Recommendation: The Chairman of the National Security Council, or his designee, should work with relevant federal entities to update strategy documents related to the nation's cybersecurity to better reflect desirable characteristics of a national strategy, to include:

• an assessment of cyber-related risk, based on an analysis of the threats to, and vulnerabilities of, critical assets and operations;

• measures of performance and formal mechanism to track progress of the execution of activities; and

• an analysis of the cost and resources needed to implement the National Cyber Strategy. (Recommendation 1)

Agency: Executive Office of the President: National Security Council
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 legislation to designate a leadership position in the White House with the commensurate authority—for example, over budgets and resources—to implement and encourage action in support of the nation's cyber critical infrastructure, including the implementation of the National Cyber Strategy. (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 Director of ICE should direct Custody Management to regularly conduct analyses of contracted facility inspections oversight data over time, within and across facilities and regions, and in a manner to enable trends in inspection deficiencies to be identified and addressed. (Recommendation 1)

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
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 ICE should direct the Office of Detention Oversight and Custody Management to take steps to ensure that data on deficiencies identified through Office of Detention Oversight's inspections are recorded in a format that is accessible to Custody Management for analysis purposes. (Recommendation 2)

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
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 ICE should regularly conduct analyses of data on deficiencies identified through Office of Detention Oversight's inspections. (Recommendation 3)

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
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 ICE should ensure that all Operational Review Self-Assessment results and corrective actions are recorded in a format that is conducive to tracking and analysis. (Recommendation 4)

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
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 ICE should regularly conduct analyses of detention-related complaint data from relevant offices, including analyses of data over time, within and across facilities and regions, and at a level necessary to identify and address potentially reoccurring complaints. (Recommendation 5)

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
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 ICE should require that ERO field offices record any actions taken on, and the resolutions of, detention-related complaints referred to them from the Detention Reporting and Information Line and Administrative Inquiry Unit in a timely manner. (Recommendation 6)

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
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 Secretaries of the Military Departments revise AFI 36-3026, Volume 1, to provide detailed guidance for financial determinations and to establish consistent medical standards for all of the military services to use in determining the dependency status of incapacitated adult children, including what household and personal expenses and income are allowable, how these are to be calculated, and what medical documentation is required. (Recommendation 1)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation and indicated that it would develop and apply a single set of financial and medical standards across the Department. DOD indicated that these standards would be published in an upcoming policy memorandum.

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness, in coordination with the Secretaries of the Military Departments and the Director of the Defense Finance and Accounting Service, identifies and implements the most effective means to provide information to families of incapacitated adult children to assist them in completing the dependency determination process. Such methods could include providing additional application instructions to families, making improvements to the DD Form 137-5, Dependency Statement – Incapacitated Child Over Age 21, such as providing detailed explanations of allowable expenses and how they should be calculated, providing detailed information about available support services, and providing additional and more advance notice to families. (Recommendation 2)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation and noted that existing instructional tools exist to help families navigate the dependency determination process. However, DOD indicated that a Under Secretary of Defense for Personnel and Readiness user group will identify additional means to improve the information available to military families.

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness clearly defines oversight responsibilities of the Department of Defense Human Resources Activity and the military services for the incapacitated adult child dependency process, including the consistent tracking, monitoring, and reporting of reliable data on incapacitated adult child dependency applications and determinations across the military services for use in data-driven decision-making. (Recommendation 3)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation and stated that while current DOD guidance does not include specific oversight responsibilities for the incapacitated adult child program DOD concurred with the need for a single office to provide oversight of the program. DOD noted that the Under Secretary of Defense for Personnel and Readiness would identify the office and assign responsibility within 60 days of our report.

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness directs the Department of Defense Human Resources Activity to exercise its oversight responsibilities for the incapacitated adult child dependency process, as clarified, including the use of consistent and reliable data on applications and determinations for data-driven decision-making to identify and address deficiencies and to inform program efforts. (Recommendation 4)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation, however DOD noted that it would address the recommendation after it takes action on our recommendation related to defining oversight responsibilities for the incapacitated adult child dependency determination process.

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness clarifies the definition of a nondependent family member in DOD Instruction 1315.19 and the circumstances under which nondependent family members should be considered for services provided by the Exceptional Family Member Program. (Recommendation 5)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation and stated that it will review its policy to determine if the definition of a nondependent family member continues to be current and appropriate.

Recommendation: The Secretary of Defense should ensure that the Secretaries of the Military Departments revise military service-level policy to ensure consistency with the DOD Instruction 1315.19 definition of nondependent family members and the circumstance under which a nondependent family member should be considered for services provided by the Exceptional Family Member Program. (Recommendation 6)

Agency: Department of Defense
Status: Open

Comments: DOD partially concurred with this recommendation and stated that if DOD determines the current definition of a nondependent family member is no longer appropriate, it will ensure that Service-level policies will be revised to be consistent with the definition.

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 Assistant Director of the Infrastructure Security Division should implement a documented process for reviewing and, if deemed necessary, revising its guidance for implementing cybersecurity measures at regularly defined intervals. (Recommendation 1)

Agency: Department of Homeland Security: Cybersecurity and Infrastructure Security Agency
Status: Open

Comments: DHS concurred with this recommendation and stated that CISA's Infrastructure Security Division (ISD) will work to develop a documented process for reviewing CFATS cybersecurity guidance at regularly defined intervals. DHS stated in its comments that once the process is documented and implemented, ISD will revise or supplement existing guidance, as appropriate. We will continue to monitor DHS's actions to address the recommendation.

Recommendation: The Assistant Director of the Infrastructure Security Division should incorporate measures to assess the contribution that its cybersecurity training is making to program goals, such as inspector- or program-specific performance improvement goals. (Recommendation 2)

Agency: Department of Homeland Security: Cybersecurity and Infrastructure Security Agency
Status: Open

Comments: DHS concurred with this recommendation stated that CISA agrees that it is important to ensure training supports program goals, whether relating to inspector-specific or program-specific performance maintenance or improvement goals. Regarding inspector performance maintenance or improvement, DHS stated that, among other things, management will ensure that each inspector's individual performance plan fully captures their expected performance goals in the area of cybersecurity. We will continue to monitor DHS's actions to address this recommendation.

Recommendation: The Assistant Director of the Infrastructure Security Division should track delivery and performance data for its cybersecurity training, such as the completion of courses, webinars, and refresher trainings. (Recommendation 3)

Agency: Department of Homeland Security: Cybersecurity and Infrastructure Security Agency
Status: Open

Comments: DHS concurred with this recommendation and stated that CISA agrees that process improvements to better document and evaluate the effectiveness of the training provided to CFATS staff are worthwhile. DHS stated in its comments that CISA will establish policies and procedures intended to ensure that all cybersecurity training provided to chemical security personnel is accounted for in a centralized mechanism. We will continue to monitor DHS's actions taken to address this recommendation.

Recommendation: The Assistant Director of the Infrastructure Security Division should develop a plan to evaluate the effectiveness of its cybersecurity training, such as collecting and analyzing course evaluation forms. (Recommendation 4)

Agency: Department of Homeland Security: Cybersecurity and Infrastructure Security Agency
Status: Open

Comments: DHS concurred with this recommendation and stated that evaluating the effectiveness of training is beneficial and CISA will work to ensure that all cybersecurity courses provided to CISA chemical security staff are evaluated for effectiveness. DHS also stated that, among other things, CISA will require course evaluation forms from each attendee of any cybersecurity training provided by CISA to its chemical facility staff. We will continue to monitor DHS's actions to address this recommendation.

