Recommendations Database

GAO’s recommendations database contains report recommendations that still need to be addressed. GAO’s priority recommendations are those that we believe warrant priority attention. We sent letters to the heads of key departments and agencies, urging them to continue focusing on these issues. Below you can search only priority recommendations, or search all recommendations.

Our recommendations help congressional and agency leaders prepare for appropriations and oversight activities, as well as help improve government operations. Moreover, when implemented, some of our priority recommendations can save large amounts of money, help Congress make decisions on major issues, and substantially improve or transform major government programs or agencies, among other benefits.

As of November 30, 2021, there are 4659 open recommendations, of which 482 are priority recommendations. Recommendations remain open until they are designated as Closed-implemented or Closed-not implemented.

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1 - 19 of 19 Recommendations
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VA Acquisition Management: Comprehensive Supply Chain Management Strategy Key to Address Existing Challenges

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1 Open Recommendations
1 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Secretary of Veterans Affairs should ensure the Veterans Health Administration (VHA) Assistant Under Secretary for Health for Support develops a comprehensive supply chain management strategy that outlines how VHA's various supply chain initiatives are related to each other and to VA-wide initiatives. This strategy should link to VA's overall plans to address its broader acquisition management challenges and reflect key practices of organizational transformations, including an implementation plan with key milestones. (Recommendation 1)
Open

VA officials expressed verbal agreement with this recommendation. To implement this recommendation, VA needs to develop a comprehensive supply chain management strategy that addresses the interrelationships between its various modernization relationships, and reflects key practices of organizational transformations, including an implementation plan with key milestones. In July 2021, VA stated that it expects to complete this plan by September 2021. However, an August 2021 court order halting planned changes in its Medical-Surgical Prime Vendor program creates uncertainty that VA must resolve

Veterans Community Care Program: Improvements Needed to Help Ensure Timely Access to Care

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1 Open Recommendations
1 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Under Secretary of Health should align its monitoring metrics with the time frames established in the VCCP scheduling process. (Recommendation 1)
Open

In April 2021, VA continues to disagree with the recommendation and states it will not take further action to close this recommendation. Although VA responded to our report by stating that the department already monitors key steps in the Veterans Community Care Program scheduling process that align with policy, we continue to believe this recommendation is valid for two reasons. First, VA's response did not address an issue we found for one of the metrics it monitors, which is inconsistent with the guidance it asks staff to follow when reviewing a referral. Second, VA has not yet established

Veteran Suicide: VA Needs Accurate Data and Comprehensive Analyses to Better Understand On-Campus Suicides

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2 Open Recommendations
2 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Under Secretary for Health should, in collaboration with relevant VBA and NCA officials, improve its process to accurately identify all on-campus veteran deaths by suicide by ensuring that it uses updated information and corroborates information with VA facility officials. (Recommendation 1)
Open

VHA concurred with this recommendation and stated that they established a standing committee that includes representatives from VHA, VBA, NCA, and the Office of Operations, Security, and Preparedness. In September 2021, VHA told us that the committee drafted changes to VA Directive 0321 to require notification of all veteran suicide deaths on VA property to the Office of Mental Health and Suicide Prevention (OMHSP), to include procedures for email notification, reconciliation, and corroboration from local officials. VHA estimates implementation of these actions by February 2022. We will

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

VA disagreed with our recommendation and stated that a root cause analysis was not the appropriate tool for conducting suicide surveillance for all cases of veteran death by suicide. In September 2021, VA stated that VHA requires issue briefs for all suicide attempts and deaths that occur at medical centers, and that the VA committee consisting of VHA, VBA, NCA, and the Office of Operations, Security, and Preparedness, will identify opportunities to expand issue brief reporting and further develop reporting methods. VA added that the committee will also identify methods for enhancing

Sexual Harassment: Inconsistent and Incomplete Policies and Information Hinder VA's Efforts to Protect Employees

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2 Open Recommendations
2 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
VA's Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness should realign VA's EEO Director position to adhere to the applicable EEOC directive by ensuring the position is not responsible for personnel functions. (Recommendation 1)
Open

VA did not agree with our recommendation. Nevertheless, in September 2020, VA met with the Equal Employment Opportunity Commission (EEOC) to discuss, among other things, alignment of VA's Equal Employment Opportunity (EEO) Director position. VA plans to continue to work with EEOC to assess the alignment of this position. We will close this recommendation when VA makes any needed changes to the EEO Director position, according to EEOC, and EEOC agrees that VA's EEO Director position is appropriately aligned.

Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
VA's Deputy Assistant Secretary for Resolution Management should complete VA's EEO Program Manager realignment initiative at VBA and VHA in accordance with VA policy. (Recommendation 2)
Open

VA agreed with our recommendation. VA completed the Equal Employment Opportunity (EEO) Program Manager realignment at VBA in early 2021. As of April 2021, VA is developing a plan to address the realignment of EEO Program Managers at VHA, which is projected to start in fiscal year 2024. We will close this recommendation when the realignment initiative is completed at VHA.

Department of Veterans Affairs: Improved Succession Planning Would Help Address Long-Standing Workforce Problems

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1 Open Recommendations
1 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Secretary of Veterans Affairs should develop a department-wide succession plan for leadership and mission-critical occupations that incorporates key leading practices for succession planning. (Recommendation 1)
Open

VA concurred with this recommendation and stated that it is developing a succession plan for leadership and mission-critical occupations that will incorporate leading practices. In August 2021, VA reported that it expects to finalize its succession plan in early fiscal year 2022. When VA provides us a copy of the final plan, we will provide updated information.

Cybersecurity: Agencies Need to Fully Establish Risk Management Programs and Address Challenges

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2 Open Recommendations
2 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Secretary of Veterans Affairs should develop a cybersecurity risk management strategy that includes the key elements identified in this report. (Recommendation 32)
Open

The Department of Veterans Affairs concurred with this recommendation. The department stated that it plans to develop a comprehensive risk management strategy in accordance with its updated cybersecurity program directive and plans to finalize the strategy by June 30, 2020. However, as of March 2021, we had not received evidence of these actions or a revised estimated completion date. Once the department has provided evidence of these actions, we plan to verify whether implementation has occurred.

Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Secretary of Veterans Affairs should establish a process for conducting an organization-wide cybersecurity risk assessment. (Recommendation 34)
Open

The Department of Veterans Affairs concurred with this recommendation. VA stated that it plans to fully document its process for an organization-wide cybersecurity risk assessment by June 30, 2020. However, as of March 2021, we had not received evidence of these actions or a revised estimated completion date. Once the department has provided evidence of these actions, we plan to verify whether implementation has occurred.

VA Real Property: Improvements in Facility Planning Needed to Ensure VA Meets Changes in Veterans' Needs and Expectations

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

VA agreed with the recommendation and indicated that it would instruct users on what data to use in planning and updates, which would help ensure veterans' input is incorporated where appropriate. As part of that effort, in January 2020 VA issued guidance to VAMCs. In particular, this guidance instructed users how to ensure that planning is consistent with veterans' needs. To fully implement this recommendation, however, VA needs to provide guidance to instruct the VAMCs how to ensure that this planning is also consistent with veterans' changing expectations. As of February 2021, VA had not

Data Protection: Federal Agencies Need to Strengthen Online Identity Verification Processes

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1 Open Recommendations
1 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Secretary of the Department of Veterans Affairs should develop a plan with time frames and milestones to discontinue knowledge-based verification, such as by using Login.gov or other alternative verification techniques. (Recommendation 6)
Open

VA agreed with our recommendation. VA has developed a plan that eliminated some uses of knowledge-based verification, bringing the agency closer to implementing the recommendation. However, to fully implement this recommendation, VA's plan needs to fully address elimination of knowledge-based verification.

Data Center Optimization: Additional Agency Actions Needed to Meet OMB Goals

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1 Open Recommendations
1 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Secretary of VA should take action to meet the data center optimization metric targets established under DCOI by OMB. (Recommendation 24)
Open

The Department of Veteran Affairs agreed with our recommendation and reported steps toward implementing this recommendation in its fiscal year 2021 budget justification. As of December 2020, the department reported that it had met its fiscal year 2020 targets for two of the four data center optimization metrics tracked by OMB. However, we continue to believe that full implementation of this recommendation will require steps beyond what the department is currently reporting. Specifically, to fully implement this recommendation, VA will need to meet all four of OMB's metrics.

Veterans Health Administration: Greater Focus on Credentialing Needed to Prevent Disqualified Providers from Delivering Patient Care

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1 Open Recommendations
1 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Under Secretary for Health should develop policies and guidance regarding DEA registrations, including the circumstances in which Drug Enforcement Administration (DEA) waivers may be required, the process for requesting them, and a mechanism to ensure that facilities follow these policies. (Recommendation 2)
Open

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

VA Disability Benefits: Improved Planning Practices Would Better Ensure Successful Appeals Reform

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2 Open Recommendations
2 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Secretary of Veterans Affairs should clearly articulate in VA's appeals plan how VA will monitor and assess the new appeals process compared to the legacy process, including specifying a balanced set of goals and measures--such as timeliness goals for all VBA appeals options and Board dockets, and measures of accuracy, veteran satisfaction, and cost--and related baseline data. (Recommendation 2)
Open

