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 CBP Commissioner should issue updated Border Patrol and OFO training materials that reflect the correct definition of a family unit and guidance for recording that information. (Recommendation 1)

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

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

Recommendation: The CBP Commissioner should provide written guidance to Border Patrol agents and OFO officers about what narrative information should be recorded on the child's and the accompanying adult's Forms I-213 to document cases in which CBP determines that a parent–child relationship may be invalid. (Recommendation 2)

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

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

Recommendation: The CBP Commissioner should develop and implement additional controls to ensure that Border Patrol agents accurately record family unit separations in its data system. (Recommendation 3)

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

Comments: In commenting on a draft of this report, DHS reported that CBP plans to add enhancements to Border Patrol's processing system that will prompt agents to create family units within the system, when applicable. Upon completion of these enhancements, CBP plans to provide training to agents to describe the enhancements to help ensure that family units are recorded when necessary. DHS estimates these actions will be completed by September 30, 2020. To fully address our recommendations, CBP should develop and implement controls to ensure agents are accurately recording family unit separations in its data system.

Recommendation: The CBP Commissioner should update Border Patrol's and OFO's data systems to ensure data captured on family unit separation reasons clearly align with CBP policy. (Recommendation 4)

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

Comments: DHS concurred with this recommendation and provided documentation of guidance that OFO and Border Patrol issued about data system updates. We are reviewing the information and documents DHS provided to assess the extent to which CBP fully addressed this recommendation.

Recommendation: The CBP Commissioner should develop and implement additional controls to ensure that Border Patrol agents include a narrative description of a family unit separation on the parent's / legal guardian's and child's Forms I-213, including the reason for the separation. (Recommendation 5)

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

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

Recommendation: The CBP Commissioner should provide guidance to Border Patrol agents and OFO officers on the narrative information they are to include about family unit separation events on the parent's / legal guardian's and child's Forms I-213. (Recommendation 6)

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

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

Recommendation: The ICE Director should develop and implement a mechanism to systematically track in its data system the family units ICE separates. (Recommendation 7)

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
Status: Open

Comments: In commenting on a draft of our report, DHS reported that ICE is modifying its data system to track separations and reunification throughout the Office of Enforcement and Removal Operations' enforcement process. DHS estimates that this process will be complete by September 30, 2020. To fully address this recommendation, ICE should ensure that it has a mechanism in its data system to systematically track the family units it separates.

Recommendation: The Secretary of Homeland Security, jointly with the Secretary of Health and Human Services, should collaborate to address information sharing gaps identified in this report to ensure that ORR receives information needed to make decisions for UAC, including those apprehended with an adult. (Recommendation 8)

Agency: Department of Homeland Security
Status: Open

Comments: In commenting on a draft of our report, DHS reported that the Office of Strategy, Policy, and Plans will work with relevant components and HHS to document current information-sharing practices to validate the remaining gaps and draft a joint plan between DHS and HHS to ensure that HHS receives information needed to make decisions for unaccompanied children, including those apprehended with an adult. DHS estimated that these actions will be completed by December 31, 2020. Further DHS and HHS collaboration about information sharing methods and ways to enhance interagency agreements would better position HHS to make informed and timely decisions for unaccompanied children.

Recommendation: The Secretary of Health and Human Services, jointly with the Secretary of Homeland Security, should collaborate to address information sharing gaps identified in this report to ensure that ORR receives information needed to make decisions for UAC, including those apprehended with an adult. (Recommendation 9)

Agency: Department of Health and Human Services
Status: Open

Comments: In commenting on a draft of our report, HHS reported that the department plans to coordinate with DHS, beginning in June 2020, on periodic updates to the interagency Joint Concept of Operations. To fully address this recommendation, HHS and DHS should address the information sharing gaps identified in our report.

Recommendation: The Secretary of Homeland Security should identify the information about family members apprehended together that its components collectively need to process those family members and communicate that information to its components. (Recommendation 1)

Agency: Department of Homeland Security
Status: Open

Comments: According to DHS, in June 2020, DHS's Office of Immigration Statistics launched a Family Status Data Standards Community of Interest (COI) under the purview of the DHS Immigration Data Integration Initiative. In August 2020, DHS reported that the Family Status COI includes subject matter experts and data system managers from DHS components, the Department of Health and Human Services, and the Executive Office for Immigration Review. The COI's mandate includes drafting common DHS-wide and interagency data standards (common codes, common definitions, common formats) for all topics related to family status, including codes to identify the reasons for family separation, members apprehended together, and unaccompanied children. DHS expects to complete these actions by September 30, 2020. Identifying and communicating department-wide information needs with respect to family members who have been apprehended together should help provide DHS with greater assurance that its components are identifying all individuals who may be eligible for relief from removal from the United States based on their family relationships.

