Recommendation: The Undersecretary for Health should consistently collect sexual orientation data in VHA's health record system, which could include adding a field for providers to input veterans' sexual orientation. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Undersecretary for Health should analyze veterans' sexual orientation data in order to assess health care outcomes for lesbian, gay, and bisexual veterans. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Undersecretary for Health should consistently collect veterans' self-identified gender identity data within and across record systems. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Undersecretary for Health should analyze veterans' self-identified gender identity data in order to assess health care outcomes for transgender veterans. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should establish steps for communicating to VA's actuarial consultant information on data quality, including any limitations, used in the actuarial modeling that informs VA's community care budget estimates. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should establish further steps for assessing and communicating to stakeholders the degree of overall uncertainty associated with actuarial projections for community care that inform the community care budget estimates. (Recommendation 2)

Agency: Department of Veterans Affairs
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 Agriculture should ensure that the agency fully implements the category management activity to reduce unaligned IT spending, by performing an analysis of alternatives to justify the agency's unaligned IT contracts. (Recommendation 1)

Agency: Department of Agriculture
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 Agriculture should ensure that the agency fully implements the category management activity to develop and implement vendor management strategies, by implementing the strategies it had developed. (Recommendation 2)

Agency: Department of Agriculture
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 Agriculture should ensure that the agency fully implements the category management activity to share prices paid, terms, and conditions for purchased IT goods and services. (Recommendation 3)

Agency: Department of Agriculture
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 Agriculture should ensure that the agency finishes implementing its process to analyze IT contract data. (Recommendation 4)

Agency: Department of Agriculture
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 Agriculture should ensure that the agency develops and implements strategies to address duplication identified through the use of spend analyses. (Recommendation 5)

Agency: Department of Agriculture
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 agency fully implements the category management activity to reduce unaligned IT spending. (Recommendation 6)

Agency: Department of Defense
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 agency documents its annual spend analyses used to identify opportunities to reduce IT contract duplication. (Recommendation 7)

Agency: Department of Defense
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 Health and Human Services should ensure that the agency uses a spend analysis on a regular basis to identify IT contract duplication. (Recommendation 8)

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 Attorney General should ensure that the Department of Justice fully implements the category management activity to reduce unaligned IT spending, by performing an analysis of alternatives to justify the agency's unaligned IT contracts. (Recommendation 9)

Agency: Department of Justice
Status: Open

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

Recommendation: The Attorney General should ensure that the Department of Justice fully implements the category management activity to share prices paid, terms and conditions for purchased IT goods and services. (Recommendation 10)

Agency: Department of Justice
Status: Open

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

Recommendation: The Attorney General should ensure that the Department of Justice fully implements the category management activity to engage the workforce in training regarding category management principles and practices, by tracking its workforce's attendance in the training. (Recommendation 11)

Agency: Department of Justice
Status: Open

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

Recommendation: The Attorney General should ensure that the Department of Justice uses a spend analysis to identify opportunities to reduce IT contract duplication. (Recommendation 12)

Agency: Department of Justice
Status: Open

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

Recommendation: The Attorney General should ensure that the Department of Justice develops and implements strategies to address duplication identified through the use of spend analyses. (Recommendation 13)

Agency: Department of Justice
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 State should ensure that the agency fully implements the category management activity to develop and implement vendor relationship management strategies, by executing its vendor management plan. (Recommendation 14)

Agency: Department of State
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 Veterans Affairs should ensure that the agency fully implements the category management activity to develop processes and policies for implementing the agency's category management efforts. (Recommendation 15)

Agency: Department of Veterans Affairs
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 Veterans Affairs should ensure that the agency fully implements the category management activity to reduce unaligned IT spending, by performing an analysis of alternatives to justify the agency's unaligned IT contracts. (Recommendation 16)

Agency: Department of Veterans Affairs
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 Veterans Affairs should ensure that the agency fully implements the category management activity to develop and implement vendor relationship management strategies. (Recommendation 17)

Agency: Department of Veterans Affairs
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 Veterans Affairs should ensure that the agency fully implements the category management activity to share prices paid, terms and conditions for purchased IT goods and services. (Recommendation 18)

Agency: Department of Veterans Affairs
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 Veterans Affairs should ensure that the agency uses a spend analysis to identify opportunities to reduce IT contract duplication. (Recommendation 19)

Agency: Department of Veterans Affairs
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 Veterans Affairs should ensure that the agency develops and implements strategies to address duplication identified through the use of spend analyses. (Recommendation 20)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: Congress should consider requiring VA to establish an overall wait-time performance measure for veterans to receive care under the VCCP that will permit VA to measure and monitor the timeliness of VCCP appointments and compare timeliness to that of VA medical facilities. (Matter for Consideration 1)

Agency: Congress
Status: Open

Comments: When we determine what steps the Congress has taken, we will provide updated information.

Recommendation: The Under Secretary of Health should align its monitoring metrics with the time frames established in the VCCP scheduling process. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary of Health should conduct a review of community provider enrollment and use of the HSRM to include identifying and taking steps to remove any challenges to community provider enrollment and use; and, if determined appropriate, establish a requirement for community providers to use the HSRM; and (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary of Health should direct VAMC leadership to assess their community care staffing and resource needs, and develop a plan to address any identified risks to their ability to schedule appointments in a timely manner, including strategies to adjust staff levels and address recruitment and retention challenges as needed. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: EBSA should explore ways to collect information on fees charged to participants or alternate payees by a retirement plan—including plan service provider fees the plan passes on to participants—for review and qualification of domestic relations orders and evaluate the burden of doing so. For example, DOL could consider collecting fee information as part of existing reporting requirements in the Form 5500. (Recommendation 1)

Agency: Department of Labor
Status: Open

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

Recommendation: EBSA should take steps to ensure that information regarding the requirements for QDROs is available and easily accessible for participants and alternate payees. For example, EBSA could develop a checklist of documents and information that parties could use to help draft a domestic relations order that would be more likely to be qualified as a QDRO on a plan administrator's first review. In addition, EBSA could conduct outreach focused on QDROs to practitioners, such as members of the family bar who may draft domestic relations orders. (Recommendation 2)

Agency: Department of Labor
Status: Open

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

Recommendation: The Under Secretary for Health should fully define in VHA policy the oversight roles and responsibilities related to ensuring facilities' adherence to disbursement agreement policies, including roles related to ReDPro and the role of VISNs. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should more clearly define in VHA policy the purposes of the periodic independent audits and the ReDPro checklist reviews—including differentiating their purposes from one another and ensuring that they do not unnecessarily overlap. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA and CBI modify the ReDPro checklist and associated guidance, to include ensuring that checklist items are clearly stated, relevant to the updated purpose of the ReDPro checklist, and not unnecessarily duplicative of items to be addressed by the periodic independent audits. The guidance should also include detailed instruction on what the compliance officers should review, and how they should determine the appropriate response for each checklist item. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA and CBI develop and provide additional ReDPro training for compliance officers, consistent with the updated checklist and guidance. This training should include general information on GME programs and disbursement agreement oversight, as well as detailed information about how ReDPro reviews should be conducted. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA implements a standardized independent audit tool that is consistent with the updated purpose of the periodic independent audits, and does not unnecessarily overlap with the ReDPro checklist. This could include modifying its existing recommended checklist, or developing a new tool. (Recommendation 5)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA develops guidance for periodic independent audits to assist the audit teams and facility management in understanding how audits are to be conducted. (Recommendation 6)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that OAA develops substantive training for independent audit team members, consistent with the updated audit purpose, guidance, and tools. This training should include general information on GME programs and disbursement agreement oversight, as well as detailed information about how the independent audits should be conducted. (Recommendation 7)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Commissioner of CBP should develop and implement additional guidance for ensuring funds appropriated for specific purposes are obligated consistent with the purpose of the funds. (Recommendation 1)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. In July 2020, CBP's Office of Finance issued new guidance on how to execute the remaining funds CBP received in the 2019 Emergency Supplemental. In September 2020, the CBP Budget Directorate's Program Analysis Division also updated its standard operating procedures to describe how it will review samples of purchase requests for supplemental funds. To fully implement our recommendation, CBP should develop and implement guidance for ensuring all funds appropriated for specific purposes, including future appropriations CBP may receive, are obligated consistent with the purpose of the funds.

Recommendation: The Commissioner of CBP should establish and document oversight roles and responsibilities to ensure funds appropriated for specific purposes are obligated consistent with the purpose of the funds. (Recommendation 2)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. In September 2020, the CBP Budget Directorate's Program Analysis Division updated its standard operating procedures to describe how it will review samples of purchase requests for supplemental funds. To fully implement our recommendation, CBP should establish and document oversight roles and responsibilities to ensure all funds appropriated for specific purposes, including regular appropriations, are obligated consistent with the purpose of the funds.

Recommendation: The Commissioner of CBP should develop and implement oversight mechanisms for CBP's implementation of policies and procedures relating to medical care for individuals in its custody to include documentation of expected practices, metrics and corresponding performance targets, and roles and responsibilities for taking corrective action. (Recommendation 3)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: The Commissioner of CBP should document what information it is using to assess whether to offer the influenza vaccine to individuals in custody, including how it weighs costs and benefits. (Recommendation 4)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: The Commissioner of CBP should develop and implement training on recognizing medical distress in children for all CBP officers and Border Patrol agents who may come into contact with children in custody. (Recommendation 5)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: The Commissioner of CBP should provide additional guidance to field personnel to ensure they classify significant incident reports on deaths, serious injuries, and suicide attempts, in accordance with CBP policy. (Recommendation 7)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: The Commissioner of CBP should update the Significant Incident Reporting System to include categories that align with CBP's directive on the reporting of significant incidents. (Recommendation 8)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: The Commissioner of CBP should provide additional guidance to components on the procedures for reporting deaths in custody to OPR and other entities within CBP. (Recommendation 9)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: The Commissioner of CBP should ensure that timely, reliable information on deaths in custody is reported to Congress, as directed, and maintain documentation on those reports. (Recommendation 10)

Agency: Department of Homeland Security: United States Customs and Border Protection
Status: Open

Comments: DHS concurred with this recommendation and said it would take steps to implement it. We will continue to monitor DHS' efforts to address this recommendation.

Recommendation: The Secretary of HHS should develop and implement a plan to improve data collected on the prevalence of brain injuries resulting from intimate partner violence and use these data to inform HHS's allocation of resources to address the issue. (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: For implementation of the EHR system at future VA medical facilities, we recommend that the Secretary of VA direct the EHRM Executive Director to clarify terminology and include adequate detail in descriptions of local workshop sessions to facilitate the participation of all relevant stakeholders including medical facility clinicians and staff. (Recommendation 1)

Agency: Department of Veterans Affairs
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 Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, consistently collect complete and accurate information about the quality of available civilian health care in proximity to its MTFs (such as ratings from the Centers for Medicare and Medicaid Services and perceptions from MTF officials who regularly coordinate with civilian providers, among other means) and assess that information to inform recommendations for future MTF restructuring decisions. (Recommendation 1)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. In its response, the department described its planned implementation steps, such as publishing measures it may use for assessing available civilian health care. We will continue to monitor the status of the measures and any other actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, consistently collect complete and accurate information about the extent to which current health care providers within the TRICARE networks meet access-to-care standards, and assess that information to inform recommendations on future MTF restructuring decisions. (Recommendation 2)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. The department noted actions underway and planned to implement it, including a centralized appointment booking system and monitoring access to care as MTFs restructure. We will continue to monitor the status of this effort and any other actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, consistently collect complete and accurate information about the extent to which non-network civilian health care providers that could be incorporated into the TRICARE network meet access-to-care standards in terms of drive time, and assess that information to inform recommendations on future MTF restructuring decisions. (Recommendation 3)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation, and described planned steps to implement it for future MTF restructuring decisions. We will continue to monitor actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, conducts a sensitivity analysis of the relative cost-effectiveness of MTF-provided care compared to civilian-provided care under varying assumptions, and document that information for decision makers to inform recommendations on future MTF restructuring decisions. Varying conditions could include different types of health care services, reducing the cost of military personnel salaries, and increasing estimated MTF wRVUs and civilian reimbursement rates. (Recommendation 4)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation. We will continue to monitor actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, establishes clear roles and responsibilities for executing and monitoring transitions for MTFs identified for restructuring. (Recommendation 5)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation and described actions underway and planned to implement it. We will continue to monitor actions the department takes to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with the Surgeons General of the military departments and the Director of the DHA, defines measurable objectives for MTF restructuring transitions, establishes thresholds and goals for each objective, and applies them to evaluate progress and challenges. For example, measurable objectives, thresholds, and goals, should include an evaluation of medical providers' clinical readiness, civilian health care provider adequacy, and the cost-effectiveness of MTF and purchased care. (Recommendation 6)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation and described actions underway and planned to implement it. We will continue to monitor actions the department takes to address the recommendation.

Recommendation: The Administrator of CMS should ensure that the Medicare & You publication includes explicit information on the services covered by the Medicare program for beneficiaries with a SUD. (Recommendation 1)

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

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

Recommendation: VA's Under Secretary for Health should provide additional information, such as best practices, about how VA medical centers and service providers participating in Coordinated Entry can collaborate with local partners on key activities (for example, making referrals and sharing data) and ensure that this information and other resources are accessible to VA medical center staff and service providers. (Recommendation 1)

Agency: Department of Veterans Affairs
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 DOL's Veterans' Employment and Training Service should document its data quality validation processes for performance data for the Homeless Veterans' Reintegration Program and disseminate these processes to service providers. (Recommendation 2)

Agency: Department of Labor
Status: Open

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

Recommendation: VA's Under Secretary for Health should clearly communicate with local VA staff and service providers about how it measures performance and how to obtain and provide feedback about performance measures. (Recommendation 3)

Agency: Department of Veterans Affairs
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 Health and Human Services should develop a mechanism to routinely monitor, evaluate, and report on coordination efforts for infectious disease modeling across multiple agencies. (Recommendation 1)

Agency: Department of Health and Human Services
Status: Open

Comments: The Department of Health and Human Services concurred with this recommendation and stated that it is developing a process whereby it will coordinate its efforts in infectious disease modeling across its components, including efforts to monitor, evaluate and report on its coordination. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Secretary of Health and Human Services should direct CDC to establish guidelines that ensure full reproducibility of CDC's research by sharing with the public all permissible and appropriate information needed to reproduce research results, including, but not limited to, model code. (Recommendation 2)

Agency: Department of Health and Human Services
Status: Open

Comments: The Centers for Disease Control and Prevention concurred with this recommendation. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Secretary of HHS, in consultation with the Council on Economic Mobility, should make information that would assist state and local entities in developing and implementing two-generation poverty reduction approaches readily available across federal programs and offices. (Recommendation 1)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS agreed with this recommendation. The agency stated that through its coordination of the Council on Economic Mobility it will promote poverty reduction approaches that aim to provide more integrated, person-centered service delivery. It will also work to identify opportunities for collaboration, promising practices, and successful models that promote economic mobility and will develop strategies for promoting them, such as through technical assistance. We will monitor the progress of these efforts.

Recommendation: The Secretary of Commerce should ensure that the agency's Chief Information Officer updates the telecommunications inventory to include all telecommunications assets and services in use at the agency, and updates Commerce's process for ongoing maintenance of the inventory to include the complete inventory. (Recommendation 1)

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

Comments: Commerce concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Commerce should ensure that the agency's Chief Information Officer completes efforts to identify future telecommunications needs using a complete inventory of existing telecommunications services; conducts and documents a comprehensive strategic analysis at all bureaus to identify areas for optimization and sharing of telecommunications resources; evaluates the costs and benefits of implementing new telecommunications technology and alternative options at all bureaus; and fully aligns Commerce's telecommunications needs with its long-term IT plans and enterprise architecture. (Recommendation 2)

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

Comments: Commerce concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Commerce should ensure that the agency's Chief Information Officer finalizes the responsibilities related to the information security management role during the telecommunications transition, and assigns the roles for providing legal expertise during the transition, as well as for managing human capital, telecommunications assets, and information security during the transition, to staff members; describes how changes and disruptions related to the transition will be communicated to end users at all bureaus and identifies the key local and regional agency transition officials responsible for disseminating information about the transition to employees and working with the vendor to facilitate transition activities in Commerce's transition communications plan; and establishes and implements configuration and change management processes for its transition. (Recommendation 3)

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

Comments: Commerce concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Commerce should ensure that the agency's Chief Information Officer identifies all of the funding needed to support the telecommunications transition; justifies requests for resources related to transition program management staff; conducts an analysis to identify staff resources needed for the entire transition effort; and analyzes training needs for staff assisting with the transition. (Recommendation 4)

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

Comments: Commerce concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Commerce should ensure that the agency's Chief Information Officer takes into account the agency's telecommunications transition risks, mission critical systems, and contingency plans in Commerce's transition time line. (Recommendation 5)

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

Comments: Commerce concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Health and Human Services should ensure that the agency's Chief Information Officer develops a policy that requires the agency's components to maintain an inventory of the telecommunications assets and services that they acquire independently from headquarters; updates the telecommunications inventory to include all telecommunications assets and services in use at HHS, and updates the agency's process for ongoing maintenance of the inventory to include the complete inventory. (Recommendation 6)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: HHS concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Health and Human Services should ensure that the agency's Chief Information Officer completes efforts to identify future telecommunications needs using a complete inventory of existing telecommunications services; and aligns HHS's telecommunications needs with its long-term IT plans. (Recommendation 7)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: HHS concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Health and Human Services should ensure that the agency's Chief Information Officer identifies and documents telecommunications transition roles and responsibilities related to (1) managing assets and human capital during the planning and execution phases of the transition and (2) providing legal expertise during the execution phase of the transition, and assigns the transition information security management role to a staff member; and establishes and implements configuration and change management processes for HHS's transition. (Recommendation 8)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: HHS concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Health and Human Services should ensure that the agency's Chief Information Officer identifies all of the funding needed to support the telecommunications transition at each of the agency's components, justifies requests for transition resources related to hardware and software upgrades, conducts an analysis to identify staff resources needed for the entire transition effort, and analyzes training needs for staff assisting with the transition. (Recommendation 9)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: HHS concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Health and Human Services should ensure that the agency's Chief Information Officer completes efforts to identify telecommunications transition measures of success that can be used to assess transition progress; and takes into account all of the agency's components, as well as its mission critical systems, contingency plans,and telecommunications transition risks, in HHS's transition time line. (Recommendation 10)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: HHS concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of State should ensure that the agency's Chief Information Officer updates the telecommunications inventory to include all telecommunications assets and services in use at the agency, and updates State's process for ongoing maintenance of the inventory to include the complete inventory. (Recommendation 11)

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

Comments: State concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: he Secretary of State should ensure that the agency's Chief Information Officer completes efforts to identify the agency's future telecommunications needs using a complete inventory of existing telecommunications services; conducts and documents a strategic analysis to justify the sharing of telecommunications resources; and aligns State's telecommunications needs with its long-term IT plans and enterprise architecture. (Recommendation 12)

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

Comments: State concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of State should ensure that the agency's Chief Information Officer identifies telecommunications transition roles and responsibilities related to (1) managing assets during the planning and execution phases of the transition and (2) providing legal expertise during the execution phase of the transition, and finalizes the responsibilities related to the information security management role for the transition; includes in State's transition communications plan the frequency with which transition status updates and meetings will occur throughout the transition, a description of how changes and disruptions related to the transition will be communicated to end-users, and the key local and regional agency transition officials responsible for disseminating information about the transition to employees and working with the vendor to facilitate transition activities; and establishes configuration management processes for the agency's transition. (Recommendation 13)

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

Comments: State concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of State should ensure that the agency's Chief Information Officer identifies all of the funding needed to support the telecommunications transition, justifies requests for resources related to transition program management staff, conducts an analysis to identify staff resources needed for the entire transition effort, and finalizes its analysis of training needs for staff assisting with the transition. (Recommendation 14)

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

Comments: State concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of State should ensure that the agency's Chief Information Officer takes into account the agency's telecommunications transition risks, mission critical systems, and contingency plans in State's transition time line. (Recommendation 15)

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

Comments: State concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Veterans Affairs should ensure that the agency's Chief Information Officer updates the telecommunications inventory to include all telecommunications assets and services in use at the agency, and updates and finalizes VA's process for ongoing maintenance of the inventory to include the complete inventory. (Recommendation 16)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: VA concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Veterans Affairs should ensure that the agency's Chief Information Officer completes efforts to identify future telecommunications needs using a complete inventory of existing telecommunications services, and determines and documents that VA's telecommunications needs are aligned with its long-term IT plans. (Recommendation 17)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: VA concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Veterans Affairs should ensure that the agency's Chief Information Officer includes in its telecommunications transition communications plan the key local and regional agency officials responsible for disseminating information about the transition to employees and working with the vendor to facilitate transition activities; and establishes and uses cost and schedule management processes in the agency's transition. (Recommendation 18)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: VA concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Veterans Affairs should ensure that the agency's Chief Information Officer identifies and documents all of the funding needed to support the telecommunications transition, including costs for all years of transition planning support; justifies requests for transition resources related to program management staff; conducts an analysis to identify staff resources needed for the entire transition effort; and analyzes training needs for staff assisting with the transition. (Recommendation 19)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: VA concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Secretary of Veterans Affairs should ensure that the agency's Chief Information Officer completes efforts to identify telecommunications transition measures of success that can be used to assess transition progress; and takes into account the agency's telecommunications transition risks, mission critical systems, and contingency plans in VA's transition time line. (Recommendation 20)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: VA concurred with this recommendation. We will continue to follow-up on the department's efforts to address it.

Recommendation: The Administrator of the National Aeronautics and Space Administration should ensure that the agency's Chief Information Officer updates the telecommunications inventory to include all telecommunications assets and services in use at the agency, and updates NASA's process for ongoing maintenance of the inventory to include the complete inventory. (Recommendation 21)

Agency: National Aeronautics and Space Administration
Status: Open

Comments: NASA concurred with this recommendation. We will continue to follow-up on the agency's efforts to address it.

Recommendation: The Administrator of the National Aeronautics and Space Administration should ensure that the agency's Chief Information Officer completes efforts to identify the agency's future telecommunications needs using a complete inventory of existing telecommunications services. (Recommendation 22)

Agency: National Aeronautics and Space Administration
Status: Open

Comments: NASA concurred with this recommendation. We will continue to follow-up on the agency's efforts to address it.

Recommendation: The Administrator of the National Aeronautics and Space Administration should ensure that the agency's Chief Information Officer identifies telecommunications transition roles and responsibilities related to (1) managing human capital during the planning and execution phases of the transition and (2) providing legal expertise during the execution phase of the transition. (Recommendation 23)

Agency: National Aeronautics and Space Administration
Status: Open

Comments: NASA concurred with this recommendation. We will continue to follow-up on the agency's efforts to address it.

Recommendation: The Administrator of the National Aeronautics and Space Administration should ensure that the agency's Chief Information Officer conducts an analysis to support the anticipated cost savings identified as part of the agency's justification for its resource requests related to hardware and software upgrades for the telecommunications transition, and justifies its resource requests for transition program management staff; conducts an analysis to identify staff resources needed for the entire transition effort; and analyzes training needs for staff assisting with the transition. (Recommendation 24)

Agency: National Aeronautics and Space Administration
Status: Open

Comments: NASA concurred with this recommendation. We will continue to follow-up on the agency's efforts to address it.

