prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 1.

Report 1: VA comprises a Veterans Affairs Central Office (VACO) and over 1,000 facilities and offices throughout the nation, as well as the U S  territories and the Philippines  As shown in figure 1, VA’s three major administrations are the Veterans Health Administration (VHA), Veterans Benefits Administration (VBA), and National Cemetery Administration (NCA)  The largest of the administrations, in terms of workforce, is VHA and its associated Veterans Integrated Service Networks (VISN)  VHA is estimated to employ about 316,800 employees in 2017, followed by the VBA and NCA with about 22,700 and 1,850 employees, respectively  The remaining 15,000 employees are in various staff offices  VA’s budget request for fiscal year 2018 of $186 4 billion includes $82 1 billion in discretionary resources and $104 3 billion in mandatory funding  The following offices are involved in addressing misconduct at VA  Office of Human Resource Management (OHRM): OHRM develops policies with regard to performance management and assesses the effectiveness of department-wide human-resource programs and policies  Office of Accountability Review (OAR): OAR was established in 2014 within VA’s Office of General Counsel and was intended to ensure leadership accountability for improprieties related to patient scheduling and access to care, whistle-blower retaliation, and related disciplinary matters that affect public trust in VA  Office of Inspector General (OIG): The VA OIG provides oversight through independent audits, inspections, and investigations to prevent and detect criminal activity, waste, abuse, and mismanagement in VA programs and operations  Office of Accountability and Whistleblower Protection (OAWP): As required by the Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017, OAWP will take on the responsibility of, among other things, receiving whistle-blower complaints  Corporate Senior Executive Management Office (CSEMO): CSEMO supports the entire life-cycle management of VA’s senior executives by developing policy and providing corporate-level personnel services, such as training and coaching to VA’s senior executive workforce  Client Services Response Team (CSRT): CSRT serves to centralize and streamline internal processes to improve VHA’s overall responsiveness to concerns of veterans, employees, and other internal and external stakeholders  This office works closely with VA and VHA program offices and facilities to review, research, and respond to inquiries sent to the Office of the Under Secretary for Health, Office of the Secretary, and other concerns received via program offices within VACO, which lack a formalized response process  National Cemetery Administration (NCA): NCA honors veterans and their families with final resting places in national shrines that commemorate their service  NCA’s Office of Management oversees and administers all human-resource management, including activities associated with labor and employee relations  Office of the Medical Inspector (OMI): OMI is responsible for assessing the quality of VA health care through investigations of VA facilities nationwide, which include employee whistle-blower allegations referred to VA by the OSC; veteran complaints referred by the OIG, Congress, or other stakeholders; and site-specific internal reviews directed by the Office of the Under Secretary for Health  Office of Research Oversight (ORO): ORO promotes the responsible conduct of research, serves as the primary VHA office in advising the Office of the Under Secretary for Health on matters of research compliance, and is to provide oversight of compliance with VA and other federal requirements related to research misconduct  Office of Resolution Management (ORM): ORM provides Equal Employment Opportunity (EEO) discrimination complaint processing services to VA employees, applicants for employment, and former employees, which include counseling, investigation, and final agency procedural decisions  Office of Security and Law Enforcement (OS&LE): OS&LE develops policies, procedures, and standards that govern VA’s infrastructure law- enforcement program  The Law Enforcement Oversight and Criminal Investigations Division is responsible for conducting investigations of serious incidents of misconduct  Veterans Benefits Administration (VBA): VBA provides benefits and services to veterans, their families and survivors  VBA’s Office of Management directs and oversees nationwide human-resources activities and supports ORM in processing EEO complaints filed by employees and applicants who allege employment discrimination  The process for addressing employee misconduct involves various components within VA that are responsible for investigating and adjudicating allegations, as shown in figure 2  Receipt of Allegation: The OIG receives allegations of criminal activity and employee misconduct from VA employees, the OSC, members of Congress, the public, or other stakeholders  The allegations received by the OIG are initially routed to the OIG Hotline Division  The OIG also receives other types of allegations outside the scope of this review, such as issues pertaining to VA employee benefits and contracts  In addition to reporting allegations of employee misconduct to the OIG, VA employees may also report allegations of misconduct directly to their supervisors  Review and Referral of Allegation: Due to the substantial number of allegations received through the OIG Hotline Division, the OIG