Government Auditing Standards: 2018 Revision Technical Update April 2021 (Supersedes GAO-18-568G)

The Yellow Book provides standards and guidance for auditors and audit organizations, outlining the requirements for audit reports, professional qualifications for auditors, and audit organization quality control. Auditors of federal, state, and local government programs use these standards to perform their audits and produce their reports.

Effective Date

The 2018 revision of the Yellow Book is effective for financial audits, attestation engagements, and reviews of financial statements for periods ending on or after June 30, 2020, and for performance audits beginning on or after July 1, 2019. Early implementation is not permitted.

The technical updates to the 2018 revision of the Yellow Book are effective upon issuance.

Revision Process

Yellow Book revisions undergo an extensive, deliberative process, including public comments and input from the Comptroller General’s Advisory Council on Government Auditing Standards. GAO considered all comments and input in finalizing revisions to the standards.

For more information, contact James R. Dalkin at (202) 512-9535 or yellowbook@gao.gov. Visit our Yellow Book website for more information on applicable updates and alerts.

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  • High-Performance Computing: NNSA Could Improve Program Management Processes for System Acquisitions
    In U.S GAO News
    What GAO Found The National Nuclear Security Administration's (NNSA) analysis of alternatives (AOA) process for its $600 million El Capitan HPC acquisition did not fully follow agency policy that states that AOA processes should be consistent with GAO best practices, where possible, and any deviations must be justified and documented. According to GAO best practices, a reliable AOA process should meet four characteristics: it should be comprehensive, well documented, unbiased, and credible. As seen in the table, the AOA process for El Capitan partially met one of these characteristics and minimally met the other three. NNSA did not justify or document the deviations from these best practices, as required by NNSA policy. GAO also found that the AOA process was conducted by the contractor that manages the El Capitan acquisition program, contrary to agency policy and guidance stating that AOAs should be conducted by an independent entity. Without following AOA best practices where possible; justifying and documenting any deviations; and ensuring AOA processes are conducted by an independent entity, as required, NNSA cannot be assured of a reliable assessment of options for meeting critical mission needs. Extent to Which the National Nuclear Security Administration (NNSA) Met the Characteristics of a Reliable Analysis of Alternatives (AOA) Process AOA characteristic GAO assessment Example of deviation Comprehensive Partially met Cost estimates are incomplete and did not follow best practices. Well documented Minimally met The alternatives' descriptions are not detailed enough for a robust analysis. Unbiased Minimally met NNSA had a predetermined solution, acquiring an HPC system, before performing the AOA process. Credible Minimally met The selection criteria appear to have been written for the preferred alternative. Source: GAO analysis of NNSA information. | GAO-21-194 GAO found that, in the second year of the El Capitan acquisition program's 5-year acquisition life cycle, NNSA has fully implemented selected key practices related to program monitoring and control. However, NNSA has only partially implemented key practices related to requirements management. Specifically, El Capitan program officials did not update and maintain acquisition program documents to include current requirements. NNSA officials stated that once the program developed its program plan early in the program's life cycle, they did not require the program to update and maintain that program plan. However, NNSA's own program management policy requires programs to update program documents throughout the duration of the program. Without updating and maintaining El Capitan program documents to include current requirements, NNSA officials may be limited in their ability to ensure that all mission requirements are met. Why GAO Did This Study NNSA is responsible for maintaining the nation's nuclear stockpile. To analyze the performance, safety, and reliability of nuclear weapons, it acquires high-performance computing (HPC) systems to conduct simulations. The latest system, El Capitan, is expected to be fully deployed by March 2024. The committee report accompanying the Energy and Water Development and Related Agencies Appropriations Act, 2019, includes a provision for GAO to review NNSA's management of its Advanced Simulation and Computing program. This report examines, among other things, (1) the extent to which NNSA's AOA process for the El Capitan acquisition met best practices and followed agency policy and guidance and (2) the extent to which NNSA is implementing selected acquisition best practices in carrying out the El Capitan acquisition program. GAO reviewed documents and interviewed NNSA officials and laboratory representatives involved in carrying out the AOA and acquisition processes.