Recommendation: The Administrator of the National Aeronautics and Space Administration should ensure that the agency's Chief Information Officer takes into account the agency's mission critical systems and contingency plans in NASA's telecommunications transition time line. (Recommendation 25)

Agency: National Aeronautics and Space Administration
Status: Open

Comments: NASA concurred with this recommendation. We will continue to follow-up on the agency's efforts to address it.

Recommendation: The Secretary of the Department of Agriculture should direct the Assistant Secretary for Civil Rights to publicize promising practices for Title IX compliance on its websites for their university grantees. (Recommendation 1)

Agency: Department of Agriculture
Status: Open

Comments: USDA agreed with the recommendation. In its March 2020 formal comment letter, the department stated that it will ensure promising practices information is posted to websites for the Office of the Assistant Secretary for Civil Rights (OASCR) and the National Institute of Food and Agriculture. Additionally, a notice will be sent to universities to ensure they are aware the information is available, along with specifics regarding access to the same.

Recommendation: The Secretary of Energy should direct the Director of the Office of Economic Impact and Diversity to publicize promising practices for Title IX compliance on its websites for their university grantees. (Recommendation 2)

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

Comments: DOE agreed with the recommendation. In its February 2020 formal comment letter, the department stated that the Office of Civil Rights and Diversity (OCRD) has identified promising practices on an ongoing basis in its Title IX compliance review reports. OCRD will develop and publicize a promising practices guide on its website for reference by university grantees. The estimated completion date is June 1, 2020. GAO will review this action once it receives documentation from DOE.

Recommendation: The Secretary of the Department of Health and Human Services should direct the Director for the Office for Civil Rights to publicize a stand-alone list of promising practices for Title IX compliance on its websites for their university grantees. (Recommendation 3)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: HHS agreed with the recommendation. In its February 2020 formal comment letter, the department stated the Office for Civil Rights will incorporate effective practices from materials posted on its website and external sources in a stand-alone list of effective practices to help universities comply with Title IX. The Office for Civil Rights will also draw from its Title IX enforcement work to update the effective practices list on an ongoing basis.

Recommendation: The Secretary of Energy should direct the Director of the Office of Economic Impact and Diversity to finalize and publish Title IX complaint procedures, consistent with DOJ's regulations. (Recommendation 4)

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

Comments: DOE agreed with the recommendation. In its February 2020 formal comment letter, the department stated that the Office of Civil Rights and Diversity (OCRD) has developed a draft outline of complaint procedures. OCRD is benchmarking these procedures against NASA and NSF external civil rights complaint procedures. OCRD will finalize and publish Title IX complaint procedures, consistent with the Department of Justice's regulations. The estimated completion date is October 31, 2020.

Recommendation: The Secretary of the Department of Agriculture should direct the Assistant Secretary for Civil Rights to finalize and publish revised Title IX complaint procedures. (Recommendation 5)

Agency: Department of Agriculture
Status: Open

Comments: USDA agreed with the recommendation to finalize and publish Title IX complaint procedures. According to the department's March 2020 formal comment letter, USDA's Departmental Regulation (DR) 4330-002, Nondiscrimination in Program and Activities Receiving Federal Financial Assistance from USDA, addresses processing Title IX administrative complaints filed with the Department in any program or activity receiving financial assistance from USDA. The Departmental Regulation (DR) 4330-002 was revised in 2019 and is currently in the clearance process for publication.

Recommendation: The Secretary of the Department of Agriculture should direct the Assistant Secretary for Civil Rights to clarify on its website that individuals on USDA-funded grants can file Title IX complaints through the Assistant Secretary for Civil Rights—including clarifying who is considered "customers." (Recommendation 6)

Agency: Department of Agriculture
Status: Open

Comments: USDA agreed with this recommendation. According to the department's March 2020 formal comment letter, USDA's Office of the Assistant Secretary for Civil Rights (OASCR) will add language on its website to make clear recipients of USDA-funded grants are included in the definition of a customer and, as such, may file Title IX complaints through OASCR. Additionally, the requested information will be added to the Frequently Asked Questions section on OASCR' s website.

Recommendation: The Secretary of the Department of Health and Human Services should direct the Director for the Office for Civil Rights to assess the feasibility of receiving and reviewing concerns of sex discrimination—including sexual harassment—and communicating to individuals on agency-funded grants the option to notify the agency of these concerns, outside of the Title IX complaint process. (Recommendation 7)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: HHS agreed with the recommendation. In its February 2020 formal comment letter, the department stated that outside of the Title IX enforcement process, the Office for Civil Rights updated its sex discrimination web pages to inform persons on how to file complaints of discrimination directly to the Office for Civil Rights, including complaints of sexual harassment. The Office for Civil Rights has also incorporated information about Title IX rights and obligations in outreach material used on university campuses, including information addressing sexual harassment.

Recommendation: The Secretary of Energy should direct the Director of the Office of Economic Impact and Diversity to assess the feasibility of receiving and reviewing concerns of sex discrimination—including sexual harassment—and communicating to individuals on agency-funded grants the option to notify the agency of these concerns, outside of the Title IX complaint process. (Recommendation 8)

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

Comments: DOE agreed with the recommendation. In its February 2020 formal comment letter, the department stated that the Office of Civil Rights and Diversity (OCRD) will evaluate the feasibility of receiving and reviewing concerns of discrimination, including sexual harassment, outside of the Title IX complaint process described in DOE's Title IX regulations, as well as communicating this option to individuals on DOE funded grants. The estimated completion date is December 31, 2020.

Recommendation: The Administrator of NASA should assess the feasibility of receiving and reviewing concerns of sex discrimination—including sexual harassment—and communicating to individuals on agency-funded grants the option to notify the agency of these concerns, outside of the Title IX complaint process. (Recommendation 9)

Agency: National Aeronautics and Space Administration
Status: Open

Comments: NASA agreed with the recommendation. According to the agency's February 2020 formal comment letter, NASA plans to assess the feasibility of receiving and reviewing concerns of sex discrimination and harassment and communicating to individuals on agency-funded grants the option to notify the agency of these concerns. In conducting the feasibility assessment, NASA will benchmark with agencies that currently have the capability to receive and review concerns of sex discrimination, including sexual harassment. NASA will also examine internal resources to ensure successful implementation. NASA estimates completion by September 20, 2020.

Recommendation: The Secretary of the Department of Agriculture should direct the Assistant Secretary for Civil Rights to assess the feasibility of receiving and reviewing concerns of sex discrimination—including sexual harassment—and communicating to individuals on agency-funded grants the option to notify the agency of these concerns, outside of the Title IX complaint process. (Recommendation 10)

Agency: Department of Agriculture
Status: Open

Comments: USDA agreed with this recommendation. According to the department's March 2020 formal comment letter, USDA is to direct the Office of the Assistant Secretary for Civil Rights (OASCR) to assess the feasibility of receiving and reviewing concerns of sex discrimination (including sexual harassment) and including language in agency-funded grants on the option to notify the agency of harassment issues outside of the Title IX complaint process. The Office of the Mission Area Liaison within OASCR will assess the feasibility of creating a tracking system to capture inquiries and concerns outside of the Title IX complaint process. If feasible, the system will serve as a risk assessment tool to identify issues, potential violations, trends, risks, and areas prime for focused compliance review, according to USDA's formal comment letter.

Recommendation: The Secretary of the Department of Health and Human Services should direct the Director for the Office for Civil Rights and the Director of NIH to develop and implement formal procedures for sharing relevant information about Title IX (compliance reviews, violations, and complaints) and sex discrimination concerns, including sexual harassment. For example, HHS components should internally share information regarding findings of Title IX violations, concerns of sex discrimination, including sexual harassment, and Title IX compliance review reports. (Recommendation 11)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: HHS agreed with the recommendation. In its February 2020 formal comment letter, the department stated that the Office for Civil Rights and NIH will review the current procedure for sharing information, and development and implement (as necessary) formal procedures for sharing relevant information about Title IX and sexual harassment concerns. Furthermore, an action plan to address the recommendation will be provided in the department's 180-day letter response to Congress.

Recommendation: The Secretary of Energy should establish goals and an overall plan to assess all of the agency's sexual harassment prevention efforts for their university grantees, including methods to regularly monitor and evaluate its sexual harassment prevention policies and communication mechanisms (e.g. Title IX or sex discrimination websites). (Recommendation 12)

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

Comments: DOE agreed with the recommendation. In its February 2020 formal comment letter, the department stated that the Office of Civil Rights and Diversity will conduct research into best practices for harassment prevention efforts for university grantees and benchmark with other federal agencies. The estimated completion date for establishment of goals is January 31, 2021 and the estimated completion date for establishment of an overall plan is August 31, 2021.

Recommendation: The Secretary of the Department of Health and Human Services should establish goals and an overall plan to assess all of the agency's sexual harassment prevention efforts for their university grantees, including methods to regularly monitor and evaluate its sexual harassment prevention policies and communication mechanisms (e.g. Title IX or sex discrimination websites). (Recommendation 13)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: HHS agreed with the recommendation. In its February 2020 formal comment letter, the department stated that NIH has created goals for all NIH grantee sexual harassment prevention efforts, as noted in GAO's report. NIH will develop a plan to assess progress towards achieving those goals, including methods to regularly monitor and evaluate policies and communication methods. To the extent Title IX enforcement and outreach efforts may prevent sexual harassment, the Office for Civil Rights will develop a plan for leveraging enforcement efforts and outreach communications to help HHS grantees implement prevention efforts. HHS will submit an action plan that fully address department efforts regarding this recommendation in its 180-day letter response to Congress.

Recommendation: The Administrator of NASA should establish goals and an overall plan to assess all of the agency's sexual harassment prevention efforts for their university grantees, including methods to regularly monitor and evaluate its sexual harassment prevention policies and communication mechanisms (e.g. Title IX or sex discrimination websites). (Recommendation 14)

Agency: National Aeronautics and Space Administration
Status: Open

Comments: NASA agreed with the recommendation. According to the agency's February 2020 formal comment letter, NASA accepts its responsibility to establish policies and communication mechanisms to help university grantees to prevent sexual harassment, and the agency is committed to ongoing monitoring and evaluation of these efforts. At the same time, NASA judges that the most effective way to discharge these responsibilities is to adopt the approach now being developed by the National Science and Technology Council. NASA will establish goals, plans, and methods pursuant to this recommendation by adopting the policies and approaches developed through the interagency process. The estimated completion is to be determined based on timelines and milestones established by the Office of Science and Technology Policy's Safe and Inclusive Research Environments Subcommittee Subcommittee.

Recommendation: The Director of NSF should establish goals and an overall plan to assess all of the agency's sexual harassment prevention efforts for their university grantees, including methods to regularly monitor and evaluate its sexual harassment prevention policies and communication mechanisms (e.g. Title IX or sex discrimination websites). (Recommendation 15)

Agency: National Science Foundation
Status: Open

Comments: NSF agreed with the recommendation. According to the agency's February 2020 formal comment letter, NSF is embarking on an assessment process to improve its policies and practices continually in order to achieve the goal of safe and inclusive research environments.

Recommendation: The Secretary of the Department of Agriculture should establish goals and an overall plan to assess all of the agency's sexual harassment prevention efforts for their university grantees, including methods to regularly monitor and evaluate its sexual harassment prevention policies and communication mechanisms (e.g. Title IX or sex discrimination websites). (Recommendation 16)

Agency: Department of Agriculture
Status: Open

Comments: USDA agreed with this recommendation. According to the department's March 2020 formal comment letter, USDA will consider developing language to include in university grantees' terms and conditions regarding allegations of sexual harassment. Additionally, the Office of the Assistant Secretary for Civil Rights (OASCR) will reach out to other agencies within the Title IX Quarterly Working Group to assess best practices for monitoring and evaluating sexual harassment prevention policies and communication mechanisms. Finally, USDA will increase its communication with university grantees and increase oversight through compliance reviews.

Recommendation: In consultation with DOE, HHS, NASA, NSF, and USDA, the Assistant Attorney General for the Department of Justice should direct the responsible Civil Rights Division sections to fully adopt two federal interagency leading practices—agree on agency's roles and responsibilities and develop mechanisms to monitor, evaluate, and report results of collaborative efforts, for its Quarterly Title IX STEM discussion group. (Recommendation 17)

Agency: Department of Justice: Office of the Assistant Attorney General for Administration
Status: Open

Comments: DOJ generally agreed with the recommendation. According to the department's February 2020 formal comment letter, the Civil Rights Division (CRT) is prepared to delineate agencies' roles and responsibilities within the Quarterly Title IX STEM Discussion Group and is willing to develop an enhanced process for evaluating, monitoring, and reporting on the group's collaborations in enforcing Title IX that is achievable within DOJ's current resource allocation, or if more resources become available.

Recommendation: The Director of NIST should establish time frames for completing NIST's initiatives, to include the information security measurement program and the cybersecurity framework starter profile, to enable the identification of sector-wide improvements from using the framework in the protection of critical infrastructure from cyber threats. (Recommendation 1)

Agency: Department of Commerce: National Institute of Standards and Technology: Office of the Director
Status: Open

Comments: In written comments provided in July 2020, the Department of Commerce (Commerce) stated that it agreed with our recommendation. It noted that to further establish its Cybersecurity Measurement program, the National Institute of Standards and Technology (NIST) will document its Cybersecurity Measurement program's scope, objectives, and approach, including an inventory of existing measurement resources. Additionally, to further amplify small business awareness of cybersecurity, and of the Cybersecurity Framework, it noted that NIST will develop and publish two Cybersecurity Framework starter profiles tailored toward risk management of business processes important to small business owners. The expected completion date is September 2020.

Recommendation: The Secretary of Agriculture, in coordination with the Secretary of Health and Human Services, should take steps to consult with respective sector partner(s), such as the SCC, DHS, and NIST, as appropriate, to collect and report sector-wide improvements from use of the framework across its critical infrastructure sector using existing initiatives. (Recommendation 2)

Agency: Department of Agriculture
Status: Open

Comments: In written comments provided in April 2020, the United States Department of Agriculture (USDA) stated that it concurred with our recommendation. The department stated that it routinely shared framework guidance provided by the Department of Homeland Security and discussed the framework as part of its monthly Sector conference calls and biannual Sector Meetings. It also added that the department will continue to strengthen its coordination efforts.

Recommendation: The Secretary of Defense should take steps to consult with respective sector partner(s), such as the SCC, DHS, and NIST, as appropriate, to collect and report sector-wide improvements from use of the framework across its critical infrastructure sector using existing initiatives. (Recommendation 3)

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

Comments: In written comments provided in July 2020, the Department of Defense concurred with our recommendation. The department noted that it had developed processes and resources to help determine the type of framework adoption across the Defense Industrial Base. These include conducting assessments on the implementation of NIST Special Publication (SP) 800-171 , "Protecting Controlled Unclassified Information in Nonfederal Systems and Organizations;" and releasing the Defense Industrial Base Implementation Guide for the NIST Cybersecurity Framework. However, the department has yet to report on sector-wide improvements using these processes and resources. Until it does so, its critical infrastructure sector may not fully understand the value of the framework to better protect its critical infrastructure from cyber threats. The expected completion dates are in September and November 2020.

Recommendation: The Secretary of Energy should take steps to consult with respective sector partner(s), such as the SCC, DHS, and NIST, as appropriate, to collect and report sector-wide improvements from use of the framework across its critical infrastructure sector using existing initiatives. (Recommendation 4)

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

Comments: In written comments provided in February 2020, the Department of Energy (DOE) stated that it partially agreed with our recommendation. It noted that DOE will coordinate with the Energy Sector to develop an understanding of sector-wide improvements from use of the framework. The expected completion date is December 2021.

Recommendation: The Administrator of the Environmental Protection Agency should take steps to consult with respective sector partner(s), such as the SCC, DHS, and NIST, as appropriate, to collect and report sector-wide improvements from use of the framework across its critical infrastructure sector using existing initiatives. (Recommendation 5)

Agency: Environmental Protection Agency
Status: Open

Comments: In written comments provided in July 2020, the Environmental Protection Agency (EPA) stated that it agreed with our recommendation. It noted that it will consult with the Water Sector Coordinating Council, the Department of Homeland Security, and the National Institute of Standards and Technology, as appropriate, to investigate options to collect and report sector-wide improvements, consistent with statutory requirements and the Sector's willingness to participate. However, the department did not provide a timeframe for completing these actions.

Recommendation: The Administrator of the General Services Administration, in coordination with the Secretary of Homeland Security, should take steps to consult with respective sector partner(s), such as the Coordinating Council and NIST, as appropriate, to collect and report sector-wide improvements from use of the framework across its critical infrastructure sector using existing initiatives. (Recommendation 6)

Agency: General Services Administration: Office of the Administrator
Status: Open

Comments: In April 2020, the General Services Administration (GSA), in coordination with its co-SSA, the Department of Homeland Security (DHS), provided documentation demonstrating that it had initiated steps to collect and report on sector-wide improvements from use of the NIST Cybersecurity Framework across its critical infrastructure sector. Specifically, the agencies from the government sector had submitted their risk management reports to DHS and OMB that described agencies' action plans to implement the framework, as required under Executive Order 13800 and evaluated the agencies against the five functions of the NIST Cybersecurity Framework: Identify, Detect, Protect, Respond, and Recover. The risk management reports are included as part of OMB's FISMA Annual Report to Congress. According to OMB's FISMA Annual Report to Congress, OMB and DHS determined that 71 of 96 agencies (74 percent) have cybersecurity programs that are either at risk or high risk. As a result, improvements were identified in the form of four core actions in the Federal Cybersecurity Risk Determination Report and Action Plan, which include: (1) Implementing the Cyber Threat Framework to increase cybersecurity threat awareness among Federal agencies, (2) Standardize IT and cybersecurity capabilities, (3) Consolidate agency SOCs to improve incident detection and response capabilities, and (4) Drive accountability across agencies through improved governance processes, recurring risk assessments, and OMB's engagements with agency leadership. We are waiting for additional information from GSA and DHS on the status of the four core actions.

Recommendation: The Secretary of Health and Human Services, in coordination with the Secretary of Agriculture, should take steps to consult with respective sector partner(s), such as the SCC, DHS, and NIST, as appropriate, to collect and report sector-wide improvements from use of the framework across its critical infrastructure sector using existing initiatives. (Recommendation 7)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: In written comments provided in January 2020, the Department of Health and Human Services (HHS) stated that it concurred with our recommendation. The department noted that it would work with the appropriate entities to refine and communicate best practices to the sector.

Recommendation: The Secretary of Homeland Security should take steps to consult with respective sector partner(s), such as the SCC and NIST, as appropriate, to collect and report sector-wide improvements from use of the framework across its critical infrastructure sectors using existing initiatives. (Recommendation 8)

Agency: Department of Homeland Security: Office of the Secretary
Status: Open

Comments: In written comments provided in February 2020, the Department of Homeland Security (DHS) stated that it agreed with our recommendation. It noted that in coordination with the IT Sector Coordinating Council, the department recently issued a survey to small and mid-sized IT sector partners to better understand framework adoption and use within the IT sector. Once the results of the survey are received, DHS's Cybersecurity and Infrastructure Security Agency will determine the feasibility of issuing similar surveys to other sectors, and the potential timelines for completing sector-specific survey modifications, issuing surveys, compiling responses, and developing white papers on the status of framework adoption for each sector. The department expects completion of this work by December 31, 2021.

Recommendation: The Secretary of Transportation, in coordination with the Secretary of Homeland Security, should take steps to consult with respective sector partner(s) such as the SCC and NIST, as appropriate, to collect and report sector-wide improvements from use of the framework across its critical infrastructure sector using existing initiatives. (Recommendation 9)

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

Comments: In written comments provided in April 2020, the Department of Transportation (DOT) stated that it concurred with our recommendation. It noted that the department (through the Office of the Secretary, Office of Intelligence, Security, and Emergency Response) and the Department of Homeland Security (through the Transportation Security Administration and United States Coast Guard) will coordinate as Co-Sector-Specific Agencies for the Transportation Systems Sector to finalize the development and distribution of a survey instrument to determine the level and type of framework adoption in the Sector. The department expects completion of this work by December 31, 2021.

Recommendation: The Secretary of the Treasury should take steps to consult with respective sector partner(s), such as the SCC, DHS, and NIST, as appropriate, to collect and report sector-wide improvements from use of the framework across its critical infrastructure sector using existing initiatives. (Recommendation 10)

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

Comments: In written comments provided in January 2020, the Department of the Treasury (Treasury) stated that it agreed with our recommendation. The department noted that it will assess using the identified initiatives and their viability for collecting and reporting sector-wide improvements from the use of the NIST Framework. The department did not provide a timeframe for completing these actions.

Recommendation: The Secretary of VA should direct GEC leadership to develop measurable goals for its efforts to address key long-term care challenges: workforce shortages, geographic alignment of care, and difficulty meeting veterans' needs for specialty care. (Recommendation 1)

Agency: Department of Veterans Affairs: Office of the Secretary
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 VA should direct GEC leadership to set time frames for and implement a consistent GEC structure at the VAMC level. (Recommendation 2)

Agency: Department of Veterans Affairs: Office of the Secretary
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 VA should direct GEC leadership to set time frames for and implement a VAMC-wide standardization of the tool for assessing the noninstitutional program needs of veterans. (Recommendation 3)

Agency: Department of Veterans Affairs: Office of the Secretary
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 HHS should direct the Biodefense Coordination Team to establish a plan that includes change management practices—such as strategies for feedback, communication, and education—to reinforce collaborative behaviors and enterprise-wide approaches and to help prevent early implementation challenges from becoming institutionalized. (Recommendation 1)

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

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

Recommendation: The Secretary of HHS should direct the Biodefense Coordination Team to clearly document guidance and methods for analyzing the data collected from the agencies, including ensuring that nonfederal resources and capabilities are accounted for in the analysis. (Recommendation 2)

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

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

Recommendation: The Secretary of HHS should direct the Biodefense Coordination Team to establish a resource plan to staff, support, and sustain its ongoing efforts. (Recommendation 3)

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

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

Recommendation: The Secretary of HHS should direct the Biodefense Coordination Team to clearly document agreed upon processes, roles, and responsibilities for making and enforcing enterprise-wide decisions. (Recommendation 4)

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

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

Recommendation: The Executive Assistant Administrator / Director of FAMS should identify and utilize a suitable system that provides information about air marshals' medical qualification status. (Recommendation 1)

Agency: Department of Homeland Security: Transportation Security Administration: Office of Law Enforcement - Federal Air Marshal Service
Status: Open

Comments: DHS concurred with this recommendation and in January 2020, DHS officials stated that FAMS is evaluating case management software to track this information and plans to pursue funding for this effort in fiscal year 2021.This action, if fully implemented, should address the intent of the recommendation. When we confirm what actions DHS has taken in response to this recommendation, we will provide updated information.

Recommendation: The Executive Assistant Administrator / Director of FAMS should develop and implement a plan to assess the health and fitness of the FAMS workforce as a whole, including trends over time. (Recommendation 2)

Agency: Department of Homeland Security: Transportation Security Administration: Office of Law Enforcement - Federal Air Marshal Service
Status: Open

Comments: DHS concurred with this recommendation and in January 2020, DHS officials stated that FAMS had established a team to develop a plan for assessing workforce health and wellness issues. Adopting and implementing a plan that assesses the health and fitness of the FAMS workforce as a whole, should address the intent of the recommendation. When we confirm what actions DHS has taken in response to this recommendation, we will provide updated information.