exercises a “right of first refusal” on misconduct cases, which allows it to take no further action, refer the case to program offices within VA for review and response, or open an investigation  For example, the OIG can either decide to (1) take no further action on matters not within the OIG’s jurisdiction or too vague to warrant further review; (2) refer allegations that warrant some action to the OMI, OAR, or VA facilities or program offices within each administration to conduct an independent review of the allegations; or (3) open cases for further review for serious allegations of criminal activity, fraud, waste, abuse, and mismanagement  Cases opened by the OIG typically involve misconduct by senior officials, or matters relating to the quality of care provided by licensed professionals  In contrast, the OIG typically refers allegations to VA facility or program offices for matters where the OIG does not have sufficient resources to open an internal case  The OIG generally does not review matters that are addressed in other legal or administrative forums, such as allegations of discrimination or whistle-blower retaliation  Notice to Employee Once Allegations Are Substantiated: The type of appointment an employee holds determines whether an employee is to be provided advance notice of planned disciplinary action once misconduct is substantiated at the conclusion of an investigation  Employees holding a permanent appointment are entitled to receive a notice of proposed action that states the specific charges for which the proposed disciplinary action is based and informs the employee of his or her right to review the material that is relied upon to support the reasons for the action  Employees in the competitive service serving in a permanent appointment (who have completed their probationary period) are treated differently than those who are still in their probationary period or serving under temporary appointments  An employee serving a probationary period or under a temporary appointment does not receive a notice of proposed action and may be immediately terminated because his or her work performance or conduct fails to demonstrate fitness or qualifications for continued employment  Temporary employees are terminated by notifying employees in writing as to why they are being separated and the effective date of the action  Disciplinary Action: VA Handbook 5021, Employee/Management Relations, governs policy for disciplinary and grievance procedures for all employees  Supervisory staff or appropriate higher-level officials use the results from investigations to help determine whether any disciplinary actions are warranted and, if so, the type and severity of each action  Other VA staff, such as human-resources and general-counsel staff may also provide guidance to management in determining appropriate disciplinary actions  After determining the facts in a case, VA may employ either disciplinary or adverse action  Adverse action involves a more- severe type of discipline (e g , removal, suspension more than 14 days, or reduction in grade) as described in table 1  As a federal agency, VA is required to report department-wide information on certain disciplinary personnel actions to the Office of Personnel Management (OPM)  OPM’s Enterprise Human Resources Integration (EHRI) system currently collects, integrates, and publishes data for executive-branch employees on a biweekly basis  This system provides federal workforce data to other government systems and the public  To adhere to this reporting requirement, VA provides information on certain disciplinary actions such as terminations and removals to OPM  The Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017 also requires the Secretary to provide a report on the disciplinary procedures and actions of the department to Congress  To understand the depth and breadth of misconduct and related issues in a large entity, such as VA, comprehensive and reliable information is needed  Standards for Internal Control in the Federal Government states that an information system represents the life cycle of information used for the entity’s operational processes that enables the entity to obtain, store, and process quality information  Therefore, management should design the entity’s information system to obtain and process information to meet each operational process’s information requirements and to respond to the entity’s objectives and risks, such as the ability to systematically analyze misconduct department-wide to identify trends and make management decisions regarding misconduct  A deficiency exists when (1) a control necessary to meet an objective is missing or (2) an existing control is not properly designed, so that even if the control operates as designed, the objective would not be met  We identified 12 fragmented information systems that VA has used, or continues to use, to collect employee misconduct and disciplinary actions  Although VA has made efforts to develop repositories to collect information pertaining to misconduct and disciplinary action, none of the 12 information systems contain complete information  Six of these systems collect partial misconduct and disciplinary action information and contain fields that could potentially be shared with other systems to obtain additional information, while the other six systems are intended for internal office use only, each containing their own unique fields and values tailored to the needs of that particular office, which are not shared  