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  • COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal Response
    In U.S GAO News
    The COVID-19 pandemic has resulted in catastrophic loss of life and substantial damage to the global economy, stability, and security. According to federal data, the U.S. had an average of 116,000 new COVID-19 cases per day from November 1 through November 12, 2020. Between January 2020 and October 2020, at least 237,000 more deaths occurred from all causes, including COVID-19, than would normally be expected, according to data from the Centers for Disease Control and Prevention (CDC). Further, while the economy has improved since July 2020, many people remain unemployed, including both those temporarily laid off and those who have permanently lost their job (see figure). Also, more households have become seriously delinquent on mortgage payments during the pandemic. In addition, GAO’s review of academic studies suggests the pandemic will likely remain a significant obstacle to more robust economic activity. Number of Unemployed Workers Permanently Losing Jobs and on Temporary Layoff, January 2019 through October 2020 In response to the pandemic and its effects, Congress and the administration have taken a series of actions to protect the health and well-being of Americans. However, as the end of 2020 approaches, urgent actions are needed to help ensure an effective federal response on a range of public health and economic issues. Medical Supplies While the Department of Health and Human Services (HHS) and the Federal Emergency Management Agency (FEMA) have made numerous efforts to mitigate supply shortages and expand the medical supply chain, shortages of certain supplies persist. In September 2020, GAO reported that ongoing constraints with the availability of certain types of personal protective equipment (PPE) and testing supplies remain due to a supply chain with limited domestic production and high global demand. In October 2020, GAO surveyed public health and emergency management officials from all states, the District of Columbia, and U.S. territories (hereafter states) and found the following: Testing supplies. Most states reported no shortages of swabs or transport media, but about one-third to one-half reported shortages in other types of testing supplies (see figure). State-Reported Testing Supply Shortages, as of October 2020   GAO surveyed officials in the 50 states; Washington, D.C.; and the five U.S. territories and received responses from 47 of the 56 locations, representing 41 states; Washington, D.C.; and all five territories. Not all states responded to every question. PPE. The majority of states that responded were mainly able to fulfill requests for supplies from organizations and entities within their states. However, availability constraints continue with certain PPE, such as nitrile gloves. Supplies for future vaccine needs. About one-third of states that responded stated that they were “greatly” or “completely” concerned about having sufficient vaccine-related supplies to administer COVID-19 vaccines. An additional 21 states indicated that they were moderately concerned. In September 2020, GAO recommended that HHS, in coordination with FEMA, should further develop and communicate to stakeholders plans outlining specific actions the federal government will take to help mitigate supply chain shortages for the remainder of the pandemic; immediately document roles and responsibilities for supply chain management functions transitioning to HHS, including continued support from other federal partners, to ensure sufficient resources exist to sustain and make the necessary progress in stabilizing the supply chain; and devise interim solutions, such as systems and guidance and dissemination of best practices, to help states enhance their ability to track the status of supply requests and plan for supply needs for the remainder of the pandemic response. HHS and the Department of Homeland Security disagreed with these recommendations, noting, among other things, the work that they had done to manage the medical supply chain and increase supply availability. In November 2020, HHS repeated its disagreement with GAO’s recommendations and noted its efforts to meet the needs of states. In light of the surge in COVID-19 cases, along with reported shortages, including GAO’s nationwide survey findings, GAO underscores the critical imperative for HHS and FEMA to implement GAO’s September 2020 recommendations. Vaccines and Therapeutics In a recent GAO report (GAO-21-207), GAO found that there has been significant federal investment to accelerate vaccine and therapeutic development, such as through Operation Warp Speed, a partnership between the Department of Defense and HHS that aims to accelerate the development, manufacturing, and distribution of COVID-19 vaccines and therapeutics. Separately, Emergency Use Authorizations (EUA), which allow for the emergency use of medical products without Food and Drug Administration (FDA) approval or licensure provided certain statutory criteria are met, have also been used for therapeutics. As of November 9, 2020, FDA had made four therapeutics available to treat COVID-19 through EUAs. In that report, GAO recommended that FDA identify waysto uniformly discloseinformation from its scientific review of safety and effectiveness data when issuing EUAs for therapeutics and vaccines. By doing so, FDA could help improve the transparency of, and ensure public trust in, its EUA decisions. HHS neither agreed nor disagreed with the recommendation, but said it shared GAO’s goal of transparency. COVID-19 Testing Guidance HHS and its component agencies have taken several key actions to document a federal COVID-19 testing strategy and provide testing-related agency guidance. However, this guidance has not always been transparent, raising the risk of confusion and eroding trust in government. In particular, while it is expected that guidance will change as new information about the novel virus