Recommendation: The OHS Director should require Head Start grantees to document that water provided to children has been tested for lead. OHS could determine various ways that are feasible and efficient for grantees to satisfy this requirement; for example, verification could be done through OHS' current grantee data collection or monitoring processes. (Recommendation 1)

Agency: Department of Health and Human Services
Status: Open

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

Recommendation: The Assistant Secretary for the Administration for Children and Families should direct OCC and OHS to develop an agreement with EPA on their roles and responsibilities in implementing the Memorandum of Understanding on Reducing Lead Levels in Drinking Water in Schools and Child Care Facilities. For example, these agreements may include the ways in which guidance and information will be shared with states and Head Start grantees, such as through webinars or email, and how frequently. (Recommendation 2)

Agency: Department of Health and Human Services
Status: Open

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

Recommendation: The Assistant Administrator of the Office of Water should develop an agreement with HHS's Offices of Child Care and Head Start on their roles and responsibilities in implementing the Memorandum of Understanding on Reducing Lead Levels in Drinking Water in Schools and Child Care Facilities. For example, these agreements may include the ways in which guidance and information will be shared with states and Head Start grantees, such as through webinars or email, and how frequently. (Recommendation 3)

Agency: Environmental Protection Agency
Status: Open

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

Recommendation: The Assistant Administrator of the Office of Water should direct the Office of Water to specify how it will track progress toward the outcomes of the Memorandum of Understanding on Reducing Lead Levels in Drinking Water in Schools and Child Care Facilities and determine how it will regularly monitor and update the MOU. For example, the Office of Water could develop performance measures for each of the MOU's outcomes. In addition, the Office of Water could submit annual reports on progress toward achieving the MOU's outcomes or it could plan to update the agreement at specific intervals. (Recommendation 4)

Agency: Environmental Protection Agency
Status: Open

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

Recommendation: The Director of ORR should clarify in its grant announcements the information and supporting documentation applicants are required to provide in their grant applications with respect to their state licensing status, eligibility, and allegations and concerns. (Recommendation 1).

Agency: Department of Health and Human Services: Administration for Children and Families: Office of Refugee Resettlement
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 ORR should take steps to develop, and ensure that officials reviewing grant applications implement, a process to verify the accuracy and completeness of information reported by grant applicants on state licensing status, eligibility, allegations and concerns. (Recommendation 2).

Agency: Department of Health and Human Services: Administration for Children and Families: Office of Refugee Resettlement
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 ORR should ensure that the grant review process includes a documented review of applicants' past performance on ORR grants for those that have previously received grants to care for unaccompanied children. This could include, for example, a systematic review of previous quarterly and annual performance reports and a review of corrective actions issued by all ORR monitoring staff to all ORR-funded facilities previously operated by the applicant. (Recommendation 3).

Agency: Department of Health and Human Services: Administration for Children and Families: Office of Refugee Resettlement
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 ORR should clarify in its instructions to grantees the information they are required to report on state licensing citations in their quarterly performance reports. (Recommendation 4).

Agency: Department of Health and Human Services: Administration for Children and Families: Office of Refugee Resettlement
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 ORR should take steps, such as through guidance or training, to ensure that project officers clearly understand the requirement that grantees report state licensing citations at any of their facilities within 24 hours and include state licensing citations in their quarterly performance reports. (Recommendation 5).

Agency: Department of Health and Human Services: Administration for Children and Families: Office of Refugee Resettlement
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 ORR should work with state agencies that license ORR-funded facilities to develop a plan for mutual information sharing, including processes for ORR outreach to states during the grant application review process and ongoing information sharing on ORR and state monitoring processes and identified deficiencies. (Recommendation 6).

Agency: Department of Health and Human Services: Administration for Children and Families: Office of Refugee Resettlement
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 ORR should ensure that ORR provides and maintains a current point of contact for each state agency that licenses ORR grantees to facilitate information sharing regarding ORR-funded facilities. (Recommendation 7).

Agency: Department of Health and Human Services: Administration for Children and Families: Office of Refugee Resettlement
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 ORR should develop a plan—including roles, responsibilities, and timeframes—to guide and focus ORR's efforts to meet its goals to:

• conduct an audit of each facility's compliance with ORR standards on preventing and responding to sexual assault, as required under the Interim Final Rule,
• conduct on-site monitoring visits to each facility at least every 2 years in accordance with ORR policy, and
• report any noncompliance to the facility within 30 days of the site visit, in accordance with ORR policy.

(Recommendation 8).

Agency: Department of Health and Human Services: Administration for Children and Families: Office of Refugee Resettlement
Status: Open

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

Recommendation: The Assistant Secretary for the Administration for Children and Families (ACF) should establish an ongoing process to proactively share information and best practices with states about programs it administers that are available to serve kin caregivers, especially in states with a relatively large share of grandparent caregivers. This could be achieved, for example, by leveraging regional office staff to provide additional assistance and information sharing, particularly related to kinship navigator programs. (Recommendation 1)

Agency: Department of Health and Human Services: Administration for Children and Families
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 for the Administration for Community Living (ACL) should establish an ongoing process to proactively share information and best practices with states about using National Family Caregiver Support Program (NFCSP) funds to serve older relative caregivers of children, especially in states with a relatively large share of grandparent caregivers. This could be achieved, for example, by leveraging regional office staff to share information from states and area agencies on aging that have successfully used this program to serve older relative caregivers. (Recommendation 2)

Agency: Department of Health and Human Services: Administration for Community Living
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 Director of BIE should establish consistent requirements for schools on making up missed special education and related services and monitor schools to ensure that they follow these requirements. (Recommendation 1)

Agency: Department of the Interior: Bureau of Indian Education
Status: Open

Comments: BIE agreed with this recommendation. The agency acknowledges that it must refine the guidance provided by its special education subject matter experts to ensure that guidance on missed special education related services is consistent. They anticipate fully implementing reforms through formally published guidance to its special education professionals.

Recommendation: The Director of BIE should work with knowledgeable stakeholders in Indian education to establish a community of practice or other formal mechanism to identify and disseminate promising practices for schools—especially those in remote locations—on recruiting, hiring, and retaining special education teachers and contracting with providers. The Director of BIE could consider conferring with BIE's special education advisory committee, OSEP, and relevant tribal and state education officials in addressing this recommendation. (Recommendation 2)

Agency: Department of the Interior: Bureau of Indian Education
Status: Open

Comments: BIE agreed with this recommendation. The agency plans to work collaboratively with all of its special education stakeholders to build on its internal human capital capabilities, Strategic Workforce Plan and other human capital improvements.

Recommendation: The Director of BIE should rescind the policy of its division overseeing tribally controlled schools that does not meet Interior's requirement to annually review all schools' documentation to verify the provision of services for every special education student, and ensure that all divisions comply with this requirement. (Recommendation 3)

Agency: Department of the Interior: Bureau of Indian Education
Status: Open

Comments: BIE agreed with this recommendation. The agency is reviewing all of its special education policies and procedures and, as of May 2020, anticipates an updated, comprehensive special education policy and handbook in the coming months. This includes replacing the Tribally-Controlled School Division's 3-year review policy with an annual review. A first draft of the new special education handbook and policy is expected in the summer of 2020.

Recommendation: The Director of BIE should update the agency's workforce plan to include a strategy and timeframe for filling vacant staff positions responsible for overseeing and supporting schools' special education programs. (Recommendation 4)

Agency: Department of the Interior: Bureau of Indian Education
Status: Open

Comments: BIE agreed with this recommendation and plans to update and expand its Strategic Workforce plan to include new function areas. They expect to update it in the coming months to include special education and Johnson O'Malley functions.