Therefore, the number of eligible fields for each information system was also limited to those not specifically designated for internal use  On the basis of our review, the 12 information systems are not currently able to communicate, or interoperate, with one another to provide a complete picture of misconduct and disciplinary actions across VA  Table 2 provides an overview of VA’s six information systems and associated data files that collect partial misconduct and disciplinary-action data that could potentially be shared with other systems  According to OHRM officials, VA’s information system for recording adverse disciplinary actions—the Personnel and Accounting Integrated Data (PAID) system—was not designed to track all misconduct cases  In addition, OHRM stated that the 53-year-old PAID system was developed primarily to track payroll actions for all employees and is the system of record that holds department-wide personnel information that is reported to OPM’s EHRI system  It contains information about adverse disciplinary actions that affect employee leave or salary, or result in a Notification of Personnel Action Form (Standard Form 50)  However, PAID does not track comprehensive information on instances of misconduct such as the offense, or the date of occurrence, and it does not include instances of other types of disciplinary actions, such as admonishments or reprimands that would not affect leave or salary, or result in a Standard Form 50  OHRM officials stated VA implemented a system called HR Smart in June 2016 that is intended to replace PAID, but the agency does not plan to upgrade the functionality of the new system to enable reliable collection of misconduct information  According to OHRM, HR Smart includes the same personnel-processing functions as PAID but will allow for tracking data changes and transaction history over time  However, as with the PAID system, adverse disciplinary actions involving leave and salary will be tracked, but other actions, such as reprimands and admonishments, will not  It also will not track information related to the offense that prompted the disciplinary action  While the HR Smart system has the capability to include modules to enhance performance features, such as the ability to track misconduct, according to OHRM officials VA does not currently have plans to implement these modules  As a result, the HR Smart system will not have the capability to track all employee misconduct department-wide and will not improve VA management’s visibility over the depth and breadth of misconduct so that it can systematically understand misconduct department-wide  VA has five additional information systems for tracking complaints or allegations of misconduct and disciplinary actions, but, similar to the agency’s PAID information system, each of these information systems contains a subset of the information that would be needed to understand all misconduct department-wide  According to Standards for Internal Control in the Federal Government, systems should include relevant data from reliable internal sources that are reasonably free from error and faithfully represent what they purport to represent  Additionally, management is advised to process data into quality information that is appropriate, current, complete, accurate, accessible, and provided on a timely basis  Management should also evaluate processed information, make revisions when necessary so that the information is quality information, and use the information to make informed decisions  Additionally, according to Standards for Internal Control in the Federal Government, management should design the entity’s information system and related control activities to achieve objectives and respond to risks  The standards add that the information system design should consider defined information requirements for each of the entity’s operational processes  Defined information requirements allow management to obtain relevant data from reliable internal and external sources  In order to achieve complete and accurate data, internal controls are needed, among other things, to ensure that fields are not left blank, data elements are clearly defined and standardized, and common data elements are included across data systems to allow for interoperability and aggregation  Our analysis of VA’s 14 data files identified the following three categories that reduced the reliability of the data: lack of data standardization, and lack of identifiers  We found that 7 data files we reviewed contained a majority of data within fields, but 5 data files were missing a significant amount of data within certain fields  We were unable to analyze the remaining two files due to a number of data-quality issues  Among the fields that were missing data were several that would be useful for analyzing misconduct, including complainant name, proposed action, and person of interest, as shown in table 4  For example, we found that in the OAR Legacy Referral Tracking List, 97 percent of the entries for the Proposed Action field (1,210 of 1,245) and 96 percent for the Disciplinary Action field (1,190 of 1,245) were blank  If available, comparison of the proposed and disciplinary action-taken fields would allow VA to assess whether actions are consistently implemented department-wide  However, the high percentages of blank values in multiple fields impair VA’s ability to conduct a comprehensive analysis of misconduct to identify and address trends  See appendix II for a further listing of the five