evolves, frequent changes to general CDC testing guidelines have not always been communicated with a scientific explanation. GAO recommends that HHS ensure that CDC clearly discloses the scientific rationale for any change to testing guidelines at the time the changeis made. HHS concurred with this recommendation. Types of COVID-19 Testing Approaches Nursing Home Care In September 2020, the Coronavirus Commission on Safety and Quality in Nursing Homes (established by the Centers for Medicare & Medicaid Services (CMS) in June 2020) made 27 recommendations to CMS on topics such as testing, PPE, and visitation. CMS released a response to the commission that broadly outlined the actions it has taken to date, but it has not fully addressed the commission’s recommendations or provided an implementation plan to track and report progress toward implementing them. While CMS is not obligated to implement all of the commission’s recommendations, the agency has not indicated any areas where it does not plan to take action. GAO recommends that CMS quickly develop a plan that further details how it intends to respond to and implement, as appropriate, the commission’s recommendations. HHS neither agreed nor disagreed with this recommendation and said it would refer to and act upon the commission’s recommendations, as appropriate. In addition, the Department of Veterans Affairs (VA) partners with state governments to provide nursing home care to more than 20,000 veterans in over 150 state veterans homes. In March 2020, VA instructed its contractor to stop in-person inspections due to concerns about COVID-19. As of September 2020, these inspections had not resumed, leaving veterans at risk of receiving poor quality care. Additionally, VA does not collect timely data on the number of COVID-19 cases and deaths occurring at each state veterans home, hindering its ability to monitor and take steps to mitigate the spread of COVID-19 in these homes. GAO recommends that VA (1) develop a plan to resume inspections of state veterans homes, which may include using in-person, a mix of virtual and in-person, or fully virtual inspections, and (2) collect timely data on COVID-19 cases and deaths in each state veterans home. VA concurred with both recommendations. Economic Impact Payments The CARES Act included economic impact payments (EIP) for eligible individuals to address financial stress due to the pandemic. As of September 30, 2020, the Department of the Treasury (Treasury) and the Internal Revenue Service (IRS) had disbursed over 165.8 million payments to individuals, totaling $274.7 billion. According to IRS data, more than 26 million non-filers—individuals who do not normally file a tax return and may be hard to reach—received a payment (see figure). However, everyone that was supposed to receive a payment was not reached. Starting in September 2020, IRS sent notices to nearly 9 million individuals who had not yet received an EIP. Number of Filers and Non-Filers Issued an Economic Impact Payment, as of September 30, 2020 Treasury and IRS officials did not plan to track and analyze the outcomes of their EIP notice mailing effort until 2021. The lack of timely analysis deprives Treasury and IRS of data they could use to assess the effectiveness of their notice strategy and redirect resources as needed to other outreach and communication efforts. GAO recommends that Treasury, in coordination with IRS, should begin tracking and publicly reporting the number of individuals who were mailed an EIP notification letter and filed for and received an EIP, and use that information to inform ongoing outreach and communications efforts. Treasury agreed with this recommendation. Unemployment Insurance The CARES Act created three federally funded temporary programs for unemployment insurance (UI) that expanded benefit eligibility and enhanced benefits. In its weekly news releases, the Department of Labor (DOL) publishes the number of weeks of unemployment benefits claimed by individuals in each state during the period and reports the total count as the number of people claiming benefits nationwide. DOL officials told GAO that they have traditionally used this number as a proxy for the number of individuals claiming benefits because they were closely related. However, the number of claims has not been an accurate estimate of the number of individuals claiming benefits during the pandemic because of backlogs in processing a historic volume of claims, among other data issues. Without an accurate accounting of the number of individuals who are relying on these benefits in as close to real time as possible, policymakers may be challenged to respond to the crisis at hand. GAO recommends that DOL (1) revise its weekly news releases to clarify that in the current unemployment environment, the numbers it reports for weeks of unemployment claimed do not accurately estimate the number of unique individuals claiming benefits, and (2) pursue options to report the actual number of distinct individuals claiming benefits, such as by collecting these already available data from states. DOL agreed with the recommendation to revise its weekly news releases, and partially agreed with the recommendation to pursue options to report the actual number of distinct individuals claiming benefits. Tax Relief for Businesses To provide liquidity to businesses during the pandemic, the CARES Act included tax measures to help businesses receive cash refunds or other reductions to tax obligations. Some taxpayers need to file an amended income tax return to take advantage of these provisions; at the same time, IRS faces an increase in mail and paper processing delays due to the pandemic, which may delay the timely processing of this paperwork and issuance of these refunds. GAO recommends that IRS update its form instructions to include information on its electronic filing capability for tax year 2019. IRS agreed with this recommendation. Program Integrity Although the extent and significance of improper payments associated with COVID-19 relief funds have