Recommendation: The Assistant Director of the Infrastructure Security Division should develop a workforce plan that addresses the program's cybersecurity-related needs, which should include an analysis of any gaps in the program's capacity and capability to perform its cybersecurity-related functions, and human capital strategies to address them. (Recommendation 5)

Agency: Department of Homeland Security: Cybersecurity and Infrastructure Security Agency
Status: Open

Comments: DHS concurred with this recommendation and stated that CISA will develop a concept of operations, which will include goals and requirements for a workforce review and planning effort to ensure the organization addresses the new program's capacity and capability to perform its regulatory, voluntary, and programmatic goals, to include its cybersecurity related functions. We will continue to monitor DHS's actions to address this recommendation.

Recommendation: The Assistant Director of the Infrastructure Security Division should maintain reliable, readily available information about the cyber integration levels of covered chemical facilities and inspector cybersecurity expertise. This could include updating the program's inspection database system to better track facilities' cyber integration levels. (Recommendation 6)

Agency: Department of Homeland Security: Cybersecurity and Infrastructure Security Agency
Status: Open

Comments: DHS concurred with this recommendation and stated that CISA retains information on cyber integration levels for regulated facilities but that it is not in a readily accessible format. DHS stated in its comments that ISD will execute a contract for new information technology development support for the CSAT system which, once executed, will work with the new support contractor to build a tool to automate the locating and reporting of a facility's cyber integration level data in a more accessible format. We will continue to monitor the status of DHS's actions to address this recommendation.

Recommendation: The Administrator of FNS should develop and implement a process, documented in policies and procedures, to analyze SNAP state-level root causes to identify potential similarities among the states and develop and implement SNAP agency-level corrective actions, if appropriate, to help address them. (Recommendation 1)

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

Comments: In commenting on our draft report, USDA stated that the Food and Nutrition Service should formalize its existing processes into a standard operating procedure to analyze the Supplemental Nutrition Assistance Programs (SNAP) state-level root causes to identify potential similarities among states, in order to improve development and implementation of SNAP agency-level corrective actions, if appropriate.

Recommendation: The Secretary of Agriculture should revise USDA's procedures to include processes for monitoring the progress and measuring the effectiveness of improper payment corrective actions. The process for measuring the effectiveness of corrective actions should clearly demonstrate the effect USDA's corrective actions have on reducing improper payments. (Recommendation 2)

Agency: Department of Agriculture
Status: Open

Comments: In commenting on our draft report, USDA stated that a proposed action plan will be developed to revise USDA's procedures for monitoring the progress and measuring the effectiveness of improper payment corrective actions. Processes will focus on the impact corrective actions have on the root causes of improper payments.

Recommendation: The Secretary of Education should revise and document Education's process for measuring the effectiveness of its corrective actions based on its new statistical estimation methodology for Direct Loan and Pell Grant improper payments. This process should clearly demonstrate the effect Education's corrective actions have on reducing improper payments. (Recommendation 3)

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

Comments: In commenting on our draft report, Education stated that Federal Student Aid (FSA) will continue to evaluate and refine its processes to measure corrective actions and the effectiveness of these actions. Further, Education stated that FSA's measurement of corrective action effectiveness and root cause identification will gain additional precision as FSA collects annual improper payment data and builds upon the new baseline of statistically valid improper payment estimates. Education stated that FSA annually measures the overall effectiveness of its corrective action plans collectively against the improper payment reduction targets, rather than measuring the effectiveness of each individual corrective action. However, OMB guidance directs agencies to measure the effectiveness of each individual corrective action annually.

Recommendation: The Secretary of Health and Human Services should document in policies and procedures HHS's improper payment corrective action plan process. As part of these procedures, HHS should include processes for (1) establishing planned completion dates, (2) monitoring the progress of implementing corrective actions, and (3) measuring the effectiveness of improper payment corrective actions. The process for measuring the effectiveness of corrective actions should clearly demonstrate the effect HHS's corrective actions have on reducing improper payments. (Recommendation 4)

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

Comments: In commenting on our draft report, HHS elaborated on the improper payment corrective action plan process that is called for in OMB guidance. HHS stated that OMB guidance provides agencies the flexibility to measure the effectiveness of corrective actions and believes that this flexibility is vital to its oversight processes to reduce improper payments.

Recommendation: The Secretary of the Treasury should determine whether Treasury's current improper payment root cause analysis provides sufficiently relevant information that can be used as a basis for proposed corrective actions in reducing EITC improper payments and, if not, update the analysis using more timely data to ensure their reliability for identifying root causes of EITC improper payments. (Recommendation 5)

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

Comments: In commenting on our draft report, Treasury stated that each year it indicates in its corrective action plan that IRS will continue to work with Treasury to develop legislative proposals that will improve refundable credit compliance and reduce erroneous payments.

Recommendation: The Secretary of the Treasury should update Treasury's strategy for addressing the root causes of EITC improper payments to include (1) coordinating with other agencies to identify potential strategies and data sources that may help in determining EITC eligibility and (2) determining whether legislative changes are needed, and developing proposals as appropriate, to help reduce EITC improper payments, such as those related to the inability to authenticate taxpayer eligibility. (Recommendation 6)

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

Comments: In commenting on our draft report, Treasury stated that each year it indicates in its corrective action plan that IRS will continue to work with Treasury to develop legislative proposals that will improve refundable credit compliance and reduce erroneous payments. Although Treasury has made certain legislative proposals, it has not made proposals to specifically help address EITC eligibility criteria issues. Additionally, Treasury's strategy does not include identifying and proposing additional legislative changes needed to help reduce EITC improper payments.

Recommendation: The Commissioner of SSA should develop and implement a process, documented in policies and procedures, to measure the effectiveness of SSA's corrective actions for OASDI and SSI improper payments. This process should clearly demonstrate the effect SSA's corrective actions have on reducing improper payments. (Recommendation 7)

Agency: Social Security Administration
Status: Open

Comments: In commenting on our draft report, SSA stated that it will determine the most cost-effective strategies to remediate the underlying causes of payment errors and monitor, measure, and revise the strategies as needed.

Recommendation: The Chief Counsel of the Internal Revenue Service, in coordination with appropriate offices, should identify and document parameters and procedures for applying enhanced collaborative approaches to regulation and other guidance development with IRS Business Operating Divisions. (Recommendation 1)

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

Comments: As of August 2020, IRS disagrees with this recommendation and does not plan to take action on it. IRS officials said their Chief Counsel Directives Manual provides sufficient guidance and flexibility to allow for enhanced collaboration when appropriate. However, officials acknowledged that this collaboration was particularly helpful in implementing TCJA provisions and greatly contributed to IRS's successful implementation. By implementing this recommendation, IRS can help ensure that institutional knowledge and beneficial practices from TCJA implementation will be documented and effectively leveraged to support implementation of future time-sensitive or complex tax law changes without restricting IRS's flexibility. Documenting procedures would ensure IRS can retain organizational knowledge and mitigate the risk of having that knowledge limited to a few personnel.