data files and the corresponding fields that were missing data  In addition, we found that several data files had options such as “not applicable” or “no” for certain fields so that the field would not be left blank, but these options were not consistently used  For example, the Complainant Name field within the Legacy Referral Tracking List was blank for some entries and not applicable (N/A) for others  Accordingly, we did not know whether data were intentionally omitted or not entered by mistake  In addition, the Offense Sustained field found within the VA-Wide Adverse Employment Action and Performance Improvement Plan Database was blank for some entries and either a yes or no for others  Eight of the 14 data files we reviewed did not have key data elements that were defined within and across information systems  In other words, the data files contained entries that described similar information in different ways  For example: The Complaints Automated Tracking System (CATS) Employment data were not mutually exclusive, or independent of one another  For example, this field includes two distinct categories of information: employment status, such as full time or part time; or hiring authority, such as Title 5 or Title 38  This method of storing information resulted in undercounting each of the separate values due to the system’s inability to account for expected overlap  For instance, an employee could be both a full-time and Title 5 employee and the field only tracks one or the other  ORM officials stated that this field has since been modified to capture more options to account for the overlap  The NCA data file’s Action Proposed/Decided/Taken data were tracked in a single field and updated with the most-recent action, rather than capturing proposed actions, decided actions, and actions taken in separate fields  We also identified standardization issues with the newly updated VA- Wide Adverse Employment Action and Performance Improvement Plan Database  For example, we found 15 different variations of Registered Nurse, such as “Registered Nurse,” “Staff RN,” and “RN” position names  In addition, we found 28 alternate values that identified Diagnostic Radiologic Technologists (e g , Diagnostic Radiologic Technologist, Diagnostic Radiological Technologist, and Radiologic Technologist)  See appendix III for a description of the fields that did not have standardization within the eight data files  We determined that 5 out of the 14 data files did not have identifiers that would allow comparisons of information across systems  Identifiers are important because they reference one unique individual or case, which makes it possible to analyze historical data pertaining to all records with the same identifier and analyze trends in employee misconduct over time  For example: The OAR VA-Wide Adverse Employment Action Database and the VBA data files had a combined total of 4,487 closed cases of misconduct that received adverse corrective action during the combined period of November 2013 through December 2016  We found that these two data files did not contain unique identifiers for complainants or accused individuals for a given case  OAR officials stated that this system does not contain Personal Identifying Information since its purpose is to track proposed and taken adverse actions  If more-specific information is needed, OAR staff coordinate with the human-resource point of contact  Although OAR may obtain additional information, this information is not entered into the OAR VA-Wide Adverse Employment Action Database, which would assist with conducting analysis  VAPS tracks misconduct in two separate subsystems, one of which tracks traffic violations and other administrative offenses, and one of which also tracks more-egregious offenses such as criminal violations  These subsystems also do not have unique identifiers that would allow data matching between the two subsystems, which could impede the analysis of this information  Even with both files, there is no ready way to capture the complete number of individuals with misconduct in both files due to the lack of a shared identifier  The newly updated VA-Wide Adverse Employment Action and Performance Improvement Plan Database does not contain unique identifiers, such as employee identification number, name of the complainant or accused, or other linking variables, to allow for the analysis of historical trends or comparison of information among other information systems  The data-quality issues described above are due in part to most of VA information systems not having data dictionaries, field definitions, or other documented guidance and procedures on data entry and automated edit checks to control for erroneous entries and blank fields  Absent guidance and procedures, VA lacks assurance that employees will enter complete and accurate information in the various data systems  Further, the lack of unique identifiers such as employee identification number, case number, or other linking variables for each of the records does not allow for analysis of historical trends or comparison of information among different information systems  Consequently, this precludes VA from determining the frequency and nature of allegations by specified category, or identifying trends, thus impeding senior officials’ ability to analyze misconduct department-wide and develop corrective actions  VA Directive 5021, Employee/Management Relations, governs policy for disciplinary procedures for all employees and outlines the provisions