not yet been determined, the impact of these improper payments, including those that are the result of fraud, could be substantial. For example, numerous individuals are facing federal charges related to attempting to defraud the Paycheck Protection Program (PPP), UI program, or other federal programs, and many more investigations are underway. To address the risk of improper payments due to fraud and other causes, GAO previously recommended the following: The Small Business Administration (SBA) should develop and implement plans to identify and respond to risks in the PPP to ensure program integrity, achieve program effectiveness, and address potential fraud. The Office of Management and Budget (OMB), in consultation with Treasury, should issue timely guidance for auditing new and existing COVID-19-related programs, including Coronavirus Relief Fund payments, as soon as possible. Audits of entities that receive federal funds are critical to the federal government’s ability to help safeguard those funds.Also, Congress should amend the Social Security Act to explicitly allow the Social Security Administration to share its full death data with Treasury for data matching to prevent payments to ineligible individuals. GAO maintains that implementing these recommendations fully is critically important in order to protect federal funds from improper payments resulting from fraud and other risks. In this report, GAO also identifies new concerns about the timely reporting of improper payments for COVID-19 programs. The COVID-19 relief laws appropriated over a trillion dollars that may be spent through newly established programs to fund response and recovery efforts, such as SBA’s PPP. However, unlike the supplemental appropriations acts that provided for disaster relief related to the 2017 hurricanes and California wildfires, the COVID-19 relief laws did not require agencies to deem programs receiving these relief funds that expend more than a threshold amount as "susceptible to significant improper payments." In addition, based on OMB guidance, improper payment estimates associated with new COVID-19 programs established in March 2020 may not be reported until November 2022, in some instances. GAO is making two recommendations: OMB should develop and issueguidance directingagencies to include COVID-19 relief funding with associated key risks, such as changes to existing program eligibility rules, as part of their improper payment estimation methodologies, especially for existing programs that received COVID-19 relief funding. SBA should expeditiously estimate improper payments and report estimates and error rates for PPP due to concerns about the possibility that improper payments, including those resulting from fraudulent activity, could be widespread. GAO is also suggesting that Congress consider, in any future legislation appropriating COVID-19 relief funds, designating all executive agency programs and activities making more than $100 million in payments from COVID-19 relief funds as “susceptible to significant improper payments.” Aviation Assistance and Preparedness GAO identified concerns about efforts to monitor CARES Act financial assistance to the aviation sector. Treasury’s Payroll Support Program (PSP) provides $32 billion in payroll support payments and loans to help the aviation industry retain its employees. While recipients have begun submitting required compliance reports, Treasury has not yet finalized a monitoring system to identify and respond to the risk of noncompliance with PSP agreement terms, potentially hindering its ability to detect program misuse in a timely manner. GAO is recommending that Treasury finish developing and implement acompliance monitoringplan that identifies and responds to risks in the PSP. Treasury neither agreed nor disagreed with this recommendation, but committed to reviewing additional measures that may further enhance its compliance monitoring and ensure that PSP funds are used as intended. In June 2020, GAO suggested that Congress take legislative action to require the Secretary of Transportation to work with relevant agencies, such as HHS, the Department of Homeland Security, and other stakeholders, to develop a national aviation-preparedness plan to limit the spread of communicable diseasethreats and minimize traveland trade impacts. GAO originally made this recommendation to the Department of Transportation in December 2015. GAO urges Congress to take swift action to require such a plan, without which the U.S. will not be as prepared to minimize and quickly respond to ongoing and future communicable disease events. As of November 12, 2020, the U.S. had over 10.3 million cumulative reported cases of COVID-19 and about 224,000 reported deaths, according to federal agencies. The country also continues to experience serious economic repercussions. Four relief laws, including the CARES Act, were enacted as of November 2020 to provide appropriations to address the public health and economic threats posed by COVID-19. As of September 30, 2020, of the $2.6 trillion appropriated by these acts, the federal government had obligated a total of $1.8 trillion and expended $1.6 trillion of the COVID-19 relief funds, as reported by federal agencies. The CARES Act included a provision for GAO to report on its ongoing monitoring and oversight efforts related to the COVID-19 pandemic. This report examines the federal government’s continued efforts to respond to and recover from the COVID-19 pandemic. GAO reviewed data, documents, and guidance from federal agencies about their activities and interviewed federal and state officials. GAO also sent a survey to public health and emergency management officials in the 50 states, Washington, D.C., and the five U.S. territories regarding medical supplies. GAO is making 11 new recommendations for agencies that are detailed in this Highlights and in the report. GAO is also raising one matter for congressional consideration. For more information, contact A. Nicole Clowers at (202)512-7114 or clowersa@gao.gov.