Recommendation: The Director of BIE should fully implement the agency's high-risk monitoring policy for IDEA and other federal education programs, including requirements for agency-wide coordination, and ensure that schools selected for such monitoring receive reports and technical assistance plans within 30 days of agency on-site visits, as required by BIE policy. (Recommendation 5)

Agency: Department of the Interior: Bureau of Indian Education
Status: Open

Comments: BIE agreed with this recommendation. Based on lessons learned in its first two years of implementation, the agency plans to make targeted refinements to the policy and process of high-risk monitoring. Regarding the timeliness of report submission and technical assistance delivery, the agency began a targeted reform designed to address this structural weakness, namely, the need to centralize the administrative functions of its oversight activities. The newly established Performance Office will assume the administrative and management oversight of the high-risk fiscal monitoring policy and handbook, including the timely delivery of monitoring reports and technical assistance plans.

Recommendation: The Director of BIE should establish special education training requirements for staff in the agency's Education Resource Centers who are responsible for supporting and overseeing schools' special education programs, and ensure that staff complete those training requirements. (Recommendation 6)

Agency: Department of the Interior: Bureau of Indian Education
Status: Open

Comments: BIE agreed with this recommendation. The agency will ensure that special education training and professional development requirements are identified as part of its planned Strategic Workforce Plan update and expansion.

Recommendation: The Director of BIE should take steps to ensure that all of the agency's Education Resource Centers conduct outreach with schools to inform them of their new roles in overseeing and supporting schools' special education programs under BIE's reorganization. (Recommendation 7)

Agency: Department of the Interior: Bureau of Indian Education
Status: Open

Comments: BIE agreed with this recommendation. As BIE makes targeted reforms to improve the delivery of special education services, it will ensure that the roles and responsibilities of Education Resource Centers (ERC) are clearly identified and communicated to responsible BIE personnel. Specifically, as it updates and expands the Strategic Workforce Plan, it will clearly and directly define the role of ERC personnel with respect to special education services. In addition, as the new Performance Office establishes timely and routine technical assistance plans, the agency will operationalize the day-to-day engagement and outreach between ERC and school level personnel regarding special education related technical assistance.

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

Agency: Department of Health and Human Services
Status: Open

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

Recommendation: The Director of OCC should establish internal written policies to effectively implement and document the State Plan review and approval process for future review and approval periods. (Recommendation 1)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us it has been working on establishing written policies (e.g., internal guidance documents and checklists) to implement and document the State Plan review and approval process. OCC expects to complete this work for the FY2022-2024 Plan period. We will continue to monitor OCC's efforts to implement this recommendation.

Recommendation: The Director of OCC should define the informational needs related to the results of program-integrity activities. (Recommendation 2)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us that it is developing the next CCDF State/Territory Plan Preprint due for submission by states and territories July 1, 2021. According to OCC, it plans to incorporate its information needs regarding the results of program integrity into the Preprint document as it develops the document. We will continue to monitor OCC's progress in implementing this recommendation.

Recommendation: The Director of OCC should communicate externally to the states its informational needs related to the results of states' program-integrity activities. (Recommendation 3)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us that it is developing the next CCDF State/Territory Plan Preprint due for submission by states and territories July 1, 2021. According to OCC, it plans to communicate its information needs regarding the results of program integrity activities to states and territories as part of the Preprint Training activities - including webinars and peer-to-peer virtual meetings - so Lead Agencies understand what is expected for them to address in the CCDF Plan. We will continue to monitor OCC's progress in implementing this recommendation.

Recommendation: The Director of OCC should communicate internally to staff its informational needs related to the results of states' program-integrity activities. (Recommendation 4)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us that it is developing the next CCDF State/Territory Plan Preprint due for submission by states and territories July 1, 2021. According to OCC, it plans to communicate its information needs regarding the results of program integrity activities to staff in both regional and central offices as part of the Preprint Training activities so staff understand what is expected for Lead Agencies to address in the CCDF Plan. We will continue to monitor OCC's progress in implementing this recommendation.

Recommendation: The Director of OCC should develop documented criteria to guide the review of CAPs submitted by states to ensure that proposed corrective actions are aimed at root causes of improper payments and are effectively implemented. (Recommendation 5)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us it revised the CAP Review Tool to in response to our recommendation. OCC also told us that it plans to implement the revised CAP Review Tool beginning September 2020 to document the review of CAPs submitted for the most recent ACF-404 reporting cycle (June 2020). We asked OCC to provide documentation showing the revised CAP Review Tool is responsive to our recommendation. We will update this recommendation status after reviewing the documentation OCC provides.

Recommendation: The Director of OCC should timely complete its effort to develop established written policies for the CAP follow-up process to ensure that OCC's oversight and monitoring of CAPs is carried out consistently. (Recommendation 6)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us it developed draft written policies for the CAP follow-up process to ensure that OCC's oversight and monitoring of CAPs is carried out consistently. However, due to the impact of the COVID-19 on staffing capacity, OCC has not presented the draft policies to regional offices for feedback. OCC told us it plans to finalize the written policies for the CAP follow-up process by December 2020. We will continue to monitor OCC's progress in implementing this recommendation.

Recommendation: The Director of OCC should develop and document criteria to assess the effectiveness of states' program-integrity control activities. (Recommendation 7)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us it analyzed information gathered from federal and state resources to develop and document criteria to be used to assess the effectiveness of states' program integrity control activities. We asked OCC to provide us the document showing all criteria to be used to assess the effectiveness of states' program integrity control activities. We will update this recommendation status after reviewing the documentation OCC provides.

Recommendation: The Director of OCC should evaluate the feasibility of collecting information from the Grantee Internal Controls Self-Assessment Instrument (Self-Assessment Instrument) and Fraud Toolkit, such as during its Monitoring System process, to monitor the effectiveness of states' program-integrity control activities. (Recommendation 8)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of the Child Care Bureau
Status: Open

Comments: In September 2020, OCC told us it is working to make the Self-Assessment Instrument and Fraud Toolkit more user-friendly to encourage increased use within the state CCDF program. With increased usage, OCC believes it will be in a better position to assess how the collection of data from these two instruments can be incorporated into the Onsite Monitoring System or other oversight activity. OCC told us it anticipates completing work to implement this recommendation by December 2020. We will continue to monitor OCC's progress in implementing this recommendation.

Recommendation: The Assistant Secretary for ACF should ensure that ACF conducts a fraud risk assessment to provide a basis for the documentation and development of an antifraud strategy that describes the CCDF program's approach to address prioritizing fraud risks identified. (Recommendation 9)

Agency: Department of Health and Human Services: Administration for Children and Families
Status: Open

Comments: In September 2020, HHS told us it anticipates completing the initial fraud risk assessment for the CCDF program by December 2020. We will continue to monitor HHS's efforts to implement this recommendation.

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 Secretary of Education should develop an online clearinghouse of sample documents from states and localities who wish to share them, past webinar recordings and their related documents, and links to other relevant resources that all SEAs can access. (Recommendation 1)

Agency: Department of Education
Status: Open

Comments: Education agreed with this recommendation. The agency said that its Office of Elementary and Secondary Education will restructure its entire website to better organize its information, and create a new web page to house all foster care-related information and resources. Additionally, Education said this office will launch a virtual portal through which SEA foster care points of contact may collaborate and share resources. We will consider closing this recommendation when these efforts are complete.

Recommendation: The Director of OHS should perform a fraud risk assessment for the Head Start program, to include assessing the likelihood and impact of fraud risks it faces. (Recommendation 1)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of Head Start
Status: Open
Priority recommendation

Comments: In February 2020, HHS told us that the Administration for Children and Families (ACF) is developing a Fraud Risk Assessment template for all of its programs (including the Office of Head Start) and is on track to complete the initial Fraud Risk Assessment for its pilot program by June 30, 2020. Upon completion of the Fraud Risk Assessment for the ACF pilot program, ACF anticipates completing its initial Fraud Risk Assessment for OHS, by March 31, 2021. We will assess these actions once completed.

Recommendation: The Director of OHS should establish procedures to monitor and evaluate OHS's new internal workflows for monitoring reviews, to include establishing a baseline to measure the effect of these workflows and identify and address any problems impeding the effective implementation of new workflows to ensure timeliness goals for monitoring reviews are met. (Recommendation 3)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of Head Start
Status: Open

Comments: HHS did not concur with this recommendation. In February 2020, HHS stated that OHS regularly evaluates its effectiveness of its workflows to determine how to best adjust the system to support effective follow-up. HHS also stated that, for Fiscal Year 2020, OHS has updated its internal workflow timelines to increase responsiveness to identified findings and ensure grantee support. We will continue to monitor HHS's efforts in this area.