Recommendation: The Commissioner of Internal Revenue should develop a process to accurately and thoroughly capture implementation status of ongoing projects in accordance with Standards for Internal Control in the Federal Government. (Recommendation 2)

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

Comments: As of August 2020, IRS disagrees with this recommendation and does not plan to take action on it. IRS officials acknowledged inconsistencies in reports but said these inconsistencies were not detrimental to overall implementation. We maintain that accurately and thoroughly capturing implementation status on ongoing projects would provide accurate information to decision makers and could prevent potential misreporting, mismanagement, or inefficient resource investment in the future.

Recommendation: The Commissioner of Small Business/Self Employed should coordinate with appropriate IRS divisions or offices to identify the costs and benefits of retroactively transcribing taxpayer data resulting from TCJA. (Recommendation 3)

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

Comments: As of August 2020, IRS disagrees with this recommendation and does not plan to take action on it. IRS officials said the retroactive transcription of TCJA returns would be a time intensive activity with significant opportunity costs, and that the benefits of retroactive transcription are currently not quantifiable. A high-level analysis of costs and benefits could help IRS management determine what, if any, data would benefit compliance and enforcement efforts. IRS could use readily available existing information (such as the number of returns affected by a certain provision, LB&I and IT cost data on conversion efforts already implemented, or the usefulness of past compliance analytics in similar areas) to inform the analysis. For example, IRS staff are manually reviewing certain forms associated with one TCJA provision for compliance purposes and IRS could use information from this effort (e.g., amount of time and any compliance results) to inform a high-level estimate of costs and benefits.

Recommendation: Based on the costs and benefits identified in recommendation 3, the Commissioner of Small Business/Self Employed should determine which TCJA provisions' data should be converted into a more useful electronic format for compliance and enforcement purposes and work with the appropriate offices to obtain the transcribed data, as appropriate. (Recommendation 4)

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

Comments: As of August 2020, IRS disagrees with this recommendation and does not plan to take action on it. IRS officials said that implementing this recommendation would require identifying the costs and benefits, which they do not plan to take action on. However, IRS officials acknowledged that IRS operating divisions and offices make strategic decisions regarding how best to use TCJA-related return data for compliance and enforcement purposes. We believe that converting data in instances where the benefits outweigh the costs would better position IRS to more effectively and efficiently pursue its mission of ensuring taxpayer compliance. For example, in the case of one TJCA provision, because IRS is not collecting information in an easily accessible format, IRS staff are manually reviewing forms to help with compliance efforts.

Recommendation: The Assistant Secretary of Tax Policy should update Treasury's internal guidance to ensure that Treasury's regulatory impact analyses include examination of the distributional effects of revenue changes when regulations influence tax liability. (Recommendation 5)

Agency: Department of the Treasury: Office of the Assistant Secretary of the Treasury (Tax Policy)
Status: Open

Comments: As of August 2020, Treasury disagrees with this recommendation and does not plan to take action on it. Treasury officials said the analyses underlying Treasury's tax regulations have fully complied with the Memorandum of Agreement established with the U.S. Office of Management and Budget (OMB), which focuses on non-revenue effects. We maintain that decisions Treasury and IRS made when developing regulations to implement TCJA could potentially impact tax liability by billions of dollars per year; however, Treasury's internal guidance dictates that these revenue effects should not be included in its economic analyses of the regulations. In some regulations, Treasury has addressed revenue effects in its analyses, but this has not been done consistently. By adjusting its internal guidance to ensure that distributional effects of revenue changes are consistently reflected in its analyses, it would better inform the regulatory decision-making process, while also providing the public with greater transparency.

Recommendation: The DEA Administrator should develop and implement additional ways to use algorithms in analyzing ARCOS and other data to more proactively identify problematic drug transaction patterns. (Recommendation 1)

Agency: Department of Justice: Drug Enforcement Administration
Status: Open
Priority recommendation

Comments: DOJ agreed with this recommendation and DEA stated it will continue to examine a variety of technologies to analyze ARCOS and other data and implement additional ways to use algorithms to more proactively identify problematic drug transaction patterns.

Recommendation: The DEA Administrator, in coordination with the department-wide efforts on data strategy, should establish and document a data governance structure to ensure DEA is maximizing its management of industry-reported drug transaction data. (Recommendation 2)

Agency: Department of Justice: Drug Enforcement Administration
Status: Open
Priority recommendation

Comments: DOJ agreed with this recommendation. As of September 2019, DEA officials stated that its Office of Information Systems' Chief Data Officer just recently started to work with DOJ and other components to develop a data strategy in response to the recently released department wide strategy, and has begun efforts to develop a governance structure. In November, 2019 DEA indicated it will continue to mature its data governance structure. The intent of this recommendation is for DEA to establish a formalized data governance structure to manage its collection and use of data used to support the Diversion Control Division's mission.

Recommendation: The DEA Administrator should establish outcome-oriented goals and associated measurable performance targets related to opioid diversion activities, using data it collects, to assess how the data it obtains and uses supports its diversion control activities. (Recommendation 3)

Agency: Department of Justice: Drug Enforcement Administration
Status: Open
Priority recommendation

Comments: DOJ neither agreed nor disagreed with this recommendation but DEA stated in November 2019, that it recognizes that measurable performance targets related to opioid diversion activities can serve as leading practices at different organizational levels including the program, project, or activity level. Our recommendation is intended to ensure that DEA can demonstrate the usefulness of the data it collects and uses to support its opioid diversion control activities.

Recommendation: The DEA Administrator, in consultation with industry stakeholders, should identify solutions to address the limitations of the ARCOS Enhanced Lookup Buyer Statistic Tool, to ensure registrants have the most useful information possible to assist them in identifying and reporting suspicious orders to DEA. (Recommendation 4)

Agency: Department of Justice: Drug Enforcement Administration
Status: Open
Priority recommendation

Comments: DOJ agreed with this recommendation and in November 2019, stated it has consulted with industry stakeholders and identified solutions to address the limitations of the tool.

Recommendation: The Administrator of CMS should ensure that state Medicaid programs have written policies and procedures that specify the extent to which covered entities can use 340B drugs for Medicaid beneficiaries, are designed to effectively identify if 340B drugs were used, and if so, how they should be excluded from Medicaid rebate requests. The policies and procedures should be made publically available and cover FFS, managed care, and all of the dispensing methods for outpatient drugs. (Recommendation 1)

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

Comments: HHS concurred with this recommendation and in August 2020 stated that it is developing guidance to state Medicaid programs directing them to strengthen policies and procedures related to 340B drugs for Medicaid beneficiaries.

Recommendation: The Administrator of HRSA should incorporate assessments of covered entities' compliance with state Medicaid programs' policies and procedures regarding the use and identification of 340B drugs into its audit process, working with CMS as needed to obtain states' policies and procedures. (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 August 2020, did not plan to take any actions to implement the recommendation. As noted in our report, covered entities' compliance with state Medicaid programs' policies and procedures is fundamental to preventing duplicate discounts. Thus, we continue to believe that HRSA's audit process should include an assessment of covered entities' compliance with state Medicaid programs' policies and procedures related to 340B drugs as it is necessary to identify potential duplicate discounts and to ensure covered entities' compliance with 340B Program requirements.

Recommendation: The Administrator of HRSA should require covered entities to work with affected drug manufacturers regarding repayment of identified duplicate discounts in Medicaid managed care. (Recommendation 3)

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 August 2020, did not plan to take any actions to implement the recommendation. As noted in our report, HRSA officials told us that covered entities' obligations for preventing duplicate discounts are the same for Medicaid fee-for-service and managed care. Thus, we continue to believe that when duplicate discounts related to Medicaid managed care have been identified, the agency should require covered entities to work with manufacturers to remedy them as they do for duplicate discounts related to Medicaid fee-for-service to help ensure compliance with 340B Program requirements.