Recommendation: The Executive Assistant Administrator / Director of FAMS should identify and implement a means to monitor the extent to which air marshals' actual shifts and rest hours are consistent with scheduling guidelines. (Recommendation 3)

Agency: Department of Homeland Security: Transportation Security Administration: Office of Law Enforcement - Federal Air Marshal Service
Status: Open

Comments: DHS concurred with this recommendation and in January 2020, DHS officials stated that FAMS will begin tracking air marshals' actual hours and examine the extent to which air marshals' actual and scheduled hours vary. This information could be helpful, for example, in assessing air marshals' schedule predictability. However, to address the intent of this recommendation, FAMS would need to monitor the extent that air marshals' actual work and rest hours are consistent with FAMS's scheduling guidelines. When we confirm what actions DHS has taken in response to this recommendation, we will provide updated information.

Recommendation: The Executive Assistant Administrator / Director of FAMS should take steps to reaffirm and strengthen efforts to prevent discrimination by, for example, updating and following through on its 2012 action plan and renewing leadership commitment to the plan's goals. (Recommendation 6)

Agency: Department of Homeland Security: Transportation Security Administration: Office of Law Enforcement - Federal Air Marshal Service
Status: Open

Comments: DHS concurred with this recommendation and in January 2020, DHS officials stated that FAMS plans to review the goals of its 2012 action plan and develop steps to strengthen efforts to prevent discrimination. These actions, if fully implemented, should address the intent of the recommendation. When we confirm what actions DHS has taken in response to this recommendation, we will provide updated information.

Recommendation: The Director of DHA should develop and implement plans with timeframes and specific actions needed for all 13 required elements to be reflected in the TRICARE contracts. (Recommendation 1)

Agency: Department of Defense: Office of the Under Secretary for Personnel and Readiness: Defense Health 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 Under Secretary for Health should take steps to improve communication to VAMC staff (including HIV lead clinicians) about the availability of data on the time frames in which test results are communicated to veterans. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should disseminate data to HIV lead clinicians on the extent to which veterans who test positive for HIV are linked to care within recommended time frames. (Recommendation 2)

Agency: Department of Veterans Affairs
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 Deputy Under Secretary for Health for Administrative Operations should develop and document a process for estimating total activation costs for major medical facility projects. This process should reflect the 12 steps for developing a reliable cost estimate outlined in the GAO Cost Guide. (Recommendation 1)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: As of July 2020, VHA is developing a policy to document its process for estimating total life cycle activation costs for major medical facility projects. VHA expects to complete this effort by December 2020.

Recommendation: The Assistant Deputy Under Secretary for Health for Administrative Operations should develop and document a process for comparing actual activation costs for major medical facility projects to estimates. This process should identify the personnel responsible for comparing the estimated costs to the actual expenses and document their responsibilities. (Recommendation 2)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: As of July 2020, VHA is developing a policy that will include guidance on comparison of actual activation costs to project estimates and that will document the parties responsibility for comparing these costs. VHA expects to complete this effort by December 2020.

Recommendation: The Assistant Deputy Under Secretary for Health for Administrative Operations should define and document what items and services officials can purchase with activation funds. (Recommendation 3)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: As of July 2020, VHA is developing a policy that will define and document what items and services officials can purchase with activation funds. VHA expects to complete this effort by December 2020.

Recommendation: The Assistant Deputy Under Secretary for Health for Administrative Operations should define and document when facilities should cease to spend activation funds. (Recommendation 4)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: As of July 2020, VHA is developing a policy that will define and document when facilities should cease to spend activation funds. VHA expects to complete this effort by December 2020.

Recommendation: The Secretary of Veterans Affairs should ensure that the Office of Enterprise Integration develops a plan—including milestones and roles and responsibilities for OEI, VBA, and VHA—to address identified challenges that have hindered research on the health care outcomes for service-connected conditions of veterans receiving disability compensation. To align VA's efforts with the goals of its 2018-2024 Strategic Plan, VA's development of this plan should be completed and ready for implementation by June 1, 2020. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation. VA stated that the Office of Enterprise Integration (OEI) will coordinate with VBA and the Veterans Health Administration (VHA) to create an operational plan that addresses challenges that have hindered research on health care outcomes for service-connected conditions of veterans receiving disability compensation. As of March 2020, VA anticipates completing this plan by June 2020. We will consider closing the recommendation when that effort is complete.

Recommendation: The Under Secretary for Benefits should develop and implement a periodic analysis of program management data for trends in the individual service-connected conditions being reevaluated as well as data on the outcomes of reevaluations. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA stated in March 2020 that it plans to develop requirements to augment its capacity to analyze reevaluation trends. According to officials, VA has determined the necessary requirements for the data needed to analyze the outcomes of reevaluations. VBA will review 12 months of data to assess trends and make recommendations based on the review. VA plans to complete the trend analysis by the end of June 2020 and will establish a process for periodic analysis of data trends. We will consider closing this recommendation when VA has analyzed multiple data points to assess trends in reevaluations on a periodic basis.

Recommendation: The Under Secretary for Benefits should implement the two recommendations in VBA's May 2018 consistency study to provide training on how to determine when a reevaluation is needed and review reevaluation decisions for accuracy at the lowest-scoring offices and take corrective action as needed. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: In November 2019, VA stated that VBA provided a reminder to all regional offices about the availability of training resources on how to determine when a reevaluation is needed. VA also stated that VBA conducted another consistency study on this issue in August 2019 and plans to use that study's results to guide its review of the lowest-scoring regional offices. This study recommended inspecting claims processed at the two lowest-scoring offices, because they may have high numbers of errors related to reevaluation requirements. VA stated that VBA would devise a statistically valid sample of claims based on the August 2019 study. In April 2020, VA provided information from national accuracy reviews and individual claims processor quality reviews for these two offices. However, these reviews were not specifically designed to assess the quality of decisions on reevaluations, and as such, do not provide generalizable information on all reevaluations decided by these two offices. To help close this recommendation, VA should take steps to focus its review on claims with reevaluations, in order to identify and correct root causes of any deficiencies, such as through additional training or the improvement of training. Using the results of both the 2018 and 2019 studies would allow VBA to more fully assess this issue.

Recommendation: The Under Secretary for Benefits should clarify guidance in its procedures manual regarding the knowledge, skills, and abilities needed to make decisions on whether to reevaluate veterans for changes in their service-connected conditions. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation in principle, acknowledging the importance of having appropriately skilled and trained employees to process reevaluations and other claims. VA stated that it believes the procedures outlined in its manual accurately describe the steps necessary for claims adjudicators to make the decision whether to reevaluate veterans for changes in their service-connected conditions. It further stated that regional office management ensures compliance with the procedures through the quality assurance program, and makes the decisions about which claims processors are best suited to perform the work. Accordingly, as of March 2020, VBA plans to assess the quality of routine future examinations requested by non-raters. Based on the results of this new quality review, VBA will determine if any additional actions are needed. VBA plans to complete this effort by October 2020. We are encouraged by VA's interest in conducting this analysis, and we will consider closing the recommendation when that effort is complete.

Recommendation: The Under Secretary for Benefits should align training requirements with the knowledge, skills, and abilities needed for reviewing claims to decide whether to conduct a reevaluation. (Recommendation 5)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation in principle. As noted in recommendation 4, as of March 2020, VBA plans to assess the quality of routine future examinations requested by non-raters, and determine if any additional actions are needed. VA also stated that if any refresher training is warranted for raters, local quality review team members can provide focused training locally. VBA plans to complete this effort by October 2020. We will consider closing the recommendation when that effort is complete.

Recommendation: The Assistant Secretary of Labor for the Employee Benefits Security Administration should evaluate whether targeted oversight in response to information received is effective for ensuring compliance with MH/SU parity requirements. If this evaluation determines the current targeted oversight approach results in significant program risks, the Employee Benefits Security Administration should develop a plan to more effectively enforce MH/SU parity requirements and if necessary seek additional oversight authority, as warranted. (Recommendation 1)

Agency: Department of Labor: Employee Benefits Security Administration
Status: Open

Comments: DOL agreed with this recommendation. In February 2020, DOL reported that its Employee Benefits Security Administration plans to evaluate its targeted approach to MH/SU parity enforcement. When we confirm what actions DOL has taken in response to this recommendation, we will provide updated information.

Recommendation: The Administrator of CMS should evaluate whether targeted oversight in response to information received is effective for ensuring compliance with MH/SU parity requirements for non-federal governmental plans. If this evaluation determines the current targeted oversight approach results in significant program risks, CMS should develop a plan to more effectively enforce MH/SU parity requirements and if necessary seek additional oversight authority, as warranted. (Recommendation 2)

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

Comments: HHS agreed with this recommendation. In August 2020, HHS reported that CMS has developed a two-part evaluation to determine whether targeted oversight of non-federal governmental plans is effective for enforcing MH/SU parity requirements. According to HHS, this evaluation will include (1) a review of non-federal governmental plan documents for compliance with MH/SU parity requirements and (2) a survey of state enforcement authority and regulatory best practices for ensuring MH/SU parity compliance. As of August 2020, HHS reported that the first part of the CMS evaluation is underway.

Recommendation: The Director of OMB should establish a process for monitoring and holding agencies accountable for authorizing cloud services through FedRAMP. (Recommendation 1)

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

Comments: OMB neither agreed nor disagreed with this recommendation and as of September 2020, the office has not provided information on its actions to implement our recommendation. To fully implement this recommendation, OMB needs to collect data on the extent to which federal agencies are using cloud services authorized outside of FedRAMP and oversee agencies' compliance with using the program. According to an OMB Associate General Counsel, the agency does not have a mechanism for enforcing agencies' compliance with its guidance on FedRAMP. However, we believe that OMB can and should hold agencies accountable for complying with its policies. By implementing this recommendation, OMB could substantially improve participation in the FedRAMP program, which is intended to standardize security requirements for federal agencies' authorizations of cloud services. We will update the status of this recommendation when OMB provides information on its corrective actions.

Recommendation: The Administrator of GSA should direct the Director of FedRAMP to clarify guidance to agencies and cloud service providers on program requirements and responsibilities. (Recommendation 2)

Agency: General Services Administration: Office of the Administrator
Status: Open

Comments: As of September 2020, GSA has not provided evidence to close this recommendation. We will continue to monitor the agency's progress and update the recommendation's status when GSA provides its corrective actions.

Recommendation: The Administrator of GSA should direct the Director of FedRAMP to improve the program's continuous monitoring process by allowing more automated capabilities, including for agencies to review documentation. (Recommendation 3)

Agency: General Services Administration: Office of the Administrator
Status: Open

Comments: As of September 2020, GSA has not provided evidence to close this recommendation. We will continue to monitor the agency's progress and update the recommendation's status when GSA provides its corrective actions.

Recommendation: The Administrator of GSA should update security plans for selected systems to include the description of security controls and reviews and approvals plan. (Recommendation 4)

Agency: General Services Administration: Office of the Administrator
Status: Open

Comments: As of September 2020, GSA has not provided evidence to close this recommendation. We will continue to monitor the agency's progress and update the recommendation's status when GSA provides its corrective actions.

Recommendation: The Administrator of GSA should update the security assessment report for the selected system to identify the summarized results of control effectiveness tests. (Recommendation 5)

Agency: General Services Administration: Office of the Administrator
Status: Open

Comments: As of September 2020, GSA has not provided evidence to close this recommendation. We will continue to monitor the agency's progress and update the recommendation's status when GSA provides its corrective actions.

Recommendation: The Administrator of GSA should update the list of corrective actions for selected systems to identify the responsible office and estimated funding required and anticipated source of funding. (Recommendation 6)

Agency: General Services Administration: Office of the Administrator
Status: Open

Comments: As of September 2020, GSA has not provided evidence to close this recommendation. We will continue to monitor the agency's progress and update the recommendation's status when GSA provides its corrective actions.

Recommendation: The Administrator of GSA should develop guidance requiring that cloud service authorization letters be provided to the FedRAMP program management office. (Recommendation 7)

Agency: General Services Administration: Office of the Administrator
Status: Open

Comments: As of September 2020, GSA has not provided evidence to close this recommendation. We will continue to monitor the agency's progress and update the recommendation's status when GSA provides its corrective actions.

Recommendation: The Secretary of HHS should direct the Director of CDC to update the security plan for the selected system to identify the authorization boundary, the system operational environment and connections, a description of security controls, and the individual reviewing and approving the plan and date of approval. (Recommendation 8)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: In June 2020, CDC stated it has taken actions to address our recommendations, but we have not received evidence of its corrective actions. We will continue to monitor the agency's progress and update the recommendation's status when CDC provides its corrective actions.

Recommendation: The Secretary of HHS should direct the Director of CDC to update the security assessment report for the selected system to identify the summarized results of control effectiveness tests. (Recommendation 9)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: In June 2020, CDC stated it has taken actions to address our recommendations, but we have not received evidence of its corrective actions. We will continue to monitor the agency's progress and update the recommendation's status when CDC provides its corrective actions.

Recommendation: The Secretary of HHS should direct the Director of CDC to update the list of corrective actions for the selected system to identify the specific weaknesses, funding source, changes to milestones and completion dates, identified source of weaknesses, and status of corrective actions. (Recommendation 10)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: In June 2020, CDC stated it has taken actions to address our recommendations, but we have not received evidence of its corrective actions. We will continue to monitor the agency's progress and update the recommendation's status once CDC provides its corrective actions.

Recommendation: The Secretary of HHS should direct the Administrator of CMS to update the system security plans for selected systems to identify a description of security controls. (Recommendation 11)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: In June 2020, HHS stated CMS took actions to close this recommendation, but CMS has not yet provided evidence of its corrective actions. We will continue to monitor the agency's progress and update the recommendation's status when CMS provides its corrective actions.

Recommendation: The Secretary of HHS should direct the Administrator of CMS to update the security assessment report for selected system to identify the summarized results of control effectiveness tests. (Recommendation 12)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: In June 2020, HHS stated CMS took actions to close this recommendation, but CMS has not yet provided evidence of its corrective actions. We will continue to monitor the agency's progress and update the recommendation's status when CMS provides its corrective actions.

Recommendation: The Secretary of HHS should direct the Administrator of CMS to update and document the CMS remedial action plan for the selected system to identify the anticipated source of funding. (Recommendation 13)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: In June 2020, HHS stated CMS took actions to close this recommendation, but CMS has not yet provided evidence of its corrective actions. We will continue to monitor the agency's progress and update the recommendation's status when CMS provides its corrective actions.

Recommendation: The Secretary of HHS should direct the Administrator of CMS to prepare letters authorizing the use of cloud services for the selected systems and submit the letters to the FedRAMP program management office. (Recommendation 14)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: In June 2020, HHS stated CMS took actions to close this recommendation, but CMS has not yet provided evidence of its corrective actions. We will continue to monitor the agency's progress and update the recommendation's status when CMS provides its corrective actions.

Recommendation: The Secretary of HHS should direct the Director of NIH to update security plans for selected systems to identify the authorization boundary, system operation in terms of mission and business processes, operational environment and connections, and a description of security controls. (Recommendation 15)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: In June 2020, NIH stated it is taking actions to address this recommendation, but the agency did not provide evidence of its corrective actions. NIH stated it will provide an update in December 2020. We will continue to monitor the agency's progress and update the recommendation's status when NIH provides its corrective actions.

Recommendation: The Secretary of HHS should direct the Director of NIH to update the security assessment report for selected systems to identify summarized results of control effectiveness tests. (Recommendation 16)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: In June 2020, NIH stated it is taking actions to address this recommendation, but the agency did not provide evidence of its corrective actions. NIH stated it will provide an update in December 2020. We will continue to monitor the agency's progress and update the recommendation's status when NIH provides its corrective actions.

Recommendation: The Secretary of HHS should direct the Director of NIH to update the NIH list of corrective actions for selected systems to identify estimated funding and anticipated source of funding, key milestones with completion dates, and changes to milestones and completion dates. (Recommendation 17)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: In June 2020, NIH stated it is taking actions to address this recommendation, but the agency did not provide evidence of its corrective actions. NIH stated it will provide an update in December 2020. We will continue to monitor the agency's progress and update the recommendation's status when NIH provides its corrective actions.

Recommendation: The Secretary of HHS should direct the Director of NIH to submit the division's letters authorizing the use of cloud services for the selected systems to the FedRAMP program management office. (Recommendation 18)

Agency: Department of Health and Human Services: Office of the Secretary
Status: Open

Comments: In June 2020, NIH stated it is taking actions to address this recommendation, but the agency did not provide evidence of its corrective actions. NIH stated it will provide an update in December 2020. We will continue to monitor the agency's progress and update the recommendation's status when NIH provides its corrective actions.

Recommendation: The Administrator of EPA should update security plan for the selected operational system to identify a description of security controls, and the individual reviewing and approving the plan and date of approval. (Recommendation 19)

Agency: Environmental Protection Agency
Status: Open

Comments: In June 2020, EPA stated it is taking actions to address this recommendation, but the agency did not provide evidence of its corrective actions. We will continue to monitor the agency's progress and update the recommendation's status when EPA provides its corrective actions.

Recommendation: The Administrator of EPA should update the security assessment report for the selected operational system to identify the summarized results of control effectiveness tests. (Recommendation 20)

Agency: Environmental Protection Agency
Status: Open

Comments: EPA did not concur with this recommendation and as of September 2020, the agency has not provided any evidence of its corrective actions. We will continue to monitor the agency's progress and update the recommendation's status when EPA provides its corrective actions.

Recommendation: The Administrator of EPA should update the list of corrective actions for the selected operational system to identify the specific weakness, estimated funding and anticipated source of funding, key remediation milestones with completion dates, changes to milestones and completion dates, and source of the weaknesses. (Recommendation 21)

Agency: Environmental Protection Agency
Status: Open

Comments: In June 2020, EPA stated it is taking action to address this recommendation, but the agency did not provide evidence of its corrective actions. We will continue to monitor the agency's progress and update the recommendation's status when EPA provides its corrective actions.

Recommendation: The Administrator of EPA should prepare the letter authorizing the use of cloud service for the selected operational system and submit the letter to the FedRAMP program management office. (Recommendation 22)

Agency: Environmental Protection Agency
Status: Open

Comments: EPA did not concur with this recommendation and as of September 2020, the agency has not provided any evidence of its corrective actions. We will continue to monitor the agency's progress and update the recommendation's status when EPA provides its corrective actions.

Recommendation: The Administrator of EPA should develop guidance requiring that cloud service authorization letter be provided to the FedRAMP program management office. (Recommendation 23)

Agency: Environmental Protection Agency
Status: Open

Comments: EPA did not concur with this recommendation and as of September 2020, the agency has not provided any additional evidence. We will continue to monitor the agency's progress and update the recommendation's status when EPA provides its corrective actions.

Recommendation: The Under Secretary for Health should ensure that any action plan for achieving health equity includes key elements for successful implementation by consistently applying criteria identified in GAO's past work on effectively managing performance, including developing performance measures to assess progress and creating clear lines of accountability by designating specific offices or officials with responsibility for coordinating efforts to implement actions and committing resources necessary for achieving its goals and objectives. (Recommendation 1)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

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

Recommendation: To ensure the availability of information on health care outcomes by race and ethnicity throughout the VA health care system, the Secretary of Veterans Affairs should conduct an assessment to determine the completeness and accuracy of race and ethnicity data captured in VA's electronic health record, and implement corrective actions as necessary to resolve any identified deficiencies. (Recommendation 2)

Agency: Department of Veterans Affairs: Office of the Secretary
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 of HRSA should ensure that the information it uses to verify nonprofit status for all nongovernmental hospitals that participate in the 340B Program is reliable—for example, by requiring and reviewing the submission of official documentation hospitals must already maintain or by ensuring the reliability of the data the agency uses. (Recommendation 1)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS concurred with this recommendation and in June 2020, reiterated that HRSA believes that the information it uses to determine nonprofit status is reliable, because hospital administrators attest to its accuracy. However, as discussed in our report, neither HRSA nor the agency that collects the data has evaluated the reliability of the data for verifying nonprofit status. Without ensuring it is using reliable information, HRSA cannot effectively determine if nongovernmental hospitals participating, or seeking to participate, in the 340B Program meet the statutory eligibility requirements.

Recommendation: The Administrator of HRSA should implement a process to verify that every nongovernmental hospital that participates in the 340B Program has a contract with a state or local government as required by statute. (Recommendation 2)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS did not concur with this recommendation and, as of June 2, 2020, did not plan to take any actions to implement the recommendation. HHS noted that requiring all covered entities to submit a state or local government contract would create a significant burden for covered entities. However, as we noted in our report, HRSA already requires hospitals to maintain copies of their state or local government contracts. Therefore, it is unclear how implementing a process to verify the existence of those contracts would represent a significant burden. Without this information, HRSA does not have reasonable assurance that nongovernmental hospitals have the statutorily required contracts to participate in the 340B Program.

Recommendation: The Administrator of HRSA should provide more specific guidance for 340B Program auditors on how to determine if nongovernmental hospitals' contracts with state and local governments require the provision of health care services to low-income individuals not eligible for Medicaid or Medicare. (Recommendation 4)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS concurred with this recommendation and in June 2020, indicated that HRSA had updated its audit guidance and procedures to more clearly specify that contracts must contain requirements for the provision of health care services to low-income individuals. However, these documents do not contain any specific guidance on how auditors are to evaluate whether contracts require these services. Without more specific guidance for auditors' review of contracts, HRSA lacks reasonable assurance that the audits are appropriately identifying deficiencies in nongovernmental hospitals' contracts with state or local governments.

Recommendation: The Administrator of HRSA should require nongovernmental hospitals participating in the 340B Program to demonstrate that they have contracts with state or local governments in effect prior to the beginning of their audits' periods of review and should apply consistent and appropriate consequences for hospitals that are unable to do so. (Recommendation 6)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS concurred with this recommendation. As noted in our report, HRSA updated its draft audit procedures for fiscal year 2020 audits in September 2019 to specify that auditors should look for effective dates that cover the entire audit period. While this is an important step, HRSA must also show that it has ceased accepting retroactive contract documentation, and has applied consistent and appropriate consequences when auditors find that nongovernmental hospitals did not have contracts in effect prior to the beginning of their audit periods. As of June 2020, HHS indicated that HRSA had not taken these actions. Allowing hospitals that are unable to demonstrate that they have contracts in place that cover their audits' periods of review to continue to participate without consequences undermines the effectiveness of HRSA's audit process and increases the risk that ineligible hospitals will receive discounts under the program.

Recommendation: The Chief Executive Officer of CNCS should develop an approach to ensure that all relevant participants are involved in the agency-wide process for prioritizing evidence needs. (Recommendation 1)

Agency: Corporation for National and Community Service
Status: Open

Comments: In comments on a draft of this report, the Corporation for National and Community Service (CNCS) neither agreed nor disagreed with this recommendation. Subsequently, in a June 2020 letter, CNCS stated that it agreed with our recommendation and described planned actions to strengthen its agency-wide evidence prioritization process. Among these planned actions were proposed changes to CNCS's approach for involving key participants from across the agency in the process. However, as of October 2020, CNCS had not yet provided us with documentation that would allow us to (1) assess the extent to which they address our recommendation and (2) confirm that these proposed changes were approved. We will continue to monitor CNCS's actions to address this recommendation.

Recommendation: The Chief Executive Officer of CNCS should define roles and responsibilities for all relevant participants involved in the agency-wide process for prioritizing evidence needs. (Recommendation 2)

Agency: Corporation for National and Community Service
Status: Open

Comments: In comments on a draft of this report, the Corporation for National and Community Service (CNCS) neither agreed nor disagreed with this recommendation. Subsequently, in a June 2020 letter, CNCS stated that it agreed with our recommendation and described planned actions to strengthen its agency-wide evidence prioritization process. Among these planned actions were workforce planning and hiring based on the knowledge, skills, and abilities needed for CNCS to address its evidence priorities. The letter stated that once those actions were completed, CNCS would revisit the roles and responsibilities of participants involved in the agency's evidence-building activities. We will continue to monitor CNCS's actions to address this recommendation.