Recommendation: The Director of OHS should provide program-wide guidance on when a student's slot should be considered vacant due to absenteeism. (Recommendation 5)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of Head Start
Status: Open

Comments: In February 2020, OHS told us that it is finalizing program guidance that will address when a child's slot should be considered vacant due to absenteeism and what a program should do fill it. OHS stated that it anticipates having a final paper published by summer, 2020. We will continue to monitor OHS's efforts in this area.

Recommendation: The Director of OHS should develop and implement a method for grantees to document attendance and services under EHS pregnancy programs. (Recommendation 6)

Agency: Department of Health and Human Services: Administration for Children and Families: Office of Head Start
Status: Open

Comments: In February 2020, OHS told us that it is developing a toolkit of resources specifically designed to offer best practice tips for Early Head Start programs on how to track attendance and services to pregnant women. OHS is surveying the Head Start community to better determine what resources are already available and how programs in different regions and cities track services to pregnant women. OHS anticipates a rollout for the toolkit by summer, 2020.

Recommendation: The Assistant Secretary for Postsecondary Education should correctly calculate its CCAMPIS program persistence rate and cost per persisting student measures. (Recommendation 1)

Agency: Department of Education
Status: Open

Comments: Education disagreed with this recommendation as it believes the currently reported persistence data are sufficiently accurate to support effective program management and oversight. In February 2020, Education noted that it was reviewing the concerns raised by GAO and taking action to address confirmed errors in its persistence calculations. Specifically, Education said it would correct a formula error in its spreadsheet and include students who transferred to another school as persisting and planned to publish corrected data. Further, it said that it was exploring the feasibility of developing a cohort model for its persistence rate measure. We appreciate the steps Education is taking to ensure that it is correctly calculating its program persistence measures. To close this recommendation, Education should provide its corrected calculations, as well as any publication with corrected persistence measures, to GAO to review and confirm that Education has corrected all of the errors we identified.

Recommendation: The Assistant Secretary for Postsecondary Education should either collect the CCAMPIS participant enrollment data needed to calculate a standard 3-year graduation rate or accurately define and calculate a different college completion measure. (Recommendation 2)

Agency: Department of Education
Status: Open

Comments: As of February 2020, Education stated that it continues to disagree with this recommendation, noting that more analysis is needed to determine whether it is appropriate to develop a more rigorous graduation rate measure for the CCAMPIS program. As we stated in our report, we recognize that collecting the enrollment data needed to calculate the standard graduation rate could place a burden on grantee schools. Our recommendation included the option to define a different college completion measure and calculate it correctly. Education reported that it will redefine its current graduation rate to be a different college completion measure and the agency will clarify the description of this metric in its information on CCAMPIS graduation rates. While the new graduation rate definition proposed by Education responds to this recommendation, Education's formula does not accurately calculate this redefined graduation rate measure. To close this recommendation, Education should correct the formula for its revised graduation rate measure and provide the updated formula and data to confirm that its calculations are accurate.

Recommendation: The Chief Operating Officer of Federal Student Aid should encourage schools—through appropriate means, such as the Federal Student Aid Handbook—to inform students via school websites about the availability of the dependent care allowance and how to request the allowance. (Recommendation 3)

Agency: Department of Education
Status: Open

Comments: While Education agreed with the spirit of this recommendation, it disagreed with the recommendation itself due to concerns that an increased emphasis on the availability of the dependent care allowance could lead to additional borrowing that might not be appropriate for all students based on their financial circumstances. To respond to the recommendation, Education told us in February 2020 that it has added a note to the 2019-2020 FSA Handbook that, when counseling students, schools should make clear the availability of the allowance and how to request it. Adding this language to the handbook is certainly helpful, but does not fully implement GAO's recommendation. Encouraging schools to provide this information to students who proactively contact a school's financial aid office to discuss their finances will likely make this information available to a relatively small number of students; however, it does nothing to make this information more broadly available to all students who may benefit from it. We are not recommending that schools should encourage all student parents to borrow more to pay for child care. Instead, we recommend that Education encourage schools to make students aware of this potential option-which federal law makes available to students-via school websites to allow them to make informed financial decisions based on their personal circumstances. We will close this recommendation when Education takes additional actions to encourage schools to make this information more broadly available to students on their websites.

Recommendation: The Administrator of CMS should work with states and relevant federal agencies to collect accurate and complete data on blood lead screening for Medicaid beneficiaries in order to ensure that CMS is able to monitor state compliance with its blood lead screening policy, and assist states with planning improvements to address states' compliance as needed. (Recommendation 1)

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

Comments: In June 2020, Centers for Medicare & Medicaid Services (CMS) officials said that obtaining complete data on blood lead screenings for children enrolled in Medicaid will not be possible, but that the agency is committed to improving the accuracy and completeness of the data. For example, in February 2020, CMS reported that the agency is planning to use a new data system-as states meet certain data quality and completeness benchmarks for the system-to generate the report that includes states' blood lead screening data. CMS stated that this will improve the agency's and states' ability to assess gaps in blood lead screening data. This is a positive step, yet any new data system will also need to consider how to help address known limitations in the current blood lead screening data, such as the under-counting of blood lead screening tests not paid for by Medicaid. To implement this recommendation, CMS should address limitations in blood lead screening data to better monitor compliance with the agency's blood lead screening policy.

Recommendation: The Administrator of CMS should regularly assess the appropriateness of performance measures and targets for the EPSDT benefit, and take any necessary actions to ensure their relevance and use, including adding, changing, or removing measures, or targets, and regularly communicating performance measures and targets to states. (Recommendation 2)

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

Comments: In June 2020, CMS officials reiterated that they do not concur with this recommendation, in part because the agency does not have the authority to set binding targets for every EPSDT measure. As we stated in our report, our recommendation does not assume that targets should be set for every measure--rather, that CMS needs to regularly assess the appropriateness of performance measures and targets for the EPSDT benefit and communicate them to states. This includes assessments of the CMS-416 performance measures, such as the participant and screening ratios. which CMS officials acknowledge have limitations.

Recommendation: The Administrator of CMS should conduct regular evaluations of state performance by comparing states' performance measurement data with CMS's EPSDT targets to identify gaps in states' performance and areas for improvement. (Recommendation 3)

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

Comments: In June 2020, CMS officials reiterated that they do not concur with this recommendation, in part because the agency provides states with information about their performance on ESPDT measures reported on the Child Core Set, including a state's performance relative to other states' performance. We noted the limitations of this approach in our report; descriptions of a state's performance relative to other states is subject to change over time. For example, because the median is the midpoint of all states' performance, it ensures that half of states will not meet it, regardless of their individual performance. A fixed target--or targeted improvement goal, such as the one developed as part of the Oral Health Initiative--would provide states with the opportunity to measure performance over prior years' results, which is a more meaningful measure that all states can strive to achieve.

Recommendation: The Administrator of CMS should assist states with planning needed improvements, including providing focused assistance, to resolve gaps in states' performance in meeting CMS's EPSDT targets. (Recommendation 4)

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

Comments: In June 2020, CMS officials reiterated that they do not concur with this recommendation, in part because the agency does not believe that it is productive or appropriate to set targets for every EPSDT measure. As we stated in our report, our recommendation does not assume that targets should be set for every measure. However, developing additional targets on performance measures critical to beneficiaries' health and well-being could help improve oversight of EPSDT. Targeted technical assistance could be valuable for CMS to provide to states after identifying gaps in states' performance relative to EPSDT targets. Doing so would allow CMS to share additional strategies to help states plan and implement needed improvements.

