For the fourth time in two years, Moody’s Investor Service downgraded the Corporate Family Rating (CFR) for Valitas Health Services, a Missouri-based company which owns Corizon Health Services, the largest inmate medical provider in the United States. A CFR is assigned to a “corporate family,” rating a parent company and its subsidiaries as though it were one entity.

In determining the ratings action, Moody’s cited volatility among Corizon’s contracts and confusion regarding the status of company’s agreement with Florida, where state prison officials claimed they would rebid around $1 billion in inmate medical contracts, but have yet to do so. Moody’s called for “greater clarity around the status of the company’s Florida contract” as one condition that would need to be fulfilled before the rating could be upgraded.

Moody’s gave Valitas a negative ratings outlook and said the company could be further downgraded if “operating performance deteriorates,” or if the company “experiences a loss of key DOC [Department of Corrections] contracts.”

Valitas is owned by the private equity firm Beecken Petty O’Keefe & Company. Previous downgrades do not seem to have moved the firm to put pressure on Valitas and its subsidiaries to clean up their acts. But then again, they’re not the ones who are truly suffering from the conditions spurring the contract terminations.

Behind nearly every lost contract were stories of inmate abuse and medical neglect. In April 2013, a Moody’s Ratings Action stated “near-term earnings pressure following the recent losses of the Maine, Maryland, and Pennsylvania DOC contracts” influenced a ratings downgrade.

In Maine, a report by the Legislature’s Office of Program Evaluation and Government Accountability uncovered medication shortages and delays in treatment. There was no evidence that prescribed medications had been dispensed to half of the inmates surveyed in the report. “Some of these deficiencies appear to be persistent, with clear implications for the adequacy and timeliness of services provided to prisoners,” investigators wrote.

After Corizon cut back on staff at the Allegheny County jail in Pennsylvania, emails surfaced between the company and county officials detailing serious problems with performing the most fundamental tasks required of them, like distributing medication.”I was just informed by the Captain on shift, the majority of the jail has not received medication AT ALL,” read one email obtained by the Pittsburgh Post-Gazette. “Staffing is at a crisis.”

Five months later, in September 2013, Moody’s downgraded Valitas again and changed their ratings outlook from stable to negative, where it has remained ever since.

Moody’s downgraded Valitas a third time in August 2014, writing, “we expect the company to continue to face near-term earnings pressure following recent contract losses and certain underperforming state Department of Corrections contracts.”

Allegheny County ended their contract with Corizon this year, as did New York City and Tennessee (where Corizon is based). Washington DC Council recently rejected a contract with the company.