Recommendation: The Secretary of Homeland Security should ensure that, at the time of apprehension, CBP collects the information that DHS components collectively need to process family members apprehended together. (Recommendation 2)

Agency: Department of Homeland Security
Status: Open

Comments: In commenting on a draft of our report, DHS reported that its Office of Immigration Statistics (OIS) will work with relevant components and offices to ensure all required information is collected at the time of apprehension on the Form I-213 when processing family members apprehended together. As of August 2020, DHS reported that DHS OIS continues to work with relevant components and offices to ensure all required information is collected at the time of apprehension on Form I-213 when processing family members apprehended together. DHS expects to complete these actions by September 30, 2020. Collecting information about the relationships between family members apprehended together and documenting that information on the Form I-213 could help address fragmentation among DHS components and improve the information available to other agencies.

Recommendation: The Secretary of Homeland Security should ensure that CBP documents the information that DHS components collectively need to process family members apprehended together on the Form I-213. (Recommendation 3)

Agency: Department of Homeland Security
Status: Open

Comments: In commenting on a draft of our report, DHS reported that, upon implementation of the steps the department plans to take in response to our second recommendation, CBP will issue guidance to the field to ensure that CBP agents and officers document the information that DHS components collectively need to process family members. In August 2020, DHS reported that component agencies continue to collaborate to define the process of family members apprehended together, as will be reflected on CBP Form I-213. DHS estimates issuing this guidance by March 31, 2021. Collecting information about the relationships between family members apprehended together and documenting that information on the Form I-213 could help address fragmentation among DHS components and improve the information available to other agencies.immigration or other proceedings.

Recommendation: The Secretary of Homeland Security should evaluate options for developing a unique identifier shared across DHS components' data systems to link family members apprehended together. (Recommendation 4)

Agency: Department of Homeland Security
Status: Open

Comments: In commenting on a draft of our report, DHS reported that its Office of Immigration Statistics (OIS) plans to work with relevant components to develop a unique shared identifier linking family members apprehended together. According to DHS, DHS OIS launched the Family Status Community of Interest (COI) in June 2020, and the COI has since established a bi-weekly meeting schedule. The COI's initial focus is on standard codes describing the reasons for family separations. Upon completing the family separation reason standard, DHS reported that the COI will prioritize developing common codes to identify family members apprehended together. DHS estimates completing these actions by March 31, 2021. Evaluating options for developing a shared unique family member identifier across components that would allow each component access to certain information about family members apprehended together would help bridge the information gaps about family relationships between components caused by DHS's fragmented data systems.

Recommendation: The Director of USCIS should ensure that, in addition to USCIS's basic asylum officer training, all asylum offices provide pre-departure training on the credible and reasonable fear processes before their officers begin screening cases at the family residential centers. (Recommendation 1)

Agency: Department of Homeland Security: United States Citizenship and Immigration Services
Status: Open

Comments: In commenting on a draft of our report, DHS reported that USCIS plans to develop a standardized pre-departure training and provide this training to all detailees prior to deployment to the family residential centers. DHS estimated that these actions would be completed by September 2020. As of August 2020, USCIS told GAO that the number of noncitizens processed under expedited removal has decreased dramatically as a result of Coronavirus Disease 2019. Therefore, details to the Family Residential Centers have largely been paused. USCIS noted that the Asylum Division is reviewing the credible fear and reasonable fear training requirements; working on an enhanced training module; and, developing a standardized pre-departure training by December 31, 2020. USCIS plans to provide the training to all detailees prior to deployment to the Family Residential Centers during calendar year 2021, should the details resume. Providing pre-departure training, in addition to USCIS's basic training for new asylum officers, would help USCIS ensure that officers from all asylum offices are conducting efficient and effective fear screenings of families.

Recommendation: The Director of USCIS should ensure asylum officers systematically record in USCIS's automated case management system if individuals receive credible fear determinations as principal applicants, dependents, or in the interest of family unity, pursuant to regulation or USCIS policy. (Recommendation 3)

Agency: Department of Homeland Security: United States Citizenship and Immigration Services
Status: Open

Comments: In commenting on a draft of our report, DHS reported that USCIS planned to explore ways to modify its case management system so that asylum officers can record whether an individual received a positive credible fear determination as a principal applicant, dependent, or in the interest of family unity. USCIS plans to make any appropriate changes to its case management system and train asylum officers on these changes by December 2020. As of August 2020, USCIS reported that the agency remains on track to complete this work as planned, provided staffing is not affected by USCIS budget issues. Having complete data in its case management system on all outcomes of credible fear screenings at family residential centers would better position USCIS to report on the scope of either the agency's policy for family members who are treated as dependents, pursuant to regulation, or USCIS's use of discretion in the interest of family unity.