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    The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) provides training to more than 45,000 medical and dental residents annually through its Graduate Medical Education (GME) program. VHA has established policy for its GME program that details many roles and responsibilities for overseeing VA medical facilities' reimbursements to affiliated academic institutions for residents' salaries and benefits. However, this policy does not define key roles and responsibilities for VHA's central office components, its regional networks, or its medical facilities. For example, VHA's regional networks do not have defined roles and responsibilities for overseeing GME disbursements—contributing to noninvolvement or inconsistent involvement in disbursement agreement oversight. VHA officials reported that they are in the process of updating disbursement agreement policy, but did not indicate if the updates would address all identified concerns. While VHA officials said that VHA's two disbursement agreement oversight mechanisms—facility periodic audits and the Resident Disbursement Audit Process (ReDPro) checklist—are meant to have distinct but complementary purposes, GAO found that VHA policy, guidance, and the tools distributed for these oversight mechanisms did not reflect the distinct purposes officials described. VHA officials said that periodic audits are intended to be a first level of defense and to review actual payments to affiliates, whereas the ReDPro checklist is intended to be a second level of defense, aimed at reviewing the process to see if the rules related to disbursement agreements are being followed by VA medical facilities. However, the ReDPro checklist tool and VHA's recommended periodic audit tool have numerous areas of overlap, including duplicative questions. This overlap causes inefficiencies and unnecessary burden on VA medical facility staff. GAO also found additional weaknesses in the tools, guidance, and training for the two oversight mechanisms. For example, GAO found an unclear ReDPro checklist tool, along with insufficient guidance and training related to conducting the ReDPro reviews. Officials from eight of 13 facilities in GAO's review indicated that the ReDPro checklist instructions were unclear regarding appropriate supporting documents for checklist responses. These weaknesses contributed to errors and inconsistencies in ReDPro responses. the lack of a standard audit tool, and inadequate guidance and training for periodic audit teams that contributed to problematic inconsistencies in the methodologies used by the audit teams and deficiencies in some of the audits conducted. Officials from 10 of 13 facilities in GAO's review indicated that they would benefit from more tools, guidance, or training related to conducting periodic audits. These weaknesses limit the effectiveness of VHA's oversight mechanisms, and put VHA at increased risk of both not being able to identify and correct facilities' lack of adherence to disbursement agreement policy and of possible improper payments to GME affiliates. Under VHA's GME program, VA medical facilities use disbursement agreements to reimburse affiliated academic institutions for residents' salaries and benefits. VHA developed policy related to establishing and administering disbursement agreements, but audits have found that facilities have not always adhered to VHA policy—resulting in improper payments to affiliates. GAO was asked to review VHA policies and procedures related to reimbursements to affiliates for GME. This report examines (1) oversight roles and responsibilities for GME disbursement agreements and (2) VHA's mechanisms for ensuring VA medical facilities adhere to policy. GAO reviewed relevant VHA documents and federal internal control standards and interviewed VHA officials. GAO also reviewed ReDPro checklist responses and documentation from 13 VA medical facilities—selected based on factors including geographic variation, GME program size, and number of affiliates. GAO also visited four of the 13 facilities and interviewed officials at the other nine facilities. GAO is making seven recommendations to VA to define key roles in policy, reduce overlap between the ReDPro checklist and facility periodic audits, and improve the oversight mechanisms' tools, guidance, and training. VA concurred with GAO's recommendations. For more information, contact Sharon M. Silas at (202) 512-7114 or silass@gao.gov.