Recommendation: The Administrator of CMS should develop a plan with time frames and interim milestones for using T-MSIS data to generate the necessary data from the Child Core Set to improve EPSDT oversight and streamline state reporting. (Recommendation 6)

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

Comments: In June 2020, CMS officials said that they are currently exploring the feasibility of using T-MSIS data to generate certain Child Core Set measures. Specifically, the agency is conducting a pilot with five Child Core Set measures. CMS officials said that they will use the pilot's results to determine the timeline for generating the additional Child Core Set measures through T-MSIS. GAO will continue to follow the agency's progress on this activity.

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

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

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

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

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

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

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

Recommendation: The Chairman of the Federal Communications Commission should determine and execute a methodology for collecting and analyzing data—such as conducting a new pilot program regarding off-premises wireless access or analyzing other data—to assess the potential benefits, costs, and challenges of making off-premises wireless access eligible for E-rate program support, and publish the results of this analysis. (Recommendation 1)

Agency: Federal Communications Commission
Status: Open

Comments: FCC officials informed us in July 2020 that FCC plans to implement this recommendation by completing an evaluative report on the E-rate pilot program. While FCC planned to implement this recommendation by July 2020, there have been delays related to COVID-19.

Recommendation: The Administrator of the Food and Nutrition Service (FNS) should improve how FNS gathers information on the effectiveness of SNAP-Ed interventions, in order to ensure that these interventions are meeting program goals. (Recommendation 1)

Agency: Department of Agriculture
Status: Open

Comments: USDA generally agreed with this recommendation. The agency noted that FNS has efforts underway to comply with the 2018 Farm Bill requirement that the department report annually on the level of coordination between its nutrition education programs.

Recommendation: The Secretary of Agriculture should direct the Under Secretaries for Food, Nutrition, and Consumer Services and for Research, Education, and Economics to develop a formal mechanism, such as a designated individual or group of individuals, for providing cross-department leadership for USDA's nutrition education efforts and facilitating cross-program information sharing. (Recommendation 2)

Agency: Department of Agriculture
Status: Open

Comments: USDA generally agreed with this recommendation. The agency noted that FNS has efforts underway to comply with the 2018 Farm Bill requirement that the department report annually on the level of coordination between its nutrition education programs.

Recommendation: The Secretary of Agriculture should direct the Under Secretaries for Food, Nutrition, and Consumer Services and for Research, Education, and Economics to identify and implement mechanisms to fully leverage the department's nutrition expertise for its nutrition education efforts. (Recommendation 3)

Agency: Department of Agriculture
Status: Open

Comments: USDA generally agreed with this recommendation. The agency noted that FNS has efforts underway to comply with the 2018 Farm Bill requirement that the department report annually on the level of coordination between its nutrition education programs.

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Policy updates its policy and instruction on providing support to the Secret Service to define the requirements for producing semiannual reports of expenditures required by the Presidential Protection Assistance Act of 1976, as amended. These requirements should, at a minimum, include (1) the steps and time frames for completing updates to the policy and instruction, (2) time frames for reporting the expenditures, and (3) an oversight mechanism to ensure that the Department of Defense consistently submits these reports to specified congressional committees. (Recommendation 2)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with the recommendation. As of July 31, 2019, DOD has not updated its policy or instruction.

Recommendation: The Secretary of Defense should ensure that the Under Secretary of Defense for Policy defines the steps, including time frames, necessary to achieve near term reporting requirements under the Presidential Protection Assistance Act of 1976, as amended, and submit the reports as required. (Recommendation 3)

Agency: Department of Defense
Status: Open

Comments: DOD concurred with the recommendation. As of July 31, 2019, DOD has not updated its policy.

Recommendation: Congress should consider developing comprehensive legislation on Internet privacy that would enhance consumer protections and provide flexibility to address a rapidly evolving Internet environment. Issues that should be considered include: (1) which agency or agencies should oversee Internet privacy; (2) what authorities an agency or agencies should have to oversee Internet privacy, including notice-and-comment rulemaking authority and first-time violation civil penalty authority; and (3) how to balance consumers' need for Internet privacy with industry's ability to provide services and innovate.

Agency: Congress
Status: Open

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

Recommendation: The Administrator of USAID should establish additional controls to improve the consistency and completeness of performance information that USAID uses to monitor counter-trafficking in persons projects. (Recommendation 5)

Agency: United States Agency for International Development
Status: Open
Priority recommendation

Comments: USAID concurred with GAO's recommendation and has begun to take corrective action in response. In a March 11, 2019 letter to congressional committees, USAID noted its commitment to address GAO's recommendation through implementing additional controls for the agency's counter-trafficking in persons projects. Specifically, USAID commented that it was implementing data systems and taking additional steps intended to strengthen data management, improve record-keeping, increase data quality, and build capacity of local partners, with a target completion date of April 2020. As of January 2020, USAID officials noted that the agency has piloted its information management system, the Development Information Solution (DIS), in 7 USAID missions and is considering a strategy to deploy the DIS agency-wide by the end of 2021. According to USAID officials and documents, work has been completed to build DIS features that will help to improve the consistency and completeness of performance information, such as the ability to create and centrally manage customized indicators within DIS as well as centrally track and manage project activities, targets, and results. USAID has also updated its performance monitoring policy to require the completion of Performance Management Plans, within 3 months of completion of the mission's Country Development Cooperation Strategy, instead of the previously required 6 months. In addition, according to USAID officials and documents GAO reviewed, USAID and the Department of State's (State) Office of U.S. Foreign Assistance Resources have developed additional administrative reports and processes that encourage increased ownership and review of data in the FACTSinfo NextGen system, the system of record for performance information related to the expenditure of foreign assistance funds. According to USAID officials and documents GAO reviewed, in order to improve quality control for this data, USAID and State will conduct a high level administrative review of the performance reporting process, including of the participation of key stakeholders in this process, beginning in March 2020. Once USAID provides additional information to GAO, including information on steps to more fully deploy the DIS and implement changes resulting from its review of the PPR process under its new grants management data system, GAO will determine whether USAID has established additional controls to improve the consistency and completeness of performance information.

Recommendation: The Acting Commissioner of the Bureau of Labor Statistics should, upon completion of the pilot Household Survey of Occupational Injuries and Illnesses, evaluate the feasibility of measuring injuries and illnesses to certain worker populations--specifically, children aged 17 and under, child household workers, and those employed on farms with 10 or fewer workers--in any final survey scope, or determine a way to gather information on these populations. (Recommendation 1)

Agency: Department of Labor
Status: Open

Comments: BLS noted that it had completed the pilot Household Survey of Occupational Injuries and Illnesses (HSOII) in December of 2018 and stated that BLS will be analyzing the quality of the data in the second and third quarters of 2019 and publishing a report at the end of 2019. To evaluate the feasibility of measuring injuries and illnesses to workers under 18, BLS stated it will conduct a literature review on questionnaire design for respondents under age 18, and reviewing the evidence on the quality of data collected through proxy reporting, e.g. adults reporting on injuries/illnesses for their children. The agency also reported that it will issue an assessment of the suitability of the existing HSOII instrument to gather data on working children at the end of fiscal year 2019. We will consider closing this recommendation after receipt and review of this final assessment report.

Recommendation: The Administrator of the Wage and Hour Division should establish specific metrics and associated targets for child labor-related outreach in agriculture. (Recommendation 2)

Agency: Department of Labor
Status: Open

Comments: The agency agreed with this recommendation. The agency noted that it has existing performance measures that separately track the number of employer outreach events and the number of events involving child labor. The agency stated that, in response to GAO's recommendation, it will introduce a new measure in FY2020 that is specific to child labor-related outreach in the agricultural industry. The agency said that for the remainder of FY2019, the agency will develop the new measure, establish a baseline, and set an appropriate target for child labor-related outreach in the agricultural industry. The agency also said staff would be trained on the new measure in early 2020. We will close this recommendation once the agency institutes this new metric.