for the adjudication of each disciplinary action and associated file documentation requirements  Specifically, files must be established before a notice of proposed adverse action is issued to the employee to document that the adjudication procedures were followed  The file must contain all available evidence upon which the notice of proposed action is based and that supports the reasons in that notice  In addition, each file should contain specific documentation related to the adjudication of employee misconduct  VA Handbook 5021 states that disciplinary actions and associated adjudication procedures for all VA employees appointed under Title 5 are governed by three basic principles: (1) an employee shall be informed in writing honestly and specifically why the action is being brought against him or her; (2) an employee shall be given a reasonable opportunity to present his or her side of the case; and (3) the employee and representative shall have assurance of freedom from restraint, interference, coercion, discrimination, or reprisal in discussing, preparing, and presenting a defense  Our review of a generalizable sample of 544 misconduct case files (from a universe of 23,622 files) associated with disciplinary actions that affect pay from October 2009 through May 2015 revealed that VA officials did not consistently adhere to VA’s policy for retaining files containing evidence of misconduct  Specifically, VA was unable to provide the files for 10 percent (55 of 544) of the files we requested  We determined that administrations and program offices within VA have various record- retention schedules  Offices that have not established a record-retention schedule refer to the general records schedule developed by the National Archives and Records Administration (NARA)  However, we found that some offices are misinterpreting OPM and NARA guidance and specify the record retention period for adverse action files as a range between 4 to 7 years rather than selecting a specific number of years in their record- retention schedules  All of the files were within VA’s record-retention range specified during the time of our review  The files that were unaccounted for were dispersed throughout most of the VISNs, but one VISN was not able to account for 19 of the missing files in our sample  On the basis of our weighted analysis of the generalizable sample, we estimate that VA would not be able to account for approximately 1,800 files in the full population that were within the record-retention period specified  In addition, VA officials did not consistently adhere to VA’s policy for documenting that procedures were followed in the adjudication of misconduct cases  We identified 22 out of 36 file requirements where VA was not able to consistently demonstrate compliance with VA policy due to the lack of documentation contained in files, based on our generalizable sample  Specific to both Title 5 and Title 38 permanent- employee misconduct case files, table 5 shows the estimated number and percentage that deviated from file documentation requirements  A list of the 22 identified requirements and the percentage of files not in compliance can be found in appendix IV  As table 5 indicates, Title 5 and Title 38 permanent employee files did not always contain documentation that employees were informed of the reason the action was brought against them  For example, on the basis of our generalizable sample, we estimate that the advance notice of proposed action, which includes a statement of the specific alleged misconduct upon which the proposed action is based, was not included in 16 percent of the files department-wide  A final decision letter, which contains a statement of the decision official’s determination regarding which charges, if any, in the advance notice were sustained, was not included for an estimated 15 percent of all files  Further, an estimated 35 percent of all files did not include a written acknowledgement from the employees that they received the final decision letter in person, and an estimated 23 percent of all files did not include the required return receipt for certified mail indicating that the decision letter was mailed to the employee  In addition, Title 5 and Title 38 permanent employee files did not always contain documentation that employees were provided a reasonable opportunity to present their side of the case  Our review found that permanent-employee disciplinary files did not adhere to basic principles outlined in VA Handbook 5021 and lacked evidence to demonstrate that employees were adequately informed regarding their rights during the adjudication procedure  Specifically, our generalizable sample found that an estimated 21 percent of all files did not include statements regarding the employee’s rights to due process, such as his or her entitlement to be represented by an attorney or other representative  In addition, an estimated 8 percent of all files did not mention that more information regarding appeal rights could be obtained by consulting Human Resources Management offices  For files where the employee provided an oral reply in response to proposed disciplinary action, an estimated 29 percent of files did not include the required written summary, which is to be signed by the official hearing the oral reply  Where a written reply was submitted, an estimated 11 percent of files did not include a copy of the employee’s written reply  Further, VA officials did not consistently adhere to VA’s best practices specific to Title 