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 Secretary of Defense should ensure that the Assistant Secretary of Defense for Sustainment, in collaboration with the military departments, provide updated guidance for the oversight of privatized military housing, to include oversight objectives for each service to monitor the physical condition of privatized homes over the remaining duration of the ground leases. (Recommendation 1)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: The Department of Defense (DOD) concurred with this recommendation. In its August 2020 response, DOD noted that the Assistant Secretary of Defense for Sustainment (ASD (S)), as the Chief Housing Officer, issued guidance requiring the military departments to monitor work order completion for housing privatized under the Military Housing Privatization Initiative based on a combination of resident input, timeliness of work order completion, and number of repeat work orders for the same repair. The guidance also required increased tracking of MHPI project work orders by installation staff. Moving forward, the ASD(S) plans to issue quarterly program review guidance that establishes oversight objectives for the military departments to monitor the physical condition of MHPI housing over the duration of their project ground leases, formalizing the requirement that the data be monitored by the Chief Housing Officer. DOD expects this to be completed by December 2020. We will continue to monitor the status of this recommendation.

Recommendation: The Secretary of the Army should take steps, in collaboration with the Army's private housing partners, to review the indicators underlying the privatized housing project performance metrics to ensure they provide an accurate reflection of the condition and quality of the homes. (Recommendation 2

Agency: Department of Defense: Department of the Army: Office of the Secretary
Status: Open

Comments: The Department of Defense (DOD) concurred with this recommendation. In its August 2020 response, DOD noted that the Secretary of the Army has taken several steps toward addressing this recommendation. For example, the Army published the Portfolio and Asset Management Handbook creating a multi-tiered assessment approach of performance metrics to measure the health of each privatized home through inspection, assessment, satisfaction, and feedback. The Army and the private housing partners revised the Incentive Fee Performance Management Plan, placing increased emphasis on resident satisfaction and work order/maintenance management. The Army also put Commanders in charge, ensuring Army leadership at every Army installation is tracking housing quality and safety. In late 2020, the Army plans to review and evaluate these actions and make a determination by 31 Jan 2021 if any changes or revisions are needed to best implement the recommendation. As such, we will continue to monitor the status of this recommendation.

Recommendation: The Secretary of the Air Force should take steps, in collaboration with the Air Force's private housing partners, to review the indicators underlying the privatized housing project performance metrics to ensure they provide an accurate reflection of the condition and quality of the homes. (Recommendation 3)

Agency: Department of Defense: Department of the Air Force: Office of the Secretary of the Air Force
Status: Open

Comments: The Department of Defense (DOD) concurred with this recommendation. In its August 2020 response, DOD noted that the Air Force is engaging in several steps to address this recommendation. Specifically, in March 2020, the Air Force tasked each of the Military Housing Offices to inspect all move-in, move-out, and change of occupancy maintenance events and all emergency, urgent, and life, health, and safety work orders, which is outlined in Air Force guidance. The Air Force is also engaging in several ongoing actions. In response to a memo to the military departments to provide consistency of performance incentive fees, the Air Force was negotiating with the privatized housing project owners to update performance incentive fee metrics in accordance with ASD directed categories and weightings. As of August 2020, agreements had been finalized with 2 partners and work was ongoing with the remaining partners. In addition, the Air Force was working with the project owners to deploy Satisfacts, a survey tool to independently measure resident satisfaction with projects' work order performance, across all Air Force projects with an expected completion by December 2020. We will continue to monitor the status of these recommendations.

