Recommendation: The Under Secretary for Health should ensure the RCS Chief Officer evaluates Vet Center productivity expectations for counselors, including (1) obtaining systematic feedback from counselors on any potentially negative effects on client care, and (2) determining whether directors and counselors need additional training or guidance on how the expectations are calculated. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure the RCS Chief Officer develops a plan and time frames for periodically reassessing its productivity expectations for counselors, and implementing any needed changes as appropriate. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure the RCS Chief Officer develops and implements a Vet Center staffing model that incorporates key practices in the design of staffing models. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should ensure the RCS Chief Officer establishes a plan and time frames for assessing and updating its staffing model regularly, and for implementing any needed changes as warranted. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should, in collaboration with relevant VBA and NCA officials, improve its process to accurately identify all on-campus veteran deaths by suicide by ensuring that it uses updated information and corroborates information with VA facility officials. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should expand the policy requirement for a root cause analysis to include all cases of on-campus veteran death by suicide, regardless of whether the veterans involved were enrolled in VHA health care services at the time of their death. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should direct the Office of Mental Health and Suicide Prevention to expand its analyses of on-campus veteran deaths by suicide to include all relevant information VA collects for these incidents, such as data from root causes analyses and information collected through the Behavioral Health Autopsy Program. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

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

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

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

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

Recommendation: The Veterans Health Administration should disseminate guidance for VISNs and VAMCs that more clearly reflects its expectation that mental health providers in specialty care should record mental health treatment plans within veterans' medical records in an easily identifiable way. (Recommendation 1)

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

Comments: VHA concurred with this recommendation and provided an update on its progress in implementing it. In December 2019, VHA reported that it had developed a new memorandum regarding mental health treatment planning that explicitly states the requirement for mental health providers in specialty care to record mental health treatment plans as a separate, easily identifiable document in the medical record. According to this memorandum, these treatment plans are expected to ensure that it is clear what treatment is being provided, that different treatments were considered, and that ongoing assessments are used to determined whether treatment changes are needed for the patient. VHA also reported that the memorandum states that facilities must either use the current treatment planning software or another method to create such a plan. Finally, VHA noted that the memorandum requires VAMCs to attest to full implementation of these requirements. According to VHA, the memorandum was distributed in May 2019 and the implementation process is currently underway across VAMCs. As of March 2020, this recommendation remains open pending further updates from VHA.

Recommendation: The Veterans Health Administration should develop and implement an approach for monitoring treatment plans for veterans with mental health conditions to ensure that such plans include documentation that different evidence-based treatment options were considered. (Recommendation 2)

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

Comments: VHA concurred with this recommendation and provided an update on its progress in implementing it. In December 2019, VHA reported that it had developed a new memorandum regarding mental health treatment planning that explicitly states the requirement for mental health providers in specialty care to record mental health treatment plans that include (among other things) an indication that different treatments were considered. VHA stated that the memorandum requires VAMCs to implement ongoing chart reviews to ensure providers were meeting treatment planning expectations. Specifically, VHA stated that the memorandum requires all VAMCs to ensure that each licensed independent provider had 5 treatment plans reviewed biannually to determine whether treatment planning expectations were achieved, including whether different evidence-based treatments were considered. Finally, VHA noted that the memorandum requires VAMCs to attest to full implementation of this process. According to VHA, the memorandum was distributed in May 2019 and the implementation of this process is currently underway across VAMCs. As of March 2020, this recommendation remains open pending further updates from VHA.

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Personnel and Readiness (USD(P&R)), in consultation with the Secretaries of the military departments, comprehensively evaluate the funding targets for Category A and B MWR programs and document any changes made to the targets and the methodology used. (Recommendation 1)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with our recommendation. As of September 2020, OSD officials stated that the Department is conducting a comprehensive review of the entire DOD MWR program that will encompass a review of the MWR funding targets. OSD officials stated that OSD, in conjunction with the Military Departments have been engaged over the last two years to complete this review. OSD officials said that once this review is complete, DOD Instruction 1015.10 and DOD Instruction 1015.15 will be updated with the new policy. OSD officials estimate completing this by 9/30/2022.

