Recommendation: The OHS Director should require Head Start grantees to document that water provided to children has been tested for lead. OHS could determine various ways that are feasible and efficient for grantees to satisfy this requirement; for example, verification could be done through OHS' current grantee data collection or monitoring processes. (Recommendation 1)

Agency: Department of Health and Human Services
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Assistant Secretary for the Administration for Children and Families should direct OCC and OHS to develop an agreement with EPA on their roles and responsibilities in implementing the Memorandum of Understanding on Reducing Lead Levels in Drinking Water in Schools and Child Care Facilities. For example, these agreements may include the ways in which guidance and information will be shared with states and Head Start grantees, such as through webinars or email, and how frequently. (Recommendation 2)

Agency: Department of Health and Human Services
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Assistant Administrator of the Office of Water should develop an agreement with HHS's Offices of Child Care and Head Start on their roles and responsibilities in implementing the Memorandum of Understanding on Reducing Lead Levels in Drinking Water in Schools and Child Care Facilities. For example, these agreements may include the ways in which guidance and information will be shared with states and Head Start grantees, such as through webinars or email, and how frequently. (Recommendation 3)

Agency: Environmental Protection Agency
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Assistant Administrator of the Office of Water should direct the Office of Water to specify how it will track progress toward the outcomes of the Memorandum of Understanding on Reducing Lead Levels in Drinking Water in Schools and Child Care Facilities and determine how it will regularly monitor and update the MOU. For example, the Office of Water could develop performance measures for each of the MOU's outcomes. In addition, the Office of Water could submit annual reports on progress toward achieving the MOU's outcomes or it could plan to update the agreement at specific intervals. (Recommendation 4)

Agency: Environmental Protection Agency
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Assistant Secretary for the Administration for Children and Families (ACF) should establish an ongoing process to proactively share information and best practices with states about programs it administers that are available to serve kin caregivers, especially in states with a relatively large share of grandparent caregivers. This could be achieved, for example, by leveraging regional office staff to provide additional assistance and information sharing, particularly related to kinship navigator programs. (Recommendation 1)

Agency: Department of Health and Human Services: Administration for Children and Families
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Administrator for the Administration for Community Living (ACL) should establish an ongoing process to proactively share information and best practices with states about using National Family Caregiver Support Program (NFCSP) funds to serve older relative caregivers of children, especially in states with a relatively large share of grandparent caregivers. This could be achieved, for example, by leveraging regional office staff to share information from states and area agencies on aging that have successfully used this program to serve older relative caregivers. (Recommendation 2)

Agency: Department of Health and Human Services: Administration for Community Living
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Director of OCC should establish internal written policies to effectively implement and document the State Plan review and approval process for future review and approval periods. (Recommendation 1)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us it has been working on establishing written policies (e.g., internal guidance documents and checklists) to implement and document the State Plan review and approval process. OCC expects to complete this work for the FY2022-2024 Plan period. We will continue to monitor OCC's efforts to implement this recommendation.

Recommendation: The Director of OCC should define the informational needs related to the results of program-integrity activities. (Recommendation 2)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us that it is developing the next CCDF State/Territory Plan Preprint due for submission by states and territories July 1, 2021. According to OCC, it plans to incorporate its information needs regarding the results of program integrity into the Preprint document as it develops the document. We will continue to monitor OCC's progress in implementing this recommendation.

Recommendation: The Director of OCC should communicate externally to the states its informational needs related to the results of states' program-integrity activities. (Recommendation 3)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us that it is developing the next CCDF State/Territory Plan Preprint due for submission by states and territories July 1, 2021. According to OCC, it plans to communicate its information needs regarding the results of program integrity activities to states and territories as part of the Preprint Training activities - including webinars and peer-to-peer virtual meetings - so Lead Agencies understand what is expected for them to address in the CCDF Plan. We will continue to monitor OCC's progress in implementing this recommendation.

Recommendation: The Director of OCC should communicate internally to staff its informational needs related to the results of states' program-integrity activities. (Recommendation 4)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us that it is developing the next CCDF State/Territory Plan Preprint due for submission by states and territories July 1, 2021. According to OCC, it plans to communicate its information needs regarding the results of program integrity activities to staff in both regional and central offices as part of the Preprint Training activities so staff understand what is expected for Lead Agencies to address in the CCDF Plan. We will continue to monitor OCC's progress in implementing this recommendation.