VA initially had concurred with this recommendation. As of July 2021, VA, along with the Board of Veterans' Appeals (Board), has addressed some issues we had identified with how it monitored and assessed performance in deciding appeals. However, VA has yet to fully implement our 2018 recommendation to collect and use information from a balanced set of measures-that, at a minimum, include timeliness, quality, and veterans' satisfaction-to monitor processing of appeals decisions. In its October 2020 action plan to address high-risk issues provided to GAO and a February 2021 progress report to

Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Secretary of Veterans Affairs should ensure that the appeals plan more fully addresses risk associated with appeals reform--for example, by assessing risks against a balanced set of goals and measures, articulating success criteria and an assessment plan for RAMP, and testing or conducting sensitivity analyses of all appeals options--prior to fully implementing the new appeals process. (Recommendation 4)
Open

VA concurred with this recommendation. VA has implemented the Appeals Modernization Act (AMA) and, along with the Board of Veterans' Appeals (Board), has made strides to simultaneously manage two appeals processes. For example, VA is monitoring workloads, in part, through modeling, which enables it to better project resource needs for processing these workloads, as we have recommended. However, as of July 2021, VA has not fully developed mitigation strategies for certain workload risks, such as veterans choosing at much higher rates the Board's hearing option, which is the most resource

Veterans Affairs Contracting: Improvements in Buying Medical and Surgical Supplies Could Yield Cost Savings and Efficiency

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1 Open Recommendations
1 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
The Director of the MSPV-NG program office should, with input from the Strategic Acquisition Center (SAC), develop, document, and communicate to stakeholders an overarching strategy for the program, including how the program office will prioritize categories of supplies for future phases of requirement development and contracting. (Recommendation 1)
Open

The Department of Veterans Affairs (VA) agreed with GAO's November 2017 recommendation. VA had planned to implement a new Medical Surgical Prime Vendor (MSPV) program, called MSPV 2.0, starting in 2020; it has also been piloting the Defense Logistics Agency's (DLA) MSPV program since 2019. However, as of August 2021, MSPV 2.0 is not yet operational, and VA's planned switch to the DLA MSPV program has been halted by a court order. As a result, there is substantial uncertainty in the path forward, and VA's strategy is unclear. To implement this recommendation, VA needs to develop an overarching

VA Health Care: Improved Monitoring Needed for Effective Oversight of Care for Women Veterans

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1 Open Recommendations
1 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
To improve care for women veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to monitor women veterans' access to key sex-specific care services--mammography, maternity care, and gynecology--under current and future community care contracts. For those key services, monitoring should include an examination of appointment scheduling and completion times, driving times to appointments, and reasons appointments could not be scheduled with community providers.
Open

VA agreed with our recommendation. According to a March 2021 update, VA said it will be modifying its existing community care quality improvement plans in order to obtain actionable data on appointment timeliness for mammography, maternity care, and gynecology services and expects to complete this process by August 2021. To implement this recommendation, VHA needs to provide documentation that, as a part of its community care program, there is a monitoring plan (including time frames, data analyzed, and actions taken) to not only examine timely appointment scheduling and completion times for

Veterans Affairs Contracting: Improvements in Policies and Processes Could Yield Cost Savings and Efficiency

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1 Open Recommendations
1 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
In order to ensure that contracting officers have clear and effective policies as soon as possible, the Secretary of Veterans Affairs should direct the OAL to identify measures to expedite the revision of the Veterans Affairs Acquisition Regulation (VAAR), which has been ongoing for many years, and the issuance of the VA Acquisition Manual.
Open

VA concurred with this recommendation and has made progress in issuing its revised VA Acquisition Regulation, as well as the companion VA Acquisition Manual to ensure its workforce has clear and effective policies. As of October 2021, VA had issued 35 proposed or final rules, with six remaining to be published.

VA Health Care: Reliability of Reported Outpatient Medical Appointment Wait Times and Scheduling Oversight Need Improvement

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1 Open Recommendations
1 Priority
Agency Recommendation Status
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
To ensure reliable measurement of veterans' wait times for medical appointments, the Secretary of VA should direct the Under Secretary for Health to take actions to improve the reliability of wait time measures either by clarifying the scheduling policy to better define the desired date, or by identifying clearer wait time measures that are not subject to interpretation and prone to scheduler error.
Open

VA agreed with our recommendation. VA has taken actions intended to address the reliability of appointment wait times through improvements in appointment scheduling, including issuing a revised scheduling policy, providing and documenting scheduler training, and improving oversight through scheduler audits. While the revised scheduling policy and subsequent guidance changed the terminology of wait-time measures, they did not substantively clarify or define the desired date. Therefore, we continue to believe that the desired date field is still subject to interpretation and prone to scheduler

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