Recommendation: The Commissioner of the Social Security Administration should clarify policies and procedures to remind staff that a diagnosis of a substance use disorder is not necessary to conduct a Drug Addiction and Alcoholism evaluation. (Recommendation 1)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation. The agency stated that it had revised related policies in February 2020, and had planned to issue guidance and video-on-demand training to further clarify policies and procedures in this area. However, SSA said its efforts to maintain mission critical activities amid the COVID-19 pandemic have delayed further implementation of this recommendation and a specific implementation date could not be provided at this time.

Recommendation: The Commissioner of the Social Security Administration should ensure that staff document their rationale for decisions involving the Drug Addiction and Alcoholism evaluation process. (Recommendation 2)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation. The agency said it had planned to issue guidance reinforcing its policy on properly documenting decisions involving the Drug Addiction and Alcoholism evaluation process. However, SSA said its efforts to maintain mission critical activities amid the COVID-19 pandemic have delayed implementation of this recommendation and a specific implementation date could not be provided at this time.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's NAC puts controls in place to better ensure the completeness of vendor FSS sales reporting. (Recommendation 1)

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

Comments: VA concurred with this recommendation and is taking steps to implement it. In August 2020, VA reported that it has taken steps to better ensure the completeness of vendor FSS sales reporting, including by conducting more active monitoring of the sales data submitted by vendors. These steps are ongoing, but NAC has reported a decrease in the number of FSS contractors not reporting sales.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's NAC assesses data on the participation of and items and services offered by veteran-owned small businesses in NAC's FSS program, in order to determine whether their program is meeting the needs of VHA contracting officers who use it given the Veterans First requirements they must meet. (Recommendation 2)

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

Comments: VA concurred with this recommendation and is taking steps to implement it. In August 2020, VA reported that NAC has conducted additional outreach to veteran-owned small businesses regarding FSS participation, and plans to conduct analysis of these businesses' participation in FSS by the end of fiscal year 2020.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's NAC directs the FSS Director to develop a mechanism to consistently obtain and analyze VHA user feedback on the FSS program. (Recommendation 3)

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

Comments: VA concurred with this recommendation and has taken several actions to more consistently obtain VHA user feedback on the FSS program, including holding meetings with each VHA regional contracting office and participating in VHA integrated project teams and other recurring meetings. We have requested documentation of these activities, but VA has yet to provide it.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's NAC provides FSS contracting staff with comprehensive FSS guidance. (Recommendation 4)

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

Comments: VA concurred with this recommendation and NAC reported in August 2020 that it has taken steps to make existing guidance on the FSS program more accessible to FSS contracting staff. We have requested more documentation from VA to confirm that the guidance is comprehensive.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's NAC develops an FSS-specific training program to include essential skills and processes to meet ongoing training needs for new and existing contracting staff. (Recommendation 5)

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

Comments: VA concurred with this recommendation and NAC reported in August 2020 that it has implemented additional introductory training for new FSS contracting staff, as well as quarterly training events for all FSS contracting staff. We have requested additional documentation from VA on the content of the quarterly training.

Recommendation: The Administrator of GSA should work with the Secretary of VA to develop a memorandum of understanding outlining the roles and responsibilities of GSA and NAC for collaborating under GSA's delegation of authority to VA for the healthcare-related Federal Supply Schedules, including the processes through which the two organizations will coordinate and share useful tools and practices. (Recommendation 6)

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

Comments: GSA concurred with this recommendation. In August 2020, GSA stated that it has met with VA and agreed to develop an interagency memorandum of understanding by December 2020.

Recommendation: The Secretary of Veterans Affairs should work with the Administrator of GSA to develop a memorandum of understanding outlining the roles and responsibilities of GSA and NAC in collaborating under GSA's delegation of authority to VA for the healthcare-related Federal Supply Schedules, including the processes through which the two organizations will coordinate and share useful tools and practices. (Recommendation 7)

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

Comments: VA concurred with this recommendation. In August 2020, GSA stated that it has met with VA and agreed to develop an interagency memorandum of understanding by December 2020.

Recommendation: The Administrator of GSA should take steps to document its delegation of authority for the healthcare-related Federal Supply Schedules to VA. (Recommendation 8)

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

Comments: GSA concurred with this recommendation. In August 2020, GSA stated that it is working to develop updated delegation of authority and will provide further details by December 2020.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's NAC assesses the appropriateness of NAC's current timeliness goals for FSS contract awards and takes steps to comprehensively identify and address barriers to achieving them. (Recommendation 9)

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

Comments: VA concurred with this recommendation. In August 2020, VA reported that NAC has confirmed that existing timeliness goals are appropriate, and that NAC officials meet on a quarterly basis to discuss barriers to meeting these goals. We have requested more detail from NAC on the barriers they have identified and steps they are taking to address them so that we can assess whether they are comprehensive.

Recommendation: The Secretary of Veterans Affairs should ensure that the Associate Executive Director of VA's National Acquisition Center takes measures to ensure greater efficiency in the offer-intake process, such as providing additional guidance for vendors or by adopting a system that includes checks for completeness of required vendor documentation. (Recommendation 10)

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

Comments: VA concurred with this recommendation. In August 2020, VA reported that NAC has developed a checklist for assessing the completeness of submitted offers, and that new offers are currently processed in an average of two days. NAC is considering adoption of an automated offer intake system. We have requested additional details from NAC on the recent average offer processing time.

Recommendation: The Secretary of Veterans Affairs should take steps to assess duplication between VA's FSS and MSPV programs, to determine if this duplication is necessary or if efficiencies can be gained. (Recommendation 11)

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

Comments: VA concurred with this recommendation. In August 2020, VA stated that it is analyzing duplication of contracting across the department as part of its Category Management efforts, and expects to complete an internal report on this issue in early 2021.

Recommendation: The Director of ONDCP should develop and document key planning elements to help the agency meet the SUPPORT Act requirements for the 2020 National Drug Control Strategy and future Strategy iterations. These planning elements should include descriptions of resource investments, time frames, and any processes, policies, roles, and responsibilities needed to address each requirement. (Recommendation 1)

Agency: Executive Office of the President: Office of National Drug Control Policy
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 ONDCP should—after developing and documenting key planning elements to meet the SUPPORT Act requirements—routinely implement an approach, based on these planning elements, to meet the requirements for the 2020 National Drug Control Strategy and future Strategy iterations. (Recommendation 2)

Agency: Executive Office of the President: Office of National Drug Control Policy
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 ONDCP should develop and document key planning elements to help the agency meet the SUPPORT Act requirements to establish a Drug Control Data Dashboard that would include descriptions of resource investments, time frames, and any processes, policies, or roles, and responsibilities needed to address this requirement. (Recommendation 3)

Agency: Executive Office of the President: Office of National Drug Control Policy
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 ONDCP should—after developing and documenting key planning elements—implement an approach, based on these planning elements, to meet the SUPPORT Act requirements to establish a Drug Control Data Dashboard. (Recommendation 4)

Agency: Executive Office of the President: Office of National Drug Control Policy
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 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 Administrator of the GSA should report for Congress and the public—for example, on GSA's prospectus website—the extent to which completed projects' construction costs and schedules were rebaselined and final construction costs, to include any additional funding tenant agencies may have provided to GSA for changes. (Recommendation 1)

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

Comments: The General Services Administration (GSA) partially concurred with this recommendation. On February 6, 2020, GSA stated that it will publish summary schedule and budget results for completed projects on GSA's public-accessible prospectus website. GAO will continue to monitor GSA's actions related to this recommendation and update information accordingly.

