Priority Open Recommendations: Nuclear Regulatory Commission

What GAO Found

In April 2020, GAO identified seven priority recommendations for the Nuclear Regulatory Commission (NRC). Since then, NRC implemented one of these recommendations by issuing a risk management strategy that addresses key elements foundational to effectively managing cybersecurity risks. The remaining six priority recommendations involve the following areas:

  • addressing the security of radiological sources.
  • improving the reliability of cost estimates.
  • improving strategic human capital management.

NRC’s continued attention to these issues could lead to significant improvements in government operations.

Why GAO Did This Study

Priority open recommendations are the GAO recommendations that warrant priority attention from heads of key departments or agencies because their implementation could save large amounts of money; improve congressional and/or executive branch decision-making on major issues; eliminate mismanagement, fraud, and abuse; or ensure that programs comply with laws and funds are legally spent, among other benefits. Since 2015, GAO has sent letters to selected agencies to highlight the importance of implementing such recommendations.

For more information, contact Mark Gaffigan at (202) 512-3841 or gaffiganm@gao.gov.

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    The Department of Veterans Affairs' (VA) process for identifying on-campus suicides does not include a step for ensuring the accuracy of the number of suicides identified. As a result, its numbers are inaccurate. VA's Veterans Health Administration (VHA) first started tracking on-campus veteran suicides in October 2017, and uses the results to inform VA leadership and Congress. GAO reviewed the data and found errors in the 55 on-campus veteran suicides VHA identified for fiscal years 2018 and 2019, including 10 overcounts (deaths that should not have been reported but were) and four undercounts (deaths that should have been reported but were not).   Examples of Errors on the Department of Veterans Affairs' (VA) List of 55 On-Campus Veteran Suicides for Fiscal Years 2018 and 2019 (as of September 2019) VA has taken some steps to address on-campus veteran suicides, such as issuing guidance and staff training. However, GAO found that the analyses informing these efforts are limited. Specifically, VHA requires root cause analyses—processes to determine what can be done to prevent recurrences of incidents—for some but not all on-campus veteran suicides. According to VHA officials, only 25 percent of on-campus suicides from October 2017 to April 2019 met the criteria for a root cause analysis. does not make use of all relevant information VA collects about these deaths, such as clinical and demographic data collected through other VA suicide prevention efforts. VHA officials said they could not link the different sources of information, but GAO found that selected medical facilities could do so. Without accurate information on the number of suicides and comprehensive analyses of the underlying causes, VA does not have a full understanding of the prevalence and nature of on-campus suicides, hindering its ability to address them. VA established suicide prevention as its highest clinical priority. In recent years, there have been reports of veterans dying by suicide on VA campuses—in locations such as inpatient settings, parking lots, and on the grounds of cemeteries. GAO was asked to review veteran deaths by suicide on VA campuses. This report examines (1) VA's process to track the number of veterans that died by suicide on VA campuses, and (2) steps VA has taken to address these types of suicides. GAO reviewed the sources of information VHA uses to identify and analyze on-campus veteran suicides, VA and VHA strategic plans and policies related to suicide prevention and reporting, and federal internal control standards. GAO also interviewed VA and VHA central office officials, and officials from three medical facilities that GAO selected because they reportedly had on-campus veteran suicides between fiscal years 2018 and 2019. GAO is making three recommendations, including that VA improve its process to accurately identify all on-campus veteran suicides and conduct more comprehensive analyses of these occurrences. VA did not concur with one of GAO's recommendations related to conducting root cause analyses. GAO continues to believe that this recommendation is valid, as discussed in the report. For more information, contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov.
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  • VA Health Care: VA Needs to Continue to Strengthen Its Oversight of Quality of State Veterans Homes
    In U.S GAO News