Recommendation: The Director of USCIS should collect and analyze additional information on case delays, including specific reasons for delays and how long they last, that asylum officers may face when screening credible and reasonable fear cases. (Recommendation 4)

Agency: Department of Homeland Security: United States Citizenship and Immigration Services
Status: Open

Comments: In commenting on a draft of our report, DHS reported that USCIS will explore ways to collect additional information on credible and reasonable fear case delays in its case management system. USCIS plans to modify the system, as appropriate, to instruct users on the changes, and begin collecting and analyzing the information by December 31, 2020. As of August 2020, USCIS reported that the agency remains on track to accomplish this work by the end of calendar year 2020, provided staffing is not adversely affected by the on-going COVID-19 pandemic and USCIS budget issues. Collecting additional information in its automated case management system on case delays would provide USCIS with more readily available information and analyzing such data could help USCIS identify case delay reasons relevant in the current environment for officers conducting fear screenings and better position USCIS to mitigate the reasons for the delays and improve efficiency in case processing.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Recommendation: The Under Secretary for Benefits should systematically solicit and collect information on potential financial exploitation from VA's Pension Management Centers and other relevant VA components, including VA's Office of General Counsel, and assess this information to inform plans to address the potential exploitation of veterans receiving pension benefits. Such plans could also address the broader population of veterans with disabilities. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of July 2020, VA reported taking steps to share data on potential financial exploitation threats, but further opportunities to collect information exist. In February 2020, VA updated its policy manual, instructing Pension Management Centers to send copies of any OIG fraud referrals to VA's Fraud, Waste, and Abuse Incident Team. This team plans to use the information to identify trends in potential fraud, and recommend changes to VA laws, policies, or procedures, as needed. VA also plans to use this data to coordinate with other Government agencies and offices to help prevent financial exploitation. However, VA has not reported taking steps to collect information from its Office of General Counsel, Pension Management Centers, and other components on threats to veterans that do not result in fraud referrals to OIG. VA asserts that collecting additional information on suspicious activities that do not meet the level of fraud that can be referred to OIG would be inappropriate because VA lacks investigative authority. As GAO noted in its report, not all suspicious activity or complaints rise to the level of fraud. Collecting additional information could improve VA's ability to understand threats to veterans and develop responses, such as outreach, and could build on VA efforts already underway with its Fraud, Waste, and Abuse Incident Team.

Recommendation: The Under Secretary for Benefits should place additional warnings on paper and electronic documents, including on benefit applications, regarding fees which veterans cannot be charged. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: As of July 2020, VA reports that it plans to include warnings on its pension applications to clarify which fees attorneys and others may charge veterans for representing them when applying for pension benefits. According to VA, information collection requests were published in the Federal Register in June 2020, and VA expects its application forms to be revised by the end of calendar year 2020. GAO will close this recommendation once VA's applications are revised.

Recommendation: The Under Secretary for Benefits should explore the costs and benefits of additional steps claims processors could take to verify that the direct deposit information provided by claimants on their applications is for the appropriate party. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: In August 2020 VA reported that it is in the process of updating its application forms to require claimants to submit documentation, such as a voided check or deposit slip, when applying for pension benefits. GAO will close this recommendation once changes to these applications are complete.

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: CMS should evaluate state survey agency processes in all states to ensure all state survey agencies are meeting federal requirements that state survey agencies are responsible for investigating complaints and facility-reported incidents alleging abuse in nursing homes, and that the results of those investigations are being shared with CMS. (Recommendation 1)

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

Comments: HHS concurred with this recommendation. As of November 2019, HHS officials have not informed us of actions taken to complete implementation of this recommendation. We will update the status of this recommendation when we receive additional information.

Recommendation: CMS should identify options for capturing information from Oregon's APS investigations of complaints and facility-reported incidents of abuse and incorporate this information into oversight of Oregon nursing homes. (Recommendation 2)

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

Comments: HHS concurred with this recommendation. As of November 2019, HHS officials have not informed us of actions taken to complete implementation of this recommendation. We will update the status of this recommendation when we receive additional information.