Recommendation: The Administrator of the GSA should update its 2005 Commissioning Guide—or replace it with appropriate industry-recognized standards and guidance—to be consistent with GSA's current design standards and industry practices. (Recommendation 2)

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

Comments: GSA concurred with this recommendation, and on February 6, 2020, stated that GSA will publish updated Commissioning Guidance. GAO will continue to monitor GSA's actions related to this recommendation and update information accordingly.

Recommendation: The Administrator of the GSA should identify and communicate—such as through policy, guidance, or other appropriate mechanism—(a) when and how Post Occupancy Evaluations should be conducted for completed projects considering resource constraints and (b) how recommendations or lessons learned from those evaluations are effectively communicated to future project teams. (Recommendation 3)

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

Comments: GSA concurred with this recommendation, and on February 6, 2020, stated that GSA will publish program guidance on how and when Post Occupancy Evaluations are conducted and communicate recommendations or lessons learned to future project teams. GAO will continue to monitor GSA's actions related to this recommendation and update information accordingly.

Recommendation: The Director of OCS, in developing the new performance management approach for the CSBG program, should ensure that its performance framework includes information on (1) details for how the national measure is linked to and used to assess the three national program goals, (2) descriptions of how the updated state and local performance outcome measures align with national program goals, and (3) a written plan for how OCS will assess the reliability of state performance outcome data. (Recommendation 1)

Agency: Department of Health and Human Services: Office of Community Services
Status: Open

Comments: HHS agreed with this recommendation and and stated that it plans to take actions to better align its performance measures with the three national performance goals outlined in the new CSBG Theory of Change. We commend HHS for its plans to address this recommendation, but encourage the agency to focus on aligning its performance outcomes with the three national goals of the CSBG program as established by the CBBG Act, which are similar but not identical to the three goals outlined in the new CSBG Theory of Change. HHS also stated that it would implement additional actions to assess the reliability of state performance outcome data.

Recommendation: The Commissioner of FDA should consult with TTB and CBP to determine and document—for example in Memorandums of Understanding or other written agreements—procedures and time frames for FDA to receive quality data from TTB and CBP that will allow FDA to complete its reconciliation process in a timely manner. (Recommendation 1)

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

Comments: According to HHS, FDA officials met with CBP officials in September, 2019, and with TTB officials in October, 2019, to discuss the development of procedures and time frames for FDA to receive data from the respective entities that will allow FDA to complete its reconciliation process in a timely manner . In August, 2020, FDA reported that the agency had provided a draft agreement to both CBP and TTB subsequent to these meetings, but that agreements had not yet been finalized. Because FDA is still in the process of developing written agreements with CBP and TTB, the recommendation remains open.

Recommendation: The Commissioner of the Social Security Administration should ensure that (a) the agency's policies and guidance are specific enough so field office staff know how to apply complex suitability criteria for assessing payee suitability, such as by providing a minimum set of specific questions; and (b) additional regional guidance that is made available to staff is centrally reviewed for compliance and completeness. (Recommendation 1)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation but did not specify plans to address it.

Recommendation: The Commissioner of the Social Security Administration should create safeguards in the Electronic Representative Payee System (eRPS) to ensure that field office staff fully document all required information, such as the rationale for their decision, before approving an application. (Recommendation 2)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation and identified actions to address it. Specifically, SSA reported that, as part of implementing the Strengthening Protections for Social Security Beneficiaries Act of 2018, planned changes to eRPS will improve documentation of selection decisions. SSA also reported it will also consider additional enhancements to eRPS in the future. We will consider closing this recommendation when this effort is complete.

Recommendation: The Commissioner of the Social Security Administration should complete a plan, including timeframes, for comprehensively evaluating if and how to leverage external sources of information on organizations' suitability, such as by conducting background checks or credit checks on organizations or key staff that handle beneficiaries' funds or requiring organizations to conduct their own background checks on key staff. (Recommendation 3)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation and identified actions to address it. SSA officials stated that it is first focusing on implementing provisions of the Strengthening Protections for Social Security Beneficiaries Act of 2018 related to background checks for certain individual payees. After completing this work, the agency plans to evaluate conducting criminal background checks and credit checks on organizational payees and their staff. While we agree that implementing background screening pursuant to the law should take precedence, SSA should seek opportunities to implement screening for organizational payees at the earliest opportunity.

Recommendation: The Commissioner of the Social Security Administration should develop and implement mechanisms to systematically obtain and review feedback from organizational payees and communicate findings to SSA management. (Recommendation 4)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation but did not identify plans to address it.

Recommendation: The Commissioner of the Social Security Administration should (a) establish a plan and time frame for periodically reviewing the predictive model's design; (b) consider additional data sources that would allow for additional screening or modeling of potentially high-risk organizational payees; and (c) ensure that subsequent design decisions are documented in sufficient detail so the development process can be more fully understood and replicated, either by SSA or a knowledgeable third party, with minimal further explanation. (Recommendation 5)

Agency: Social Security Administration
Status: Open
Priority recommendation

Comments: SSA agreed with this recommendation in 2019 and identified actions to address it. The agency stated that it would pursue other data sources to develop additional screening tools and models to identify potentially high-risk organizational payees, but that it is unable to incorporate additional data into the existing model. They reported they cannot use new data to modify the existing model, which was built from cases and transactions that occurred many years ago. We recognize that the current model, which focuses on misuse findings and is based on historical data, presents challenges for both updating and including new data sources. Therefore, as SSA considers additional screening tools and models to identify high-risk, low-volume organizational payees, SSA should develop a plan for revising the existing model that allows for more timely updates and results in documentation of related design decisions. In April 2020, SSA officials reported that the agency is finalizing a plan to revise the existing model and would pursue other data sources to develop additional screening tools and models to identify potentially high-risk organizational payees.

Recommendation: The Commissioner of the Social Security Administration should require field offices to contact payees about missing or problematic annual accounting forms within a specific time frame. (Recommendation 6)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation but did not identify plans to address it.

Recommendation: The Commissioner of the Social Security Administration should revise the annual accounting form to enhance its effectiveness. Such revisions could include (but not be limited to) more fully ascertaining the use of collective accounts, adopting stakeholders' recommendations on using the form to collect more meaningful data, and reflecting best practices from behavioral science insights in the design of the form. (Recommendation 7)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation but did not identify plans to address it.

Recommendation: The Commissioner of the Social Security Administration should enhance the eRPS system to ensure that field offices are (a) alerted when collective accounts are due to be reviewed; and (b) able to take action on expired collective account information and thereby avoid payees' continued use of these accounts without oversight. (Recommendation 8)

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation and identified actions to address it. SSA officials reported that they would work with staff to ensure staff know where to find alerts for expiring accounts and enhance how eRPS displays information on collective accounts that have already expired. We agree with SSA's proposed actions. However, we adjusted our recommendation to clarify that SSA should enhance eRPS in a manner that ensures staff take action on expired accounts and that payees do not continue to use expired accounts without oversight.