Recommendation: The Administrator of the Wage and Hour Division should develop performance metrics or other measures specific to its child labor enforcement approach, such as whether WHD investigations are conducted at establishments where children are likely to be working. (Recommendation 3)

Agency: Department of Labor
Status: Open

Comments: WHD agreed that it could develop either an internal performance metric or new planning guidance and reporting requirements to ensure that WHD's child labor enforcement efforts focus on industries, establishments, and time periods in which children are likely to be working or injured. Although planning guidance and reporting requirements can encourage field office staff to focus more on child labor, we believe it is important to include a measurement of WHD's overall child labor enforcement approach as part of any new planning guidance and reporting requirements. We will consider closing this recommendation when WHD develops such performance metrics.

Recommendation: The Administrator of the Wage and Hour Division and the Assistant Secretary of the Occupational Safety and Health Administration should update and routinely monitor the 1990 WHD and Occupational Safety and Health Administration memorandum of understanding and establish documented procedures for monitoring the exchange of and actions taken on referrals. (Recommendation 4)

Agency: Department of Labor
Status: Open

Comments: To implement this recommendation, WHD and OSHA have agreed to establish a working group by the second quarter of FY2019, which will aim to maximize efficient information sharing between the two agencies. Specifically, this working group will update the existing WHD-OSHA Memorandum of Understanding, assess the results of referrals between WHD and OSHA, and make recommendations regarding the need for data collection and review. We will close this recommendation when these efforts are complete and supporting documentation has been provided.

Recommendation: The Administrator of the Food and Nutrition Service (FNS) should improve its estimate of children's participation in the SFSP by focusing on addressing, at a minimum, data reliability issues caused by variations in the number of operating days of meal sites and in the months in which states see the greatest number of meals served. (Recommendation 1)

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

Comments: In March 2019, Department of Agriculture's Food and Nutrition Service (FNS) submitted its 180-day letter and a subsequent response to report recommendations in GAO-18-369. In its response, FNS stated that it anticipates completing an evaluation of how they calculate SFSP participation by summer 2020. GAO will continue to monitor FNS actions to address this recommendation, including the status of its evaluation and steps taken to improve the agency's estimate of children participating in SFSP. GAO will consider this recommendation closed when FNS provides documentation that it has addressed, at a minimum, data reliability issues in the participation estimate caused by variations in the number of operating days of meal sites and in the months in which states see the greatest number of meals served. FNS plans to provide us with the status of its efforts by the end of FY 2020.

Recommendation: The Administrator of FNS should communicate to all SFSP stakeholders the circumstances it considers in approving requests for flexibility with respect to the requirement that children consume SFSP meals on-site in areas that have experienced crime and violence, taking into account the feasibility of accessing data needed for approval, to ensure safe delivery of meals to children. (Recommendation 2)

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

Comments: In late May 2018, the Department of Agriculture's Food and Nutrition Service (FNS) provided guidance to states regarding changes in policies related to SFSP waivers and demonstration projects and held a webinar to clarify the changes. In March 2019, FNS reported that this guidance and the webinar provided information about participation in the demonstration for exceptional circumstances, which is the means through which FNS had granted states and program providers flexibility for children to consume SFSP meals off-site in areas that had experienced crime and violence. However, the guidance documents do not directly acknowledge that FNS includes areas with crime and violence as exceptional circumstances for purposes of the demonstration, and neither the guidance nor the webinar provided new information about the circumstances FNS considers when granting the flexibility for such areas. GAO will therefore continue to monitor FNS actions to address this recommendation and consider it closed when the agency communicates the circumstances it considers in approving such requests for flexibility with response to the requirement that children consume SFSP meals on-site in areas that have experienced crime and violence. FNS plans to provide us with the status of its efforts by the end of FY 2020.

Recommendation: The Administrator of FNS should evaluate and annually report to Congress, as required by statute, on its use of waivers and demonstration projects to grant states and sponsors flexibility with respect to the requirement that children consume SFSP meals on-site in areas experiencing crime or violence, to improve its understanding of the use and impact of granting these flexibilities on meeting program goals. (Recommendation 3)

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

Comments: In March 2019, Department of Agriculture's Food and Nutrition Service (FNS) reported that it had drafted the report to Congress to meet its statutory requirement summarizing the use of waivers and demonstration projects. FNS also indicated that the report was being reviewed internally, and planned to submit the final report to Congress following that review. GAO will consider closing this recommendation when FNS submits the final report to Congress. FNS plans to provide us with the status of its efforts by the end of FY 2020.

Recommendation: The Administrator of FNS should disseminate information about existing flexibilities available to state agencies to streamline administrative requirements for sponsors participating in the SFSP and other child nutrition programs to help lessen the administrative burden. For example, FNS could re-distribute existing guidance to state agencies that explains available flexibilities and encourage information sharing. (Recommendation 4)

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

Comments: In March 2019, Department of Agriculture's Food and Nutrition Service (FNS) submitted its 180-letter and a subsequent response to recommendations in GAO-18-369. In its response, FNS stated that it plans to address streamlining flexibilities that impact the SFSP and other child nutrition programs in a future regulatory action. GAO will therefore continue to monitor FNS's progress with this rule-making and any other actions taken to address this recommendation. FNS plans to provide us with the status of its efforts by the end of FY 2020.

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

Agency: Department of Health and Human Services
Status: Open

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

Recommendation: GAO recommends that the Director of OMB consider developing a goal that addresses a coordinated federal approach to child well-being among its next set of cross-agency priority (CAP) goals, including working with relevant agencies to ensure their strategic plans include goals and objectives related to the CAP goal. (Recommendation 1)

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

Comments: OMB neither agreed nor disagreed with this recommendation. In November 2017, OMB staff noted that the agency was developing its next set of CAP goals, which are usually reserved for a limited set of priorities, and expects to announce these goals concurrent with the FY19 budget. As part of the process, agency staff said they consult relevant Congressional committees and other stakeholders. As of September 2019, OMB had not provided an update on its efforts.

Recommendation: The Acting Commissioner of the Social Security Administration should analyze the SEIE data to determine why a large proportion of transition-age youth on SSI with reported earnings did not benefit from the SEIE and, if warranted, take actions to ensure that those eligible for the incentive benefit from it.

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation. In August 2018, the agency reported that it was evaluating the accuracy of its SEIE data and once completed, the agency would analyze these data to determine whether there are significant numbers of students with earnings who are not benefiting from the SEIE. In February 2020, SSA reported that it was still working to resolve the issues with SEIE data identified during GAO's audit. SSA does not currently have a timeline for completing its analysis of its SEIE data. SSA also reported that it has submitted legislative proposals in several Presidential Budgets, most recently in fiscal year 2021, that would eliminate earnings reporting for youth, which would prevent similar concerns in the future. GAO will close this recommendation when SSA analyzes SEIE data and, if warranted, takes actions needed to ensure those eligible for SEIE benefit from it, or when all students with earnings receive SEIE because SSA's legislative proposal was enacted.

Recommendation: The Acting Commissioner of the Social Security Administration should analyze options to improve communication about SSA-administered work incentives and the implications of work on SSI benefits, with a goal of increasing understanding of SSI program rules and work incentives among transition-age youth and their families. This should include, but not necessarily be limited to, updating SSAs procedures for staff meeting with SSI applicants, recipients, and their families to regularly and consistently discuss - when applicable--how work incentives can prevent reductions in benefit levels and how work history is considered during eligibility redeterminations.