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    The roles and responsibilities of the Centers for Disease Control and Prevention (CDC) during a multistate foodborne illness outbreak include analyzing federal foodborne illness surveillance networks to identify outbreaks, leading investigations to determine the food causing the outbreak, and communicating with the public. CDC also works to build and maintain federal, state, territorial, and local capacity to respond to foodborne illness outbreaks by awarding funds to state and local public health agencies and through other initiatives. In identifying and responding to multistate foodborne illness outbreaks, CDC faces challenges related to clinical methods and communication, and it has taken some steps to respond to these challenges. One challenge stems from the increasing clinical use of culture-independent diagnostic tests (CIDTs). CIDTs diagnose foodborne illnesses faster and cheaper than traditional methods, but because they do not create DNA fingerprints that can specify a pathogen, they may reduce CDC's ability to identify an outbreak. A CDC working group recommended in May 2018 that CDC develop a plan to respond to the increasing use of CIDTs. By developing a plan, CDC will have greater assurance of continued access to necessary information. CDC also faces a challenge in balancing the competing needs for timeliness and accuracy in its outbreak communications while maintaining public trust. CDC has an internal framework to guide its communications decisions during outbreaks, and it recognizes that stakeholders would like more transparency about these decisions. By making its framework publicly available, CDC could better foster public trust in its information and guidance during outbreaks. CDC has taken steps to evaluate its performance in identifying and responding to multistate outbreaks. Specifically, CDC has developed general strategic goals (see fig.) and taken initial steps to develop performance measures. However, CDC has not yet established other elements of a performance assessment system—an important component of effective program management. CDC's Use of Elements of Program Performance Assessment Systems In particular, CDC has not set specific performance goals, used performance measures to track progress, or conducted a program evaluation of its multistate foodborne illness outbreak investigation efforts. By implementing all elements of a performance assessment system, CDC could better assess its progress toward meeting its goals, identify potentially underperforming areas, and use that information to improve its performance. CDC has estimated that each year, one in six people in the United States gets a foodborne illness, 128,000 are hospitalized, and 3,000 die. CDC data show increases in the number of reported multistate foodborne illness outbreaks—groups of two or more linked cases in multiple states—in recent years. Such outbreaks are responsible for a disproportionate number of hospitalizations and deaths, compared with single-state outbreaks. GAO was asked to review CDC's response to multistate foodborne illness outbreaks. This report examines (1) CDC's roles and responsibilities, (2) challenges that CDC faces and the extent to which it has addressed these challenges, and (3) the extent to which CDC evaluates its performance. GAO reviewed agency documents and data; conducted site visits and case studies; and interviewed federal, state, and local public health officials, as well as representatives of stakeholder groups. GAO is recommending that CDC (1) develop a plan to respond to the increasing use of CIDTs, (2) make publicly available its decision-making framework for communicating about multistate foodborne illness outbreaks, and (3) implement all the elements of a performance assessment system. CDC concurred with all three recommendations. For more information, contact Steve D. Morris at (202) 512-3841 or morriss@gao.gov.
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    The Indian Health Service's (IHS) oversight of federally operated health care facilities' decision-making process about the use of funds has been limited and inconsistent. Funds include those from appropriations, as well as payments from federal programs, such as Medicaid and from private insurance, for care provided by IHS to American Indians and Alaska Natives (AI/AN). While some oversight functions are performed at IHS headquarters, the agency has delegated primary responsibility for the oversight of health care facilities' decision-making about the use of funds to its area offices. Area office officials said the oversight they provide has generally included (1) reviewing facilities' scope of services, and (2) reviewing facilities' proposed expenditures. However, GAO's review found that this oversight was limited and inconsistent across IHS area offices, in part, due to a lack of consistent agency-wide processes. While IHS officials from all nine area offices GAO interviewed said they reviewed facilities' scope of services and coordinated with tribes when doing so, none reported systematically reviewing the extent to which their facilities' services were meeting local health needs, such as by incorporating the results of community health assessments. Such assessments can involve the collection and assessment of data, as well as the input of local community members and leaders to identify and prioritize community needs. These assessments can be used by facilities to assess their resources and identify priorities for facility investment. While IHS has identified such assessments as a priority, the agency does not require federally operated facilities to conduct such assessments or require the area offices to use them as they review facilities' scope of services. To ensure that facilities are effectively managing their resources, IHS has a process to guide its review of facilities' proposed construction projects that cost at least $25,000. However, IHS does not have a similar process to guide its oversight of other key proposed expenditures, such as those involving the purchase of major medical equipment, the hiring of providers, or the expansion of services. Specifically, GAO found limitations and inconsistencies with respect to requiring a documented justification for proposed expenditures; documenting the review and approval of decisions; and conducting an impact assessment on patient access, cost, and quality of care. The limitations and inconsistencies that GAO found in IHS's oversight are driven by the lack of consistent oversight processes across the area offices. Without establishing a systematic oversight process to compare federally operated facilities' current services to population needs, and to guide the review of facilities' proposed expenditures, IHS cannot ensure that its facilities are identifying and investing in projects to meet the greatest community needs, and therefore that federal resources are being maximized to best serve the AI/AN population. IHS, an agency of the Department of Health and Human Services, provides care to AI/AN populations through a system of federally operated and tribally operated health care facilities. AI/AN have experienced long standing problems accessing needed health care services. GAO has previously reported that IHS has not been able to pay for all eligible health care services; however, the resources available to federally operated facilities have recently grown. This report assesses IHS oversight of federal health care facilities' decision-making about the use of funds. GAO reviewed IHS policies and documents; and interviewed IHS officials from headquarters, nine area offices, and three federally operated facilities (two hospitals and one health clinic). GAO recommends that IHS develop processes to guide area offices in (1) systematically assessing how federally operated facilities will effectively meet the needs of their patient populations, and (2) reviewing federal facilities' spending proposals. HHS concurred with these recommendations. For more information, contact Jessica Farb at (202) 512-7114 or farbj@gao.gov.