Recommendation: The Commissioner of the Social Security Administration should, as it carries through with its plan to develop a risk assessment for the organizational payee program, ensure that that the plan reflects periodic consideration of findings from onsite reviews and audits. (Recommendation 9)

Agency: Social Security Administration
Status: Open
Priority recommendation

Comments: SSA agreed with this recommendation. In April 2020, SSA officials reported starting its Representative Payee Fraud Risk Assessment. We will consider closing this recommendation when SSA ensures that its risk assessment plan reflects periodic consideration of findings from onsite reviews and audits.

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

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

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

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

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

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

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: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations develop and implement a process to assess veterans' changing expectations and disseminate this information to VAMCs. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation, but noted that it had already developed and implemented effective systems for obtaining Veterans' input in facility planning. However, we found that the information VA collects through these efforts may be limited based on our review of VA's surveys, including VSignals and the Survey of Enrollees, as well as our discussions with several Veterans Service Organizations. For example, we found that VA's efforts were limited because they either focused on overall veteran expectations without a means of assessing how they differed by demographics, or they focused on veteran satisfaction with their past experiences. Moreover, satisfaction with past experiences, as operationalized by VA for the surveys we reviewed, measured how someone is with what they received--while "expectations," as defined by VA, would measure or gain insight into what it is that someone would want, and which may or may not be what they are receiving. Thus, while satisfaction, as operationalized by VA, can be an indicator of an expectation, as defined by VA, the two are not synonymous. Although VA considers this recommendation closed, we are working with them to identify ways that expectations, as VA has defined the term, can be measured.

Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations instruct VAMCs on how to meet VA's strategic goal of incorporating veterans' changing needs and expectations into facility planning, such as by identifying certain resources or tools and directing VAMCs to use them. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: VA agreed with the recommendation and indicated that it would instruct users on what data to use in planning and updates, which would help ensure veterans' input is incorporated where appropriate. As of its fiscal year 2021 budget justification, VA still had not provided this guidance to the VAMCs, but noted that it would provide it in scheduled facility planning calls that were expected to start in the second quarter of fiscal year 2020.

Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations provide additional instruction to VAMCs on how to incorporate the concept of foundational health services into facility planning. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and noted that it would clarify prior guidance on the foundational health services for VAMCs, which it expected to complete in June 2019. In November 2019, VA told us that it had reviewed this prior guidance from August 2017 that had defined foundational services, and has rescinded it. However, we are working with VA to determine if this decision to rescind the prior guidance was distributed to VAMCs.

Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations systematically gather feedback from facility planners and address (as necessary) their concerns with the reliability of the SCIP process, including providing additional information on how SCIP's space estimates are derived. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: VA agreed with this recommendation and indicated that it would update its training instructions to facility planners by adding an explanation of how SCIP space estimates are derived. In addition, VA noted that it would survey facility planners about their concerns with the SCIP space estimates, and use these results to either address the concerns or make improvements to SCIP. As of November 2019, VA had not completed the training or the survey, but noted that they are in the process of updating training materials for the FY22 SCIP planning process--which was targeted to start 2019. We will work with VA to obtain relevant documentation of these efforts.

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 Secretary of the Army should ensure that the Surgeon General of the Army Medical Command (1) collaborate with the Navy Bureau of Medicine and Surgery and the Air Force Medical Service to develop a common set of planning standards to be used to help determine dental clinic staffing needs, and (2) incorporate these standards into the Army's dental corps staffing model. (Recommendation 1)

Agency: Department of Defense: Department of the Army
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 Navy should ensure that the Surgeon General of the Navy Bureau of Medicine and Surgery (1) collaborate with the Army Medical Command and the Air Force Medical Service to develop and implement a common set of planning standards to be used to help determine dental clinic staffing needs, and (2) incorporate these standards into the Navy's dental corps staffing model. (Recommendation 2)

Agency: Department of Defense: Department of the Navy
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 Air Force should ensure that the Surgeon General of the Air Force Medical Service (1) collaborate with the Army Medical Command and the Navy Bureau of Medicine and Surgery to develop and implement a common set of planning standards to be used to help determine dental clinic staffing needs, and (2) incorporate these standards into the Air Force's dental corps staffing model. (Recommendation 3)

Agency: Department of Defense: Department of the Air Force
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 Army should ensure that the Surgeon General of the Army Medical Command evaluates the effectiveness of its recruitment and retention programs for military dentists, including the need for and effectiveness of the recruitment and retention incentives currently offered. (Recommendation 4)

Agency: Department of Defense: Department of the Army
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 Navy should ensure that the Surgeon General of the Navy Bureau of Medicine and Surgery evaluates the effectiveness of its recruitment and retention programs for military dentists, including the need for and effectiveness of the recruitment and retention incentives currently offered. (Recommendation 5)

Agency: Department of Defense: Department of the Navy
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 Air Force should ensure that the Surgeon General of the Air Force Medical Service evaluates the effectiveness of its recruitment and retention programs for military dentists, including the need for and effectiveness of the recruitment and retention incentives currently offered. (Recommendation 6)

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

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

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 Administrator of CMS should complete a comprehensive, national risk assessment and take steps, as needed, to assure that resources to oversee expenditures reported by states are adequate and allocated based on areas of highest risk. (Recommendation 1)

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

Comments: CMS has taken steps to conduct a comprehensive national risk assessment. As of October 2019, CMS had developed a standard tool to assess risk and staff capacity. The agency indicated that once the assessment is complete, CMS will identify opportunities to increase resources, review the current allocation of financial staff, and determine the appropriate allocation of staff by state. We will continue to monitor CMS's action to complete this assessment.

Recommendation: The Administrator of CMS should clarify in internal guidance when a variance analysis on expenditures with higher match rates is required. (Recommendation 2)

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

Comments: In October 2019, CMS indicated that the agency held meetings to clarify internal guidance on the variance analysis and is the process of drafting updated guidance for the CMS-64 review. We will continue to monitor CMS's actions to update the guidance.

Recommendation: The Administrator of CMS should revise the sampling methodology for reviewing expenditures for the Medicaid expansion population to better target reviews to areas of high risk. (Recommendation 3)

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

Comments: In October 2019, CMS indicated that given their current resources, they believe the sampling methodology is sufficient and have no plans to revise it. The agency noted that the current methodology requires a minimum sample size but gives reviewers the flexibility to expand the size of the sample if warranted by risk and as resources permit. We continue to believe that the current methodology does not sufficiently target areas of high risk.

Recommendation: The Under Secretary of Health should ensure all RME inspections are being conducted and reported as required and that the inspection results VHA has are complete. (Recommendation 1)

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

Comments: VA agreed with this recommendation and indicated it would establish an oversight process for reviewing and monitoring findings from inspections. VA has described some of the oversight actions it has put in place and noted that actions would be completed in 2020. We will update the status of this recommendation when additional information is received.

Recommendation: The Under Secretary of Health should examine the Sterile Processing Services workforce needs and take action based on this assessment, as appropriate. (Recommendation 3)

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

Comments: VA agreed with this recommendation and indicated it would review workforce needs and take necessary actions. VA has described some of the actions taken and noted that actions would be completed in 2019. We will update the status of this recommendation when additional information is received.