Recommendation: The Chief Executive Officer of CNCS should revise written guidance for the agency-wide process for prioritizing evidence needs to ensure it identifies all relevant participants and their respective roles and responsibilities. (Recommendation 3)

Agency: Corporation for National and Community Service
Status: Open

Comments: In comments on a draft of this report, the Corporation for National and Community Service (CNCS) neither agreed nor disagreed with this recommendation. Subsequently, in a June 2020 letter, CNCS stated that it agreed with our recommendations and described planned actions to strengthen its agency-wide evidence prioritization process. However, as of October 2020, CNCS had not yet provided us with documentation that would allow us to (1) confirm that these proposed changes were approved and (2) assess the extent to which written guidance for the revised process addresses our recommendation. We will continue to monitor CNCS's actions to address this recommendation.

Recommendation: The Secretary of Labor should develop an approach to ensure that all relevant participants are involved in the department-wide process for prioritizing evidence needs. (Recommendation 6)

Agency: Department of Labor
Status: Open

Comments: In a November 2019 letter providing comments on a draft of this report, the Department of Labor (DOL) agreed with this recommendation. The letter further described actions DOL planned to take to address it. DOL stated that in fiscal year 2020 it would update its written guidance to formalize the involvement of relevant participants in department-wide evidence-building activities. However, as of October 2020, DOL had not yet provided us with documentation that would allow us to assess the extent to which its updated guidance addresses our recommendation. We will continue to monitor DOL's actions to address this recommendation.

Recommendation: The Secretary of Labor should revise written guidance for the department-wide process for prioritizing evidence needs to ensure it identifies all relevant participants and their respective roles and responsibilities. (Recommendation 7)

Agency: Department of Labor
Status: Open

Comments: In a November 2019 letter providing comments on a draft of this report, the Department of Labor (DOL) agreed with this recommendation. The letter further described actions DOL planned to take to address it. DOL stated that in fiscal year 2020 it would update its written guidance to formalize the involvement of relevant participants in department-wide evidence-building activities. However, as of October 2020, DOL had not yet provided us with documentation that would allow us to assess the extent to which its updated guidance addresses our recommendation. We will continue to monitor DOL's actions to address this recommendation.

Recommendation: The Director of DHA should define data sharing requirements with more specificity in its transition guidance for outgoing and incoming contractors, including the time period covered and the types of data that must be shared. (Recommendation 1)

Agency: Department of Defense: Office of the Under Secretary for Personnel and Readiness: Defense Health 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 Director of DHA should revise the process the agency has in place for resolving issues raised between contractors during transition to ensure such issues are resolved within time frames that will not adversely affect the transition schedule. (Recommendation 2)

Agency: Department of Defense: Office of the Under Secretary for Personnel and Readiness: Defense Health 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 Director of DHA should incorporate lessons learned from this transition and ensure that subject matter experts review PRV/PRAV requirements and performance guarantees prior to the issuance of the request for proposal for the next transition. These requirements should be reviewed to ensure their feasibility and effectiveness for assessing contractor readiness. (Recommendation 3)

Agency: Department of Defense: Office of the Under Secretary for Personnel and Readiness: Defense Health 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 take steps to ensure appropriate agency-funded research data are readily findable and accessible to the public. (Recommendation 1)

Agency: Department of Defense
Status: Open

Comments: The Department of Defense partially concurred with this recommendation noting the challenge with balancing ensuring public access to research data with considerations of national security and personally identifiable information. As discussed in our report, balancing these considerations is a challenge that agency officials and stakeholders identified during our work. Accordingly, our recommendation to DOD regarding findability and accessibility of agency-funded research data was qualified to pertain to appropriate agency-funded research data--recognizing that it might not be appropriate to make certain datasets publically available because of national security or other concerns. When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of Education should take steps to ensure appropriate agency-funded research data are readily findable and accessible to the public. (Recommendation 2)

Agency: Department of Education
Status: Open

Comments: The Department of Education concurred with this recommendation. According to its response to our report, the Department awarded a contract to support enhancements to its Education Resources Information Center (ERIC) to link scholarly research publications supported by the Department to its publicly accessible datasets. The Department indicated it expects to complete this work by September 30, 2020. When we confirm what actions the Department has taken to implement this recommendation we will provide additional information.

Recommendation: The Director of the Agency for Healthcare Research and Quality should take steps to ensure appropriate agency-funded research data are readily findable and accessible to the public. (Recommendation 3)

Agency: Department of Health and Human Services: Public Health Service: Agency for Healthcare Research and Quality
Status: Open

Comments: The Agency for Healthcare Research and Quality concurred with this recommendation. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Commissioner of the Food and Drug Administration should take steps to ensure appropriate agency-funded research data are readily findable and accessible to the public. (Recommendation 4)

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

Comments: The Food and Drug Administration concurred with this recommendation. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Secretary of Homeland Security should take steps to ensure appropriate agency-funded research data are readily findable and accessible to the public. (Recommendation 5)

Agency: Department of Homeland Security
Status: Open

Comments: The Department of Homeland Security concurred with this recommendation and noted that it was in the process of establishing a portal on its website to increase public access to agency-funded research. The department estimated these efforts would be completed by June 30, 2020. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Secretary of Veterans Affairs should take steps to ensure appropriate agency-funded research data are readily findable and accessible to the public. (Recommendation 6)

Agency: Department of Veterans Affairs
Status: Open

Comments: The Department of Veterans Affairs concurred with this recommendation but indicated in its comments on the report that had already taken steps to implement it. As discussed in the report, the department's efforts to ensure research data availability pertained to a portion of the agency's federally-funded research data. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Director of the National Science Foundation should fully implement plans to ensure appropriate agency-funded research data are readily findable and accessible to the public. (Recommendation 7)

Agency: National Science Foundation
Status: Open

Comments: NSF concurred with this recommendation. According to its response to our report, NSF is expanding its public access repository to include metadata records about data that support publications resulting from NSF-funded research. NSF's response stated that, by storing metadata records for supporting datasets alongside metadata records for publications, the public will be able to more easily find and access appropriate agency funded research data. We will provide an update when we obtain additional information about the status of implementing this recommendation.

Recommendation: The Secretary of Defense should complete development of data management plan requirements for extramural researchers. (Recommendation 8)

Agency: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation noting planned steps to complete development of data management plan requirements. When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Director of the Agency for Healthcare Research and Quality should complete development of data management plan requirements. (Recommendation 9)

Agency: Department of Health and Human Services: Public Health Service: Agency for Healthcare Research and Quality
Status: Open

Comments: The Agency for Healthcare Research and Quality concurred with this recommendation. When we confirm what actions the agency has taken to implement the recommendation we will provide updated information.

Recommendation: The Secretary of Homeland Security should complete development of data management plan requirements. (Recommendation 10)

Agency: Department of Homeland Security
Status: Open

Comments: The Department of Homeland Security concurred with this recommendation, stating that it would develop a departmentwide management directive for research and development data as well as data management plan guidance and a template to document requirements. The department estimated that these efforts would be completed by June 30, 2020. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The U.S. Agency for International Development Administrator should complete development of data management plan requirements for extramural researchers. (Recommendation 11)

Agency: United States Agency for International Development
Status: Open

Comments: The U.S. Agency for International Development agreed with this recommendation. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Secretary of Agriculture should complete development of guidance and provide training to agency officials or others involved in reviewing the merits of researchers' data management plans. (Recommendation 12)

Agency: Department of Agriculture
Status: Open

Comments: The U.S. Department of Agriculture agreed with the findings of our report. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The U.S. Agency for International Development Administrator should complete development of and provide training for agency officials or others involved in reviewing the merits of researchers' data management plans. (Recommendation 13)

Agency: United States Agency for International Development
Status: Open

Comments: The U.S. Agency for International Development agreed with this recommendation. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Commissioner of the Food and Drug Administration should evaluate training needs for agency officials or others involved in reviewing the merits of researchers' data management plans and, if additional training is found to be warranted, develop and provide such training. (Recommendation 14)

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

Comments: The Food and Drug Administration concurred with this recommendation. When we confirm what actions the agency has taken to implement the recommendation we will provide updated information.

Recommendation: The Secretary of Homeland Security should evaluate training needs for agency officials or others involved in reviewing the merits of researchers' data management plans and, if additional training is found to be warranted, develop and provide such training. (Recommendation 15)

Agency: Department of Homeland Security
Status: Open

Comments: The Department of Homeland Security concurred with this recommendation, and indicated it would evaluate training needs for data management plan reviews and develop plans to fulfill any additional training needs identified. The department estimated these efforts would be completed by September 30, 2020. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Secretary of Veterans Affairs should evaluate training needs for agency officials or others involved in reviewing the merits of researchers' data management plans and, if additional training is found to be warranted, develop and provide such training. (Recommendation 16)

Agency: Department of Veterans Affairs
Status: Open

Comments: The Department of Veterans Affairs concurred with this recommendation and identified several planned steps to identify and meet training needs for those involved in reviewing researchers' data management plans. The department estimated these efforts would be completed by September 30, 2020. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Director of the Agency for Healthcare Research and Quality should evaluate training needs for agency officials or others involved in reviewing the merits of researchers' data management plans and, if additional training is found to be warranted, develop and provide such training. (Recommendation 17)

Agency: Department of Health and Human Services: Public Health Service: Agency for Healthcare Research and Quality
Status: Open

Comments: The Agency for Healthcare Research and Quality concurred with this recommendation stating that it would assess training needs for agency officials and others involved in reviewing the merits of researchers' data management plans and would develop and provide additional training if warranted. When we confirm what actions the agency has taken to implement the recommendation we will provide updated information.

Recommendation: The Secretary of Defense should evaluate training needs for agency officials or others involved in reviewing the merits of researchers' data management plans and, if additional training is found to be warranted, develop and provide such training. (Recommendation 18)

Agency: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Secretary of Energy should evaluate training needs for agency officials or others involved in reviewing the merits of researchers' data management plans and, if additional training is found to be warranted, develop and provide such training. (Recommendation 19)

Agency: Department of Energy
Status: Open

Comments: The Department of Energy concurred with this recommendation and stated it would assess and develop a plan to meet the training needs of internal DOE staff and external peer reviewers of data management plans. DOE estimated these efforts would be completed by December 31, 2020. When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Environmental Protection Agency Administrator should evaluate training needs for agency officials or others involved in reviewing the merits of researchers' data management plans and, if additional training is found to be warranted, develop and provide such training. (Recommendation 20)

Agency: Environmental Protection Agency
Status: Open

Comments: The Environmental Protection Agency agreed with this recommendation stating that, during fiscal year 2020, the agency will evaluate training needs for agency officials who review researchers' data management plans. When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of Agriculture should develop and implement a mechanism to ensure researcher compliance with the public access plan and associated requirements. (Recommendation 21)

Agency: Department of Agriculture
Status: Open

Comments: The U.S. Department of Agriculture agreed with the findings of our report. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Secretary of Defense should develop and implement a mechanism to ensure researcher compliance with the public access plan and associated requirements. (Recommendation 22)

Agency: Department of Defense
Status: Open

Comments: The Department of Defense concurred with this recommendation When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Director of the Agency for Healthcare Research and Quality should develop and implement a mechanism to ensure researcher compliance with the public access plan and associated requirements.(Recommendation 23)

Agency: Department of Health and Human Services: Public Health Service: Agency for Healthcare Research and Quality
Status: Open

Comments: The Agency for Healthcare Research and Quality concurred with this recommendation. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Commissioner of the Food and Drug Administration should develop and implement a mechanism to ensure researcher compliance with the public access plan and associated requirements. (Recommendation 24)

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

Comments: The Food and Drug Administration concurred with this recommendation. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Director of the National Institutes of Health should fully develop and implement a mechanism to ensure researcher compliance with the public access plan and associated requirements. (Recommendation 25)

Agency: Department of Health and Human Services: Public Health Service: National Institutes of Health
Status: Open

Comments: The National Institutes of Health concurred with this recommendation but stated that the agency already had mechanisms in place to ensure compliance with public access plan and associated requirements for publications and data. As discussed in the report, we believe our recommendation, as worded, appropriately reflected the extent to which the agency had implemented researcher compliance mechanisms at the time of issuance of our report. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Secretary of Homeland Security should develop and implement a mechanism to ensure researcher compliance with the public access plan and associated requirements. (Recommendation 26)

Agency: Department of Homeland Security
Status: Open

Comments: The Department of Homeland Security concurred with this recommendation and stated it would develop a mechanism to ensure researcher compliance with the department's public access plan and data management plan requirements. The department estimated these efforts would be completed by September 30, 2020. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The National Oceanic and Atmospheric Administration Administrator should fully develop and implement a mechanism to ensure researcher compliance with the public access plan and associated requirements. (Recommendation 27)

Agency: Department of Commerce: National Oceanic and Atmospheric Administration
Status: Open

Comments: The Department of Commerce agreed with this recommendation and the National Oceanic and Atmospheric Administration indicated it was pursuing multiple mechanisms to implement it. When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of Energy should fully develop and implement a mechanism to ensure researcher compliance with the public access plan and associated requirements. (Recommendation 28)

Agency: Department of Energy
Status: Open

Comments: The Department of Energy concurred with this recommendation stating that it would develop a compliance mechanism to identify researchers receiving funding from DOE financial assistance awards who are not compliant with DOE's public access plan for publications. DOE estimated these efforts would be completed by December 31, 2020. When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of Veterans Affairs should fully develop and implement a mechanism to ensure researcher compliance with the public access plan and associated requirements. (Recommendation 29)

Agency: Department of Veterans Affairs
Status: Open

Comments: The Department of Veterans Affairs concurred with this recommendation but indicated in its comments on the report that had already taken steps to implement it. As discussed in the report, the department's public access compliance mechanism covered a portion of the agency's federally-funded research data.. When we confirm what actions the agency has taken in response to the recommendation, we will provide updated information.

Recommendation: The Secretary of Transportation should fully develop and implement a mechanism to ensure researcher compliance with the public access plan and associated requirements. (Recommendation 30)

Agency: Department of Transportation
Status: Open

Comments: The Department of Transportation concurred with this recommendation. According to its response to our report, the Department will build upon existing compliance mechanisms to ensure researcher compliance with its public access plan and associated requirements. As part of this process, the Department reported that it plans to update its public access plan, and expects to complete these actions by December 31, 2020. When we confirm what actions the Department has taken to implement this recommendation we will provide additional information.

Recommendation: The National Institute of Standards and Technology Director should fully develop and implement a mechanism to ensure researcher compliance with the public access plan and associated requirements. (Recommendation 31)

Agency: Department of Commerce: National Institute of Standards and Technology
Status: Open

Comments: The Department of Commerce agreed with this recommendation and the National Institute of Standards and Technology identified several planned steps to implement it with full completion anticipated by December 31, 2020. When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: As the Subcommittee on Open Science moves forward, the Office of Science and Technology Policy co-chair, in coordination with other co-chairs and participating agencies, should take steps to fully implement leading practices that enhance and sustain collaboration. (Recommendation 32)

Agency: Executive Office of the President: Office of Science and Technology Policy
Status: Open

Comments: OSTP disagreed with GAO's November 2019 recommendation, stating that the subcommittee had already taken steps to implement the leading practices GAO identified. However, OSTP officials did not provide documentation of these efforts and GAO continued to believe the recommendation was warranted. In March 2020, OSTP provided information on steps the subcommittee has taken to address issues associated with public access to federally funded research results, including certain areas GAO identified as presenting challenges to public access plan implementation in the November 2019 report. GAO will collect and evaluate additional information to determine the extent to which these steps incorporate leading practices for interagency collaboration GAO has identified. By taking steps to fully implement the relevant leading practices we have identified, the subcommittee and its member agencies could better marshal their collective efforts to address common public access plan implementation challenges that agency officials and stakeholders identified.

Recommendation: As the Subcommittee on Open Science moves forward, the Department of Defense co-chair, in coordination with other co-chairs and participating agencies, should take steps to fully implement leading practices that enhance and sustain collaboration. (Recommendation 33)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with GAO's November 2019 recommendation, noting that DOD participates in subcommittee initiatives, including a working group on disclosure risk management, which is a topic of great importance to DOD. In March 2020, the Office of Science and Technology Policy provided information on steps the subcommittee has taken to address issues associated with public access to federally funded research results, including certain areas GAO identified as presenting challenges to public access plan implementation in the November 2019 report. GAO will collect and evaluate additional information to determine the extent to which these steps incorporate leading practices for interagency collaboration GAO has identified. By taking steps to fully implement the relevant leading practices we have identified, the subcommittee and its member agencies could better marshal their collective efforts to address common public access plan implementation challenges that agency officials and stakeholders identified.

Recommendation: As the Subcommittee on Open Science moves forward, the Department of Energy co-chair, in coordination with other co-chairs and participating agencies, should take steps to fully implement leading practices that enhance and sustain collaboration. (Recommendation 34)

Agency: Department of Energy
Status: Open

Comments: DOE concurred with GAO's November 2019 recommendation. DOE noted that, as a co-chair of the subcommittee, it is actively identifying areas of collaboration across agencies in implementing open science practices. In March 2020, the Office of Science and Technology Policy provided information on steps the subcommittee has taken to address issues associated with public access to federally funded research results, including certain areas GAO identified as presenting challenges to public access plan implementation in the November 2019 report. GAO will collect and evaluate additional information to determine the extent to which these steps incorporate leading practices for interagency collaboration GAO has identified. By taking steps to fully implement the relevant leading practices we have identified, the subcommittee and its member agencies could better marshal their collective efforts to address common public access plan implementation challenges that agency officials and stakeholders identified.

Recommendation: As the Subcommittee on Open Science moves forward, the National Institutes of Health co-chair, in coordination with other co-chairs and participating agencies, should take steps to fully implement leading practices that enhance and sustain collaboration. (Recommendation 35)

Agency: Department of Health and Human Services: Public Health Service: National Institutes of Health
Status: Open

Comments: NIH concurred with GAO's November 2019 recommendation. NIH stated that the subcommittee and its working groups are actively coordinating and building consensus on issues and processes to implement leading practices that enhance and sustain collaboration across federal agencies. In March 2020, the Office of Science and Technology Policy provided information on steps the subcommittee has taken to address issues associated with public access to federally funded research results, including certain areas GAO identified as presenting challenges to public access plan implementation in the November 2019 report. GAO will collect and evaluate additional information to determine the extent to which these steps incorporate leading practices for interagency collaboration GAO has identified. By taking steps to fully implement the relevant leading practices we have identified, the subcommittee and its member agencies could better marshal their collective efforts to address common public access plan implementation challenges that agency officials and stakeholders identified.

Recommendation: As the Subcommittee on Open Science moves forward, the National Oceanic and Atmospheric Administration co-chair, in coordination with other co-chairs and participating agencies, should take steps to fully implement leading practices that enhance and sustain collaboration. (Recommendation 36)

Agency: Department of Commerce: National Oceanic and Atmospheric Administration
Status: Open

Comments: NOAA concurred with GAO's November 2019 recommendation, noting that NOAA would work with the subcommittee to identify more opportunities for collaboration to promote access to research results. In March 2020, the Office of Science and Technology Policy provided information on steps the subcommittee has taken to address issues associated with public access to federally funded research results, including certain areas GAO identified as presenting challenges to public access plan implementation in the November 2019 report. GAO will collect and evaluate additional information to determine the extent to which these steps incorporate leading practices for interagency collaboration GAO has identified. By taking steps to fully implement the relevant leading practices we have identified, the subcommittee and its member agencies could better marshal their collective efforts to address common public access plan implementation challenges that agency officials and stakeholders identified.

Recommendation: As the Subcommittee on Open Science moves forward, the National Science Foundation co-chair, in coordination with other co-chairs and participating agencies, should take steps to fully implement leading practices that enhance and sustain collaboration. (Recommendation 37)

Agency: National Science Foundation
Status: Open

Comments: The National Science Foundation concurred with GAO's November 2019 recommendation. In March 2020, the Office of Science and Technology Policy provided information on steps the subcommittee has taken to address issues associated with public access to federally funded research results, including certain areas GAO identified as presenting challenges to public access plan implementation in the November 2019 report. GAO will collect and evaluate additional information to determine the extent to which these steps incorporate leading practices for interagency collaboration GAO has identified. By taking steps to fully implement the relevant leading practices we have identified, the subcommittee and its member agencies could better marshal their collective efforts to address common public access plan implementation challenges that agency officials and stakeholders identified.

Recommendation: The Administrator of ACL should work with other relevant HHS officials to document the department's plan to focus on the specific nutritional needs of older adults in the 2025-2030 update of the Dietary Guidelines for Americans, which would include, in part, plans to identify existing information gaps on older adults' specific nutritional needs. (Recommendation 1)

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

Comments: HHS agreed with this recommendation, stating that ACL plans to work with the Office of Disease Prevention and Health Promotion and other relevant HHS officials and agencies to document HHS's plans to emphasize the specific and varying nutritional needs of older adults in the 2025-2030 update. HHS also stated that ACL plans to acquire the services of a registered dietician with specialized expertise in older adults' nutritional needs. We will consider closing this recommendation when these efforts are completed.

Recommendation: The Administrator of ACL should direct regional offices to take steps to ensure states are monitoring providers to ensure meal consistency with federal nutrition requirements for meals served in the congregate and home-delivered meal programs. (Recommendation 2)

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

Comments: HHS agreed with this recommendation. HHS stated that ACL's program and evaluation offices will collaborate on the development of plans to ensure state compliance with federal requirements.

Recommendation: The Administrator of FNS should take steps to improve its oversight of CACFP meals provided in adult day care centers. For example, FNS could amend its approach for determining federal onsite reviews of CACFP meal providers to more consistently include adult day care centers. (Recommendation 3)

Agency: Department of Agriculture: Office of the Secretary: Food, Nutrition and Consumer Services: Food and Nutrition Service
Status: Open

Comments: In May 2020, the Department of Agriculture's Food and Nutrition Service told us that, in an effort to improve oversight of the CACFP meals provided in adult day care centers, it will place a special interest on lessons learned from onsite local reviews that are conducted by states where the adult portion of the CACFP is administered separately by the state department of aging and thus, adult day care institutions are always selected for local onsite reviews as part of their management evaluation. Further, Food and Nutrition Service told us it will commit to sharing this information with other state agencies that administer the CACFP. Food and Nutrition Service estimates completing this action by the end of calendar year 2020. We will review the status of this recommendation upon receipt of Food and Nutrition Service updates at the end of 2020.

Recommendation: The Administrator of ACL should centralize information on promising approaches for making meal accommodations to meet the nutritional needs of older adult participants in the congregate and home-delivered meal programs, for example in one location on its National Resource Center on Nutrition and Aging website, to assist providers' efforts. (Recommendation 4)

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

Comments: HHS agreed with this recommendation. The agency stated that ACL will award a contract in fiscal year 2020 for a new National Resource Center on Nutrition and Aging to, among other things, centralize information on promising approaches so nutrition services providers can access it easily. We will consider closing this recommendation when this effort is complete.