Agency: Social Security Administration
Status: Open

Comments: SSA disagreed with this recommendation. In August 2018, SSA noted it already requires staff to meet with SSI recipients regularly and instructs staff to discuss relevant work incentives, and that there is no indication that staff are not providing youth with appropriate work incentive information. However, SSA did not explain how it knows or ensures that staff are providing this information and SSA policies do not instruct staff to consistently convey information to youth and families on how work may or may not affect age 18 redetermination. SSA also reported that Work Incentives Planning and Assistance (WIPA) projects must prioritize working with youth who are referred to them. While we recognize the important role that WIPA projects play in providing work incentives counseling to SSI youth, as we previously reported, WIPA projects have limited capacity for serving youth along with other SSI recipients and disability insurance beneficiaries. In June 2019, SSA reported it had updated a brochure-containing information in English or Spanish on age-18 redeterminations, impact of earnings on benefits, work incentives and contact information to include information on SSA work incentives that may allow recipients who work to keep their Medicaid benefits. As of February 2020, the agency reported that it began sending this brochure to approximately 358,000 youth between the ages of 14 and 17 who receive SSI, and made this brochure available on its website. SSA also reported that it has begun exploring ways to better utilize social media to reach youth. While these are positive steps, we previously reported that written information may not be sufficient for conveying complex information. GAO continues to believe that SSA field office staff are both obliged and best-positioned to explain these rules. Moreover, in response to an SSA request for information in January 2018, SSA received public feedback on how it might improve transition outcomes for youth on SSI through better communication, suggesting that SSA's current communication strategies may not be sufficiently effective. We will consider closing this recommendation when SSA has taken further steps to ensure field staff are providing consistent and accurate information.

Recommendation: The Acting Commissioner of the Social Security Administration should work with the Secretary of Education to determine the extent to which youth on SSI are not receiving transition services through schools that can connect them to VR agencies and services.

Agency: Social Security Administration
Status: Open

Comments: SSA partially agreed with this recommendation, but after discussing it with the Department of Education, reported that significant challenges exist to pursuing certain implementation approaches. In December 2019, SSA reported that it continues to support research to identify the connection between youth on SSI and the receipt of VR services through its Retirement and Disability Research Consortia and its Analyzing Relationships Between Disability, Rehabilitation, and Work programs. SSA also reported that until very recently, data on open VR cases were unavailable at the national level; thus, it has not been possible to actively monitor SSI and VR participation in a timely manner. However, SSA reported that the agency will explore the possibility of using newly available data on open VR cases as resources allow. Determining the extent to which SSI youth are receiving or have access to services may help youth on SSI achieve employment and, potentially, self-sufficiency.

Recommendation: The Acting Commissioner of the Social Security Administration should explore various options for increasing connections to VR agencies and services, including their potential costs and benefits. One option, among others, could be to expand the Ticket to Work program to include youth.

Agency: Social Security Administration
Status: Open

Comments: SSA agreed with this recommendation and, in August 2018, SSA officials reported that they had taken several steps to explore and pursue options for increasing youths' connections to vocational rehabilitation agencies and services. Specifically, officials previously reported that they published a request for information (RFI) in the Federal Register in January 2018 that asks, among other things, for strategies to connect youth receiving Supplemental Security Income (SSI) with vocational rehabilitation agencies and about options for programs like a Ticket to Work for youth. In July 2019, SSA reported receiving and analyzing almost 200 responses to its RFI and indicated that it plans to discuss its findings with federal partners and other stakeholders. SSA officials also previously reported that the agency reviewed the Social Security Act and that the law precludes SSA from directly or indirectly referring youth on SSI to vocational rehabilitation agencies. Therefore, as of December 2019, the agency reported that it has submitted legislative proposals in several presidential budgets, including its fiscal year 2021 budget justification, that would allow SSA to refer youth to vocational rehabilitation agencies. SSA officials also reported that the agency has initiated demonstration projects to determine whether youth on SSI benefit from referrals to vocational rehabilitation agencies and commissioned reports related to services for youth.. According to information provided in July 2019, one of SSA's demonstration projects analyzes an experimental intervention to improve the outcomes of children receiving SSI by providing personalized information to families about the likelihood that a child will not continue on SSI as an adult, as well as resources to help these youth with the transition to employment. The resources offered will include: math tutoring, SAT/ACT test preparation, and help with applying for vocational rehabilitation services. In addition, according to information SSA provided in July and December 2019, the agency's second demonstration project will involve testing direct referrals to VR in one state for 19 year olds who are or may become SSI or Social Security Disability Insurance beneficiaries, and involves data sharing between SSA and the state on individuals eligible to participate in the project. This project is scheduled to begin recruiting participants in January 2020. SSA also reported that it has commissioned two reports on youth services that will help it identify implementable polices related to youth. Exploring the potential costs and benefits of employment support services for youth who receive or are at risk of being disability program beneficiaries as adults may help SSA develop programs to support the self-sufficiency of these youth. However, to date, SSA has not indicated that it has explored, or it may be too soon to explore, the costs and benefits of any of the options SSA has considered for increasing access to vocational rehabilitation agencies for youth on SSI.

Recommendation: To better ensure FEMA's regional activities effectively support individuals with disabilities, the Secretary of Homeland Security should direct the FEMA Administrator to take steps to establish written procedures for how regions should involve the Office of Disability Integration and Coordination in clarifying disability integration staff's roles, evaluating staff performance, and setting expectations for how staff communicate with headquarters and the regions.

Agency: Department of Homeland Security
Status: Open

Comments: FEMA agreed with this recommendation and FEMA's Office of Disability Integration and Coordination (ODIC) is in the process of establishing a working group that will clarify and codify the roles, responsibilities, and expectations among the various agency offices and personnel involved in carrying out the agency's disability integration mission. In January 2018, FEMA reported that it had created Regional Integration Teams in the regions to improve the efficiency and efficacy of mission delivery. In August 2018, ODIC reported its goal to meet with Regional Administrators and other senior leaders across the agency by the end of CY 2018 to refine the role for disability integration staff. The reported intent of refining the role is to better align it with the FEMA Administrator's goal of empowering emergency managers in states, localities, tribes, and territories. In June 2019, ODIC officials reported plans to convene a workgroup to examine the role of the Regional Disability Integration Specialist, including their reporting chain and their roles and responsibilities in each of FEMA's ten regions. The workgroup will meet over two months and develop recommendations to be considered by FEMA's Chief of Staff by August 23, 2019. GAO is encouraged by FEMA's efforts to engage Regional Administrators and other senior leaders in its refinement of the role of disability integration staff, and awaits evidence of FEMA establishing documentation of the agency's procedures for carrying out its disability integration mission.

Recommendation: To help ensure its key training on incorporating access and functional needs into emergency planning reaches a sufficiently wide audience, the Secretary should direct the FEMA Administrator to collect information about the potential pool of participants, set general goals for the number of state and local emergency managers that will take this course, and implement the delivery methods needed to meet these goals.

Agency: Department of Homeland Security
Status: Open

Comments: FEMA agreed with this recommendation and reported that it will work with its regional staff to map potential training participants in each state and set goals for delivery of the course to state and local emergency managers. The agency also reported that it may be able to use data in the State Preparedness Report and states' self-reporting on the need for training on integrating the needs of people with access and functional needs into emergency management. As of January 2018, the Office of Disability Integration and Coordination reported plans to hire a permanent staff person to review, assess, and recommend how FEMA should incorporate disability into all internal and external training. In August 2018, FEMA reported hiring a new Program and Policy Branch Chief in July 2018, and noted that this individual will formulate a plan to incorporate the needs of people with disabilities into internal and external training over several weeks. However, FEMA did not address whether this individual will seek information about the potential pool of external participants, or set goals for the number of state and local emergency managers who could participate in external training. FEMA also reported providing just-in-time training in the field to support field staff in providing services to people with disabilities. The agency anticipates completing these efforts by December 31, 2019 and we will consider closing this recommendation when the agency can document it has addressed the recommendation.

Recommendation: To help improve tribes' ability to maintain safe, stable, and permanent care for children, the Secretary of Health and Human Services should direct the Children's Bureau to explore the reasons for low tribal participation and identify actions to increase this participation in the title IV-E Guardianship Assistance Program.

Agency: Department of Health and Human Services
Status: Open

Comments: HHS agreed with this recommendation. HHS reported that it would take several actions: 1) task the Tribal Workgroup with identifying reasons for low tribal participation in GAP and identifying actions to increase participation in GAP; 2) improve its website offerings on Tribal IV-E, including providing the briefing materials as well direct IV-E and pass-through related products created by the CB Central and Regional Offices and the Capacity Building Center for Tribes; 3) improve coordination with non-governmental organizations that provide technical assistance and direct outreach to tribes for Title IV-E; and 4) encourage states to work with tribes on GAP. HHS noted that some states have already developed GAP frequently asked questions, practice guides, and other GAP support products to raise awareness and engage tribal interest in GAP. GAO awaits documentation that these actions have been completed. The agency also hopes to host a national tribal consultation to solicit feedback and determine priorities to address tribal participation in GAP; and develop a strategy for serving tribes interested in and implementing IV-E, including GAP, to be posted on the website. GAO will close this recommendation when the agency shows that these efforts have been completed.