5 permanent employees only  We found that in a majority of these files (an estimated 72 percent) the proposal letters did not include a statement that assured the employee he or she had freedom from restraint, discrimination, or reprisal in discussing, preparing, and presenting a defense  VA Handbook 5021, Employee/Management Relations, also states that Title 5 employees should provide their written responses through supervisory channels to the decision official  We estimate that a total of 6,819 files (47 percent) of Title 5 permanent employee files did not provide their written reply through supervisory channels to the decision official  Although OHRM is responsible for assessing the effectiveness of department-wide human resource programs and policies of VA Handbook 5021, according to OHRM officials, each facility is responsible for oversight of implementing policies and guidelines pertaining to how disciplinary actions are processed  We found no evidence that OHRM has assessed whether documentation exists that demonstrates adherence to policy governing cases involving disciplinary actions or provided oversight of VA’s implementation of record-retention requirements, or that human- resource personnel adhere to basic principles outlined in policy to ensure employees are informed of their rights during the adjudication process  The resulting lack of oversight to HR policies increases the risk that employees will not be adequately informed of their rights during the adjudication process  Accordingly, employees may not (1) be provided with information on why an action is being brought against them, (2) be provided with a reasonable opportunity to present their case, and (3) be adequately protected from potential reprisal in preparing their defense  Regarding retention of records, according to NARA, disciplinary and adverse action case files should be destroyed no sooner than 4 years but no later than 7 years after the case is closed  According to OPM, to implement this authority, each agency must select one fixed retention period between 4 and 7 years and publish the retention in the agency’s records disposition manual  We determined that some offices are misinterpreting OPM and NARA guidance by not selecting a specific number of years in their record- retention schedules  For example, three of the six policy record-retention schedules we reviewed did not establish a specific number of years for record retention  Specifically, record-retention policies for the Office of Information and Technology, VACO staff offices, and VBA specified the record-retention period for adverse action files as a range between 4 to 7 years rather than selecting a fixed retention period  For example, we found that the Records Control Schedule pertinent to VACO was dated June 30, 1967, without references to new or revised items since 1969  Our results are consistent with an October 2016 inspection conducted by NARA  The inspection report contained 16 findings and 19 recommendations for improvement of the records-management program at VA  Among the findings and recommendations were the following  Finding: The VA records management program has not ensured that the VACO maintains a current Records Management Handbook and a current Records Control Schedule, which together establish program objectives, responsibilities, and authorities for the creation, maintenance, and disposition of agency records  Recommendation: The Department Records Office must update and maintain the VACO handbook and the Records Control Schedule for Central Office Staff Offices and the Offices of the Assistant Secretaries to include specific Records Management roles and responsibilities for all VACO staff and to include mandates for implementation of records management policies and procedures in accordance with Federal statutes and regulations  Finding: The VA Departmental Records Management program does not conduct regular records management evaluations within VACO and the Offices of the Secretary and Assistant Secretaries or monitor the oversight activities of the Administrations  Recommendation: The VA Departmental Records Management program, working with the Administrations, VACO, and Enterprise Risk Management, must establish effective Records Management evaluation programs to monitor VA compliance with Federal regulations  Recommendation: The VA Departmental Records Management program, working with the Senior Agency Official for Records Management, must establish effective Records Management evaluation programs to monitor the records management practices within the Office of the Secretary and Assistant Secretaries to ensure compliance with Federal regulations  Finding: VACO Staff Offices and the Offices of the Assistant Secretaries are not routinely conducting records inventories  Recommendation: VACO Staff Offices and the Offices of the Assistant Secretaries, with support from the Department Records Management program, must conduct inventories of existing electronic and non-electronic records to identify scheduled, unscheduled, and vital records  In response to NARA findings, VA is to submit a plan of corrective action that specifies how the agency will address each inspection report recommendation, including a timeline for completion and proposed progress reporting dates  VA does not have a method in place to evaluate the implementation of records-management practices outside of those being conducted by VHA and VBA  Accordingly, VA has not been conducting records-management oversight with