Recommendation: The Secretary of HHS should establish numeric enrollment targets for healthcare.gov, to ensure it can monitor its performance with respect to its objectives. (Recommendation 2)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS does not concur with this recommendation. In October 2018, the agency noted that there are numerous external factors, such as the state of the economy and plan premiums, that may affect the number of people who decide to enroll in coverage. HHS also stated that it does not believe that numeric enrollment targets are relevant to assess the performance of objectives related to a successful open enrollment period. We continue to believe that the development of numeric enrollment targets is important for effective monitoring of the program and management of its resources. As of September 2019, HHS had not provided any additional information about steps to implement this recommendation. The status of this recommendation will be reconsidered once relevant action is taken.

Recommendation: Should the agency continue to focus on enhancing the consumer experience as a goal for the program, the Secretary of HHS should assess other aspects of the consumer experience, such as those it previously identified as key, to ensure it has quality information to achieve its goal. (Recommendation 3)

Agency: Department of Health and Human Services
Status: Open

Comments: HHS concurs with this recommendation, and in October 2018, stated that as it is looking for ways to improve the consumer experience, it will consider focusing its assessment on other aspects of the consumer experience as needed. As of September 2019, HHS had not provided evidence of any additional steps it had taken to improve the consumer experience. The status of this recommendation will be reconsidered once relevant action is taken.

Recommendation: The Secretary of Defense should direct the Assistant Secretary of Defense (Health Affairs) to provide written documentation of DOD's approach to developing and approving the TRICARE Select access standards, as well as the final access standards, to Congress. (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 VHA Undersecretary for Health should provide updated guidance to VAMCs on the governance of the patient advocacy program, including clear definitions of reporting lines. (Recommendation 1)

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

Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) partnered with VA's Center for Healthcare Organization and Implementation Research (CHOIR) to better understand the current state of patient advocacy services in VHA, focusing on position descriptions, grade levels, and reporting structures. VA medical center staff completed questionnaires about the patient advocacy program in January 2019 and VHA analyzed the results. CHOIR officials are conducting site visits to interview key staff directly to identify the benefits and opportunities for improvements with patient advocacy services, including reporting structure. Upon completion of site visits to validate questionnaire findings, CHOIR will present their final recommendations to OPA. OPA will develop reporting structure guidance and work with workforce management and VHA senior leaders to communicate and implement the guidance. VHA's target completion for these efforts is December 2019.

Recommendation: The VHA Undersecretary for Health should assess and provide guidance to VAMCs on appropriately staffing the patient advocacy program, including guidance on how to determine the appropriate number and type of staff. (Recommendation 2)

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

Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) partnered with VA's Center for Healthcare Organization and Implementation Research (CHOIR) and VHA's Workforce Management to develop an evidence-based patient advocacy staffing model that accounts for facility size, complexity and geographic region. A set of questions was distributed to all VAMCs in December 2018. Responses to these questions have been analyzed by CHOIR, and on-site interviews at select facilities are in progress to validate the report findings. VHA's Workforce Management is working with CHOIR and OPA to use the results to develop a recommended and validated staffing model. This guidance will also be incorporated in the future revision of the VHA directive. The target completion of these efforts is December 2019.

Recommendation: The VHA Undersecretary for Health should monitor PATS data-entry practices to ensure all complaints are entered into PATS and that veterans' feedback is coded consistently. (Recommendation 5)

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

Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) receives a weekly report from both the Patient Advocate Tracking System (PATS) and PATS-Replacement (PATS-R) Systems reporting on the number of new cases entered at every VA medical center (VAMC). With development of the PATS-R web-based tool, OPA, the Veterans Experience Office and the PATS-R developers have conducted a review of existing codes and are currently working with various VHA program offices to standardize codes across various data systems. VA plans to develop an auditing toolkit to ensure standardized, timely documentation of complaints, including accurate coding within PATS. The target completion date for these efforts is December 2019.

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 Commissioner of FDA should develop performance metrics and use them to evaluate the implementation of the least burdensome requirements, such as during its planned audits of medical device deficiency letters. (Recommendation 1)

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

Comments: In July 2019, FDA reported on efforts to increase device staff knowledge of least burdensome requirements and the implementation of a "least burdensome flag," which allows the submitter to flag a submission for FDA if it believes that the agency's request is not the least burdensome or that it was being held to an inappropriate review standard. In August 2020, FDA described its analysis of the flags, including the number of times it was used and the time it took to resolve them relative to FDA's goal. FDA indicated that it will continue to monitor the usage of the flag program to identify signals or trends that should be addressed. The agency indicated that the recommendation should remain open, and GAO will continue to monitor the implementation of 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 Undersecretary for Health should develop and implement a process to accurately count all physicians providing care at each medical center, including physicians who are not employed by VHA. (Recommendation 1)

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

Comments: As of January 2020, VHA continues to disagree with the recommendation and has not taken any action. Although VA responded to our report by stating that the ability to count physicians does not affect its ability to assess workload, we maintain that an accurate count of all physicians providing care at each medical center is necessary for accurate workforce planning. To implement the first recommendation, VHA needs to develop a system-wide process to collect information on all physicians providing care at VAMCs, including physicians that are not employed by VHA. This information should be available at the local level for workforce planning purposes.

Recommendation: The Undersecretary for Health should develop and issue guidance to the VAMCs on determining appropriate staffing levels for all mission-critical physician occupations. (Recommendation 2)

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

Comments: VHA concurred with this recommendation. In November 2017, VHA's Executive in Charge chartered the Specialty Care Provider Staffing and Network Model Workgroup to develop a methodology for determining the scope and complexity of specialty care services. The Workgroup also developed an analytical tool to support local decision-making around specialty staffing levels. According to VHA, the Specialty Care Services Staffing model has been validated across some VHA regions. The Workgroup was directed to develop an Executive Decision Memorandum for an official determination as to implementation of the model. As of January 2020, VHA was awaiting the results of the Governing Board's decision on the Executive Decision Memorandum, the guidance documents, and analytical template. VHA reported the target date for completion is March 2020.

Recommendation: The Undersecretary for Health should establish a system-wide method to share information about physician trainees to help fill vacancies across VAMCs. (Recommendation 4)

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

Comments: VHA concurred with this recommendation. VHA is working to develop the necessary capacity to enable a system-wide method for sharing information about physician trainees to help fill vacancies. In April 2019, VHA anticipated having this system in place by the end of fiscal year 2019. However, VHA has not submitted any additional information since April 2019. VHA has also created a VHA-Trainee Recruitment and Hiring Workgroup (the Workgroup). The Workgroup serves as the advisory group on trainee recruitment and hiring, for the purpose of developing a permanent Trainee Recruitment and Hiring Function. The Workgroup is holding Virtual Trainee Recruitment Events for critical occupations. Until GAO sees evidence of a system-wide method for sharing information about physician trainees, this recommendation will remain open.

Recommendation: To improve the management of the Armed Forces Sports Program and better determine whether the program is achieving its desired results, the Secretary of Defense should direct the Under Secretary of Defense for Personnel and Readiness to develop and implement performance measures for the Armed Forces Sports Program that measure the desired outcomes for the program and, at a minimum, demonstrate linkage to the program's goals or mission, have a measurable target, and include a baseline that can be used to demonstrate program performance.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with our recommendation. As of September 2019, DOD officials stated that the Armed Forces Sports Council approved performance measures for the Armed Forces Sports Program at a council meeting held in April 2018. Officials said the approved performance measures went into effect in January 2019 in conjunction with the Armed Forces Sports Program's 2019 calendar year. Officials said that the baseline year for the performance measures is 2019 which they are currently collecting data for. Officials plan to provide an update on the program once they have collected and reviewed the 2019 baseline year performance measures. Additionally, officials said that OSD is working to update DOD Instruction 1330.04 to require the Armed Forces Sports Council to develop and implement performance measures for the Armed Forces Sports Program and review and track performance metrics annually. The DOD Instruction language has been updated and is currently pending review prior to the start of formal coordination.

