were sub-standard. Some SPHs had outsourcing agreements with external HEs to have clinical tests, X-rays, and EEGs performed, as well as other specialized medical services provided for them. Most such HEs, however, are located elsewhere, which contravenes the Mental Health Standards. The SPHs in Karlukovo and Karvuna are located away from populated areas and are served by poor road infrastructure, which is an additional impediment to the timely provision of other specialized medical services and tests for their mental illness inpatients. Acting on a recommendation by the NPM, the SPH in Pazardzhik had procured electroconvulsive therapy (ECT) equipment. Pharmacies exist at the SPHs, but not all of them operate in keeping with the requirements of Ordinance No. 28 of 9 December 2008 on the set up and standard operating procedures of pharmacies and on the nomenclature of medicinal products for humans (Наредба № 28 от 9.12.2008 г. за устройството, реда и организацията на работата на аптеките и номенклатурата на лекарствените продукти). Shortage of medicaments for the medical treatment process at the hospitals did not appear to exist. As regards staffing of healthcare establishment, there remains a trend towards an increasing loss of medical and non-medical specialists. In some places discharged patients work as volunteer orderlies. Shift work is performed by the minimum possible number of staff, which poses risks for both the staff and the inpatients. Of all the hospital inspected only the SPH in Pazardzhik was adequately staffed. All mental healthcare establishments are required to comply with the Mental Health Standards approved by MoH Ordinance No. 24 of 7 July 2004. Only the SPH in Pazardzhik, however, meets the standards. The hospital is accredited with an excellent evaluation for a period of five years and is designated as an active treatment teaching psychiatric hospital. The NPM has repeatedly recommended that the MoH should initiate legislative amendments designed to establish levels of competence of residential SPH and MHC structures in accordance with medical standards. The 2015 amendments to the Healthcare Establishments Act regulate the establishment of levels of competence of MHC structural units. The NPM insists that such change should be legislated also in regard to the SPHs in implementation of the recommendation for changes to the funding structure for those healthcare establishments. This year's NPM inspections identified, once again, long hospital stays and repeated hospitalizations of patients of low socioeconomic status (SES), who are homeless or rejected by their families or guardians. Due to the shortage of beds in nursing and residential care facilities, the Social Assistance Directorates are either unwilling or, in most cases, truly unable to cooperate and accommodate discharged low SES patients with mental illness in specialized social service facilities. The NPM has repeatedly alerted the MLSP and has recommended that more social service facilities for persons with mental illness should be opened. To date, however, no actions have been taken for this purpose. The NPM inspection identified a higher lethality rate at the SPH in Karlukovo compared to the SPH average for the country and considered that to be an unflattering indication of the treatment process quality. The daily food allowance at the SPH in Lovech was found to be lower that the SPH average for the country, which in the opinion of the NPM was an unflattering indication of the quality of mental health care. Social rehabilitation and psychological care in SPHs was found to be underdeveloped. The physical environment and equipment of some of the hospitals are in poor condition (e.g., the SPH in Karlukovo), most SPHs are understaffed, and overall there is no statutory regulation of the conditions for engaging persons with mental illness in work activities as per Article 151 of the Healthcare Act. In most cases, inpatients were kept on medication therapy alone plus open 70