Recommendation: The Administrator of FNS should take steps to better disseminate existing information that could help state and local entities involved in providing CACFP meals meet the varying nutritional needs of older adult participants, as well as continue to identify additional promising practices or other information on meal accommodations to share with CACFP entities. (Recommendation 5)

Agency: Department of Agriculture: Office of the Secretary: Food, Nutrition and Consumer Services: Food and Nutrition Service
Status: Open

Comments: In May 2020, the Department of Agriculture's Food and Nutrition Service told us that it will take several actions over the next 12 months to address our recommendation. Food and Nutrition Service actions will include holding listening sessions specifically focused on the adult day care side of the program at two national CACFP conferences this year to understand the specific information providers are looking for the address the needs of older adults and identify promising strategies for accommodating those needs; review existing guidance for training opportunities and areas that could benefit from further clarifications; and updating the Adult Day Care Handbook to include promising practice examples to address specific information and concerns gathered from the listening sessions, GAO's report findings, and further clarifications from existing guidance. Food and Nutrition Service also told us it will use multiple channels to ensure the handbook is widely disseminated to state agencies and adult day care program operators. We will review the status of this recommendation upon receipt of additional updates from Food and Nutrition Service regarding the aforementioned actions to be taken over the next 12 months.

Recommendation: The Administrator of CMS should require states to submit and make public projections of administrative costs when seeking approval of demonstrations, including those with work requirements and all other demonstrations. (Recommendation 1)

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

Comments: HHS did not concur with this recommendation in its September 2019 comments on the report. We maintain that the recommendation is valid because requiring states to make public information about administrative costs would help to ensure that demonstration proposals provide sufficient information to ensure meaningful public input.

Recommendation: The Administrator of CMS should account for the administrative costs of demonstrations, including those with work requirements and all other demonstrations, when assessing whether demonstrations are budget neutral. (Recommendation 2)

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

Comments: HHS did not concur with this recommendation in its September 2019 comments on the report. We maintain that the recommendation is valid because including administrative costs in its assessments will help HHS ensure that demonstrations are budget neutral.

Recommendation: The Administrator of CMS should assess the risks of providing federal funds for costs to administer work requirements that are not allowable and should respond to risks by improving oversight procedures, as warranted. This assessment should consider risks related to costs for information systems, beneficiary supports, and managed care. (Recommendation 3)

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

Comments: HHS did not concur with this recommendation in its September 2019 comments on the report. We maintain that the recommendation is valid and that assessing these risks of providing federal funds for costs that are not allowable and improving oversight, as warranted, would help HHS to ensure the integrity of the Medicaid program.

Recommendation: The VA Under Secretary of Health should use workload data from the most recently completed fiscal year as part of the models that inform VISNs' and medical centers' general purpose funding needs, when doing so would not significantly delay the allocation of funds. (Recommendation 1)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The VA Under Secretary of Health should establish a formal process to document VHA's review of VISNs' adjustments to medical center allocation levels. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The VA Under Secretary of Health should revise VHA's existing guidance to require VISNs to provide information on how they determined how much and for what reasons they made adjustments to medical center allocation levels. (Recommendation 3)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The VA Under Secretary of Health should revise its existing guidance to require VISNs—in conjunction with medical centers—to develop and submit approaches to improve efficiency at medical centers with declining workload that received adjusted funding levels. These approaches could include adjusting the level of services offered. (Recommendation 4)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open
Priority recommendation

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The VA Under Secretary of Health should require VISNs to provide explanations on the amount of funds redistributed between VISNs and medical centers and VHA to document its review of these redistributions. (Recommendation 5)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: ASPR should develop a response personnel strategy to ensure, at a minimum, a lead ASPR liaison officer is consistently at the local emergency operations center(s) during an emergency support functions (ESF) #8 response and another liaison, if not more, is at strategic location(s) in the area. (Recommendation 1)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
Status: Open

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

Recommendation: As ASPR finalizes its federal patient movement framework, the agency should exercise the framework with its National Disaster Medical System (NDMS) partners to ensure that patients evacuated through NDMS will be consistently tracked from the start of their evacuation. (Recommendation 2)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
Status: Open

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

Recommendation: ASPR should put controls in place to ensure data on all NDMS evacuated patients are complete and accurate. (Recommendation 3)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
Status: Open

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

Recommendation: ASPR Region II should revise its Incident Response Plans for the territories to include strategies for providing chronic and primary care in isolated communities. These strategies could include the incorporation of Federally Qualified Health Centers and other local health clinics as part of a response. (Recommendation 4)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
Status: Open

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

Recommendation: ASPR should work with support agencies to develop and finalize memorandums of agreement that include information on the capabilities and limitations of these agencies to meet ESF#8 core capabilities. (Recommendation 5)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
Status: Open

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

Recommendation: ASPR should develop a strategy demonstrating how it ESF#8 core capabilities can be provided through HHS and ESF#8 support agencies if DOD's capacity to respond is limited. (Recommendation 6)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
Status: Open

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

Recommendation: ASPR should take steps to ensure the perspectives of key external parties are incorporated in the development of HHS's after-action reviews, following future ESF#8 activations. (Recommendation 7)

Agency: Department of Health and Human Services: Office of the Assistant Secretary for Preparedness and Response
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 of CMS should, to the extent feasible, maintain more complete information on both the total amount of funding allocated for quality measurement activities and the extent to which this funding supports each of its quality measurement strategic objectives. (Recommendation 1)

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid 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 Administrator of CMS should develop and implement procedures to systematically assess the measures it is considering developing, using, or removing in terms of their impact on achieving CMS's strategic objectives and document its compliance with those procedures. (Recommendation 2)

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid 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 Administrator of CMS should develop and use a set of performance indicators to evaluate the agency's progress towards achieving its quality measurement strategic objectives. (Recommendation 3)

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid 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 Secretary of the VA should direct the Under Secretary for Health to collect complete staffing data for the Family Caregiver Program that includes Caregiver Support Program Office funded staff, VAMC funded staff, and staff that assist the program as a collateral duty at each VAMC. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation. The Veterans Health Administration (VHA) has reported that the Caregiver Support Program Office had identified a solution for identifying VHA Family Caregiver Program staff in the Human Resource (HR) Smart system. VHA reported that current full- and part-time employees funded by the Caregiver Support Program Office will be identified with a specific specialty code in HR Smart. However, as of April 2020, this capability was not yet available in HR Smart and staffing for the program continued to be manually updated and tracked. Further, the proposed use of HR Smart will still not result in complete information that the Caregiver Support Program Office can use to track all staff who support the program because according to VHA, staff that assist the program as a collateral duty and VAMC-funded staff who support the program will not be tracked through HR Smart. As of July 2020, this recommendation remains open pending further updates from VHA.

Recommendation: The Secretary of the VA should direct the Under Secretary for Health to establish a process to ensure that the Family Caregiver Program staffing data that are collected and reported to the Caregiver Support Program Office are accurate. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VHA concurred with this recommendation. In February 2020, the Veterans Health Administration (VHA) reported that the Caregiver Support Program Office had identified a solution for identifying full-time VHA Family Caregiver Program staff in the Human Resource (HR) Smart system through the use of a specific specialty code. VHA reported that once implemented, the use of the HR SMART specialty code would provide more accurate information regarding staffing. In April 2020, VHA stated that were would also be a static field called "position skill type" that would track positions with a skill type category of caregiver and that Veterans Integrated Service Network (VISN) leads for the Family Caregiver Program would use this field to cross check the new specialty code and identify and correct any reporting inconsistencies. As of July 2020, this recommendation remains open pending further updates from VHA.

Recommendation: The Administrator of CMS should ensure the agency's Medicaid third-party liability guidance is consistent with federal law related to

• the requirement for states to apply cost avoidance procedures to claims for labor, delivery, and postpartum care services,
• the requirement for states to make payments without regard to potential third-party liability for pediatric preventive services unless the state has made a determination related to cost-effectiveness and access to care that warrants cost avoidance for 90 days, and
• state flexibility to make payments without regard to potential third-party liability for pediatric services provided to child support enforcement beneficiaries. (Recommendation 1)

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

Comments: On November 14, 2019, CMS issued an Informational Bulletin providing further guidance to Medicaid Bipartisan Budget Act (BBA) of 2018 and changes to Medicaid Provisions Passed in April 2019-Third Party Liability in Medicaid and CHIP. The intent of the information Bulletin is to further clarify CMS guidance issued in the agency's June 2018 Bulletin on key provisions related to third party liability in Medicaid and CHIP. The Bulletin also addresses April 2019 changes to the Bipartisan Budget Act of 2013. The bulletin clarifies CMS guidance on two of the three issues we identified in our 2019 report. The bulletin notes that (1) effective February 9, 2018 a state is required to use standard coordination of benefits cost avoidance when processing claims for prenatal services which now includes labor and delivery and postpartum care claims, and (2) effective October 1, 2019, a state is required to make payments without regard to third party liability for pediatric preventive services unless the state has made a determination related to cost-effectiveness and access to care that warrants cost avoidance for 90 days. However, with regard to the third issue, the bulletin notes that, effective April 18, 2019, a state is allowed 100 days to pay claims related to child support enforcement, but does not note that states may choose to make payment within 30 days, if the state determines doing so is cost-effective and necessary to ensure access to care. We will continue to monitor CMS guidance on payments related to child support enforcement to assess whether the recommendation is fully implemented.

Recommendation: The Administrator of CMS should determine the extent to which state Medicaid programs are meeting federal third-party liability requirements and take actions to ensure compliance as appropriate. Such actions can include ensuring that state plans reflect the law. (Recommendation 2)

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

Comments: As of February 2020, we are unaware of any actions taken by CMS to implement this recommendation.

Recommendation: The Under Secretary for Health should document same-day services objectives and develop performance goals and related performance measures to facilitate the periodic assessment of the impact of same-day services on veterans' access to care. (Recommendation 1)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

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

Recommendation: The Under Secretary of Health should require that all failures to meet quality standards are cited as deficiencies on SVH inspections. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA concurred with this recommendation and, as of July 2020, had taken some initial steps to address the recommendation such as modifying the SVH contractor's contract to stop the practice of using 'recommendations' for low-level deficiencies and beginning the process of revising a VA policy to address this practice.

Recommendation: The Under Secretary of Health should develop guidance for Veterans Affairs Medical Center staff conducting optional onsite CNH reviews. (Recommendation 3)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA concurred in principle with this recommendation and indicated in January 2020 that it had begun taking actions to address this recommendation such as developing a memo of clarification and planning the release of additional guidance for staff.

Recommendation: The Under Secretary of Health should provide information on the quality of all SVHs that is comparable to the information provided on the other nursing home settings on its Access to Care website. (Recommendation 4)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA concurred in principle and, as of July 2020, had begun taking some steps to address this recommendation such as exploring options for presenting SVH quality measure data.

Recommendation: The Under Secretary for Health should develop a process to assess the overall performance of VISNs in managing and overseeing medical centers. (Recommendation 1)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: VHA concurred with our recommendation. In December 2019, VHA reported efforts to modernize its governance structure with a newly created VHA Governance Board. In February 2020, VHA reported additional efforts to charter governance councils to support the VHA Governance Board and work continues to develop these councils and responsibilities, with a target completion date of September 2020. For closure, VHA will need to provide documentation that shows the process developed to assess the overall performance of VISNs in managing medical centers. Providing documentation explaining how these governance structures plan to assess overall VISN performance, including any metrics or tools that would be used as a part of this process, would be useful in determining if this recommendation can be considered for closure.

Recommendation: The Under Secretary for Health should establish a comprehensive policy that clearly defines VISN roles and responsibilities for managing and overseeing medical centers. (Recommendation 2)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open
Priority recommendation

Comments: VHA concurred in principle with our recommendation. In December 2019, VHA told us they were working to streamline reporting structures at all levels, focusing on governance and workflow, including defining consistent levels of authority. In February 2020, VHA told us they were realigning Central Office in addition to making changes to the governance structure to support clarity of roles and responsibilities. VHA plans to crosswalk existing policies to the new structure and organizations, with a target completion date of September 2020. Following completion of VHA's efforts to streamline Central Office and ensure reporting structures are in place, VHA will need to provide policy documentation that clearly outlines VISN roles and responsibilities, including how these governance structures plan to define the VISN's roles and responsibilities. While governance and reporting structures are a first step, it is important for roles and responsibilities to be clearly outlined in a policy vehicle, as VHA requires the use of policy to assign responsibilities for executing a course of action to individuals or groups.

Recommendation: The Under Secretary for Health should establish a process to routinely oversee VISN staffing, to include ensuring VISNs are consistent with VHA's standardized VISN staffing levels and positions, and documenting the rationale for approving staffing that does not adhere to VHA's standardized approach. (Recommendation 3)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: VHA concurred with our recommendation. In December 2019, VHA reported its office for Manpower Management began reviewing changes to VISN organizational structure and positions. In February 2020, VHA provided GAO with the guidance for VISN staffing and a draft Manpower Management directive, with target completion date of May 2020 for approval. For closure, VHA should provide the approved VA Directive 5010 documentation outlining the process developed to routinely oversee VISN staffing, including efforts by the DUSHOM in partnership with Workforce Management and Consulting and Manpower and Management, such as policy directives, organizational charts, amongst others.

Recommendation: The administrator of CMS should require that abuse and perpetrator type be submitted by state survey agencies in CMS's databases for deficiency, complaint, and facility-reported incident data, and that CMS systematically assess trends in these data. (Recommendation 1)

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

Comments: HHS concurred with this recommendation. In February 2020, HHS said CMS is developing the ability to review survey trends related to alleged perpetrator and alleged abuse types and aims to implement this recommendation by December 2020.

Recommendation: The administrator of CMS should develop and disseminate guidance—including a standardized form—to all state survey agencies on the information nursing homes and covered individuals should include on facility-reported incidents. (Recommendation 2)

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

Comments: HHS concurred with this recommendation. In February 2020, HHS said CMS will list the elements that all nursing homes should report to state agencies and aims to implement this recommendation by December 2020.

Recommendation: The administrator of CMS should require state survey agencies to immediately refer complaints and surveys to law enforcement (and, when applicable, to Medicaid Fraud Control Units (MFCU)) if they have a reasonable suspicion that a crime against a resident has occurred when the complaint is received. (Recommendation 3)

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

Comments: HHS concurred with this recommendation. In February 2020, HHS said CMS will require state survey agencies to immediately refer complaints upon receipt and surveys to law enforcement (and, when applicable, to Medicaid Fraud Control Units) if they have a reasonable suspicion that a crime against a resident has occurred and aims to implement this requirement by December 2020.

Recommendation: The administrator of CMS should conduct oversight of state survey agencies to ensure referrals of complaints, surveys, and substantiated incidents with reasonable suspicion of a crime are referred to law enforcement (and, when applicable, to MFCUs) in a timely fashion. (Recommendation 4)

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

Comments: HHS concurred with this recommendation. In February 2020, HHS said CMS will revise guidance to ensure state survey agencies will investigate and track incidents of abuse and neglect and report substantiated findings to local law enforcement. CMS aims to implement this recommendation by December 2020.

Recommendation: The administrator of CMS should develop guidance for state survey agencies clarifying that allegations verified by evidence should be substantiated and reported to law enforcement and state registries in cases where citing a federal deficiency may not be appropriate. (Recommendation 5)

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

Comments: HHS concurred with this recommendation. In February 2020, HHS said CMS will provide clarification to the state survey agencies regarding the definition of substantiated and when cases need to be referred to law enforcement. CMS aims to implement this recommendation by December 2020.

Recommendation: The administrator of CMS should provide guidance on what information should be contained in the referral of abuse allegations to law enforcement. (Recommendation 6)

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

Comments: HHS concurred with this recommendation. In February 2020, HHS said it will provide guidance to state agencies and nursing homes on identifying and reporting potential abuse and neglect of residents and will develop a list of standardized elements that should be included when reporting an abuse allegation to law enforcement. HHS aims to implement this recommendation by July 2020.

Recommendation: The Secretary of Defense should direct DHA to ensure that MTFs' referral management center staff are trained to process and accurately document information in MHS Genesis about specialty care referrals, including the receipt of CLRs, the submission of referral results, and the closure of referrals. (Recommendation 1)

Agency: Department of Defense
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 direct DHA to ensure that MHS Genesis is configured to produce reports that accurately reflect the use and outcomes of specialty care referrals. (Recommendation 2)

Agency: Department of Defense
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 of ACL should take steps to better centralize access to and promote awareness of information on promising practices or other useful information pertinent to serving rural older adults.

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

Comments: HHS agreed with this recommendation, stating that it would encourage its resource centers to identify promising practices and other information specific to rural communities so that these resources would be searchable. In December 2019, ACL stated that it would continue to list all resource centers on its website so that anyone can find resources specific to any topic funded by ACL. The agency also noted that it would begin implementation of this action with new resource centers funded with FY 2020 appropriations. GAO continues to encourage ACL to centralize access to information pertinent to rural older adults by making it easily searchable across these websites or compiling it in other ways and promoting awareness of this information.

Recommendation: The Administrator of CMS should develop and communicate a policy that defines when changes to a pending section 1115 demonstration application are considered major and should prompt a new review of the application against the transparency requirements applicable to the pending application. (Recommendation 1)

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

Comments: In response to this recommendation, HHS stated that existing regulations permit CMS at its discretion to direct an additional public comment period when states make a modification to an application that substantially changes the design. In July 2020, CMS officials said the agency would continue to exercise its regulatory discretion as needed and planned no further action in response to this recommendation. In light of past CMS decisions to not require states to first seek public comment before submitting major changes to their demonstration applications, we maintain that a policy is needed defining when changes are considered major and should prompt a new review of the application against transparency requirements. We will continue to monitor CMS's actions in this area.

Recommendation: The Administrator of CMS should develop and communicate a policy whereby applications for section 1115 demonstration amendments that may have significant impact are subject to transparency requirements comparable to those for new demonstrations and extensions. (Recommendation 2)

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

Comments: HHS stated that it plans to implement a policy applying state public input processes and application criteria to amendments proposing significant or substantial changes in the same manner as for new demonstrations. In July 2020, CMS stated the agency plans to develop criteria for determining whether an amendment application proposes a substantial change to an existing demonstration and to include this in guidance by early 2021. We will continue to monitor CMS's actions in this area and will close this recommendation once this policy guidance is issued.

Recommendation: The Secretary of Energy should take action to educate and communicate the agency's scientific integrity polices to staff through, for example, regular training. (Recommendation 1)

Agency: Department of Energy
Status: Open

Comments: In July 2020, DOE provided an update on the status of this recommendation. In that update, DOE said the scientific integrity official will be responsible for leading and coordinating with other elements of the Department, in the development of measures to educate and communicate DOE's scientific integrity policies to staff.

Recommendation: The Secretary of Energy should establish steps and a time frame for designating a scientific integrity official to oversee the department's scientific integrity activities. (Recommendation 3)

Agency: Department of Energy
Status: Open

Comments: In July 2020, DOE provided an update on the status of this recommendation. In that update, DOE said that it was still in the process of identifying an individual to serve as a scientific integrity official.

Recommendation: The Secretary of Energy should develop mechanisms to regularly monitor and evaluate implementation of the department's scientific integrity policy, including mechanisms to remediate identified deficiencies and make improvements where necessary. (Recommendation 4)

Agency: Department of Energy
Status: Open

Comments: In July 2020, DOE provided an update on the status of this recommendation. In that update, DOE stated that the Department's scientific integrity official will have the responsibility to lead and coordinate with other elements of the Department in developing procedures to monitor and evaluate the implementation of DOE's scientific integrity policy, including mechanisms to remediate identified deficiencies and make improvements where necessary.

Recommendation: The Secretary of Transportation should develop mechanisms to regularly monitor and evaluate implementation of the department's scientific integrity policy, including mechanisms to remediate identified deficiencies and make improvements where necessary. (Recommendation 5)

Agency: Department of Transportation
Status: Open

Comments: In September 2020, the Department of Transportation provided an update on the status of this recommendation. In that update, officials said that DOT was still working on this action. According to officials, the department will implement several mechanisms to address the recommendation, including conducting annual reviews of the scientific integrity policy and making the policy available to all relevant employees. DOT estimated it would complete these actions by the end of March 2021.

Recommendation: The Director of NIST should develop mechanisms to regularly monitor and evaluate implementation of the agency's scientific integrity policy, including mechanisms to remediate identified deficiencies and make improvements where necessary. (Recommendation 6)

Agency: Department of Commerce: National Institute of Standards and Technology
Status: Open

Comments: In Commerce's written comments, NIST had stated that, beginning in fiscal year 2019, the agency would review implementation of its policy at least annually and make recommendations to the Director of NIST as to whether any improvements were needed. In a September 2020 update, NIST provided a memorandum reporting that in fiscal year 2019 the Scientific Integrity Officer and General Counsel had discussed an allegation related to scientific integrity, and that it was determined that programmatic factors, not a lapse in scientific integrity, had occurred. According to NIST, it monitors the effectiveness of the implementation of its documented scientific integrity policy, order, and procedure by means of informal feedback from NIST researchers and supervisors, as documented in the memorandum.

Recommendation: The NOAA Administrator should develop mechanisms to regularly monitor and evaluate implementation of the agency's scientific integrity policy, including mechanisms to remediate identified deficiencies and make improvements where necessary. (Recommendation 7)

Agency: Department of Commerce: National Oceanic and Atmospheric Administration
Status: Open

Comments: In Commerce's written comments, NOAA stated that it will identify additional metrics for monitoring and evaluating its policy. As of October 2020, we have requested an update from the agency but have not yet received information to evaluate implementation of this recommendation.

Recommendation: The Director of USGS should develop mechanisms to regularly monitor and evaluate implementation of the agency's scientific integrity policy, including mechanisms to remediate identified deficiencies and make improvements where necessary. (Recommendation 8)

Agency: U.S. Geological Survey
Status: Open

Comments: In September 2020, the Department of the Interior provided an update on this recommendation. In that update, officials stated that the expected completion date is the end of November 2022.

Recommendation: The Secretary of Energy should develop documented procedures for identifying and addressing alleged violations of its scientific integrity policy. (Recommendation 9)

Agency: Department of Energy
Status: Open

Comments: In July 2020, DOE provided an update on the status of this recommendation. In that update, DOE stated that the department's scientific integrity official will be responsible for leading and coordinating with other elements of the Department in developing procedures for identifying and addressing alleged violations of DOE's scientific integrity policy.

Recommendation: The Administrator of NASA should develop documented procedures for identifying and addressing alleged violations of its scientific integrity policy. (Recommendation 10)

Agency: National Aeronautics and Space Administration
Status: Open

Comments: NASA officials stated that the agency is undergoing additional internal and external reviews-with NASA officials working through the National Science and Technology Council's Joint Committee on Research Environments, which supports scientific security, rigor, and integrity-and that completion of the implementation of the recommendation is due October 31, 2020.

Recommendation: As VA and IHS revise the MOU and related performance measures, the Secretary of Veterans Affairs should ensure these measures are consistent with the key attributes of successful performance measures, including having measurable targets. (Recommendation 1)

Agency: Department of Veterans Affairs
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 Veterans Affairs should, in consultation with IHS and tribes, establish and distribute a written policy or guidance on how referrals from IHS and Tribal Health Program (THP) facilities to VA facilities for specialty care can be managed. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: As VA and IHS revise the MOU and related performance measures, the Director of IHS should ensure these measures are consistent with the key attributes of successful performance measures, including having measurable targets. (Recommendation 3)

Agency: Department of Health and Human Services: Public Health Service: Indian Health Service
Status: Open

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

Recommendation: The Under Secretary for Health should ensure that facility officials who are responsible for credentialing, reviewing credentials, and hiring receive periodic mandatory training. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of March 2020, VA officials told us that they expect to have this recommendation implemented during calendar year 2020.

