribute to the variation, including  complexity of the complaint, variation in the programs’ criteria for  accepting cases, program resources, or characteristics of the court or  state mental health system. For example, SAMHSA officials told us that possible explanations for variation could include a program accepting  particularly challenging cases, or a program obtaining additional funding  from other nonfederal grants that could provide greater legal staff support  in addressing complaints. All eight selected programs reported closing cases in each of the three  categories of complaints: abuse, neglect, and rights violations during  fiscal year 2016. Five of the eight programs reported that a majority of  their cases were related to complaints about rights violations, which  occurred in both facility- and community-based settings (see fig. 1). These complaints included denials of legal assistance or privacy rights,  employment discrimination, or—the most frequently reported case  complaint—failure to provide special education consistent with state  requirements. Issues of abuse and neglect of individuals with mental  illness were also common. The most frequent complaint reported by the  eight selected programs related to neglect was a lack of discharge  planning for release from a facility, and for alleged abuse, it was failure to  provide appropriate mental health treatment. Program staff reported examples of how state PAIMI programs resolved  cases related to abuse, neglect, and rights violations for individuals in  institutions and the community: Program staff in California described a rights violation case of a young  girl with a mental health disability who was eligible for special  education services, but the district placed her in a restricted,  segregated school setting where she was restrained multiple times.  The program staff negotiated her move to a general education  campus with classroom behavior support. The PAIMI program  monitored her transition, including ensuring her inclusion in school  activities, academic remediation, and social skill development. Program staff in Georgia reported that they were contacted by a  woman in a hospital who was overmedicated such that they could not  initially understand what she was saying. The staff worked with her  hospital treatment team to adjust her medication and the woman  became more articulate. In working to address her overmedication,  the staff further discovered there were not appropriate discharge  plans for her and so they worked to ensure that she was discharged  into an appropriate facility. To address individual cases, selected programs reported using a variety  of strategies, ranging from administrative actions to legal remedies.  Programs reported that the most frequently utilized strategy (used 62  percent of the time in fiscal year 2016) was “short-term assistance”— time-limited advice or counseling, such as assisting a client with preparing  a letter or making a phone call to resolve an issue. Selected programs  reported using legal remedies about 5 percent of the time in fiscal year  2016. Outcomes of Systemic  Activities The eight selected programs conducted a range of systemic activities,  and reported successfully concluding a total of 367 of these activities in  fiscal year 2016 (see figure 2). Facility monitoring was reported as the most frequent systemic activity in  fiscal year 2016, comprising about 71 percent of the total systemic  activities concluded by the selected programs. The selected programs  described a range of activities involving facility monitoring. For example,  California reported that the program had an effort focused on monitoring  the conditions at selected county jail systems and juvenile halls. As part  of that work, the program reported that it released five public reports and  worked with counties on policy improvements, such as reducing the use  of pepper spray on youth. Another program, Louisiana, reported that staff  used to conduct regular monitoring visits to a state’s psychiatric hospital  and addressed patient complaints that they heard during these visits.  However, with limited resources and other emerging urgent issues at  other facilities, the program decided to cease the regular monitoring and  now conducts as-needed visits to the hospital in response to specific  complaints from the patients or staff. In addition to facility monitoring activities, other systemic activities  conducted varied across the selected programs, reflecting differences in  their resources and priorities. Some systemic activities—such as class  action litigation—take significant time and resources to undertake, and  program staff may consider various factors before beginning one. For  example, program staff from Indiana told us the program filed a lawsuit  alleging restrictive housing of prisoners with significant mental illness that  involved 4 years of negotiations. In addition, program staff from Vermont  told us after engaging in successful litigation against hospitals that helped  reduce unnecessary force, isolation, and coercion tactics, the program re- prioritized and focused on other issues, such as helping individuals  integrate into the community from facilities. However, the program  recently noticed an increase in force, isolation, and coercion tactics and  predicted another shift in focus to once more address those issues. Performance on Program  Priority Goals Through their efforts to resolve individual cases and systemic activities,  selected programs reported largely meeting the performance  benchmarks—priority goals, objectives, and targets—they determine for  themselves. For example, the Georgia program reported that to meet its  fiscal year 2016 priority goal of protecting individuals with psychiatric  disabilities in Georgia from abuse and neglect, its objective was to  investigate and advocate to address allegations of abuse and neglect,  including suspicious or unexplained deaths and inappropriate treatment  or medication issues