Recommendation: The Secretary of Defense should ensure that the USD(P&R), in consultation with the Secretaries of the military departments, develop measurable goals for its MWR programs' performance measures to determine the programs' cost-effectiveness. (Recommendation 2)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with our recommendation. OSD officials stated that the Department is conducting a comprehensive review of the entire DOD MWR program that will encompass a review of the MWR funding targets. OSD officials said that OSD, in conjunction with the Military Departments have been engaged over the last two years to complete this review. OSD officials said that once this review is complete, DOD Instruction 1015.10 and DOD Instruction 1015.15 will be updated with the new policy. OSD officials said that after agreement on the new funding targets is reached, work will begin to develop measurable performance goals. OSD officials estimate that this work will be completed by 9/30/2022.

Recommendation: The Assistant Secretary for Mental Health and Substance Use should establish procedures to better ensure that mid-performance changes to program priority goals, objectives, and targets are examined across multiple years. (Recommendation 1)

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

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

Recommendation: To increase its assurance that PTSD and TBI are appropriately considered prior to separating certain servicemembers from the military for misconduct, the Secretary of Defense should direct the Air Force and Navy to address inconsistencies with DOD policy in their policies related to training servicemembers, including officers, on how to identify mild TBI symptoms in the deployed setting.

Agency: Department of Defense
Status: Open

Comments: At the time of report publication DOD indicated it did not concur with this recommendation. However after publication, the department indicated it concurred with the recommendation. As of September 2020, DOD is continuing to take actions to address this recommendation. When actions have been completed, GAO will update the status of the recommendation.

Recommendation: To increase its assurance that PTSD and TBI are appropriately considered prior to separating certain servicemembers from the military for misconduct, the Secretary of Defense should ensure that the military services routinely monitor adherence to policies related to screening certain servicemembers for PTSD and TBI prior to separation for misconduct.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of July 2018, the department indicated that it was addressing the recommendation by requiring the military services to submit a report in March 2018 and March 2019 on how they are monitoring adherence to policies related to screening certain servicemembers for PTSD and TBI prior to separation for misconduct. In August 2020, the department indicated it completed a cycle of compliance reporting by the military services in April 2020. DOD stated it would conduct a final compliance reporting cycle in March 2021. GAO maintains that monitoring of compliance on a routine basis (i.e., ongoing) is necessary and will keep the recommendation open until the department indicates that routine monitoring will occur.

Recommendation: To increase its assurance that PTSD and TBI are appropriately considered prior to separating certain servicemembers from the military for misconduct, the Secretary of Defense should ensure that the military services routinely monitor adherence to policies related to training servicemembers, including officers, on how to identify mild TBI symptoms in the deployed setting.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of September 2020, the department is continuing to take actions to address this recommendation. When actions have been completed, GAO will update the status of the recommendation.

Recommendation: To increase its assurance that PTSD and TBI are appropriately considered prior to separating certain servicemembers from the military for misconduct, the Secretary of Defense should ensure that the military services routinely monitor adherence to policies related to counseling about VA benefits and services during the process of separating certain servicemembers for misconduct.

Agency: Department of Defense
Status: Open

Comments: DOD concurred with this recommendation. As of July 2018, the department indicated that it was addressing the recommendation by requiring the military services to submit a report in March 2018 and March 2019 on how they are monitoring adherence to policies related to counseling about VA benefits and services during the process of separating certain servicemembers for misconduct. In August 2020, the department indicated it completed a cycle of compliance reporting by the military services in April 2020. DOD stated it would conduct a final compliance reporting cycle in March 2021. GAO maintains that monitoring of compliance on a routine basis (i.e., ongoing) is necessary and will keep the recommendation open until the department indicates that routine monitoring will occur.