Recommendation: The Under Secretary for Health should develop policies and guidance regarding DEA registrations, including the circumstances in which Drug Enforcement Administration (DEA) waivers may be required, the process for requesting them, and a mechanism to ensure that facilities follow these policies. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: As of March 2020, this recommendation remains open. VA sent a letter to DEA asking for clarification about DEA employment waivers and received a response from DEA dated November 26, 2019. VA officials told us that they are considering the input from DEA and consulting with relevant stakeholders to determine next steps. To fully implement this recommendation, VA needs to provide evidence of actions taken to ensure that DEA requirements regarding DEA registrations and employment waivers are met. Such actions include developing policies regarding when a DEA employment waiver may be necessary and guidance about how to request such a waiver.

Recommendation: The Under Secretary for Health should identify and review providers whose DEA registrations were revoked or surrendered for cause and determine whether an employment waiver may be needed from DEA. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: As of March 2020, VA has reported important steps toward implementing this recommendation. Specifically, VA officials told us that they reviewed licensed independent practitioners to see if any that are currently employed at VA have a revoked or surrendered DEA registration. They identified at least one provider with a revoked or surrendered DEA registration. To fully implement this recommendation, VA needs to provide evidence that appropriate action was taken for this provider, such as obtaining a DEA waiver if necessary.

Recommendation: The Secretary of Health and Human Services should revise HHS's process for conducting improper payment risk assessments for Head Start to help ensure that it results in a reliable assessment of whether the program is susceptible to significant improper payments. This should include preparing sufficient documentation to support its risk assessments. (Recommendation 1)

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

Comments: The Department of Health and Human Services (HHS) concurred with this recommendation. In fiscal year 2019, HHS reported that it utilized Microsoft SharePoint to facilitate and begin to automate the Improper Payment Risk Assessment process. According to HHS, the SharePoint risk assessment form included the added ability to track the status of submissions and collect any applicable supporting documentation. Also, HHS stated that the Assistant Secretary for Financial Resources staff discussed the importance of maintaining supporting documentation during the fiscal year 2019 Improper Payment Risk Assessment Kick-Off meeting with HHS's operating divisions, and also built this feature into the SharePoint form. In fiscal year 2020, HHS reported that the implementation of the long-term solution to conducting improper payment risk assessments, the Risk Assessment Portal (previously called the Automated Improper Payment Framework), is underway and went into production in March 2020. Additionally, HHS indicated that it has revised its improper payment questionnaire and scoring process to ensure HHS performs a reliable assessment of susceptibility to significant improper payments. Also, HHS stated that it will leverage the Risk Assessment Portal, new questionnaire, and revised scoring process in the fiscal year 2020 risk assessment reporting period. Further, HHS stated that it is reviewing GAO reports and resources, capturing best practices from other agencies, and soliciting feedback from HHS's operating divisions to further improve its processes. Last, HHS stated that it will continue to develop policies, procedures, and supporting tools throughout calendar year 2020. We will continue to monitor the agency's actions to address this recommendation.

Recommendation: The Secretary of Health and Human Services should revise HHS's procedures for conducting improper payment risk assessments to help ensure that all programs and activities are assessed for susceptibility to significant improper payments at least once every 3 years, as required by IPIA. (Recommendation 2)

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

Comments: The Department of Health and Human Services (HHS) concurred with this recommendation. In fiscal year 2019, HHS reported that it utilized DATA Act information to create an inventory of programs and activities that could potentially be subject to improper payment risk assessment requirements. According to HHS, it developed a risk-based methodology for selecting programs and activities for review using the DATA Act files. Data fields within the DATA Act files allow HHS to further analyze the program and activity inventory. For example, the object class data enabled HHS to categorize the program's spending to provide insight into each program's unique risks. HHS stated that this methodology was used and documented in fiscal year 2019 but HHS plans to further refine and finalize this approach. In fiscal year 2020, HHS reported that its Office of the Inspector General (OIG) is currently reviewing the methodology as part of the Annual Inspector General review of HHS's improper payment reporting under the Improper Payments Elimination and Recovery Act of 2020. HHS stated that it will implement any feedback from the OIG, as well as lessons learned from the fiscal year 2019 and fiscal year 2020 risk assessment reporting period, in fiscal year 2021. We will continue to monitor the agency's actions to address this recommendation.

Recommendation: The Attorney General should revise DOJ's process for conducting improper payment risk assessments for Law Enforcement to help ensure that it results in a reliable assessment of whether the program is susceptible to significant improper payments. This should include preparing sufficient documentation to support DOJ's risk assessments. (Recommendation 4)

Agency: Department of Justice
Status: Open
Priority recommendation

Comments: The Department of Justice (DOJ) did not concur with this recommendation. In January 2020, DOJ reiterated that it continues to not concur with the recommendation. DOJ stated that its risk assessment methodology provides DOJ management with a reasonable basis for determining whether the law enforcement program, as well as DOJ's other four mission-aligned programs, are susceptible to significant improper payments. In addition, DOJ reiterated that it continues to not concur with GAO's conclusion that DOJ's risk assessment documentation is not adequate. DOJ stated that its documentation meets all of the requirements in the Improper Payments Information Act of 2002 (IPIA), as amended, and the Office of Management and Budget's (OMB) implementing guidance. Therefore, DOJ stated that it does not believe it would be a prudent use of limited resources to expand on the documentation that already exists. DOJ stated that notwithstanding its differences from GAO on the recommendation, it will continue to examine its risk assessment methodology. Finally, DOJ stated that its goal has been, and continues to be, meeting the requirements of IPIA, as amended, and OMB's implementing guidance in a cost effective manner. We continue to believe this recommendation is appropriate because DOJ's risk assessment documentation did not adequately demonstrate how DOJ determined the weighting of the risk factors or the numerical risk level ranges or whether a program is or is not susceptible to significant improper payments. We will continue to monitor the agency's actions to address the recommendation.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with Director of the DHA and the Surgeons General of the military departments, define and analyze the 16 operational readiness and installation-specific medical functions currently excluded from transfer to the DHA to determine whether opportunities exist to reduce or better manage duplicative functions and improve efficiencies in the administration of the MTFs. (Recommendation 1)

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: DOD concurred with this recommendation. According to responses provided by DOD officials in December 2019, the department provided guidance on the division of the 16 operational readiness and installation-specific medical functions in a March 2019 memorandum from the Office of the Under Secretary of Defense for Personnel and Readiness. However, further detail is needed regarding what analysis DOD completed to assess the 16 functions for duplication.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with DHA Assistant Director for Health Care Administration and the Secretaries of the military departments, validate headquarters-level personnel requirements to determine that they are established at the minimum levels necessary--per DOD guidance--to accomplish missions and achieve objectives before transferring authority, direction, and control of the MTFs to the DHA for the third phase. (Recommendation 2)

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: DOD concurred with this recommendation. In December 2019, DOD officials stated that DOD conducted a review of the DHA personnel requirements and that the military departments also conducted reviews. DOD officials also stated that DOD will continue to evaluate the mix of contractors, military, and civilian employees during and after the transition. However, the review of DHA personnel requirements DOD officials referenced in their December 2019 responses, as GAO previously reported in GAO-19-53, did not validate personnel requirements. Further information is needed regarding what steps DOD is taking to validate headquarters-level personnel requirements.

Recommendation: The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs, in coordination with DHA Assistant Director for Health Care Administration and the Secretaries of the military departments, conduct a comprehensive review to identify the least costly mix--per DOD guidance--of military, civilian, and contractors needed to meet validated requirements--that is, to perform the functions identified at the DHA headquarters and intermediate management organizations and at the military departments' headquarters and intermediate commands. Additionally, this comprehensive review should be completed before transferring authority, direction, and control of the MTFs to the DHA for the third phase. (Recommendation 3)

Agency: Department of Defense
Status: Open
Priority recommendation

Comments: DOD concurred with this recommendation. In December 2019, DOD officials stated that through the review of the budget development process, DOD transferred 1,900 personnel to the military departments for the management of their respective readiness missions. Further, DOD officials mentioned a 2018 report concerning a review of DHA personnel requirements. As reported in GAO-19-53, the report on DHA personnel requirements was specific to DHA and did not include information regarding the military departments' headquarters and intermediate commands. Further information is needed to determine whether DOD's efforts included a comprehensive review that considers the least costly mix--per DOD guidance--of military, civilian, and contractor personnel.

Recommendation: As MHS governing bodies conduct their recurring reviews of quality measures selected for MHS's Core Dashboard and Purchased Care Dashboards, the Assistant Secretary of Defense for Health Affairs should direct those bodies to prioritize, as appropriate, the selection of measures that apply to both direct and purchased care at the provider level and that expand the range of quality measure types and medical conditions that are assessed. (Recommendation 1)

Agency: Department of Defense: Office of the Assistant Secretary of Defense (Health Affairs)
Status: Open

Comments: As of January 2020, DOD officials described proposed actions to address key elements of our recommendation. Specifically, DOD officials described compiling a comprehensive library of existing inpatient and outpatient quality measures for both direct and purchased care; categorizing those measures by type and medical condition; and identifying 8 measures that are common across direct and purchased care. DOD stated it is considering expanding those 8 common measures to 12 measures. The new measures would cover three cancer screening measures and an additional inpatient satisfaction measure. However, DOD officials noted these 12 measures are not reported at the provider level for purchased care given current contract reporting requirements and would require contract modifications. DOD officials also said they are participating in an interagency partnership to use a common set of quality measures across federal programs, including under the Department of Veterans Affairs. Once those quality measures are determined, DOD may expand the range of quality measures common across direct and purchased care to be consistent with other federal programs. We will keep this recommendation open until DOD provides additional information on actions taken to select and expand quality measures across direct and purchased care.

Recommendation: The Assistant Secretary of Defense for Health Affairs should establish, as appropriate, performance standards related to the Purchased Care Dashboard measures that are consistent with the MHS's performance standards for direct care; ensure they are applied to individual purchased care providers; and take steps, such as amending its managed care support contracts, if necessary, to require corrective actions to be taken when providers do not meet those standards. (Recommendation 2)

Agency: Department of Defense: Office of the Assistant Secretary of Defense (Health Affairs)
Status: Open

Comments: As of January 2020, DOD officials said that once a common set of quality measures is adopted to the extent possible across direct and purchased care (as discussed in Recommendation 1), DOD plans to establish consistent performance standards applied to individual providers and plans to develop processes to issue corrective actions for individual direct and purchased care providers who do not consistently meet established standards. We will update this recommendation as DOD provides progress updates on the implementation of these plans.

Recommendation: The Secretary of Veterans Affairs should ensure that the role and responsibilities of the Interagency Program Office are clearly defined within the governance plans for acquisition of the department's new electronic health record system. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: The Department of Veterans Affairs (VA) concurred with our recommendation to ensure that the role and responsibilities of the Interagency Program Office (IPO) were clearly defined within the governance plans for acquisition of the department's new electronic health record system. As of December 2019, VA and the Department of Defense (DOD) have replaced the IPO with a new joint governance body. Specifically, the Federal Electronic Health Record Modernization (FEHRM) program office has been established to serve as the single point of accountability in the delivery of a common health record between the departments and the advancement of interoperability with the private sector. In its charter, the FEHRM was described as a single decision-making authority to manage issues in support of the departments' integrated electronic health record objectives and its leadership is responsible for, among other things, working to formulate, oversee, de-conflict, and ensure adherence to electronic health record-related VA and DOD policies. However, the corresponding Implementation Plan that is intended to document how the FEHRM executes its full responsibilities has yet to be issued. To fully implement this recommendation, VA needs to document the role and responsibilities of the FEHRM with respect to VA's acquisition of its new electronic health record system, explaining the role, if any, the FEHRM will have in the governance process. We will continue to monitor the departments' incorporation of the FEHRM into the plans for the ongoing acquisition.

Recommendation: The Director of IHS should obtain, on an agency-wide basis, information on temporary provider contractors, including their associated cost and number of full-time equivalents, and use this information to inform decisions about resource allocation and provider staffing. (Recommendation 1)

Agency: Indian Health Service
Status: Open

Comments: In February 2020, IHS reported that challenges in rolling-up contractor information on a national level stem from the fact that the agency often uses single contract vehicles, such as staffing companies, to hire multiple providers for temporary periods of time. IHS's contract databases do not centrally track the numbers of individual providers through such staffing contracts. The ability to analyze and compare detailed actual costs of federal hires vs. contract hires is currently limited to local information sources and on a narrow area of focus, such as one provider category or one facility at a time. IHS reported that the agency is implementing a monthly reporting requirement for IHS Areas and plans to use this information to inform decisions about resource allocation and provider staffing. We will review these reporting requirements when they have been fully implemented.

Recommendation: The Administrator of CMS should eliminate impediments to collaborative audits in managed care conducted by audit contractors and states, by ensuring that managed care audits are conducted regardless of which entity--the state or the managed care organization--recoups any identified overpayments. (Recommendation 2)

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

Comments: CMS agreed with and has taken some steps to address this action, as recommended by GAO in July 2018. In September 2019, CMS reported that in July 2019 CMS held a meeting with states and collaborative audit contractors to discuss coordination of managed care audits, including a wide range of challenges with managed care audits. As result of the feedback and recommendations received, CMS is evaluating several process improvements and reiterated that audit contractors will continue to work with states to provide support and assistance in Medicaid managed care, and that Medicaid managed care audits should not be limited by MCO contract language. Although CMS has communicated to states the need to increase audits in managed care and address identified issues, it is unclear if these actions will remove known impediments to managed care audits or result in an increase in the number of collaborative audits. Implementing GAO's July 2018 recommendation is needed because few audits of Medicaid managed care have been conducted and overpayments can be significant based on the findings from federal and state audits and investigations that have been completed. .

Recommendation: The Administrator of HRSA should require covered entities to register contract pharmacies for each site of the entity for which a contract exists. (Recommendation 1)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS does not concur with this recommendation and, as of July 2020, did not plan to take any actions to implement the recommendation. As noted in our report, without complete information on contract pharmacy arrangements--including information on with sites of a covered entity have contracts with a contract pharmacy--HRSA cannot ensure that it is optimally targeting the limited number of audits done each year. Additionally, manufacturers lack important information to help ensure that 340B discounted drugs are only provided to pharmacies with a valid 340B contract with the covered entity site for which the drug is being dispensed.

Recommendation: The Administrator of HRSA should issue guidance to covered entities on the prevention of duplicate discounts under Medicaid managed care, working with CMS as HRSA deems necessary to coordinate with guidance provided to state Medicaid programs.(Recommendation 2)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open
Priority recommendation

Comments: HHS concurred with this recommendation. In July 2020, HHS indicated that it believes that guidance does not provide HRSA appropriate enforcement capability and that this recommendation can only be accomplished after policy is issued. HRSA has requested regulatory authority for all aspects of the 340B Program in the FY 2021 President's Budget.

Recommendation: The Administrator of HRSA should incorporate an assessment of covered entities' compliance with the prohibition on duplicate discounts, as it relates to Medicaid managed care claims, into its audit process after guidance has been issued and ensure that identified violations are rectified by the entities. (Recommendation 3)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open
Priority recommendation

Comments: HHS concurred with this recommendation. In July 2020, HHS indicated that it believes that guidance does not provide HRSA appropriate enforcement capability and that this recommendation can only be accomplished after policy is issued. HRSA has requested regulatory authority for all aspects of the 340B Program in the FY 2021 President's Budget.

Recommendation: The Administrator of HRSA should issue guidance on the length of time covered entities must look back following an audit to identify the full scope of noncompliance identified during the audit.(Recommendation 4)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS concurred with this recommendation. In July 2020, HHS indicated that it believes that guidance does not provide HRSA appropriate enforcement capability and that this recommendation can only be accomplished after policy is issued. HRSA has requested regulatory authority for all aspects of the 340B Program in the FY 2021 President's Budget.

Recommendation: The Administrator of HRSA should require all covered entities to specify their methodology for identifying the full scope of noncompliance identified during the audit as part of their corrective action plans, and incorporate reviews of the methodology into their audit process to ensure that entities are adequately assessing the full scope of noncompliance. (Recommendation 5)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS does not concur with this recommendation and, as of July 2020, did not plan to take any actions to implement the recommendation. HHS noted that requiring all covered entities subject to an audit to specify their methodology for identifying the full scope of noncompliance identified during the audit would create a significant burden for covered entities. However, as noted in our report, HRSA already requires covered entities with audit findings to determine the full scope of noncompliance and requires entities subject to a targeted audit to provide their methodology for such assessments to HRSA. Thus, it is unclear how requiring covered entities subject to risk-based, as opposed to targeted, audits to provide HRSA with a written description of methodologies that they are already required to formulate and implement would create a significant additional burden. Without this information, HRSA does not have reasonable assurance that the majority of covered entities have adequately identified all instances of noncompliance.

Recommendation: The Administrator of HRSA should require all covered entities to provide evidence that their corrective action plans have been successfully implemented prior to closing audits, including documentation of the results of the entities' assessments of the full scope of noncompliance identified during each audit.(Recommendation 6)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS does not concur with this recommendation and, as of July 2020, did not plan to take any actions to implement the recommendation. HHS stated that requiring all covered entities with audit findings to provide evidence that their corrective action plans have been successfully implemented would create an undue burden for covered entities. However, HRSA already requires such evidence from covered entities subject to targeted audits, and it is unclear how providing evidence of implementation of corrective actions that entities developed and are required to implement would create significant additional burden for these entities. Additionally, without such evidence HRSA does not have a reasonable assurance that the majority of covered entities audited have corrected the issues identified in the audit, and are not continuing practices that could lead to noncompliance.

Recommendation: The Administrator of HRSA should provide more specific guidance to covered entities regarding contract pharmacy oversight, including the scope and frequency of such oversight. (Recommendation 7)

Agency: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration
Status: Open

Comments: HHS concurred with this recommendation. In July 2020, HHS indicated that it believes that guidance does not provide HRSA appropriate enforcement capability and that this recommendation can only be accomplished after policy is issued. HRSA has requested regulatory authority for all aspects of the 340B Program in the FY 2021 President's Budget.

Recommendation: The Undersecretary for Health should ensure that Central Office, Veterans Integrated Service Networks (VISN), and medical facilities document the actions they take towards achieving OSI goals. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with the recommendation. To fully implement this recommendation, VHA needs to provide information about the new documentation requirements described in the November 2019 update.

Recommendation: The Undersecretary for Health should ensure that any OSI goals that have not been met have clearly defined, measurable outcomes, including milestones or numerical targets, as appropriate, and timeframes. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with the recommendation. To fully implement this recommendation, VHA needs to provide information about specific actions, described in the November 2019 update, taken to address the recommendation including documentation showing the actions taken to review the OSI goals and documentation of new OSI goals, metrics, and timelines.

Recommendation: 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)

Agency: Department of Health and Human Services: Public Health Service: Substance Abuse and Mental Health Services Administration
Status: Open

Comments: As of October 2019, HHS reported that the Substance Abuse and Mental Health Services Administration (SAMHSA) would add new additional features to its web-based system for overseeing the mental health protection and advocacy programs, with an implementation target date of October 2020. The agency described one new feature as a tracking tool to monitor program requests to revise priority goals, objectives, and targets over multiple years. In the meantime, SAMHSA has developed a manual tracking tool for its project officers to use until the electronic tool is in place. Another new feature is a workflow that will allow project officers, team leaders, and branch chiefs to review and approve changes made by the programs. However, SAMHSA has not yet provided documentation of the latter feature to demonstrate that it has developed procedures for project officers to review the changes over multiple years. Therefore, the agency 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. We will review the web-based tracking tool when available and continue to monitor SAMHSA's efforts to develop procedures for examining changes to benchmarks over multiple years.

Recommendation: The Commissioner of FDA should develop a timeline for updating the risk assessment on arsenic in rice. (Recommendation 1)

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

Comments: As of August 2020, FDA stated that it will update the risk assessment when more scientific evidence becomes available. In the meantime, FDA noted that it will continue to monitor research in this area, including ongoing work by the National Academies of Sciences (NAS) Board on Environmental Studies and Toxicology, which is currently reviewing EPA's work on inorganic arsenic, specifically on EPA's IRIS Toxicological Assessments of Inorganic Arsenic. GAO will assess whether FDA has taken action responsive to the recommendation when additional information becomes available.

Recommendation: The Administrator of CMS should ensure that CMS has complete data on terminations of enrollee coverage for nonpayment of premiums by requiring issuers to report these data. (Recommendation 1)

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid 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 Administrator of CMS should provide a transparent process for issuers and CMS to systematically reconcile discrepancies in their data on terminations of enrollee coverage for nonpayment of premiums. (Recommendation 2)

Agency: Department of Health and Human Services: Centers for Medicare and Medicaid 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 Secretary of HHS should direct ACF to provide additional guidance and technical assistance to states to address known challenges and enhance their understanding of CAPTA requirements, including the requirements for health care providers to notify CPS of substance-affected infants and the development of a plan of safe care for these infants.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS did not agree with this recommendation. The agency stated that it clarified guidance in the areas we raised. HHS also believes it is necessary to allow states the flexibility to meet the requirements in the context of their state CPS program. However, we found that states reported issues with the guidance and it did not address a key ongoing challenge regarding CAPTA requirements. HHS indicated that it will continue to provide technical assistance to states and fund demonstration sites to establish or enhance collaboration across community agencies and courts. Although continuing to provide technical assistance to states should be beneficial, our findings demonstrate that additional guidance is also needed. We continue to believe our recommendation is warranted. As of February 2020, the agency continues to disagree.

Recommendation: The Administrator of CMS should issue written criteria for when CMS will allow limited evaluation of a demonstration or a portion of a demonstration, including defining conditions, such as what it means for a demonstration to be longstanding or noncomplex, as applicable. (Recommendation 2)

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

Comments: HHS agreed with this recommendation. In November 2019, HHS reported that it was applying limited evaluation requirements to certain demonstration types, including routine family planning demonstrations. In July 2020, CMS stated that it continues to work with states as they apply for new or extensions of approved demonstrations to determine whether the demonstrations as a whole or certain components would qualify for limited evaluation. The agency, however, reiterated that it needs more experience before developing generalized guidance and that was not a priority for 2020. We will continue to monitor CMS's progress and will review whether to close the recommendation when these criteria are issued.

Recommendation: The Administrator of CMS should provide guidance and clarify requirements regarding the monitoring and reporting of deficiencies that states using home and community-based services (HCBS) waivers are required to report on their annual reports. (Recommendation 1)

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

Comments: CMS concurred with this recommendation and indicated the agency would provide guidance and clarify requirements regarding the monitoring and reporting of deficiencies in states' annual reports. According to CMS's fiscal year 2021 Budget Justification the agency expects to issue sub-regulatory guidance pertaining to health and welfare of Medicaid beneficiaries in residential facilities by the close of 2020.To fully implement this recommendation, the sub-regulatory guidance should clarify requirements for states' monitoring and reporting of deficiencies in HCBS annual reports. GAO will continue to monitor CMS actions in response to this recommendation.

Recommendation: The Administrator of CMS should establish standard Medicaid reporting requirements for all states to annually report key information on critical incidents, considering, at a minimum, the type of critical incidents involving Medicaid beneficiaries, and the type of residential facilities, including assisted living facilities, where critical incidents occurred. (Recommendation 2)

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

Comments: HHS neither agreed nor disagreed with this recommendation. According to CMS' fiscal year 2021 Budget Justification, the agency expects to issue sub-regulatory guidance pertaining to health and welfare of Medicaid beneficiaries in residential facilities by the close of 2020. To fully implement this recommendation, the sub-regulatory guidance should establish standard Medicaid reporting requirements for all states to report critical incidents annually. GAO will continue to monitor CMS actions in response to this recommendation.