    The Department of Veterans Affairs (VA) pays over $1 billion a year to state veterans homes (SVH)—homes owned and operated by the states—to provide nursing home care to approximately 20,000 veterans. In fiscal year 2019, VA paid SVHs $1.17 billion for an average daily census of 20,072 veterans (51 percent of the total veterans receiving nursing home care through VA). Further, VA projects its payments to SVHs will continue to increase; VA projects it will pay $1.7 billion to SVHs to provide care to veterans in fiscal year 2022. VA oversees the quality of care veterans receive at SVHs mainly through annual inspections that VA hires a contractor to perform. In its July 2019 report, GAO found that VA's SVH contractor performed the required annual inspections for all SVHs in 2018, but VA needed to take action to enhance its oversight of SVHs and to ensure that information on quality of care provided in this setting is publicly available to veterans. Specifically, GAO found the following: VA does not require its SVH contractor to identify all failures to meet quality standards during its inspections as deficiencies . For example, GAO found that VA allows its SVH contractor to cite some failures to meet quality standards as “recommendations,” rather than as deficiencies. VA officials said they do not track or monitor the nature of the recommendations or whether they have been addressed. As a result, VA does not have complete information on all failures to meet quality standards at SVHs and cannot track this information to identify trends in quality across these homes. VA is not conducting all monitoring of its SVH contractor. GAO found that, at the time of its review, VA had not monitored the SVH contractor's performance of inspections through regular observational assessments to ensure that contractor staff effectively determine whether SVHs are meeting required standards. Specifically, VA officials said they intended to observe the SVH contractor's inspections on a quarterly basis; however, at the time of GAO's review, VA officials could not recall when VA last observed the SVH contractor's inspections. In July 2020, VA provided information indicating that they will regularly monitor the SVH contractor's performance in conducting inspections through observational assessments. VA does not share information on the quality of SVHs on its website. GAO found that, while VA provides information on the quality of other nursing home care settings on its website, it does not do so for SVHs. According to VA officials, there is no requirement to provide information on SVH quality on its website, as SVHs are owned and operated by the states. VA is the only federal agency that conducts regular oversight inspection on the quality of care of all SVHs and, as a result, is the only agency that could share such quality information on its website. Veterans—like over a million other Americans—rely on nursing home care to help meet their health needs. For eligible veterans whose health needs require skilled nursing and personal care, VA provides or pays for nursing home care in three nursing home settings: the VA-owned and -operated community living centers, public- or privately owned community nursing homes, and state-owned and -operated SVHs. In fiscal year 2019, VA provided or paid for nursing home care for over 39,000 veterans. The majority of these veterans received care at SVHs. This statement summarizes the GAO's July 2019 report, GAO-19-428 , with a focus on issues related to SVHs. Specifically, it describes the: (1) use of and expenditures for SVHs, (2) inspections used by VA to assess the quality of SVH care and VA's oversight of the inspection process, and (3) information VA provides publicly on the quality of SVH care. As part of that work GAO analyzed VA data on expenditures for SVHs and interviewed VA officials. For this statement GAO reviewed expenditure and utilization data for fiscal year 2019. In its July 2019 report, GAO made three recommendations related to SVHs, including that VA require that all failures to meet quality standards are cited as deficiencies on SVH inspections. VA concurred with two recommendations and concurred in principle with the third. VA has addressed one recommendation and continued attention is needed to address the two remaining recommendations. For more information, contact Sharon M. Silas at (202) 512-7114 or silass@gao.gov.
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  • Newport News Tax Preparer Pleads Guilty to Preparing False Return
    In Crime News
    A Newport News, Virginia, tax preparer pleaded guilty today to aiding and assisting the preparation of a false tax return, announced Principal Deputy Assistant Attorney General Richard E. Zuckerman of the Justice Department’s Tax Division and U.S. Attorney G. Zachary Terwilliger for the Eastern District of Virginia.
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  • Man Sentenced to Prison for Sextorting Numerous Children Around the Country
    In Crime News
    A Virginia man was sentenced today to 31 years in prison for a years-long sextortion scheme in which he coerced numerous preteen and teenage victims to create and send him images of themselves engaged in sexually explicit conduct. The defendant was further sentenced to a lifetime of supervised release and ordered to pay restitution to the victims.
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  • Mississippi Tax Preparer Sentenced to Prison for False IRS Returns
    In Crime News