Recommendation: The Director of OCC should develop documented criteria to guide the review of CAPs submitted by states to ensure that proposed corrective actions are aimed at root causes of improper payments and are effectively implemented. (Recommendation 5)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us it revised the CAP Review Tool to in response to our recommendation. OCC also told us that it plans to implement the revised CAP Review Tool beginning September 2020 to document the review of CAPs submitted for the most recent ACF-404 reporting cycle (June 2020). We asked OCC to provide documentation showing the revised CAP Review Tool is responsive to our recommendation. We will update this recommendation status after reviewing the documentation OCC provides.

Recommendation: The Director of OCC should timely complete its effort to develop established written policies for the CAP follow-up process to ensure that OCC's oversight and monitoring of CAPs is carried out consistently. (Recommendation 6)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us it developed draft written policies for the CAP follow-up process to ensure that OCC's oversight and monitoring of CAPs is carried out consistently. However, due to the impact of the COVID-19 on staffing capacity, OCC has not presented the draft policies to regional offices for feedback. OCC told us it plans to finalize the written policies for the CAP follow-up process by December 2020. We will continue to monitor OCC's progress in implementing this recommendation.

Recommendation: The Director of OCC should develop and document criteria to assess the effectiveness of states' program-integrity control activities. (Recommendation 7)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us it analyzed information gathered from federal and state resources to develop and document criteria to be used to assess the effectiveness of states' program integrity control activities. We asked OCC to provide us the document showing all criteria to be used to assess the effectiveness of states' program integrity control activities. We will update this recommendation status after reviewing the documentation OCC provides.

Recommendation: The Director of OCC should evaluate the feasibility of collecting information from the Grantee Internal Controls Self-Assessment Instrument (Self-Assessment Instrument) and Fraud Toolkit, such as during its Monitoring System process, to monitor the effectiveness of states' program-integrity control activities. (Recommendation 8)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us it is working to make the Self-Assessment Instrument and Fraud Toolkit more user-friendly to encourage increased use within the state CCDF program. With increased usage, OCC believes it will be in a better position to assess how the collection of data from these two instruments can be incorporated into the Onsite Monitoring System or other oversight activity. OCC told us it anticipates completing work to implement this recommendation by December 2020. We will continue to monitor OCC's progress in implementing this recommendation.

Recommendation: The Assistant Secretary for ACF should ensure that ACF conducts a fraud risk assessment to provide a basis for the documentation and development of an antifraud strategy that describes the CCDF program's approach to address prioritizing fraud risks identified. (Recommendation 9)

Agency: Department of Health and Human Services: Administration for Children and Families
Status: Open

Comments: In September 2020, HHS told us it anticipates completing the initial fraud risk assessment for the CCDF program by December 2020. We will continue to monitor HHS's efforts to implement this recommendation.

Recommendation: The Assistant Secretary for Postsecondary Education should correctly calculate its CCAMPIS program persistence rate and cost per persisting student measures. (Recommendation 1)

Agency: Department of Education
Status: Open

Comments: Education disagreed with this recommendation as it believes the currently reported persistence data are sufficiently accurate to support effective program management and oversight. In February 2020, Education noted that it was reviewing the concerns raised by GAO and taking action to address confirmed errors in its persistence calculations. Specifically, Education said it would correct a formula error in its spreadsheet and include students who transferred to another school as persisting and planned to publish corrected data. Further, it said that it was exploring the feasibility of developing a cohort model for its persistence rate measure. We appreciate the steps Education is taking to ensure that it is correctly calculating its program persistence measures. To close this recommendation, Education should provide its corrected calculations, as well as any publication with corrected persistence measures, to GAO to review and confirm that Education has corrected all of the errors we identified.

Recommendation: The Assistant Secretary for Postsecondary Education should either collect the CCAMPIS participant enrollment data needed to calculate a standard 3-year graduation rate or accurately define and calculate a different college completion measure. (Recommendation 2)

Agency: Department of Education
Status: Open

Comments: As of February 2020, Education stated that it continues to disagree with this recommendation, noting that more analysis is needed to determine whether it is appropriate to develop a more rigorous graduation rate measure for the CCAMPIS program. As we stated in our report, we recognize that collecting the enrollment data needed to calculate the standard graduation rate could place a burden on grantee schools. Our recommendation included the option to define a different college completion measure and calculate it correctly. Education reported that it will redefine its current graduation rate to be a different college completion measure and the agency will clarify the description of this metric in its information on CCAMPIS graduation rates. While the new graduation rate definition proposed by Education responds to this recommendation, Education's formula does not accurately calculate this redefined graduation rate measure. To close this recommendation, Education should correct the formula for its revised graduation rate measure and provide the updated formula and data to confirm that its calculations are accurate.