for people with psychiatric disabilities. The  measurable target for this objective was to conduct 50 such  investigations. In its performance report for the fiscal year, the program  reported that it had completed 51 investigations of allegations of  extensive abuse and neglect during the performance year. Overall, the  selected programs reported meeting more than 95 percent of their priority  goals in fiscal year 2016. While selected programs varied in their priority  goals, all had a goal that focused on protecting individuals from abuse,  neglect, and rights violations. (See Appendix II for more information about  the types of priority goals set by the selected programs.) When objectives  were not met, the programs reported, for instance, focusing on other  priorities or that an activity was still ongoing and could not be included as  part of their performance for the year. Although the eight selected PAIMI programs reported that they largely  met their goals, they also reported several overarching challenges to their  efforts to do so, such as limited resources, lack of access authority, or  delays in access (e.g., to documents, records, or institutions). For  instance, the selected programs collectively reported that 617 PAIMI- eligible clients were not served within 30 days due to insufficient funding  in fiscal year 2016. Additionally, five selected programs reported delays in  access to records. For example, Vermont program staff reported delays in  receiving records related to the status of prisoner grievances or medical  records, and Texas program staff reported delays and use of significant  attorney resources to address facilities that challenge their ability to  access records or premises. 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. We found evidence  that SAMHSA had identified and resolved a variety of compliance issues  through these activities. Ongoing Monitoring On an annual basis, SAMHSA monitors compliance with statutory and  regulatory program requirements by reviewing information reported by the  programs through the application and program performance report. (See  table 4.) SAMHSA’s project officers review and approve the applications  and performance reports submitted by the state PAIMI programs using a  checklist developed by the agency that prompts them to record specific  information, such as whether there are vacant advisory council seats. Not  all areas of compliance are covered by the checklist; however, SAMHSA  officials told us that the entire application and performance report are  reviewed, and that a project officer’s approval signature on a checklist  indicates that potential issues observed during a review have been  resolved satisfactorily. 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. For  example, SAMHSA followed up with one program in which the advisory  council had failed to meet the threshold of 60 percent of its membership  being individuals who have received or are receiving mental health  services, or are family members of such individuals. Failing to meet this  threshold could raise concerns about whether a program is sufficiently  engaging individuals and family members affected by mental illness as  required by regulation. In this instance, SAMHSA requested a plan of  action to recruit and maintain members to meet the threshold, which the  program provided along with updated information that they had  successfully recruited an additional member that put the council make-up  over the threshold. In another example, SAMHSA followed up with one  program that had reported not meeting 3 of 6 objectives and requested a  plan of action for reducing the number of unmet objectives. The program  subsequently provided information that it had incorrectly categorized  some objectives they had met as “not met.” (See table 5.) In addition to the annual application and performance report reviews,  SAMHSA officials told us that they use monthly conversations with other  federal agencies, referred to as federal partners, to help them identify  potential compliance issues. These federal partners oversee federal  grants for other populations of people with disabilities made to the  protection and advocacy systems that administer the PAIMI program.  SAMHSA officials told us that coordination with these federal partners  helped identify risks in at least two of our selected programs, Puerto Rico  and Oklahoma. For example, one of the federal partners conducted an  onsite monitoring visit to Puerto Rico and found several issues with its  protection and advocacy system, such as inadequately trained staff and  conflicts of interest arising from a lack of independence from the  governor’s office. Puerto Rico’s protection and advocacy system failed  to develop an adequate corrective action plan to address the federal  partner’s findings, leading the federal partner to place the system in  restricted—that is, high-risk—status. According to SAMHSA officials,  these actions led them to more closely monitor Puerto Rico’s PAIMI  program, resulting in the identification of the protection and advocacy  system’s failure to comply sufficiently with PAIMI program requirements.  