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    On this day 32 years ago, December 21, 1988, at 7:03 p.m. local time, a bomb destroyed Pan Am Flight 103 as it flew 31,000 feet above Lockerbie, Scotland. The massive Boeing 747 plane, known as the “Clipper Maid of the Seas,” exploded and fell to the ground in countless pieces scattered across 840 square miles, nearly the entire width of Scotland. The explosion killed all 259 people on board—243 passengers and 16 crew members, including 190 Americans. Falling debris claimed the lives of 11 Lockerbie residents on the ground, many of whom were in their homes and had just sat down for dinner.
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  • Global Health Security: USAID and CDC Funding, Activities, and Assessments of Countries’ Capacities to Address Infectious Disease Threats before COVID-19 Onset
    In U.S GAO News
    Pour la version française de cette page, voir GAO-21-484. What GAO Found As of March 31, 2020, the U.S. Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC) had obligated a combined total of more than $1.2 billion and disbursed about $1 billion for global health security (GHS) activities, using funds appropriated in fiscal years 2015 through 2019. USAID and CDC supported activities to help build countries' capacities in 11 technical areas related to addressing infectious disease threats. The obligated funding supported GHS activities in at least 34 countries, including 25 identified as Global Health Security Agenda (GHSA) partner countries. U.S.-Supported Activities in Ethiopia to Strengthen Global Health Security U.S. officials' assessments of 17 GHSA partner countries' capacities to address infectious disease threats showed that at the end of fiscal year 2019, most countries had some capacity in each of the 11 technical areas but faced various challenges. U.S. interagency country teams produce biannual capacity assessments that USAID and CDC headquarters officials use to track the countries' progress. According to fiscal year 2019 assessment reports, 14 countries had developed or demonstrated capacity in most technical areas. In addition, the reports showed the majority of capacities in each country had remained stable or increased since 2016 and 2017. The technical area antimicrobial resistance showed the largest numbers of capacity increases—for example, in the development of surveillance systems. GAO's analysis of the progress reports found the most common challenges to developing GHS capacity were weaknesses in government institutions, constrained resources, and insufficient human capital. According to agency officials, some challenges can be overcome with additional U.S. government funding, technical support, or diplomatic efforts, but many other challenges remain outside the U.S. government's control. This is a public version of a sensitive report that GAO issued in February 2021. Information that USAID and CDC deemed sensitive has been omitted. Why GAO Did This Study The outbreak of Coronavirus Disease 2019 (COVID-19) in December 2019 demonstrated that infectious diseases can lead to catastrophic loss of life and sustained damage to the global economy. USAID and CDC have led U.S. efforts to strengthen GHS—that is, global capacity to prepare for, detect, and respond to infectious disease threats and to reduce or prevent their spread across borders. These efforts include work related to the multilateral GHSA initiative, which aims to accelerate progress toward compliance with international health regulations and other agreements. House Report 114-693 contained a provision for GAO to review the use of GHS funds. In this report, GAO examines, for the 5 fiscal years before the onset of the COVID-19 pandemic, (1) the status of USAID's and CDC's GHS funding and activities and (2) U.S. agencies' assessments, at the end of fiscal year 2019, of GHSA partner countries' capacities to address infectious disease threats and of challenges these countries faced in building capacity. GAO analyzed agency, interagency, and international organization documents. GAO also interviewed agency officials in Washington, D.C., and Atlanta, Georgia, and in Ethiopia, Indonesia, Senegal, and Vietnam. GAO selected these four countries on the basis of factors such as the presence of staff from multiple U.S. agencies. In addition, GAO analyzed interagency assessments of countries' capacities to address infectious disease threats in fiscal year 2019 and compared them with baseline assessments from 2016 and 2017. For more information, contact David Gootnick at (202) 512-3149 or gootnickd@gao.gov.