Recommendation: The Chief Operating Officer of Federal Student Aid should encourage schools—through appropriate means, such as the Federal Student Aid Handbook—to inform students via school websites about the availability of the dependent care allowance and how to request the allowance. (Recommendation 3)

Agency: Department of Education
Status: Open

Comments: While Education agreed with the spirit of this recommendation, it disagreed with the recommendation itself due to concerns that an increased emphasis on the availability of the dependent care allowance could lead to additional borrowing that might not be appropriate for all students based on their financial circumstances. To respond to the recommendation, Education told us in February 2020 that it has added a note to the 2019-2020 FSA Handbook that, when counseling students, schools should make clear the availability of the allowance and how to request it. Adding this language to the handbook is certainly helpful, but does not fully implement GAO's recommendation. Encouraging schools to provide this information to students who proactively contact a school's financial aid office to discuss their finances will likely make this information available to a relatively small number of students; however, it does nothing to make this information more broadly available to all students who may benefit from it. We are not recommending that schools should encourage all student parents to borrow more to pay for child care. Instead, we recommend that Education encourage schools to make students aware of this potential option-which federal law makes available to students-via school websites to allow them to make informed financial decisions based on their personal circumstances. We will close this recommendation when Education takes additional actions to encourage schools to make this information more broadly available to students on their websites.

Recommendation: GAO recommends that the Director of OMB consider developing a goal that addresses a coordinated federal approach to child well-being among its next set of cross-agency priority (CAP) goals, including working with relevant agencies to ensure their strategic plans include goals and objectives related to the CAP goal. (Recommendation 1)

Agency: Executive Office of the President: Office of Management and Budget
Status: Open

Comments: OMB neither agreed nor disagreed with this recommendation. In November 2017, OMB staff noted that the agency was developing its next set of CAP goals, which are usually reserved for a limited set of priorities, and expects to announce these goals concurrent with the FY19 budget. As part of the process, agency staff said they consult relevant Congressional committees and other stakeholders. As of September 2019, OMB had not provided an update on its efforts.

Recommendation: The Secretary of HHS should expeditiously develop a plan--that includes priorities, timeframes, clear roles and responsibilities, and methods for assessing progress--to effectively implement the NAS-related recommendations identified in the Protecting Our Infants Act: Final Strategy. (Recommendation 1)

Agency: Department of Health and Human Services
Status: Open
Priority recommendation

Comments: HHS concurred with this recommendation. HHS' Behavioral Health Coordinating Council finalized a plan for implementing the Strategy in 2019 . The plan includes priorities, timeframes, and clear roles and responsibilities for implementing NAS-related recommendations in the Strategy. The plan does not specifically identify methods for assessing progress on the recommendations, but HHS officials told us in November 2019 that the department holds quarterly conference calls to share updates and formal written updates will be collected at the end of each year. To close this recommendation, HHS needs to provide documentation-such as, the formal written updates-to show how the department assesses progress on the recommendations.

Recommendation: In light of the need for accurate and complete information on children's access to health services under Medicaid and CHIP, the requirement that states report information to CMS on certain aspects of their Medicaid and CHIP programs, and problems with accuracy and completeness in this state reporting, the Administrator of CMS should work with states to identify additional improvements that could be made to the CMS 416 and CHIP annual reports, including options for reporting on the receipt of services separately for children in managed care and fee-for-service delivery models, while minimizing reporting burden, and for capturing information on the CMS 416 relating to children's receipt of treatment services for which they are referred.

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open

Comments: In August 2019, CMS stated that the agency's long-term plan is to use the Transformed Medicaid Statistical Information System (T-MSIS) to analyze information on children's receipt of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. As of June 2020, CMS had developed a new CMS-416 reporting form that gives states the option of having CMS calculate the measures for the report using T-MSIS. CMS stated that it intends to implement this option for states for fiscal year 2020 CMS-416 reports, which are due in April 2021. As of August 2020, the new CMS-416 form was undergoing Paperwork Reduction Act review. CMS is also exploring using T-MSIS to generate the Core Set of Children's Health Care Quality Measures for Medicaid and CHIP, some of which are included in the CHIP annual report. As of June 2020, CMS had begun a pilot test to generate five of the Core Set measures using 2018 T-MSIS data. GAO considers this recommendation open and will continue to monitor CMS's progress towards its long-term goal of using T-MSIS to monitor children's receipt of EPSDT services.