Recommendation: The Secretary of the Navy should take steps, in collaboration with the Navy and Marine Corps' private housing partners, to review the indicators underlying the privatized housing project performance metrics to ensure they provide an accurate reflection of the condition and quality of the homes. (Recommendation 4)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Department of Defense (DOD) concurred with this recommendation. In its August 2020 response, DOD noted that the Navy and Marine Corps are engaging in several steps to address this recommendation. Specifically, the Navy and Marine Corps have developed a centralized electronic data warehouse, which receives data from privatized housing partner maintenance systems to display work order and survey performance dashboards. By February 2021, the Navy expects to complete the development of metrics displayed by the data warehouse to include key service call performance metrics and resident feedback data. The Navy and Marine Corps are also developing a web-based monitoring matrix tool housing officials can use to evaluate the performance of privatized housing partners. The tool is intended to provide improved tracking capabilities and improved accessibility to information, thus providing more consistent oversight and improved advocacy service members and their families. The Navy is also working to hire 247 additional Navy and Marine Corps housing staff to review and analyze private partner provided recurring maintenance and customer satisfaction reports in an effort to strengthen oversight and monitoring, with an estimated completion of September 2020. Moving forward, we will continue to monitor the status of these and other efforts.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Sustainment, in collaboration with the military departments and private housing partners, establish minimum data requirements and consistent terminology and practices for work order data collection for comparability across installations and projects and to track trends over time. (Recommendation 5)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: e Department of Defense (DOD) partially concurred with this recommendation. In its August 2020 response, DOD stated that the Assistant Secretary of Defense for Sustainment (ASD(S)), as the Chief Housing Officer, plans to issue a policy directing the military departments to establish, to the maximum extent practical, minimum data requirements and consistent terminology and practices for MHPI housing unit work order collection to aid in comparability across installations and projects, and for tracking trends over time. However, DOD noted that the department cannot mandate changes to existing MHPI project legal documents. DOD estimates that this effort will be completed by December 2021. We will continue to monitor the status of this recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Sustainment require the military departments to establish a process to validate data collected by the private housing partners to better ensure the reliability and validity of work order data and to allow for more effective use of these data for monitoring and tracking purposes. (Recommendation 6)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: The Department of Defense (DOD) concurred with this recommendation. In its August 2020 response, DOD noted that the Assistant Secretary of Defense for Sustainment (ASD(S)), as the Chief Housing Officer, issued guidance directing the military departments to exercise proper oversight to ensure Military Housing Privatization Initiative (MHPI) projects perform in accordance with legal agreements, to include due diligence in monitoring and auditing project maintenance records and other project performance data. The guidance also required military departments to review their entire portfolios of MHPI projects to ensure accurate and appropriate work order management processes. In response to the new guidance, DOD noted that the military departments put in place appropriate oversight measures and undertook the required reviews, though the investigations of project business practices were ongoing in some cases. As another step, the ASD(S) plans to issue guidance directing the military departments to establish a process to validate data collected by their respective MHPI Project Owners to better ensure the reliability and validity of work order data and to allow for more effective use of these data for monitoring and tracking purposes. DOD expects this to be completed by the end of September 2020. We will continue to monitor the status of this recommendation.

Recommendation: The Secretary of Defense should ensure the Assistant Secretary of Defense for Sustainment, in collaboration with the military departments, develop a process for collecting and calculating resident satisfaction data from the military departments to ensure that the data are compiled and calculated in a standardized and accurate way. (Recommendation 7)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: The Department of Defense (DOD) partially concurred with this recommendation based on the fact that the draft report listed the incorrect office as the source for addressing the deficiency, but subsequently changed its response to concur after the recommendation was directed to the appropriate office in the final report. In its August 2020 response, DOD noted that the Assistant Secretary of Defense for Sustainment (ASD(S)) plans to issue guidance establishing a department-wide process for collecting and calculating resident satisfaction data to ensure that the data are compiled and calculated in a standardized and accurate way effective with the survey collection effort in Fiscal Year 2021. The department expects this effort to be completed by October 2020. We will continue to monitor the status of this recommendation.

Recommendation: The Secretary of Defense should ensure the Assistant Secretary of Defense for Sustainment provides additional explanation of the data collected and reported in future reports to Congress, such as explaining the limitations of available survey data, how resident satisfaction was calculated, and reasons for any missing data, among other things. (Recommendation 8)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: The Department of Defense (DOD) partially concurred with this recommendation. In its August 2020 response, DOD noted that the Assistant Secretary of Defense for Sustainment (ASD(S)) would provide additional explanation of the MHPI resident satisfaction data collected and reported in future annual Military Housing Privatization Initiative (MHPI) reports to Congress, effective with the annual report covering fiscal year 2019. DOD noted that the additional information will include, among other things, an explanation of the limitations of available survey data, how resident satisfaction was calculated, and reasons for any missing data. As of August 2020, the annual MHPI report covering fiscal year 2018 was in final coordination and the department noted that the report would addresses a vast majority, but not all, of the requirements identified in our recommendation. DOD noted that the additional information would be provided in the next annual MHPI report. We will continue to monitor the status of this recommendation.