any uniformity department-wide  Further, VA’s use of multiple retention periods for adverse action files, and in some cases the lack of adherence to OPM and NARA guidance in defining a specific retention period for these files, results in inconsistent retention of these files across VA  The OIG receives allegations of employee misconduct from VA employees, the OSC, members of Congress, the public, and other stakeholders  When the OIG receives allegations it can either take no further action, open an investigation, or refer the case to facility or program offices within VA for review and response  For cases referred to facility or program offices, the OIG has developed a policy for VA facilities and program offices to use when investigating allegations of misconduct  This policy includes six elements that VA facility and program officials are to incorporate in their investigations, as shown in table 6  According to OIG officials, if the reviewing employees have concerns about the adequacy of the response provided, the OIG can either ask for additional information to supplement the response or open an internal case  Departmental heads (Under Secretaries for Health, Benefits, and Memorial Affairs, Assistant Secretaries, and other key officials) are responsible for ensuring that referrals are properly reviewed, documented, and answered within specified time frames  Our review of the 23 OIG cases of alleged misconduct between calendar years 2011 and 2014 involving senior officials found that VA facility and program offices did not consistently follow policies and procedures established by the OIG for investigating such allegations  In several instances, VA facility and program offices did not include one or more of the six elements required in their investigative response to allegations of misconduct  In addition, our review of the 23 cases found instances in which VA facility and program offices did not include sufficient documentation for their findings, or provide a timely response to the OIG  The OIG was not able to produce the documentation provided by the facility or program office that was used to close 2 of the 23 cases in our review  All of the requested files were within the OIG’s 7-year record- retention period during the time of our review  As shown in table 7, we identified four cases that did not contain evidence of an independent review by an official separate from and at a higher pay grade than the accused  In three of the four cases that were not reviewed by an independent official at a higher grade, the review was performed by the medical center director, who was one of the accused named in the allegation  For example, in one case involving alleged time-and-attendance abuse by a physician, the medical center director, who was also named in the allegation as having received a similar complaint against the physician 2 years earlier, reviewed the allegations made against the physician and himself  The documentation provided showed that the medical center director conducted the investigation of allegations and found the allegations were not substantiated and no corrective actions were implemented  In all four cases, both the independence and higher-grade criteria were not followed when the accused senior officials investigated allegations against themselves  As shown in table 8, we generally found that VA facility and program offices reviewed each allegation contained in the original referrals, although in one case the reviewer did not respond directly to all allegations  As shown in table 9, VA facility and program offices clearly indicated their findings for each allegation in 14 of the 21 cases of misconduct involving senior officials for which files could be located, as well as their assessment of whether the allegations were substantiated or unsubstantiated  However, we identified seven cases in which VA discussed its findings but did not provide a clear indication of whether all allegations were substantiated or unsubstantiated  Responses lacking a clear statement of substantiation may be more difficult for subsequent reviewers, including OIG and OAR investigators, to track and perform follow-up where necessary  For example, in one case involving 11 allegations, no statement of substantiation was provided, but VA’s response included seven recommendations, three of which involved disciplinary action  We did not find evidence in the case file that follow-up was performed by the OIG personnel to clarify this discrepancy, and the case was closed  As shown in table 10, most allegations involving senior officials (16 of 21 cases for which files could be found) were not formally substantiated and did not require a recommendation for corrective action based on OIG case-referral criteria  Specifically, the criteria require a description of corrective actions taken or proposed as a result of substantiated allegations, but make no mention of allegations that were not substantiated as part of VA’s response  For one substantiated allegation, however, we found no evidence of a recommendation for corrective action  Table 11 shows that 17 cases from VA facility and program offices did not provide the supporting documentation they used to reach their conclusions about the OIG case referrals  In 17 cases, including one case reviewed by an AIB panel, VA referenced documents reviewed but did not attach any of the supporting evidence  OIG case-referral criteria state that VA facility or program offices must provide supporting documentation used in their