Recommendation: The Administrator of CMS should ensure that all states submit annual reports for HCBS waivers on time as required. (Recommendation 3)

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

Comments: CMS concurred with this recommendation and stated that it will review and update its communications with states to reaffirm reporting requirements and ensure that all HCBS annual reports are submitted on time. According to CMS' fiscal year 2021 Budget Justification, the agency expects to issue sub-regulatory guidance pertaining to the health and welfare of Medicaid beneficiaries in residential facilities by the close of 2020. To fully implement this recommendation, the sub-regulatory guidance should ensure that all states submit annual reports on time. GAO will continue to monitor CMS actions in response to this recommendation.

Recommendation: The Administrator of CMS should ensure that all types of Medicaid HCBS programs have requirements for states to avoid or mitigate potential conflicts of interest on the part of entities that conduct needs assessments that are used to determine eligibility for HCBS and to develop HCBS plans of service. These requirements should address both service providers and managed care plans conducting such assessments. (Recommendation 1)

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

Comments: HHS concurred with our recommendation. However, in an April 2018 update, HHS noted that the recommendation should be closed based on existing Medicaid regulations. GAO disagrees. The existing regulations--which GAO reviewed at the time of this study--do not address all types of Medicaid HCBS programs. For example, specific conflict of interest requirements are generally not in place for needs assessments that are used to inform HCBS eligibility determinations. Similarly, managed care plans may have a financial interest in the outcome of HCBS assessments used for both determining eligibility and service amounts. GAO maintains that states should be required to avoid or mitigate potential conflicts of interest on the part of entities-including both service providers and managed care plans-that perform the needs assessments that states use for eligibility determinations and to develop plans of service. As of December 2019, HHS officials have not informed us of any additional actions taken to ensure that states avoid or mitigate potential conflict of interests in needs assessments for all types of Medicaid HCBS programs. We will update the status of this recommendation when we receive additional information.

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: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to annually report improper payment estimates and error rates for the advance PTC program.

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

Comments: The Department of Health and Human Services (HHS) concurred with this recommendation. On May 23, 2018, HHS's Centers for Medicare and Medicaid Services (CMS) stated that it is currently in the process of developing an improper payment measurement for the advance premium tax credit (PTC). The development of the measurement methodologies will be a multi-year process which consists of the development of measurement policies, procedures, and tools. It also includes extensive pilot testing to ensure an accurate and efficient improper payment estimate, as well as, acquisition activities for procurement of improper payment measurement contractors. In January 2020, CMS stated that it is still in the process of developing an improper payment measurement for the advance PTC. Further, CMS stated that it provided progress updates in the fiscal year 2019 HHS agency financial report (AFR), and will continue to do so in future AFRs until an improper payment rate is estimated. We will continue to monitor the agency's actions to address this recommendation.

Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, and until annual reporting of improper payment estimates and error rates for the advance PTC program is performed, the Secretary of Health and Human Services should direct the Administrator of CMS to disclose significant matters relating to the Improper Payments Information Act (IPIA) estimation, compliance, and reporting objectives for the advance PTC program in the agency financial report, including CMS's progress and timeline for expediting the achievement of those objectives and the basis for any delays in meeting IPIA requirements.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS concurred with this recommendation. On February 28, 2018, the Department of Health and Human Services's (HHS) Centers for Medicare and Medicaid Services (CMS) stated that updates on the advance premium tax credit (PTC) program improper payment measurement development were provided in the fiscal year (FY) 2017 Agency Financial Report (AFR), which was published in November 2017. In FY 2018, we reviewed the FY 2017 AFR that HHS's CMS cited in support for closing this recommendation. Based on our review, the FY 2017 AFR does not address our recommendation as it does not provide a timeline for reporting an improper payment estimate. In FY 2019, we reviewed HHS's FY 2018 AFR published in November 2018, which includes a statement that HHS will continue to update its annual AFRs on the status of the measurement program development until the improper payment estimate is reported. However, this latest AFR also does not provide a timeline for reporting an improper payment estimate for HHS's PTC program. In January 2020, CMS stated that it is in the process of procuring federal contractors to perform the improper payment measurement. However, CMS further stated that due to uncertainties surrounding the timing of the procurement, CMS does not anticipate publishing a reporting timeline until the contracts have been awarded. We will continue to monitor the agency's actions to address this recommendation.

Recommendation: To improve annual reporting on PTC improper payments, control activities related to eligibility determinations, and calculations of advance PTC, the Secretary of Health and Human Services should direct the Administrator of CMS to design and implement procedures for verifying the identities of phone and mail applicants to reasonably assure that ineligible individuals are not enrolled in qualified health plans in the marketplaces or provided advance PTC.

Agency: Department of Health and Human Services
Status: Open

Comments: The Department of Health and Human Services (HHS) neither agreed nor disagreed with this recommendation. Regarding verification of filer identity, HHS stated, in response to the draft report, that for individuals starting an application via phone, the call center representatives use verbal attestations for verifications from individuals. HHS stated that for paper applications, individuals must provide names and complete addresses as well as other information. In addition, HHS stated that individuals must attest that the information they provide on all applications is accurate by signing under penalty of perjury. However, these steps do not involve the verification of an applicant's identity to a third-party source. In August 2018, HHS officials stated that they are exploring alternatives for assessing risk and ensuring integrity of applicant information that is provided to the program and ways to ensure personal information provided by an individual is accurate through a variety of means. After this analysis phase, they will assess resource requirements, cost, and operational implications for potential implementation approaches with a target date for completion of 2019. As of December 2018, HHS had not designed and implemented procedures for verifying the identities of phone and mail applicants, as GAO recommended. As of January 2020, HHS indicated that it is developing new policy and guidance which could significantly change potential solutions or requirements. However, HHS did not provide us a time frame for when it plans to finalize the new policy and guidance. We will continue to monitor agency's actions to address the recommendation.

Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to assess the program against applicable IPIA-defined thresholds and conclude on its susceptibility to significant improper payments, and revise the scope of its improper payments susceptibility assessment for the PTC program to include instances in which advance PTC is greater than or equal to the amount of PTC claimed on the tax return. If the program meets the IPIA definition for being susceptible to significant improper payments based on this assessment, estimate and report improper payments associated with the PTC program consistent with IPIA requirements.

Agency: Department of the Treasury: Internal Revenue Service
Status: Open
Priority recommendation

Comments: The Internal Revenue Service (IRS) partially agreed with this recommendation. On December 13, 2019, IRS provided us a status update and stated that its Research, Applied Analytics and Statistics division completed an analysis of net premium tax credit (PTC) using National Research Program (NRP) tax years 2015 and 2014 data during the 4th quarter of fiscal year 2019 and developed improper payment estimates using two different methodological approaches. However, IRS indicated that it did not publish these improper payment estimates in Treasury's Agency Financial Report for two reasons: (1) there is as yet insufficient NRP data to develop an estimate that is within the confidence interval and margin of error prescribed by the Office of Management and Budget for improper payments sampling, and (2) the Department of the Treasury (Treasury) wishes to engage with Health and Human Services' Centers for Medicare & Medicaid Services on the potential for developing a joint rate estimate for advance PTC and PTC. In addition, IRS noted that it had not yet determined whether this is even possible from a data compatibility standpoint. Further, IRS stated that while the estimates do not meet the statistical precision requirement, they do suggest that Net PTC would meet the criteria to be considered susceptible to significant improper payments. IRS indicated that when it last discussed this recommendation with GAO, it was suggested this recommendation would be closed once improper payment rates are published. However, IRS would now like GAO to consider closing this recommendation at this time given (1) the IRS's efforts to analyze potential improper payments, (2) Treasury's new approach to reporting, and (3) the need for additional years of data before a statistically valid estimate can be developed. We do not believe the recommendation should be closed at this time based on the three reasons IRS has listed above. However, we credit IRS for exploring ways to meet the intent of the recommendation. We will continue to monitor the agency's actions to address this recommendation.

Recommendation: To comply with improper payments reporting requirements and improve procedures related to processing PTC information on tax returns, the Commissioner of Internal Revenue should direct the appropriate officials to assess and document the feasibility of approaches for incorporating information from the marketplaces on individuals who did not demonstrate that they met the eligibility requirements for citizenship or lawful presence in the tax compliance process. If determined feasible, IRS should work with Treasury to require marketplaces to periodically provide such information on individuals and use such information to recover advance PTC made for those individuals.

Agency: Department of the Treasury: Internal Revenue Service
Status: Open

Comments: The Internal Revenue Service (IRS) agreed with this recommendation. In December 2018, an IRS official indicated that IRS conducted a detailed review of the recommendation. IRS informed GAO that it is internally discussing an alternative way to address the recommendation to prevent premium tax credit to noncitizens. The IRS official indicated that IRS is reviewing this alternative with the Department of the Treasury and the Department of Health and Human Services' Centers for Medicare & Medicaid Services. IRS did not provide GAO with a time frame for its implementation. On December 13, 2019, IRS provided us a status update and stated that it had no new information for this recommendation. We will continue to monitor the agency's actions to address this recommendation.

Recommendation: To help ensure that its efforts to increase patients' electronic access to health information are successful, the Secretary of HHS should direct ONC to use the information these performance measures provide to make program adjustments, as appropriate. Such actions may include, for example, assessing the status of program operations or identifying areas that need improvement in order to help achieve program goals related to increasing patients' ability to access their health information electronically.

Agency: Department of Health and Human Services
Status: Open

Comments: As of May 2019, ONC is collecting and evaluating information from national surveys, program data, and third-party data sources. As ONC works to implement its evaluations, it should identify how evidence collected from national surveys, program data and third-party data sources has been used to assess the outcomes of key efforts and adjust programs accordingly.

Recommendation: The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to incorporate medical screening questions specific to gambling disorder as part of a systematic screening process across DOD, such as DOD's annual Periodic Health Assessment, for behavioral and mental-health issues.

Agency: Department of Defense
Status: Open

Comments: DOD non-concurred with this recommendation. However, the FY 2019 National Defense Authorization Act mandated that DOD implement this recommendation. As of August 2019, DOD had modified the Health Related Behaviors Survey (HRBS) to include questions on gambling and DOD and the Services are in the process of updating the electronic Periodic Health Assessment (PHA) assessment forms to capture the gambling screening data required by the legislation. Once the PHA is updated to include the gambling screening data, we will be able to close this recommendation.

Recommendation: The Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to update DOD Instruction 1010.04, Problematic Substance Use by DOD Personnel, to explicitly include gambling disorder as defined in the 2013 Diagnostic and Statistical Manual of Mental Disorders.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of August 2019, DOD stated that this guidance is still in internal DOD coordination. Moreover, guidance related to gambling disorder screening, referral, and treatment needs to be coordinated with the Addictive Substance Misuse Advisory Committee (ASMAC) before issuance, which is anticipated to be July 2020.

Recommendation: The Secretary of Defense should direct the Secretary of the Army to update Army Regulation 600-85, The Army Substance Abuse Program, to explicitly include gambling disorder.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of August 2019, the Army did not have any updates to provide on the status of this recommendation.

Recommendation: The Secretary of Defense should direct the Secretary of the Navy to update Naval Operations Instruction 5350.4D, Navy Alcohol and Drug Abuse Prevention and Control, to explicitly include gambling disorder.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of August 2019, Navy officials stated that the draft Navy instruction was returned back to the Navy's Drug Detection and Deterrence Program Office to add language regarding the Secretary of the Navy's ban on hemp/CBD products that was announced this month. The Navy has added the language and pushed the instruction out to the main stakeholders for coordination. It is due back to the Director, Navy Staff no later than 30 August 2019 where it will go back into the queue for signature. Navy officials anticipate signature sometime later this fall.

Recommendation: The Commandant of the Coast Guard should update Commandant Instruction M6000.1F, Coast Guard Medical Manual, to classify gambling disorder as an addiction and not as an impulse control issue.

Agency: Department of Homeland Security: United States Coast Guard
Status: Open

Comments: The U.S. Coast Guard/DHS concurred with this recommendation. As of August 2019, the Coast Guard stated that updates to this manual are ongoing. According to Coast Guard officials, including gambling disorder in this manual is one of many significant updates the program is adjudicating for this manual and it's a lengthy clearance process. No timeline was provided for expected issuance.

Recommendation: To improve care for women veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to strengthen the environment of care inspections process and VHA's oversight of this process by expanding the list of requirements that facility staff inspect for compliance to align with VHA's women's health handbook, ensuring that all patient care areas of the medical facility are inspected as required, clarifying the roles and responsibilities of VA medical facility staff responsible for identifying and addressing compliance, and establishing a process to verify that noncompliance information reported by facilities to VHA Central Office is accurate and complete.

Agency: Department of Veterans Affairs
Status: Open

Comments: As of October 2018, VA has taken some actions to address this recommendation, but additional actions are needed to fully implement it. We will update the status of this recommendation when we receive additional information from VA.

Recommendation: To improve care for women veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to monitor women veterans' access to key sex-specific care services--mammography, maternity care, and gynecology--under current and future community care contracts. For those key services, monitoring should include an examination of appointment scheduling and completion times, driving times to appointments, and reasons appointments could not be scheduled with community providers.

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: As of June 2017, VHA still lacks data and performance measures for the availability under Choice of sex-specific care, such as mammograms, maternity care, or gynecology. In contrast, for another VA care in the community program, PC3 (a program that the Choice third party administrators also administer) VHA collects data and has performance measures to evaluate women veterans' access to mammography and maternity care. To fully implement this recommendation, VHA needs to extend the collection of data to include care delivered through the Choice Program and other community care programs and establish related performance measures. VA is in the process of letting contracts for its new community care program and is expected to have contracts in place for all regions of the country in fiscal year 2019

Recommendation: To fully assess the size and composition of the medical force, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to conduct a new analysis of the required number of active-duty and civilian medical personnel that mitigates known limitations.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of August 2020, DOD has not addressed this recommendation. In response to a provision in Senate Report 115-125, we assessed DOD's interim and final draft responses to a requirement in the National Defense Authorization Act (NDAA) for Fiscal Year 2017 to assess the required number of wartime medical and dental personnel. In our ensuing February 2019 report, we found that DOD had not determined the required size and composition of its operational medical and dental personnel who support the wartime mission or submitted a complete report to Congress. Specifically, leaders from the Office of the Secretary of Defense (OSD) disagreed with the military departments' initial estimates of required personnel that were developed to report to Congress. OSD officials cited concerns that the departments had not applied assumptions for operating jointly in a deployed environment and for leveraging efficiencies among personnel and units. We found that the military departments applied different planning assumptions in estimating required personnel, such as the definition of "operational" requirements. Further, although not required by the NDAA for Fiscal Year 2017, DOD's assessment did not include civilian medical personnel. Until DOD completes such an analysis, it cannot be assured that its medical force is appropriately sized.

Recommendation: To strengthen ongoing efforts to analyze the costs of medical force readiness and establish clinical currency standards, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to take steps to identify and mitigate limitations regarding the standard for maintaining providers' clinical skills, including improving the accuracy of information concerning providers' workload and conducting an analytically rigorous calculation of active-duty providers' time devoted to military-specific responsibilities.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of August 2020, DOD has taken steps to address this recommendation, but has not completed all necessary actions. In February 2019, we reported that DOD had begun work on a metric to assess the clinical readiness of providers, but noted that the department's methodology was limited. In particular, the methodology did not provide complete, accurate, and consistent data or fully demonstrate results. Further, although DOD provided documentation in February 2020 outlining the medical specialties to which its clinical readiness metric would apply, it has not fully budgeted for the cost of implementing the metric. DOD's July 2018 report in response to Section 703 of the National Defense Authorization Act for Fiscal Year 2017 notes steps taken to assess the accuracy of information concerning providers' workload, but does not address the time active-duty providers devote to military-specific responsibilities. Until DOD addresses these issues, its efforts to analyze the costs of medical force readiness and establish clinical currency standards will remain limited.

Recommendation: To help achieve DOD's goals for transferring health care into its own facilities and increasing the productivity of active-duty medical providers, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to develop a strategy for achieving these goals that reflects the leading practices of effective federal strategic planning.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of September 2020, DOD has not yet addressed this recommendation.

Recommendation: To strengthen ongoing efforts within DOD to address the Study's recommendations to use the provider model outputs to inform execution of health care delivery and to refine the model for future use, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to modify DOD's model to reflect the military service of the physicians and military treatment facilities included in the model.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of September 2020 DOD has not implemented this recommendation. In its July 2018 report in response to Section 703 of the National Defense Authorization Act for Fiscal Year 2017, DOD stated in response to this recommendation that facilities in several large Military Health System (MHS) markets are staffed in a multi-service manner. While this is an important point, it remains true that, as the report notes, DOD's model "assumed uniformed providers were interchangeable," and that such an approach does not reflect the single-service nature of most medical treatment facilities within the MHS. Until DOD's model reflects this, the results of its approach will continue to be limited.

Recommendation: To strengthen any future assessments of additional changes to DOD's network of military treatment facilities, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to describe steps taken to assess the reliability of data supporting the assessment, including, at a minimum, the sources of data, data limitations, and efforts to test data reliability.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of September 2020, DOD has taken steps to address this recommendation, but has not completed all necessary actions. In its July 2018 report in response to Section 703 of the National Defense Authorization Act for Fiscal Year 2017, DOD included the sources of its data and some data limitations, but not efforts to test data reliability. Until DOD fully incorporates assessments of data reliability into its analysis of future changes to the Military Health System, such as its implementation plan Section 703, it will continue to lack assurance that its approach is fully supported by reliable information.

Recommendation: To strengthen any future assessments of additional changes to DOD's network of military treatment facilities, the Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to include in any accompanying cost estimates an appropriate level of detail, all significant costs, and an assessment of the reliability of the data supporting the cost estimate.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of September 2020, DOD has not addressed this recommendation. As we reported in May 2020, DOD's plan to restructure MTFs in response to Section 703 of the National Defense Authorization Act for Fiscal Year 2017, DOD concluded that civilian health care was more cost-effective than care in its MTFs without considering other assumptions that could affect its conclusions. For example, DOD applied assumptions about the cost of military personnel salaries, MTF workloads, and reimbursement rates for TRICARE that likely underestimated the cost-effectiveness of MTFs. Until DOD's approach to assessing changes to its network of MTFs is accompanied by cost estimates with an appropriate level of detail, all significant costs, and an assessment of the reliability of the data supporting the cost estimate, its approach will remain limited.

Recommendation: To improve the accessibility and reliability of SNF expenditure data, the Acting Administrator of CMS should take steps to improve the accessibility of SNF expenditure data, making it easier for public stakeholders to locate and use the data.

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

Comments: In September 2016, GAO recommended that CMS improve the accessibility and reliability of SNF expenditure data, thereby making it easier for public stakeholders to locate and use the data. The agency concurred with this recommendation in 2016 and stated that it would review the feasibility of increasing the accessibility of this data. However, in August 2017, HHS told GAO that it now believes that the cost of implementing this recommendation would outweigh its benefits. HHS confirmed in July 2019 that its position on this recommendation has not changed. GAO continues to hold that data on SNFs' relative expenditures should be readily accessible to the public to ensure transparency in SNF expenditures.

Recommendation: To improve the accessibility and reliability of SNF expenditure data, the Acting Administrator of CMS should take steps to ensure the accuracy and completeness of SNF expenditure data.

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

Comments: In September 2016, GAO recommended that CMS take steps to ensure the accuracy and completeness of SNF expenditure data. However, the agency did not concur with this recommendation. HHS reported in 2016 that the amount of time and resources to verify the accuracy and completeness of SNF expenditure data could be substantial, without assurance of benefit to the agency and the public. However, during the course of our work, GAO found that CMS uses this expenditure data to update overall SNF payment rates, in addition to more general purposes. GAO continues to believe that CMS should take steps to ensure reliable expenditure data are accurate and complete. As of July 2019, the agency continues to non-concur with this recommendation.

Recommendation: To understand the extent to which incomplete inactivation occurs and whether incidents are being properly identified, analyzed, and addressed, the Secretary of Health and Human Services should direct the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) to develop clear definitions of inactivation for use within their respective guidance documents that are consistent across the Select Agent Program, NIH's oversight of recombinant pathogens, and the Biosafety in Microbiological and Biomedical Laboratories manual.

Agency: Department of Health and Human Services
Status: Open

Comments: As of April 2020, the Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH) within the Department of Health and Human Service (HHS) are taking steps to address this recommendation. Specifically, in January and March 2017, HHS, in collaboration with the United States Department of Agriculture (USDA), issued updated select agent regulations and guidance that included clear definitions of inactivation and a validated inactivation procedure that are consistent across the Federal Select Agent Program. Additionally, HHS stated in December 2016 that NIH will consider providing clear and consistent definitions of inactivation in future guidance that is harmonized with the select agent regulations. Moreover, NIH and CDC told us they plan to include a new appendix in the revised Biosafety in Microbiological and Biomedical Laboratories manual that specifically addresses the development, validation, and implementation of inactivation protocols, which they anticipate releasing in June 2020, according to a CDC official.

Recommendation: To help ensure that inactivation protocols are scientifically sound and are effectively implemented, the Secretary of Health and Human Services should direct CDC and NIH to create comprehensive and consistent guidance for the development, validation, and implementation of inactivation protocols--to include the application of safeguards--across the Select Agent Program, NIH's oversight of recombinant pathogens, and the Biosafety in Microbiological and Biomedical Laboratories manual.

Agency: Department of Health and Human Services
Status: Open

Comments: In March 2017, the Department of Health and Human Services (HHS), in collaboration with the United States Department of Agriculture (USDA), issued Federal Select Agent Program guidance on the inactivation of select agents and toxins. According to HHS, this guidance is intended to provide additional information to regulated entities to assist them in meeting new requirements for rendering samples with select agents as non-viable. HHS also stated that the Federal Select Agent Program will continue to work with other federal agencies to ensure that the federal government is addressing inactivation in a consistent manner. In addition, according to HHS, the National Institutes of Health (NIH) will consider providing clear and consistent guidance related to inactivation that is harmonized with the Federal Select Agent Program as appropriate. As of April 2020, NIH and the Centers for Disease Control and Prevention (CDC) were in the process of revising the Biosafety in Microbiological and Biomedical Laboratories manual to include a new appendix that addresses the development, validation, and implementation of inactivation protocols. HHS plans to release the updated manual in June 2020, according to a CDC official.

Recommendation: To help ensure that dangerous pathogens can be located in the event there is an incident involving incomplete inactivation, the Secretary of Health and Human Services should direct the Directors of CDC and NIH, when updating the Biosafety in Microbiological and Biomedical Laboratories manual, to include guidance on documenting the shipment of inactivated material.

Agency: Department of Health and Human Services
Status: Open

Comments: The Department of Health and Human Services (HHS) stated in March 2017 that the National Institutes of Health (NIH) and Centers for Disease Control and Prevention (CDC) are in the process of revising the Biosafety in Microbiological and Biomedical Laboratories manual to include a new appendix that addresses inactivation methods, including guidance on documenting the shipment of inactivated material. HHS plans to release the updated manual in June 2020, according to a CDC official.

Recommendation: To help the Department of Health and Human Services ensure accuracy in Part B drug payment rates, Congress should consider requiring all manufacturers of Part B drugs paid at ASP, not only those with Medicaid drug rebate agreements, to submit sales price data to CMS, and ensure that CMS has authority to request source documentation to periodically validate all such data.