Recommendation: The Administrator of the Food and Nutrition Service (FNS) should identify and disseminate strategies to states and service providers for increasing the participation of SNAP recipients referred to the SNAP E&T program. (Recommendation 1)

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

Comments: FNS officials agreed with this recommendation and indicated they are taking steps towards closing it. Specifically, FNS officials said they plan to take the following actions to disseminate strategies on increasing participation among SNAP recipients referred to the SNAP E&T program: 1) update the SNAP E&T Best Practices Study to include strategies on increasing participation by December 2021; 2) publish results from Pilot Projects to Reduce Dependency and Increase Work Requirements and Work Effort Under the Supplemental Nutrition Assistance Program that include information regarding which outreach, referral, and enrollment processes are most effective by 2021; and 3) provide technical assistance through SNAP to Skills with new attention on increasing SNAP E&T participation and engagement among eligible SNAP participants. We will continue to monitor FNS's efforts to disseminate strategies through these mechanisms with a particular focus on ensuring these strategies reach both state officials and service providers.

Recommendation: The Administrator of FNS should take additional steps to address data reliability issues in the state-reported data on SNAP E&T participant characteristics and outcomes, including steps to address imprecise instructions on data collection forms and staff confusion at the state level. (Recommendation 2)

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

Comments: FNS generally agreed with this recommendation. They noted that they have been providing continued technical assistance to states to improve data quality and in October 2018 made updates to the SNAP E&T data report. FNS plans or has additional changes pending to the SNAP E&T data report and SNAP Quality Control guidance that it plans to use to collect improved SNAP E&T data in fiscal year 2021. In addition, FNS plans to leverage results from data and technical assistance grants upon their completion in September 2020 to disseminate best practices to help states improve outcome reporting data. We are encouraged by FNS's efforts in these areas and will evaluate the results of these actions as we continue to monitor the agency's progress in addressing this recommendation.

Recommendation: The Administrator of FNS should determine and communicate to states how the agency will use newly reported outcome and participant characteristics data to assess the effectiveness of state SNAP E&T programs. (Recommendation 3)

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

Comments: FNS officials agreed with this recommendation. FNS officials noted that with the submission of January 2019 outcome reporting measures, the agency has a complete year of data which FNS will use to establish a baseline for each State's SNAP E&T program. However, FNS has not yet articulated how the data will be used to assess effectiveness of the programs, or provided examples of how FNS has used the data to provide feedback on the effectiveness of SNAP E&T programs. We will continue to monitor FNS's efforts to communicate to the states how the outcome data can be used to assess program effectiveness.

Recommendation: The Director of ICE should take steps to document and implement its review process to ensure accuracy in its budget documents.

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
Status: Open

Comments: ICE provided us with documentation showing the agency has implemented a review process to prioritize all agency resource requests and document management approval. As of June 2020, we are awaiting documentation that demonstrates this process has been implemented and provides an assurance of accuracy in ICE's budget documents. We will continue to monitor and evaluate ICE's actions to close this recommendation.

Recommendation: The Director of ICE should take steps to assess ICE's adult bed rate methodology to determine the most appropriate way to project the adult bed rate, including any inflation rates used.

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
Status: Open

Comments: As of June 2020, ICE is taking steps to assess the adult bed rate methodology. ICE provided a verification and validation assessment on the adult bed rate conducted to meet the GPRA Modernization Act of 2010 requirements. From the documentation provided, it is unclear that the assessment examines the methodology of the adult bed rate. According to ICE officials, the agency is working towards conducting an analysis on the methodology of the adult bed rate calculations. We will continue to monitor and evaluate ICE's actions to close the recommendation.

Recommendation: The Director of ICE should take steps to update ICE's adult bed rate methodology by incorporating necessary changes based on its assessment, and ensure the use of appropriate inflation rates and the removal of family beds from all calculations.

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
Status: Open

Comments: As part of addressing this recommendation, ICE developed a bed rate calculator that the agency stated ensures the use of proper inflation rates and the removal of family beds. ICE provided documentation demonstrating changes to the calculations of the adult bed rate, including the removal of family beds from its budget calculations. As of June 2020, we are awaiting documentation from ICE that demonstrates the use of appropriate inflation rates. We will continue to monitor and evaluate ICE's actions to close this recommendation.

Recommendation: The Director of ICE should take steps to determine the most appropriate way to project the ADP for use in the congressional budget justification and document the methodology and rationale behind its ADP projection. As part of that determination, ICE should consider the extent to which a statistical model could be used to accurately forecast ADP.

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
Status: Open

Comments: ICE provided us with documentation on the statistical model and its methodology during the course of our review and utilized the model during the fiscal years 2019 and 2020 budget cycles. ICE used the model to provide a point estimate within a specific confidence interval and documented the interval that the agency used and the reasoning behind the use of that interval. As of June 2020, we are following up with ICE regarding the extent to which the model was used to determine the total number of detention beds.