For example, SAMHSA found that Puerto Rico’s PAIMI program did not  have the capacity to protect and advocate for individuals with mental  illness, as required by statute, because they had an insufficient number of  attorneys. Furthermore, the federal partner that originally placed Puerto  Rico’s protection and advocacy system in restricted status requested that  SAMHSA do so as well. As a result, SAMHSA also placed the Puerto  Rico PAIMI program in restricted status. Periodic Onsite Monitoring  Reviews In addition to its ongoing monitoring, SAMHSA has procedures to oversee  state PAIMI program compliance during its periodic onsite monitoring  reviews. When SAMHSA conducts an onsite monitoring review, its  procedures specify that officials are to interview program staff, governing  board members, and advisory council members; as well as review a  sample of case record files and other documentation of program  activities. The state PAIMI program is also to submit a detailed set of  documentation to support the program’s compliance with statutory and  regulatory requirements. Agency officials are to review this information  and report back to the programs on any compliance issues or  recommendations to improve program processes. In our review of fiscal year 2015 and 2016 documentation for the nine  onsite monitoring reviews SAMHSA conducted, we found evidence that  this process helped identify and resolve a range of potential compliance  issues. For example, SAMHSA found that one program’s bylaws could be  misinterpreted to permit lobbying for legislation for PAIMI-eligible  individuals using PAIMI funding, when federal law prohibits grants  programs from using federal funds to engage in such activity. As a result, the program’s governing board reviewed and modified the bylaws to  clearly indicate that PAIMI funds are not to be used for lobbying. As another example, SAMHSA found that one program did not have  sufficient documentation to support that the advisory council chair was an  individual who had received or was receiving mental health services, or a  family member of such an individual, as required by regulations. As a  result, the program revised its practice to include having the advisory  council chair verify in writing that he or she meets the criteria for serving  in the position. (See table 6.) 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. First, SAMHSA’s PAIMI program monitoring did  not consistently record changes to program priority goals, objectives, and  targets—collectively, “benchmarks”—made during a performance year,  and the agency did not have procedures for examining such changes  over time. Second, the agency did not provide timely information to  programs on identified deficiencies from onsite monitoring. As of March  2018, SAMHSA was in the process of implementing new processes for its  oversight of state PAIMI programs that officials believe will streamline the  agency’s monitoring activities. However, these changes may not fully  address the weaknesses we identified. 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. According to federal internal  control standards, an agency should evaluate the results of its  monitoring—in this case, the information collected regarding benchmark  modifications—to determine program performance. In our review of SAMHSA’s oversight of 10 programs for fiscal years 2015  and 2016, we found that SAMHSA did not consistently record program  modifications to performance benchmarks. Specifically, we found that  four programs appeared to have modified their performance benchmarks  during the year—in some cases upward when results exceeded original  targets, and in other cases downward when results were lower than  original targets. However, these changes were not recorded by SAMHSA  reviewers in the review checklists. For instance, one program revised 17  of its 21 targets to closely match the program’s actual results, but these  changes were not recorded in the area of the review checklist that  prompts the project officer to note if such changes were made. According to SAMHSA officials, in fiscal year 2017, SAMHSA transitioned  from paper forms to a web-based system for submission and review of  applications and performance reports. Officials told us that under the new  system, programs will be required to consult with SAMHSA officials about  and submit modifications to performance benchmarks through the  system. The system will record and display both the original priority goals,  objectives, and targets as approved at the time of the application, as well  as any modifications a program submits throughout the year. The system  will also record that information over time, providing the ability to review  and track program modifications to benchmarks over multiple years. SAMHSA’s new system should improve recording of benchmark changes,  however, SAMHSA lacks procedures for examining such changes across  years to assess whether the changes could indicate larger performance  issues. SAMHSA officials acknowledged that they did not have specific  procedures in place directing project officers to examine changes to  performance benchmarks across multiple years, but said that other  relevant procedures were in place. For example, officials noted that  programs are not able to modify benchmarks without approval by  SAMHSA project officers. However, without implementing procedures  aimed specifically at examining trends in benchmark modifications across  years, SAMHSA 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,  such as revising its targets downwards over multiple years. Failure to Provide Timely  Information on Identified  Deficiencies We found that SAMHSA generally failed to meet its timelines for  producing and providing onsite monitoring review reports to the state  PAIMI programs under review during fiscal years 2015 and 2016. This  inability to produce and provide onsite monitoring reports to PAIMI  programs in a timely manner is inconsistent with SAMHSA’s internal  requirements and with federal internal control standards regarding  evaluating issues and remediating deficiencies on a timely basis. Specifically, for onsite monitoring reviews, SAMHSA’s procedures specify  the agency is to provide an initial report to the reviewed program within  150 days of the onsite visit. However, for eight of the nine monitoring  review reports we reviewed for fiscal years 2015 and 2016, SAMHSA  provided the report more than a year after the visit. One program that had  just received its report at the time of our review told us that it was difficult  to plan the necessary changes to its work without an official report with  findings and recommendations to help guide them in restructuring their  operations. Program staff said they had moved ahead and made some  changes but were uncertain whether those changes would