Recommendation: The Secretary of the Army should develop and implement a plan to clearly and systematically communicate to residents the difference between the military housing office and the private partner. At a minimum, these plans should include the Army housing office's roles, responsibilities, locations, and contact information and should ensure that all residents are aware that they can directly contact Army housing office officials. (Recommendation 9)

Agency: Department of Defense: Department of the Army: Office of the Secretary
Status: Open

Comments: The Department of Defense (DOD) concurred with this recommendation. In its response, DOD noted that the Army developed a "Plain Language" briefing as required by the 2020 National Defense Authorization Act that included the Army Housing Office's roles, responsibilities, location, and contact information at each privatized housing project site. DOD noted that the intent of the briefing was to ensure that all residents were aware of their ability to directly contact Army Housing Office and/or the Garrison Commanders. DOD stated that the briefing was disseminated to all of the Military Housing Offices, who are using it in newcomer briefings, and stated that the briefing would be provided to all current residents of privatized military housing, but that measure would not be tracked due to attrition. In addition, DOD noted that Headquarters, Department of the Army was tasking Army Materiel Command to develop a more detailed plan to communicate to residents the difference between the Army Housing Office and the private housing partner. The Army's intent is to not only capture residents upon their arrival at an installation, but making the services of the MHO known over the duration of a resident's time on at installation. We will continue to monitor the status of this recommendation.

Recommendation: The Secretary of the Navy should develop and implement a plan to clearly and systematically communicate to residents the difference between the military housing office and the private partner. At a minimum, these plans should include the Navy housing office's roles, responsibilities, locations, and contact information and should ensure that all residents are aware that they can directly contact Navy housing office officials. (Recommendation 11)

Agency: Department of Defense: Department of the Navy: Office of the Secretary
Status: Open

Comments: The Department of Defense (DOD) concurred with this recommendation. In its August 2020 response, DOD noted that the Navy has taken various steps to address this recommendation, with additional steps planned. For example, the Navy has ensured that each installation has a specific issue resolution process description marketing flyer available, both in hard copy and on the public housing websites, with a reminder that residents can contact both the privatized housing property manager and the Navy housing office with any issues. Moreover, every housing unit has been provided with a refrigerator magnet reminding residents that they can and should contact the Navy housing office if they have any issues with their home. In addition, the Navy and Marine Corps have established a requirement to contact each privatized housing resident not later than 15 days after move-in and again 60 days after move-in to provide an opportunity to request assistance and remind them of available support. Moving forward, the Navy has an ongoing effort to require private housing companies to market the same messaging as the service issue resolution processes for the MHOs that they support, for consistent advocacy messaging to the tenants. The information will be added to PPV partner websites, printed material and resident handbooks. The Navy also plans to use its annual survey to tracks resident satisfaction and awareness of the Navy's issue resolution process, with expected completion by October 2020. In addition, the Marine Corps has identified a near-term initiative to procure name tags for all MHO employees to wear, identifying themselves as distinct and separate from privatized housing property management company, which will be standardized across all USMC installations. The Marine Corps also plans to develop a standard welcome aboard package to include magnets and other items with key point of contact information. The Marine Corps expects these efforts to be completed by the end of September 2020.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Sustainment, in collaboration with the military departments, assess the risks of proposed initiatives aimed at improving the privatized military housing program on the financial viability of the projects. (Recommendation 12)

Agency: Department of Defense: Office of the Secretary of Defense
Status: Open

Comments: The Department of Defense (DOD) concurred with this recommendation. In its August 2020 response, DOD noted that the Assistant Secretary of Defense for Sustainment, as the Chief Housing Officer, planned to issue a policy establishing the assessment of Military Housing Privatization Initiative (MHPI) project financial viability as part of quarterly program reviews as a long-term requirement. The department noted that the program review data would be augmented by input from the MHPI companies, who are assessing the likely impact of proposed initiatives in conjunction with their third party lenders. The department expected this effort to be completed by December 2020. We will continue to monitor the status of this recommendation.