Recommendation: To help ensure vulnerable unaccompanied children receive child advocate services, the Secretary of the Department of Health and Human Services should direct ORR to develop a monitoring process that includes: (1) regularly reviewing referrals to the program contractor, including identifying which care providers in locations with a child advocate program do not make referrals; and (2) reviewing information on the children the program contractor determines it is unable to serve.

Agency: Department of Health and Human Services
Status: Open

Comments: In June 2016, the Office of Refugee Resettlement (ORR) reported that it was working with the child advocate contractor to develop standard operating procedures (SOP) to assign child advocates for children. In February 2020, ORR reported that the finalized SOPs are being implemented. Agency officials stated that they are reviewing program referrals through monthly reporting and calls with the contractor. ORR officials also said they allow the contractor to determine which unaccompanied children are provided a child advocate and there are insufficient resources to assign advocates to all children that are referred. In August 2020, ORR reported that the agency is in the process of developing a new case management system that will enhance its monitoring of the child advocate program, including the ability to analyze child advocate referral data. This system is expected to be fully operational in late 2021.

Recommendation: The Secretary of the Department of Health and Human Services should direct the Office of Refugee Resettlement to develop a process to ensure all information collected through its existing post-release efforts are reliable and systematically collected so that they can be compiled in summary form and provide useful information to other entities internally and externally.

Agency: Department of Health and Human Services
Status: Open

Comments: In March of 2016, the Office of Refugee Resettlement (ORR) created a new section in its unaccompanied children's policy guide that require ORR staff to make safety and well-being (SWB) follow-up calls to children and their sponsors after the child is release from ORR custody. In addition, in October of 2016, ORR added another section to its policy guide that included case reporting, records management, retention, and information sharing requirements for post-release service (PRS) providers. According to ORR officials, ORR collects and analyzes data from both its SWB calls and PRS providers. SWB call data include efforts made to contact both sponsor and child; participation rates; confirmation the child is currently residing with the sponsor; referrals made to the ORR National Call Center (NCC) for additional resources; any concerns regarding the child's safety and well-being; and whether any reports were made to the ORR Federal Field Specialist, child protective services, local law enforcement, and/or the ORR Sexual Abuse Hotline. PRS data include the reason for referral; level of services provided; services areas accessed by the child and/or sponsor; outcomes; any concerns regarding the child's safety and well-being; and when services were discontinued, according to ORR officials. According to ORR officials, because ORR is currently in the process of developing a new case management system, the majority of information from SWB calls and post-release efforts is collected manually, outside of ORR's current case management system. Information collected through ORR's SWB calls is aggregated quarterly and a fact sheet containing aggregate data is distributed internally to ORR leadership. ORR officials say the new case management system will include information on SWB calls and post-release efforts. ORR tentatively plans for the first phase of the system to be operational by November 2020 and to deploy a finished product with all planned enhancements in late 2021. GAO will close this recommendation once ORR completes this system and demonstrates that it can be used for the purpose of collecting reliable safety and well-being and post-release services data and disseminating it internally and externally, as appropriate.

Recommendation: To help ensure the Bureau focuses its resources on those activities that show promise for substantially reducing enumeration cost, in advance of the 2016 Census Test and later tests, the Secretary of Commerce should direct the Under Secretary of the Economics and Statistics Administration and the Director of the U.S. Census Bureau to, ensure systematic capture of information about fieldwork cases that experience problems by including information in enumerator training about where to record the issues, who to contact, what details to include, and the importance of doing so.

Agency: Department of Commerce
Status: Open
Priority recommendation

Comments: Commerce concurred with this recommendation. The Census Bureau informed us in December 2015 that no later than the end of December 2015, it would document how these matters have been addressed in the enumerator training (or in help screens on their mobile device) planned for the 2016 Census Test, and that it would use results and observations from that test to further refine such information for future tests and for the 2020 Census. The Bureau provided us with related training materials for the 2016 Test, yet we made similar observations during the 2016 test and the 2018 End-to-End test. For the Bureau to be informed on any additional training needs or other operational decisions for 2020, it will need to continue to expand its efforts in collecting information on enumerator-reported problems per our 2015 recommendation. In April 2020, Bureau officials said that it was not likely they would be able to incorporate additional changes for the 2020 Census field operations. With the Bureau's more recent April announcement to further delay field operations due to the Covid-19 outbreak, we are continuing to ask the Bureau if there is opportunity to address this recommendation. To fully implement this recommendation, the Bureau needs to identify what information it finds valuable to have from its enumerators, such as the incidence of specific technical problems with the survey instrument or mobile device and ensure that enumerators and their first-line supervisors are made aware of the importance of recording such information and how to do so.

Recommendation: To increase the efficiency and improve the accuracy of the interagency UAC referral and placement process, the Secretaries of Homeland Security and Health and Human Services should jointly develop and implement a documented interagency process with clearly defined roles and responsibilities, as well as procedures to disseminate placement decisions, for all agencies involved in the referral and placement of UAC in HHS shelters.

Agency: Department of Homeland Security
Status: Open
Priority recommendation

Comments: Since our 2015 report, DHS and HHS developed two documents to guide interagency procedures related to the processing of UAC. Specifically, in April 2018, HHS and DHS established a memorandum of agreement regarding information sharing for UAC. Subsequently, on July 31, 2018, DHS and HHS issued a Joint Concept of Operations to memorialize interagency policies, procedures, and guidelines related to the processing of UAC. However, in February 2020, we reported that DHS and HHS officials' indicated that, in practice, the agencies have not resolved long-standing differences in opinion about whether and how agencies are to share information, and what type of information is needed to inform decisions about the care and placement of UAC. In commenting on our draft report, DHS stated that its components are working with HHS to document current information sharing practices, to validate remaining information sharing gaps, and to draft a joint plan between DHS and HHS to ensure that HHS receives information needed to make decisions for UAC. In their comments, HHS officials stated that they intend to reach out to counterparts at DHS in June 2020 to discuss potential periodic updates to the Joint Concept of Operations. In August 2020, DHS informed us that the department is working with HHS to document current information sharing practices, validate gaps, and draft a joint plan between DHS and HHS, among other actions. DHS estimates that it will complete these actions by March 31, 2021. To fully address the recommendation, DHS and HHS should ensure that they have implemented procedures aimed at improving the efficiency and accuracy of the interagency UAC referral and placement process.

Recommendation: To increase the efficiency and improve the accuracy of the interagency UAC referral and placement process, the Secretaries of Homeland Security and Health and Human Services should jointly develop and implement a documented interagency process with clearly defined roles and responsibilities, as well as procedures to disseminate placement decisions, for all agencies involved in the referral and placement of UAC in HHS shelters.

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

Comments: Since our 2015 report, DHS and HHS developed two documents to guide interagency procedures related to the processing of UAC. Specifically, in April 2018, HHS and DHS established a memorandum of agreement regarding information sharing for UAC. Subsequently, on July 31, 2018, DHS and HHS issued a Joint Concept of Operations to memorialize interagency policies, procedures, and guidelines related to the processing of UAC. However, in February 2020, we reported that DHS and HHS officials' indicated that, in practice, the agencies have not resolved long-standing differences in opinion about whether and how agencies are to share information, and what type of information is needed to inform decisions about the care and placement of UAC. In commenting on our draft report, DHS stated that its components are working with HHS to document current information sharing practices, to validate remaining information sharing gaps, and to draft a joint plan between DHS and HHS to ensure that HHS receives information needed to make decisions for UAC. In their comments, HHS officials stated that they intend to reach out to counterparts at DHS in June 2020 to discuss potential periodic updates to the Joint Concept of Operations. In August 2020, DHS informed us that the department is working with HHS to document current information sharing practices, validate gaps, and draft a joint plan between DHS and HHS, among other actions. DHS estimates that it will complete these actions by March 31, 2021. To fully address the recommendation, DHS and HHS should ensure that they have implemented procedures aimed at improving the efficiency and accuracy of the interagency UAC referral and placement process.