Recommendation: The Director of ICE should take steps to ensure that ICE's budget estimating process more fully addresses cost estimating best practices.

Agency: Department of Homeland Security: United States Immigration and Customs Enforcement
Status: Open

Comments: As of June 2020, ICE is taking steps to address this recommendation, and has provided documentation. For example, ICE has developed a sliding bed rate scale from conducting a sensitivity analysis and has detailed some of its calculations and assumptions for the adult bed rate. We will continue to work with ICE to obtain additional documentation needed to evaluate the agency's efforts to improve its detention cost estimating practices.

Recommendation: To help college financial aid administrators more effectively implement eligibility rules for unaccompanied homeless youth, the Secretary of Education should make available an optional worksheet or form that college financial aid administrators can voluntarily use to document unaccompanied homeless youth status or encourage the use of existing forms that are available.

Agency: Department of Education
Status: Open

Comments: Education agreed that it would be helpful to make forms developed by outside organizations knowledgeable about homelessness issues available for financial aid administrators to use for documenting the status of unaccompanied homeless youth. Education also said that it plans to highlight the availability of these forms and provide guidance at its annual conference and in updates to the Federal Student Aid Handbook. Education noted that it will not endorse the use of a specific form but that it will highlight forms that already exist that may be useful to financial aid administrators. In July 2020, Education reported that it planned to update the Federal Student Aid Handbook by the spring of 2021 to inform financial aid administrators about the availability of such forms that have been developed by outside entities. We will close this recommendation when Education provides GAO with the updated handbook.

Recommendation: To improve the transparency and accountability of HHS's section 1115 Medicaid demonstration approval process, and to ensure that federal Medicaid funds for the demonstrations do not duplicate other federal funds, the Secretary of Health and Human Services should issue criteria for assessing whether section 1115 expenditure authorities are likely to promote Medicaid objectives.

Agency: Department of Health and Human Services
Status: Open

Comments: The Department of Health and Human Services (HHS) partially concurred with this recommendation and has taken some steps to address the problems GAO identified. Initially, in August 2015, HHS posted on its website general criteria for assessing whether Medicaid section 1115 demonstration expenditure authorities are likely to promote Medicaid objectives, but GAO found the general criteria were not sufficiently specific. HHS later removed these criteria from its website and replaced them with six broad areas of reform that HHS encourages states to consider. As of January 2020, HHS does not have specific criteria for approving section 1115 expenditure authorities, but officials noted that the agency had begun including in approval letters the agency's rationale for approving specific expenditure authorities. GAO considers this a positive step towards improving the transparency of HHS's approval decisions, and if implemented consistently would address the intent of GAO's recommendation. HHS officials indicated that this step would be included in written protocols the agency is drafting but did not have a date for their completion. If these protocols are completed and consistently implemented, HHS's bases for its approvals of expenditure authorities, which can amount to billions of dollars in federal spending, will be more transparent. We will continue to monitor HHS's actions in response to this recommendation.

Recommendation: To improve the transparency and accountability of HHS's section 1115 Medicaid demonstration approval process, and to ensure that federal Medicaid funds for the demonstrations do not duplicate other federal funds, the Secretary of Health and Human Services should ensure the application of these criteria is documented in all HHS's approvals of section 1115 demonstrations, including those approving new or extending or modifying existing expenditure authorities, to inform internal and external stakeholders, including states, the public, and Congress, of the basis for the agency's determinations that approved expenditure authorities are likely to promote Medicaid objectives.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS agreed with this recommendation and, as of January 2020, had taken some steps to ensure that the bases for its approval decisions are documented in all approvals of section 1115 demonstrations. In December 2017, HHS's Centers for Medicare & Medicaid Services (CMS) issued a letter to state Medicaid officials, stating it had begun requesting additional documentation of the demonstration purposes being served by certain types of previously approved funding in demonstration proposals. Additionally, the agency noted it was taking certain steps to ensure that only allowable costs were matched by federal Medicaid funds. In April 2018, CMS officials stated that the agency had begun addressing in approval documents how each intervention proposed by the state was determined to be likely to promote Medicaid objectives. Officials reported that this step would be included in formal written protocols that outline the agency's procedures for application review and preparation of approval documents for section 1115 demonstrations, but as of January 2020, the agency did not have time frames for the completion of these protocols. If CMS completes and implements the written protocols, stakeholders should be able to more easily and consistently assess the agency's decisions. We will continue to monitor CMS's efforts in this area.