Recommendation: The Assistant Secretary of the Army for Civil Works should direct the Chief of Engineers and the Commanding General of the U.S. Army Corps of Engineers to strengthen the Corps' internal review process for feasibility studies by including steps to ensure consistency with best practices for transparency, such as verifying that all of the important assumptions and limitations in models and their implications for the economic analysis are consistently, clearly, and fully described. (Recommendation 1)

Agency: Department of Defense: Department of the Army: Office of the Assistant Secretary (Civil Works)
Status: Open

Comments: In its letter dated January 14, 2020, the Department of Defense concurred with GAO's recommendation and provided a corrective action plan in response to the recommendation. According to the corrective action plan, the Corps estimates that guidance will be issued to ensure that Corps reports adequately describe and justify the models, analytical choices, assumptions, and data used such that it is consistent with best practices by December 31, 2020.

Recommendation: Congress should consider giving CMS authority to establish additional enforcement remedies for hospices that do not meet federal health and safety requirements. (Matter for Consideration 1)

Agency: Congress
Status: Open

Comments: In October 2019, we suggested that Congress should consider giving CMS authority to establish additional enforcement remedies for hospices that do not meet federal health and safety requirements. As of June 2020, Congress has not implemented this suggestion.

Recommendation: The Administrator of CMS should incorporate the use of additional information, such as quality measures or other information that could identify potential quality of care issues, into its survey process for overseeing hospice providers. (Recommendation 1)

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

Comments: HHS concurred with this recommendation. In May 2020, HHS said CMS is evaluating ways in which the Hospice Consumer Assessment of Health Providers and Systems (CAHPS) survey data can be used to inform surveys of hospice providers. HHS also said CMS intends to incorporate use of the current Hospice Quality Reporting Program (HQRP) measurement data into the survey process to provide additional items that inform a surveyor's evaluation of a hospice provider. HHS noted that these changes would be incorporated into a more comprehensive update to the survey process to target providers and areas where risk of noncompliance is greatest. HHS projected the updated process would be implemented by the end of the first quarter of calendar year 2021. In order for us to close the recommendation, CMS has to implement an updated survey process that incorporates the use of additional information that could identify potential quality of care issues, such as that described above.

Recommendation: The Commissioner of FDA should take additional steps to address inconsistency in its written comments to generic drug applicants—including the clarity of writing and the content of comments—among reviewers, such as requiring additional training for reviewers. (Recommendation 1)

Agency: Department of Health and Human Services: Food and Drug Administration
Status: Open

Comments: FDA concurred with this recommendation and is taking steps to implement it. As of August 2020, FDA stated that it is evaluating methods to improve the clarity and content of primary reviewer comments by developing and providing training and work aids on written communication to ensure that FDA conveys deficiency comments in a clear and consistent manner to applicants. FDA noted that best practices on ensuring consistency in deficiency comments will be shared with primary reviewers. In addition, FDA stated that the agency is reviewing current training and providing coaching for secondary reviewers to exchange, compare, discuss, and improve the content and consistency of common deficiencies communicated in primary reviewer comments.

Recommendation: The Commissioner of FDA should assess the extent to which the timing of brand-name drug companies' drug labeling changes affect the approval of generic drug applications in the first review cycle, and take steps, as appropriate, to limit the effect of brand-name drug labeling changes on pending generic drug applications. (Recommendation 2)

Agency: Department of Health and Human Services: Food and Drug Administration
Status: Open

Comments: FDA concurred with this recommendation and is taking steps to implement it. As of August 2020, FDA reported that it is identifying and assessing examples of applications in which the brand-name drug company submitted a supplemental application for a labeling change that impacted the timeline of the generic drug approval. After gathering data, FDA officials stated that they will assess what particular actions could address this issue, including whether FDA has the authority to take any such identified actions.