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  • Government Auditing Standards: 2018 Revision Technical Update April 2021 (Supersedes GAO-18-568G)
    In U.S GAO News
    The Yellow Book provides standards and guidance for auditors and audit organizations, outlining the requirements for audit reports, professional qualifications for auditors, and audit organization quality control. Auditors of federal, state, and local government programs use these standards to perform their audits and produce their reports. Effective Date The 2018 revision of the Yellow Book is effective for financial audits, attestation engagements, and reviews of financial statements for periods ending on or after June 30, 2020, and for performance audits beginning on or after July 1, 2019. Early implementation is not permitted. The technical updates to the 2018 revision of the Yellow Book are effective upon issuance. Revision Process Yellow Book revisions undergo an extensive, deliberative process, including public comments and input from the Comptroller General's Advisory Council on Government Auditing Standards. GAO considered all comments and input in finalizing revisions to the standards. For more information, contact James R. Dalkin at (202) 512-9535 or yellowbook@gao.gov. Visit our Yellow Book website for more information on applicable updates and alerts.
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  • Decennial Census: Bureau Should Assess Significant Data Collection Challenges as It Undertakes Planning for 2030
    In U.S GAO News
    What GAO Found In March 2020, the Census Bureau (Bureau) delayed the start of field data collection because of COVID-19 safety, and then revised several operational timelines in response to the pandemic and Department of Commerce (Commerce) decisions. Nationally the Bureau reported completing more than 99 percent of nonresponse follow-up cases (households that have not responded to the census) by October 15, 2020. The Bureau attributes the use of technology as among the reasons it completed the work by this date. The Bureau, however, had lower completion percentages ranging between 94 and 99 for 10 local geographic areas, in part because of natural disasters and COVID-19. For example, according to the Bureau, in Shreveport, Louisiana, short-term closures stemming from the hurricane impacted data collection for 82,863 housing units. As a mitigation strategy, the Bureau shifted the Shreveport operation to telephone enumeration and brought in more than 1,200 enumerators from travel teams. Despite these efforts, the Bureau was unable to complete 22,588 cases in Shreveport before data collection ended. For these cases the Bureau will need to rely on alternate methods including imputation, which draws data from similar nearby households to determine whether a housing unit exists, whether it is occupied, and, if so, by how many people. In addition to the challenges brought on by natural disasters, the Bureau encountered other difficulties during nonresponse follow-up, such as, the inability of supervisors to reassign open cases in a timely fashion. GAO found that census field supervisors did not have the authority to reassign cases and had to wait for the field manager to make those reassignments. Bureau officials told GAO it would consider the reassignment of cases as it moves towards planning for the 2030 Census. To monitor nonresponse follow-up, the Bureau used quality control procedures, such as real-time monitoring of enumerator activities by supervisors and training assessments. However, GAO found the Bureau did not have proper controls in place, allowing some enumerators to work without having passed the required training assessment. The Bureau agreed that additional controls were necessary. The Bureau planned to count individuals living in group quarters, such as skilled-nursing and correctional facilities, between April 2, 2020, and June 5, 2020, but revised those dates to July 1, 2020, through September 3, 2020. The pandemic made it difficult to count group quarters. For example, Bureau staff found it challenging to locate a point of contact at some group quarters because facilities were closed due to the pandemic. Bureau officials told us that in December 2020 they decided to re-contact more than 24,000 out of approximately 272,000 group quarter facilities to collect data, and that imputation would be used to count individuals at the remaining facilities still reporting a zero population count. The Bureau is updating plans to assess operations and identify resulting lessons learned from the 2020 Census. As part of its planning for 2030, it will be important for the Bureau to assess the impact of the 2020 late design changes and the operations' challenges that arose. Why GAO Did This Study The 2020 Census was conducted under extraordinary circumstances. In response to the COVID-19 pandemic and related Commerce decisions, the Bureau made a series of late changes to the design of the census. As GAO previously reported, these changes introduced risks to the quality of data that the Bureau provides for congressional apportionment and redistricting purposes. GAO was asked to review the Bureau's implementation of the 2020 Census. This report assesses the Bureau's implementation of the: (1) nonresponse follow-up operation, (2) group quarters enumeration, and (3) plans to assess those operations. To address these objectives, GAO conducted a series of surveys of all 248 census offices during the collection of data for those operations. GAO also monitored the cost and progress of operations and interviewed census field supervisors for each operation.
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