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

Agency: Department of Defense
Status: Open

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

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

Agency: Department of Defense
Status: Open

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

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

Agency: Department of Defense
Status: Open

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

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

Agency: Department of Defense
Status: Open

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

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

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

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

Recommendation: To help determine if programs are effective at supporting those individuals with serious mental illness, the Secretaries of Defense, Health and Human Services, Veterans Affairs, and the Attorney General--which oversee programs targeting individuals with serious mental illness--should document which of their programs targeted for individuals with serious mental illness should be evaluated and how often such evaluations should be completed.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS did not concur with this recommendation. The Helping Families in Mental Health Crisis Reform Act of 2016 enacted in December 2016 included a requirement for HHS to develop a strategy for conducting ongoing evaluations of programs related to mental illness--including serious mental illness--and substance use disorders. HHS has said that it is in the process of preparing a report that identifies key programs and activities across the department, as well as summarizes data on those programs and develops criteria for use in prioritizing programs for evaluation. However, as of June 2019, HHS has not indicated that this report is complete or provided a copy to GAO. We will continue to monitor HHS's efforts in this regard and look for documentation of HHS plans for future evaluations of programs for individuals with serious mental illness.

Recommendation: To assist states that rely on or are planning to contract with an MCO to administer Medicaid prescription benefits, and to help provide effective oversight of psychotropic medications prescribed to children in foster care, the Secretary of Health and Human Services should issue guidance to state Medicaid, child-welfare, and mental-health officials regarding prescription-drug monitoring and oversight for children in foster care receiving psychotropic medications through MCOs.

Agency: Department of Health and Human Services
Status: Open

Comments: In an October 2018 written response, Health and Human Services (HHS) noted that they released 2017-2018 Drug Utilization Review Summaries for Prescription Drug Fee-For-Service Programs as it relates to national statistics on state oversight of psychotropic medications, as well as new state requirements to report on their Medicaid managed care organizations. However, as of August 2019, HHS confirmed they have not issued any guidance to state Medicaid, child-welfare, and mental-health officials regarding prescription-drug monitoring and oversight for children in foster care receiving psychotropic medications through MCOs, as we recommended. We continue to believe that additional HHS guidance that helps states implement oversight strategies within the context of a managed-care environment is needed to help ensure appropriate monitoring of psychotropic medications prescribed to children in foster care.

Recommendation: To help DOD obtain reasonable assurance that all active and Reserve component servicemembers to whom the PDHRA requirement applies are provided the opportunity to have their health concerns identified, the Assistant Secretary of Defense for Health Affairs and the military services should take steps to ensure that PDHRA questionnaires are included in DOD's central repository for each of these servicemembers.

Agency: Department of Defense
Status: Open

Comments: In its comments to this report, the Department of Defense (DOD) concurred with this recommendation. On October 2009, DOD's Force Health Protection and Response Office sent a memo to each of the military service Surgeons General emphasizing the need for the post-deployment health reassessment (PDHRA) to be offered to all service members who are eligible to complete the assessment. In 2010, DOD's noted that the services would work with the Armed Forces Health Surveillance Center (AFHSC) repository to ensure PDHRAs are submitted correctly, without transmission errors. DOD's 2011 case records showed that the Air Force and Army had developed data verification processes to ensure that AFHSC received PDHRAs. Further, the Defense Medical Data Center (DMDC) had planed to create a file consisting of the date of deployment for deployed personnel, and that the file would be available to the services in order to match DMDC with data from each of the service-specific systems, in accordance to requirements. In September 2011, although DMDC and the services had agreed to match rosters of deployed service members, there were still inconsistencies in deployment dates. In March 2012, DOD was still verifying data inconsistencies which, until resolved, leads to inaccurate reporting based on errors in the deployment dates. As of September 2019, DOD has not provided information or documentation to address this recommendation.