Recommendation: To improve the transparency of the process for reviewing and approving spending limits for comprehensive section 1115 demonstrations, the Secretary of Health and Human Services should reconsider adjustments and costs used in setting the spending limits for the Arizona and Texas demonstrations, and make appropriate adjustments to spending limits for the remaining years of each demonstration.

Agency: Department of Health and Human Services
Status: Open

Comments: As of January 2020, the Department of Health and Human Services (HHS) has taken steps to address GAO's 2013 recommendation, but more actions are needed for GAO to consider this recommendation implemented. Beginning in May 2016, the Centers for Medicare & Medicaid Services (CMS) began implementing a new budget neutrality policy. The new policy was outlined in a Letter to State Medicaid Directors in 2018, and it addressed certain problems GAO identified regarding states' allowed methods for determining budget neutrality of their demonstrations. CMS has begun phasing in the methods established under this new policy for all states, including the two states (Arizona and Texas) for which GAO recommended adjustments. One portion of the policy--under which spending limits will be updated to reflect more recent spending data--will be implemented beginning in 2021 and will address concerns GAO identified in Arizona's spending limit once its demonstration is renewed. In January 2019, CMS officials told GAO that the agency continues to allow states to include hypothetical costs when determining demonstration spending limits, an action GAO identified as a concern in Texas' demonstration. While CMS officials provided documentation on changes the agency made in the spending limit approved for Texas' new demonstration period beginning in January 2018, GAO reviewed these changes and found that further adjustments are needed to remove additional hypothetical costs from the Texas' spending limit.

Recommendation: In light of the need for accurate and complete information on children's access to health services under Medicaid and CHIP, the requirement that states report information to CMS on certain aspects of their Medicaid and CHIP programs, and problems with accuracy and completeness in this state reporting, the Administrator of CMS should work with states to identify additional improvements that could be made to the CMS 416 and CHIP annual reports, including options for reporting on the receipt of services separately for children in managed care and fee-for-service delivery models, while minimizing reporting burden, and for capturing information on the CMS 416 relating to children's receipt of treatment services for which they are referred.

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

Comments: In August 2019, CMS stated that the agency's long-term plan is to use the Transformed Medicaid Statistical Information System (T-MSIS) to analyze information on children's receipt of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. As of June 2020, CMS had developed a new CMS-416 reporting form that gives states the option of having CMS calculate the measures for the report using T-MSIS. CMS stated that it intends to implement this option for states for fiscal year 2020 CMS-416 reports, which are due in April 2021. As of August 2020, the new CMS-416 form was undergoing Paperwork Reduction Act review. CMS is also exploring using T-MSIS to generate the Core Set of Children's Health Care Quality Measures for Medicaid and CHIP, some of which are included in the CHIP annual report. As of June 2020, CMS had begun a pilot test to generate five of the Core Set measures using 2018 T-MSIS data. GAO considers this recommendation open and will continue to monitor CMS's progress towards its long-term goal of using T-MSIS to monitor children's receipt of EPSDT services.

Recommendation: To enhance the provision of dental care to children covered by Medicaid and CHIP, and to help ensure that HHS's Insure Kids Now Web site is a useful tool to help connect children covered by Medicaid and CHIP with participating dentists who will treat them, the Secretary of HHS should require states to verify that dentists listed on the Insure Kids Now Web site have not been excluded from Medicaid and CHIP by the HHS-OIG, and periodically verify that excluded providers are not included on the lists posted by the states.

Agency: Department of Health and Human Services
Status: Open

Comments: As of September 2020, CMS has not indicated taking steps to require states to ensure excluded providers are not listed on the Insure Kids Now website, nor has it indicated taking steps to periodically verify that providers excluded from Medicaid and CHIP are not on the list. CMS has said that it relies on states to provide accurate lists of eligible dentists and that data issues prevent the agency from independently verifying that excluded providers are not included on the Insure Kids Now website. We continue to believe that CMS should require states to ensure that excluded providers are not listed on the website and periodically verify that excluded providers are not included on the lists posted by the states, so that the website does not present inaccurate information about providers available to serve Medicaid-covered children.

Recommendation: Because EPA alone cannot address the complexities of the nation's challenges in addressing environmental health risks for children, Congress may wish to consider re-establishing a government-wide task force on children's environmental health risks, similar to the one previously established by Executive Order 13045 and co-chaired by the Administrator of EPA and the Secretary of Health and Human Services. Congress may wish to consider charging it with identifying the principal environmental health threats to children and developing national strategies for addressing them. Congress may also wish to consider establishing in law the Executive Order's requirement for periodic reports about federal research findings and research needs regarding children's environmental health.

Agency: Congress
Status: Open

Comments: As of March 2020, we have not identified actions by the Congress to establish in law requirements such as those in Executive Order 13045.

Recommendation: Given the potential for improving compliance now and in the future, Congress may wish to provide IRS with the authority to use math error checks to identify and correct returns with ineligible (1) IRA "catch-up" contributions, and (2) contributions to traditional IRAs from taxpayers over age 70-1/2.

Agency: Congress
Status: Open

Comments: As of March 2020, Congress has expanded IRS's math error authority in certain circumstances, but not as broadly as GAO suggested in February 2010. Section 208 of division Q of the Consolidated Appropriations Act, 2016 (Public Law 114-113 enacted in December 2015) gave IRS the authority to use math error authority if (1) a taxpayer claimed the Earned Income Tax Credit, Child Tax Credit, or the American Opportunity Tax Credit (AOTC) during the period in which a taxpayer is not permitted to claim such credit as a consequence of either having made a prior fraudulent or reckless claim; or (2) a taxpayer omitted information required to be reported because the taxpayer made prior improper claims of the Child Tax Credit or the AOTC. While expanding math error authority is consistent with what GAO suggested in February 2010, GAO maintains that a broader authorization of math error authority with appropriate controls would enable IRS to correct obvious noncompliance, would be less intrusive and burdensome to taxpayers than audits, and would potentially help taxpayers who underclaim tax benefits to which they are entitled. If Congress decides to extend broader math error authority to IRS, controls may be needed to ensure that this authority is used properly such as requiring IRS to report on its use of math error authority. The Administration also requested that Congress expand IRS's math error authority as part of the Service's Congressional Budget Justification and Annual Performance Report and Plan for fiscal year 2019. Specifically, the Administration requested authority to correct a taxpayer's return in the following circumstances: 1) the information provided by the taxpayer does not match the information contained in government databases; 2) the taxpayer has exceeded the lifetime limit for claiming a deduction or credit; or 3) the taxpayer has failed to include with his or her return certain documentation that is required by statute. As of April 2019, the Congress had not provided IRS with such authority.

Recommendation: To meet its fiduciary responsibility of ensuring that section 1115 waivers are budget neutral, the Secretary of Health and Human services should better ensure that valid methods are used to demonstrate budget neutrality, by developing and implementing consistent criteria for consideration of section 1115 demonstration waiver proposals.

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

Comments: As of January 2020, the Department of Health and Human Services (HHS) had taken some action to address GAO's 2002 recommendation. In August 2018, HHS issued written guidance through a State Medicaid Directors Letter documenting four key changes it made in 2016 to its budget neutrality policy. These changes addressed some, but not all of the questionable methods GAO identified in its reports. To fully address this recommendation, HHS should also address these other questionable methods, such as setting demonstration spending limits based on hypothetical costs-what the state could have paid-rather than payments actually made by the state. GAO has found that the use of hypothetical costs has the potential to inflate spending limits and thus threatens budget neutrality of demonstrations