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 improve the oversight of privacy and security controls over the state-based marketplaces, the Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to define procedures for overseeing state-based marketplaces, to include day-to-day activities of the relevant offices and staff.

Agency: Department of Health and Human Services
Status: Open

Comments: The agency concurred with the recommendation and is actively working on addressing the recommendation. We will continue to work with the agency to verify whether implementation has occurred.

Recommendation: To improve the oversight of privacy and security controls over the state-based marketplaces, the Secretary of Health and Human Services should direct the Administrator of the Centers for Medicare & Medicaid Services to require continuous monitoring of the privacy and security controls over state-based marketplaces and the environments in which those systems operate to more quickly identify and remediate vulnerabilities.

Agency: Department of Health and Human Services
Status: Open

Comments: The agency concurred with the recommendation and is actively working on addressing the recommendation. We will continue to work with the agency to verify whether implementation has occurred.

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 help ensure that agencies report consistent and comparable data on federal spending, the Director of OMB, in collaboration with the Secretary of the Treasury, should provide agencies with additional guidance to address potential clarity, consistency, or quality issues with the definitions for specific data elements including Award Description and Primary Place of Performance and that they clearly document and communicate these actions to agencies providing this data as well as to end-users.

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

Comments: OMB has taken some actions to address this recommendation related to procurement awards, such as adopting a shorter character limit for the "Award Description" element and providing additional guidance for the "Primary Place of Performance" element. However, it needs to provide additional guidance for these data elements related to grant awards to ensure collection of consistent and comparable information.

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 help ensure that the department can better achieve business process reengineering and enterprise architecture outcomes and benefits, the Secretary of Defense should utilize the results of our portfolio manager survey to determine additional actions that can improve the department's management of its business process reengineering and enterprise architecture activities.

Agency: Department of Defense
Status: Open

Comments: DOD has made progress implementing the recommendation. Specifically, in January 2017, the department issued a business enterprise architecture improvement plan. The plan was intended to address business enterprise architecture usability and deficiencies in information supporting the investment management process. As part of its planning efforts, the department identified opportunities to address the results of our survey. For example, according to the plan, our survey results were used to identify opportunities for improving management and integration of existing enterprise business processes and investments; assessing duplication early in the analysis phase and finding process and capability reuse across the department; and providing a federated business enterprise architecture information environment and capabilities to discover and exchange information from other sources. The plan included delivering three major capabilities. In October 2019, the office of the Chief Management Officer (CMO) demonstrated its new capabilities to GAO. Further, in October 2019, staff within the office of the CMO were working to move the capabilities to a government-approved host environment, although the office had not yet finalized its plan to do so. As of November 2019, the department had not yet deployed the capabilities.

Recommendation: To ensure that the Family Caregiver Program is able to meet caregivers' demand for its services, the Secretary of the Department of Veterans Affairs should expedite the process for identifying and implementing an IT system that fully supports the program and will enable VHA program officials to comprehensively monitor the program's workload, including data on the status of applications, appeals, home visits, and the use of other support services, such as respite care.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with our recommendation and the Veterans Health Administration (VHA) and the Office of Information and Technology (OIT) have been working jointly on projects since 2015 to improve and replace the IT system for the Family Caregiver Program. However, two of these projects were terminated without delivering viable software improvements or a replacement system. According to two independent assessments, these prior efforts lacked both effective leadership and implementation of the processes needed for requirements management. In March 2019, VA began a third project, the Caregiver Record Management Application (CARMA), in which OIT and VHA began to acquire and implement a commercial product to replace the program's existing IT system. In February 2020, VA reported that to support the administrative needs of the Family Caregiver Program it had transitioned from its previous IT system to CARMA, its new IT system, in two stages: 1) In October 2019, VA deployed an initial release of CARMA for data entry of veterans and caregivers newly participating in the program, and 2) On December 2, 2019 the transition of existing veterans and caregivers to CARMA occurred. VA also reported in February 2020 that further enhancements and improvements to CARMA would be released over the coming months. However, the department has not yet fully committed to a date by which it will certify that CARMA fully supports the program. As of July 2020, this recommendation remains open pending further updates.

Recommendation: The Secretary of the Department of Veterans Affairs should direct the Undersecretary for Health to use data from the IT system, once implemented, as well as other relevant data to formally reassess how key aspects of the program are structured and to identify and implement modifications as needed to ensure that the program is functioning as envisioned so that caregivers can receive the services they need in a timely manner.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation. VA transitioned in late 2019 to a new IT system, the Caregiver Record Management Application (CARMA). However, the Department has not yet certified the readiness of CARMA to fully support the needs of the Program of Comprehensive Assistance for Family Caregivers (Family Caregiver Program). Prior to the transition to CARMA, VA had developed manual processes to obtain and monitor key data points, allowing it to reassess policies and procedures for the Family Caregiver Program. In its September 2019 update, VA reported that it anticipates being able to certify the IT system when proposed regulatory changes to enable the expansion of the Family Caregiver Program are finalized and the necessary changes which have an impact on IT are implemented. VA also reported that following certification, IT development will continue on IT requirements that do not directly impact VA's ability to expand the program, such as improving the program's ability to track and report on clinical appeals. As of July 2020, this recommendation remains open pending further updates on how VA plans to use data from the IT system to monitor and assess the program's performance.

Recommendation: To help states identify and address quality-of-care concerns among individuals with developmental disabilities receiving Medicaid HCBS waiver services, the Administrator of CMS should encourage states to (1) include death as a critical incident and conduct mortality reviews if they do not already do so and (2) broaden their mortality review processes if they already include death as a critical incident and conduct mortality reviews.

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

Comments: As of August 2020, CMS had taken some steps to address this recommendation but additional actions are needed to fully implement it. In June 2018 CMS issued a Medicaid update to states explaining that CMS strongly encourages them to include unexpected deaths in their definition of reportable critical incidents. CMS also stated in the update that states should conduct a preliminary review of all beneficiary deaths and investigations should focus on those deaths determined to be unexpected. Further, CMS has shared with states best practices for state mortality reviews that include, for example, the use of an interdisciplinary review committee and taking actions to address identified quality of care problems. CMS also developed a webinar training (Incident Management 101) to help states improve their incident management systems for the Medicaid HCBS waiver. The webinar outlines the key elements of building a comprehensive incident management system (e.g., establishing a process for conducting investigations of incidents, tracking and trending incidents to help prevent and mitigate incidents from occurring) and reiterates CMS's expectation that states identify and address unexplained deaths on an ongoing basis in order to meet the waiver's health and welfare assurance. In late 2018, CMS planned to include in its revised waiver application questions to determine practices regarding states' review and evaluation of unexpected deaths. In September 2019, CMS officials notified us that it will provide an updated status report on this recommendation in November 2019. As of August 2020, CMS officials have not provided us information regarding its revised waiver application and technical guide. We will update the status of this recommendation when we receive this information.