be deemed  sufficient because of the lack of feedback from the agency. SAMHSA officials told us that they may have missed some deadlines as a  result of competing priorities and restricted resources—for example,  recently only two of four PAIMI project officer positions have been  occupied. Officials reported that the agency was taking steps to  streamline the process to make it more efficient and to bring on more staff  resources. The officials said that in 2018 SAMHSA planned to shift  responsibility for the project officers’ portion of the onsite reviews to a  dedicated onsite monitor, which they hoped would expedite the review  process. In addition, the agency had taken steps to streamline its onsite  monitoring review process, such as by revising and standardizing its  reporting template. There are uncertainties with regard to how effective these changes will be  in increasing timeliness. For example, the planned efficiencies target  some, but not all, of the key components of the reviews. In particular,  SAMHSA officials told us that these review process changes do not  pertain to the portion of the onsite review that focuses on state PAIMI  program compliance with applicable fiscal requirements. Officials noted  that the SAMHSA office that conducts the fiscal portion of the review has  had staff shortages for the past 16 months and is not able to operate  within normal time frames for completing this portion of the report.  Without meeting its deadlines for completing its review and providing  timely, detailed information and feedback to PAIMI programs, SAMHSA  cannot ensure that identified issues are resolved in a timely manner, thus  potentially endangering the effectiveness of the programs. Conclusions Individuals with mental illness can face abuse, neglect, and rights  violations in both institutional and community treatment settings, including their own homes. The protection and advocacy services provided by state  PAIMI programs play an important role in reducing these serious issues  for this vulnerable population. Therefore, it is important to monitor how  effective the programs are in addressing such issues. SAMHSA has a  number of procedures in place to monitor program compliance with  statutory and regulatory requirements, which enable the agency to  identify and resolve potential issues with program compliance, and it is  taking steps to streamline and improve its compliance oversight. At the  same time, the agency’s processes for oversight of program effectiveness  could be improved, such as by examining trends in mid-performance  changes programs make to their priority goals, objectives, and targets  across multiple years. Without such monitoring, SAMHSA may not  recognize a pattern of changes that signal larger concerns about that  program’s effectiveness. Finally, SAMHSA has not been timely in  completing its onsite monitoring reviews or providing the results of these  reviews to the programs. 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.  (Recommendation 2) Agency Comments We provided a draft of this report to HHS for comment.  In its written  comments, HHS concurred with both of our recommendations and  indicated that it will examine ways to implement them.  HHS’s comments  are reprinted in appendix III. HHS also provided technical comments,  which we incorporated as appropriate. We are sending copies of this report to the appropriate congressional  committees, the Secretary of Health and Human Services, and other  interested parties. In addition, the report is available at no charge on the  GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or at iritanik@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix IV. 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. Our analysis of the priority goals reported  in the annual program performance reports by eight selected state PAIMI  programs found that all programs had at least one priority goal focused  on Protection and Civil Rights in fiscal year 2016 (see fig. 3).  Access/Discrimination was the next most frequently set priority goal  category—with seven of the eight programs establishing these goals. We  also reviewed program goal categories from fiscal year 2015 and  identified few significant differences between 2015 and 2016. Eight priority goal categories emerged from our analysis: Access/Discrimination: This category refers to issues broadly  related to access to services or benefits, and reduction of  discrimination, e.g., advocating for access to legal services or  elimination of barriers to housing, employment, and education  services. Community Integration: This category refers to issues of integrating  the individual into community facilities or ensuring they can be  independent outside of a facility. Education: This category refers to specific issues related to access  or equality in education services. Employment: This category refers to specific issues related to  access to employment. Health Care Services: This category refers to specific issues related  to access to health care services within the community or state. Housing: This category refers to specific issues related to access to  housing. Information/Outreach: This category refers to activities related to  distributing publications or performing outreach to individuals. Protection and Civil Rights: This category refers to issues broadly  related to rights violations and protection from restraint, seclusion, or  other abuse or neglect. Appendix III: Agency Comments from the  Department of Health and Human Services Appendix IV: GAO Contact and Staff  Acknowledgments GAO Contact Staff  Acknowledgments In addition to the contact named above, Susan Barnidge, Assistant  Director; Hannah Marston Minter, Analyst-in-Charge; Joanna Wu  Gerhardt; and Emily Beller Holland made key contributions to this report.  Also contributing were Jennie Apter, Muriel Brown, and Emily Wilson.
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. 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.