    A Moss Point, Mississippi, resident was sentenced to 22 months in prison for preparing false tax returns, announced Principal Deputy Assistant Attorney General Richard Zuckerman of the Justice Department’s Tax Division and U.S. Attorney Mike Hurst for the Southern District of Mississippi.
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  • Iranian Nationals Charged with Conspiring to Evade U.S. Sanctions on Iran by Disguising $300 Million in Transactions Over Two Decades
    In Crime News
    A federal criminal complaint unsealed today charges 10 Iranian nationals with running a nearly 20-year-long scheme to evade U.S. sanctions on the Government of Iran by disguising more than $300 million worth of transactions – including the purchase of two $25 million oil tankers – on Iran’s behalf through front companies in the San Fernando Valley, Canada, Hong Kong and the United Arab Emirates.
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  • Space Acquisitions: DOD Faces Challenges and Opportunities with Acquiring Space Systems in a Changing Environment
    In U.S GAO News
    What GAO Found The Department of Defense (DOD) is making changes to its space-related processes and organization that will present both opportunities and challenges to the way it acquires its space systems. GAO has reported over the past decades on challenges DOD faces in its space acquisitions—including schedule delays, multibillion-dollar cost increases, significant reductions in capabilities, and in some cases cancelation—and made recommendations that have improved program outcomes. For example, DOD took actions to implement a GAO recommendation to use an incremental approach to acquiring space launch services. DOD's modified approach reduced risk by allowing it to incorporate knowledge gained from early launch competitions to inform subsequent competitions. Many of the most troubled programs are nearing completion, and DOD is starting new programs to develop the next generation of capabilities, some of which are being acquired under a streamlined acquisition process known as the middle-tier of acquisition pathway (see table below). Starting new programs is an opportunity to learn from past mistakes and take measures to put programs on successful paths. GAO's work has shown that in many cases, DOD is attempting to do so. Selected New DOD Space Programs and Near-Term Estimated Costs Dollars in billions New program Current estimated costs for 5-year middle-tier effort Evolved Strategic SATCOM (ESS) Protected satellite communications $1.4 Future Operationally Resilient Ground Evolution (FORGE) Ground control for Next Generation Overhead Persistent Infrared satellites $3.0 Next Generation Overhead Persistent Infrared (OPIR) Block 0 Missile warning, infrared intelligence, surveillance, and reconnaissance $8.4 Protected Tactical SATCOM (PTS) Protected satellite communications $1.0 Source: Department of Defense (DOD) data. | GAO-21-520T However, DOD faces challenges because it will be starting these new programs amid significant changes to the acquisition environment. Some of these changes are external to DOD, such as increased threats to on-orbit space systems. But over the past several years, DOD also initiated substantial organizational and acquisition process changes. While the Space Force offers an important opportunity to streamline lines of authority, accountability, and decision-making and avoid duplication of effort, many details will require careful consideration. In addition, adopting leading practices for acquisition, as previously recommended, could help DOD achieve faster delivery of new capabilities, especially if DOD balances new, streamlined acquisition processes with sufficient oversight to help ensure program success. Why GAO Did This Study DOD space systems provide critical capabilities that support military and other government operations. Space systems can be expensive to acquire and field, costing billions of dollars each year. The U.S. Space Force was recently established as the sixth branch of the U.S. military. As planned, the Space Force will consolidate leadership, planning, and management for some DOD space programs, as appropriate and authorized. This statement discusses the challenges and opportunities DOD faces as it acquires space systems amid changes to the acquisition environment. This statement is based on GAO reports issued over the past 10 years on DOD space programs. It also draws on recent work supporting GAO's 2021 annual report on the progress of major defense acquisition programs.
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  • Manufacturers of “Spice” Sentenced for Operating a Continuing Criminal Enterprise and Other Crimes
    In Crime News
    Two defendants were sentenced Wednesday to 20 years each in federal prison for crimes committed in connection with the manufacture of synthetic cannabinoid products (commonly referred to as “spice”), operating a continuing criminal enterprise, manufacturing and distributing controlled substance analogues, wire fraud, mail fraud, money laundering, maintaining a drug premises, and possession of a listed chemical with the intent to manufacture a controlled substance.
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