Agency: Congress
Status: Open

Comments: As of June 2020, no action has been taken on this Matter for Congressional Consideration.

Recommendation: CMS should periodically verify the sales price data submitted by a sample of drug manufacturers by requesting source documentation from manufacturers to corroborate the reported data, either directly or by working with the HHS Office of Inspector General as necessary.

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

Comments: In September 2018, HHS officials reiterated that they believe the agency has addressed our recommendation because CMS works with HHS's Office of Inspector General (OIG) as appropriate to collect source documentation from drug manufacturers and takes action as warranted. HHS stated that CMS has continued to provide information regarding problematic ASP submissions to OIG for evaluation of misreporting and continues to use AMP and other benchmarks as comparisons for pricing determinations. They further stated that they do not believe that additional collection of detailed sales information about ASP, such as invoices, is authorized under Part B drug payment provisions in section 1847A or under section 1927(b). As of June 2020, CMS did not provide any additional updates. While we recognize that CMS conducts routine checks to assess the completeness of ASP data submitted by drug manufacturers, we do not believe these activities are enough to close the recommendation. Specifically, CMS only collects source documentation from manufacturers under very limited circumstances (e.g., when there are obvious inconsistencies in the data submitted by manufacturers). CMS does not periodically verify the accuracy of ASP data for a sample of manufacturers by tracing the data to and from drug manufacturers' source documents, such as sales invoices. Because CMS does not routinely verify the accuracy of the underlying data used to determine Medicare payment rates, the resulting payment rates may be inaccurate if drug manufacturers do not report accurate data. With regards to CMS's authority to collect additional information, such as invoices, we believe the agency could work through OIG to collect such information.

Recommendation: To make the best use of federal resources directed toward combating FGM/C in the United States, the Attorney General and the Secretaries of Education, Health and Human Services, Homeland Security, and State should each develop a written plan that describes the agency's approach for conducting education and outreach to key stakeholders in the United States regarding FGM/C.

Agency: Department of Education
Status: Open

Comments: The Department of Education (Education) concurred with this recommendation. In February 2020, Education told us that it had awarded three grants that, while not focused on FGM/C, may be used for student safety and health at the U.S. state and local levels. After it evaluates grantees' need for information and resources related to FGM/C, Education will determine its next steps. In addition, Education reported that it continues to participate on the federal interagency workgroup devoted to FGM/C and has dedicated program staff to respond to issues related to FGM/C. Education expects to finalize its written plan by August 2020.

Recommendation: To make the best use of federal resources directed toward combating FGM/C in the United States, the Attorney General and the Secretaries of Education, Health and Human Services, Homeland Security, and State should each communicate the plan with other relevant federal agencies and stakeholder groups, as appropriate.

Agency: Department of Education
Status: Open

Comments: The Department of Education (Education) concurred with this recommendation, and noted in a February 2020 update that it is in the process of determining next steps for certain FGM/C awareness activities that may be included in the written plan it will develop. Education expects that it will finalize its written plan by August 2020, at which point it should also communicate that plan with other federal agencies and stakeholder groups to address our recommendation.

Recommendation: To ensure that FDA can effectively coordinate and integrate its medical product centers' programs and emerging issues, the Secretary of Health and Human Services should direct the Commissioner of FDA to engage in a strategic planning process to identify challenges that cut across the medical product centers and document how it will achieve measurable goals and objectives in these areas.

Agency: Department of Health and Human Services
Status: Open

Comments: FDA concurred with the recommendation and in September 2016 and January 2018 described steps it had taken toward strategic planning for its medical product centers. However, in June 2020, FDA informed GAO that there had been several senior leadership changes and its agency-wide strategic planning process was paused to focus on the covid-19 pandemic response. Officials also noted that FDA continues to address existing strategic priorities. We will update the status of this recommendation when we receive additional information.

Recommendation: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments and to improve the accuracy of CMS's calculation of coding intensity, the Administrator should modify that calculation by taking actions such as the following: (1) including only the three most recent pair-years of risk score data for all contracts; (2) standardizing the changes in disease risk scores to account for the expected increase in risk scores for all MA contracts; (3) developing a method of accounting for diagnostic errors not coded by providers, such as requiring that diagnoses added by MA organizations be flagged as supplemental diagnoses in the agency's Encounter Data System to separately calculate coding intensity scores related only to diagnoses that were added through MA organizations' supplemental record review (that is, were not coded by providers); and (4) including MA beneficiaries enrolled in contracts that were renewed from a different contract under the same MA organization during the pair-year period.

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

Comments: CMS is working to improve the accuracy of its calculation of coding intensity, as GAO recommended in April 2016. In October 2017, CMS officials told GAO that the agency is reevaluating the design of the risk adjustment data validation audits to ensure their rigor in the context of all the payment error data acquired since the original design of the audits. As part of this work, CMS officials told GAO that the agency will examine whether coding intensity is the best criterion to use to select contracts for audit. As a result, in October 2018, CMS told GAO that rather than coding intensity, it plans to implement a new methodology using payment error as the key sampling driver beginning with audits for payment year 2014. Additionally, CMS was taking steps to modernize its audit system to improve reliability. For example, it initiated a project to explore how to directly receive electronic medical record documentation. As of January 2020, the agency is continuing to reevaluate the design of these audits. Unless CMS takes this and other actions to improve the risk adjustment data validation contract-level audit process, it will fail to recover improper payments of hundreds of millions of dollars annually.

Recommendation: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should modify CMS's selection of contracts for contract-level RADV audits to focus on those contracts most likely to have high rates of improper payments by taking actions such as the following: (1) selecting more contracts with the highest coding intensity scores; (2) excluding contracts with low coding intensity scores; (3) selecting contracts with high rates of unsupported diagnoses in prior contract-level RADV audits; (4) if a contract with a high rate of unsupported diagnoses is no longer in operation, selecting a contract under the same MA organization that includes the service area of the prior contract; and (5) selecting some contracts with high enrollment that also have either high rates of unsupported diagnoses in prior contract-level RADV audits or high coding intensity scores.

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

Comments: CMS is working to modify the selection of MA contracts for audit, as GAO recommended in April 2016. In October 2017, CMS officials told GAO that the initial RADV audit design was based on a limited set of payment error data available at the time. As part of efforts to improve the audits, CMS officials told GAO that the agency will examine whether coding intensity is the best criterion to select contracts for audit. In October 2018, CMS told GAO that it plans to implement a new methodology using payment error as the key sampling driver-rather than coding intensity-beginning with audits for payment year 2014. As of January 2020, the agency is using the revised methodology on the 2014 and 2015 payment year audits. They expect to conclude this process in late fiscal year 2020 and 2021, respectively. Unless CMS completes actions to improve the RADV contract-level audit process, it will fail to recover improper payments of hundreds of millions of dollars annually.

Recommendation: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should enhance the timeliness of CMS's contract-level RADV process by taking actions such as the following: (1) closely aligning the time frames in CMS's contract-level RADV audits with those of the national RADV audits the agency uses to estimate the MA improper payment rate; (2) reducing the time between notifying MA organizations of contract audit selection and notifying them about the beneficiaries and diagnoses that will be audited; (3) improving the reliability and performance of the agency's process for transferring medical records from MA organizations, including assessing the feasibility of updating Electronic Submission of Medical Documentation for use in transferring medical records in contract-level RADV audits; and (4) requiring that CMS contract-level RADV auditors complete their medical record reviews within a specific number of days comparable to other medical record review time frames in the Medicare program.

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

Comments: HHS concurred with this recommendation in its fiscal year 2021 budget justification. HHS reaffirmed its commitment to identifying and correcting improper payments in the MA program. It has begun taking steps to improve the timeliness of the contract-level RADV audit process, such as aligning the time frames in CMS's contract-level RADV audits with those of the national RADV audits. Once completed, CMS needs to provide evidence that the actions taken by the agency have enhanced the timeliness of CMS's contract-level RADV process.

Recommendation: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should improve the timeliness of CMS's contract-level RADV appeal process by requiring that reconsideration decisions be rendered within a specified number of days comparable to other medical record review and first-level appeal time frames in the Medicare program.

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

Comments: CMS is working to improve the timeliness of the agency's contract-level risk adjustment data validation appeals process, as GAO recommended in April 2016. In October 2017, CMS officials told GAO that the agency is actively considering options for expediting the appeals process. For example, CMS is considering the appropriate number of days for rendering reconsideration decisions while allowing for a complete and thorough adjudication. In December 2019, CMS officials told GAO they expect to issue a final rule in January 2021 that will establish uniform timelines to expedite the appeals process. Specifically, they plan to require that a findings determination be made within 60-90 days of an arbiter's receipt of each party's arguments at each stage of an appeal. Unless CMS takes such actions to improve the risk adjustment data validation contract-level audit process, it will fail to recover improper payments of hundreds of millions of dollars annually.

Recommendation: As CMS continues to implement and refine the contract-level RADV audit process to improve the efficiency and effectiveness of reducing and recovering improper payments. The Administrator should ensure that CMS develops specific plans and a timetable for incorporating a RAC in the MA program as mandated by the Patient Protection and Affordable Care Act.

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

Comments: CMS has attempted to incorporate a recovery audit contractor in the Medicare Advantage program, as GAO recommended in April 2016. After failing to receive any proposals when CMS first issued a request for proposals (RFP) in 2014, CMS issued a request for information to industry in December 2015, which included a draft Statement of Work to solicit feedback, gauge interest, and conduct market research regarding CMS entering into a contract with a recovery audit contractor to identify underpayments and overpayments associated with diagnosis data submitted to CMS by Medicare Advantage Organizations. CMS reported that it subsequently issued another RFP in 2016 and did not receive any proposals for a second time. In December 2019, CMS officials told GAO that the functions of the Part C recovery Audit programs are being performed through other program integrity mechanisms. CMS subsequently reported in its fiscal year 2021 budget justification that CMS believes the proposed scope of the Part C RAC has been subsumed by RADV and CMS will demonstrate that the RADV program satisfies this recommendation. Until CMS completes efforts to improve the risk adjustment data validation contract-level audit process and demonstrates that it has satisfied the requirement to incorporate a recovery audit contractor in the MA program, CMS will fail to recover improper payments of hundreds of millions of dollars annually.

Recommendation: To ensure states have appropriate and current guidance to assist them in designing and administering Medicaid NEMT, the Secretary of HHS should direct CMS to assess current Medicaid NEMT guidance and update that guidance as needed.

Agency: Department of Health and Human Services
Status: Open

Comments: As of July 2019, HHS officials reported that they are waiting for a policy decision from leadership concerning non-emergency medical transportation. GAO will continue to monitor and update the status of this recommendation.

Recommendation: To ensure effective implementation of the Inclusion Policy in a manner consistent with the Revitalization Act's provisions regarding the design of certain clinical trials, the NIH Director should report on this summary data and the results of this analysis in NIH's regular biennial report to Congress on the inclusion of women in research.

Agency: Department of Health and Human Services: Public Health Service: National Institutes of Health
Status: Open

Comments: In August 2020, NIH reported that summary data as described in our Recommendation 4--that is, data and analysis on awardees' plans to conduct valid analysis by sex/gender--will be included in the 2019-2020 version of this publication, which the agency expects will be published in October 2021. We will continue to monitor NIH's actions on this matter.

Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should augment MA network adequacy criteria to address provider availability.

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

Comments: HHS concurred with this recommendation, and noted in a February 2018 update that CMS requires MAOs to identify provider availability in certain circumstances, such as in granting exceptions to the agency's network adequacy criteria. CMS also stated that it would consider augmenting MA network adequacy criteria to address provider availability in future years. However, CMS's 2018 MA network adequacy guidance stated that the agency does not currently consider provider availability when reviewing an organization's network adequacy, and this guidance was not updated in 2019. As a result, as of September 2019, agency officials have not implemented this recommendation.

Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should verify provider information submitted by MAOs to ensure validity of the Health Services Delivery data.

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

Comments: HHS concurred with this recommendation, and noted in a February 2018 update that the agency has standardized existing protocols to ensure the validity of the Health Services Delivery data submitted by MAOs with regards to exceptions requests and partial county justifications. However, CMS's 2018 MA network adequacy guidance stated that MAOs remain responsible for conducting validation of Health Services Delivery data. Unless CMS verifies provider information submitted by MAOs, the agency cannot be confident that MAOs are meeting network adequacy criteria. As of September 2019, agency officials have not implemented this recommendation.

Recommendation: To improve its oversight of network adequacy in MA, the Administrator of CMS should set minimum requirements for MAO letters notifying enrollees of provider terminations and require MAOs to submit sample letters to CMS for review.

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

Comments: HHS concurred with this recommendation. In a September 2017 update, the agency stated that it had met the spirit of our recommendation by adding its best practice suggestions of what should be included in the written termination notice to the Medicare Managed Care Manual. However, as we noted in our report, those practices are not required, nor are the letters regularly reviewed. As of September 2019, agency officials have not yet implemented this recommendation.

Recommendation: To improve the transparency and accountability of HHS's section 1115 Medicaid demonstration approval process, and to ensure that federal Medicaid funds for the demonstrations do not duplicate other federal funds, the Secretary of Health and Human Services should issue criteria for assessing whether section 1115 expenditure authorities are likely to promote Medicaid objectives.

Agency: Department of Health and Human Services
Status: Open

Comments: The Department of Health and Human Services (HHS) partially concurred with this recommendation and has taken some steps to address the problems GAO identified. Initially, in August 2015, HHS posted on its website general criteria for assessing whether Medicaid section 1115 demonstration expenditure authorities are likely to promote Medicaid objectives, but GAO found the general criteria were not sufficiently specific. HHS later removed these criteria from its website and replaced them with six broad areas of reform that HHS encourages states to consider. As of January 2020, HHS does not have specific criteria for approving section 1115 expenditure authorities, but officials noted that the agency had begun including in approval letters the agency's rationale for approving specific expenditure authorities. GAO considers this a positive step towards improving the transparency of HHS's approval decisions, and if implemented consistently would address the intent of GAO's recommendation. HHS officials indicated that this step would be included in written protocols the agency is drafting but did not have a date for their completion. If these protocols are completed and consistently implemented, HHS's bases for its approvals of expenditure authorities, which can amount to billions of dollars in federal spending, will be more transparent. We will continue to monitor HHS's actions in response to this recommendation.

Recommendation: To improve the transparency and accountability of HHS's section 1115 Medicaid demonstration approval process, and to ensure that federal Medicaid funds for the demonstrations do not duplicate other federal funds, the Secretary of Health and Human Services should ensure the application of these criteria is documented in all HHS's approvals of section 1115 demonstrations, including those approving new or extending or modifying existing expenditure authorities, to inform internal and external stakeholders, including states, the public, and Congress, of the basis for the agency's determinations that approved expenditure authorities are likely to promote Medicaid objectives.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS agreed with this recommendation and, as of January 2020, had taken some steps to ensure that the bases for its approval decisions are documented in all approvals of section 1115 demonstrations. In December 2017, HHS's Centers for Medicare & Medicaid Services (CMS) issued a letter to state Medicaid officials, stating it had begun requesting additional documentation of the demonstration purposes being served by certain types of previously approved funding in demonstration proposals. Additionally, the agency noted it was taking certain steps to ensure that only allowable costs were matched by federal Medicaid funds. In April 2018, CMS officials stated that the agency had begun addressing in approval documents how each intervention proposed by the state was determined to be likely to promote Medicaid objectives. Officials reported that this step would be included in formal written protocols that outline the agency's procedures for application review and preparation of approval documents for section 1115 demonstrations, but as of January 2020, the agency did not have time frames for the completion of these protocols. If CMS completes and implements the written protocols, stakeholders should be able to more easily and consistently assess the agency's decisions. We will continue to monitor CMS's efforts in this area.

Recommendation: Because challenges associated with the fragmented federal food safety system are long-standing, decision makers do not have an integrated perspective on federal food safety performance, and centralized mechanisms for broad-based collaboration have not been sustained, Congress should consider directing OMB to develop a government-wide performance plan for food safety that includes results oriented goals and performance measures and a discussion of strategies and resources.

Agency: Congress
Status: Open

Comments: As of March 2020, Congress had not acted on this matter. OMB informed GAO in January 2020 that they had no plans to develop a government-wide performance plan for food safety. We continue to believe that such a plan is necessary for effective federal oversight of food safety.

Recommendation: Because challenges associated with the fragmented federal food safety system are long-standing, decision makers do not have an integrated perspective on federal food safety performance, and centralized mechanisms for broad-based collaboration have not been sustained, Congress should consider formalizing the FSWG through statute to help ensure sustained leadership across food safety agencies over time.

Agency: Congress
Status: Open

Comments: As of March 2020, Congress had not acted on this matter.

Recommendation: To ensure that CMS and ONC can effectively monitor the effect of the EHR programs and progress made toward goals, the Secretary of Health and Human Services should direct the agencies to develop performance measures to assess outcomes of the EHR programs--including any effects on health care quality, efficiency, and patient safety and other health care reform efforts that are intended to work toward similar outcomes.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS neither agreed nor disagreed with our recommendation. In July 2015, CMS noted that the agency is working to align the programs to better enable monitoring using outcome-oriented performance measures and noted that the agency is collecting data that will help them to develop such measures. CMS did not indicate when HHS plans to develop such measures as GAO recommended. In June 2016, CMS also noted that it analyzed the results of the EHR programs as of October 2015, but did not indicate that it used performance measures that assess outcomes. In September 2017, HHS officials provided us a variety of publically available reports, which they indicated show how program participants are progressing in the EHR programs and the related impacts. In 2018, CMS changed the name of these programs to the Promoting Interoperability programs to focus on improving interoperability and patients' access to health information, and officials noted that the agency is working to develop related outcome-based measures. To fully implement this recommendation, CMS needs to develop performance measures that enable the agency to assess whether the Promoting Interoperability programs are improving outcomes, such as health care quality, efficiency, and patient safety, as we recommended.

Recommendation: To ensure that CMS and ONC can effectively monitor the effect of the EHR programs and progress made toward goals, the Secretary of Health and Human Services should direct the agencies to use the information these performance measures provide to make program adjustments, as appropriate, to better achieve program goals.

Agency: Department of Health and Human Services
Status: Open

Comments: In written responses provided by HHS in February 2014, on a draft of the report, the agency indicated that it agrees that outcome-oriented performance measures will be useful to evaluating the extent that the EHR programs--enacted through legislation--achieve the expected results. However, HHS did not identify any specific actions that it might undertake to address our recommendation. In July 2015, CMS indicated that the agency is still working to develop additional performance measures, which is a necessary first step towards implementing our recommendation to HHS that CMS and ONC use the outcome-oriented performance measures to make program adjustments, as appropriate. In September 2017 and March 2018, HHS officials provided us documents, which they indicated show how information gathered through monitoring activities was used to inform the EHR programs. In November 2018, HHS officials noted that CMS is actively working to use data submitted for the Promoting Interoperability Programs to improve upon the outcomes of patients, and also indicated (as noted above) that CMS is collaborating with stakeholders to develop outcome-based measures for the Promoting Interoperability Programs. To fully implement this recommendation, CMS needs to develop outcome-oriented performance measures and then demonstrate it is using them to make appropriate program adjustments. We will update the status of this recommendation when we receive additional information.

Recommendation: To help address the uncertainty NIH faces, related to the potential impact of increasing indirect costs on its funding of future research, the Director of NIH should assess the impact of growth in indirect costs on its research mission, including, as necessary, planning for how to deal with potential future increases in indirect costs that could limit the amount of funding available for total research, including the direct costs of research projects.

Agency: Department of Health and Human Services: Public Health Service: National Institutes of Health
Status: Open

Comments: As of July 7, 2015, NIH provided some information indicating that it had taken action to address our recommendation by tracking the size of indirect costs as a proportion of NIH's overall budget as part of the agency's annual budget planning process and risk assessment program. However, we determined that the actions did not fully address the recommendation because they focus on the agency's overall budget and do not assess the potential ongoing impact of indirect costs for universities on its mission. As of September 2018, NIH officials have not informed us of any additional actions taken to implement this recommendation. We will update the status of this recommendation when we receive additional information.

Recommendation: To ensure that nonmedical DOD research organizations coordinate with the Assistant Secretary of Defense for Health Affairs early in the research process to understand medical research requirements and avoid inefficiencies that may lead to duplicative work, the Secretary of Defense should direct the Under Secretary of Defense for Acquisition, Technology and Logistics to communicate to DOD's nonmedical research organizations the importance of coordination with the Joint Program Committee for Combat Casualty Care chair on combat casualty care issues, and require this coordination early in the research process when these organizations conduct research with implications for combat casualty care.

Agency: Department of Defense
Status: Open

Comments: DOD took several actions in 2014 to communicate to DOD's nonmedical research organizations the importance of coordination with the Joint Program Committee for Combat Casualty Care. Specifically, DOD chartered the Armed Services Biomedical Research Evaluation and Management Community of Interest to include both medical and non-medical researchers and to improve coordination, collaboration, and cooperation. DOD also appointed senior leaders to work in both this community of interest and in other DOD research communities of interest, to improve coordination. Furthermore, DOD conducted joint research meetings to share research data across the medical and non-medical communities. However, DOD had not indicated a requirement for this coordination to occur early in the research process, as included in GAO's recommendation. As of September 2019, DOD has not provided additional information or documentation to address this recommendation.

Recommendation: In order to ensure an equitable allocation of CHS program funds, the Congress should consider requiring IHS to develop and use a new method to allocate all CHS program funds to account for variations across areas that would replace the existing base funding, annual adjustment, and program increase methodologies, notwithstanding any restrictions currently in federal law.

Agency: Congress
Status: Open

Comments: As of August 2019, Congress has not acted on this recommendation. We will update the status of this recommendation if Congress takes action.

Recommendation: To help ensure appropriate payments to MA plans, the Administrator of CMS should take steps to improve the accuracy of the adjustment made for differences in diagnostic coding practices between MA and Medicare FFS. Such steps could include, for example, accounting for additional beneficiary characteristics, including the most current data available, identifying and accounting for all years of coding differences that could affect the payment year for which an adjustment is made, and incorporating the trend of the impact of coding differences on risk scores.

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

Comments: CMS indicated in January 2020 that it has no plans to take further action regarding our recommendation. CMS stated that, given the complexity of measuring coding changes attributable to plan behavior and the difficulty of measuring countervailing factors, there is not a single correct factor within the viable range of adjustment factors. In addition, the agency noted that there is policy discretion with respect to the appropriate adjustment factor for the payment year. In the Medicare Advantage Call Letter of April 2019, CMS stated that it will apply the statutory minimum adjustment of 5.90 percent for calendar year 2020. As of February 2020, CMS had not provided any documentation of its analysis and the basis for its determination. Although the application of the 5.90 percent adjustment and other recent changes CMS has made to its methodology for calculating the diagnostic coding adjustment (i.e., the exclusion of diagnosis codes that were differentially reported in Medicare fee-for-service and Medicare Advantage) likely brings CMS's adjustment closer to what GAO's analysis projects to be an accurate adjustment, a modified methodology that incorporates more recent data, accounts for all relevant years of coding differences, and incorporates the effect of coding difference trends would better ensure an accurate adjustment in future years. Until CMS shows the sufficiency of the diagnostic coding adjustment or implements an adjustment based on analysis using an updated methodology, payments to Medicare Advantage plans may not accurately account for differences in diagnostic coding between these plans and traditional Medicare providers.