review, such as copies of pertinent documents  However, the criteria do not specify whether copies of all documentation reviewed must be included in the file  Supporting documentation, which must be provided according to OIG policy, will vary depending on the circumstances of the case, but those used to support the findings and recommendations should be included  For example, we reviewed one case where pertinent documents were referenced to support the allegation, but documents supporting the findings and recommendation were not included  The case contained allegations involving false patient wait-time documentation and abuse of authority  Specifically, a medical center director instructed staff to review patient wait times between follow-up appointments in order to meet VA’s 14-day timeliness metric  The investigation revealed that VA staff had changed several hundred veteran appointment wait times  The investigation concluded that the false documentation allegation was substantiated, but attributed the cause to the staff not understanding how to enter a follow-up appointment date into the system  However, there was no documentation in the files to support (1) that the medical center director had not abused his authority by instructing staff to review wait times greater than 14 days to determine how they could be reduced, and (2) findings for the conclusion that the original wait times were entered in error  Absent supporting documentation, it is difficult for the OIG to determine whether enough evidence was gathered before closing alleged cases of misconduct that were found to be unsubstantiated or closing substantiated cases of misconduct that required further action  VA Directive 0701 states that copies of voluminous transcripts of interviews, the entire claims folder, and medical charts are not necessary  However, VA Directive 0701 further states that such materials should be available if the OIG subsequently requests them within the record-retention period  Case examples of allegations reviewed, and subsequently closed, by the VA OIG based on its evaluation of evidence provided by facility and program offices in response to allegations of misconduct can be found in appendix V  As shown in table 12, VA facilities’ or program offices’ response letters, which were sent to the OIG, included a point of contact for further questions in 15 of the 21 OIG case referrals involving senior officials, including the individual’s name and a means of contact (phone or e-mail)  In 2 of the 15 cases where a point of contact was provided, the contact was also one of the accused in the allegation  Although that is not technically a violation of OIG criteria, it likely presents a conflict of interest in regard to independent reviewers obtaining objective case information  In six other cases, no contact was listed, although the letter was signed by the reviewer  If a specific point of contact is not identified, including position title, it may be assumed erroneously by employees involved in the case, or following up on the case, that the default contact is the reviewer, who may not be the appropriate point of contact, and may or may not be able to provide objective case information  OIG guidelines state that VA facilities and program offices assigned Hotline case referrals are responsible for reporting written findings to the Hotline Division within 60 days, unless an extension is requested  Our review of the 21 cases found instances in which VA facility or program offices did not always provide a timely response to the OIG  Table 13 shows five instances in which VA facility or program offices submitted a response after the deadline requested by the OIG  One response was not reported timely after an extension was provided by the OIG  In one of the five cases involving allegations of abuse of authority by a VA medical center director, the reviewer requested an extension, which is permitted by OIG policy, but still missed the revised deadline  The five case files did not contain any information regarding any follow-up actions taken in response to delays  According to OIG officials, when a case has been referred to a program office for investigation, the OIG reviews the program office’s response for completeness and sufficiency before closing the case  However, there is no requirement for the OIG to ensure that the responses contain the six elements listed in VA Directive 0701 and confirm that case referral allegations have been addressed  Consequently, the lack of verification could have contributed to insufficient evidence that does not meet the requirements outlined by the OIG  Additionally, VA facility and program offices have not consistently adhered to VA Directive 0701 policy and do not always provide supporting documentation for their findings and recommendations, or always provide a timely response when reporting findings to the OIG’s Hotline division  Inconsistent adherence to the reporting standards provided by the OIG to VA facilities and program offices for investigating and resolving misconduct case referrals from the OIG Hotline impedes VA’s ability to ensure that misconduct cases are being handled appropriately  According to OIG officials, the OIG has taken steps to enhance the review of case responses  Specifically, OIG officials stated that in April 2018 the OIG implemented a new Enterprise Management System to reduce reliance on certain manual processes  According to OIG officials, Hotline analysts will now have more time to review their work and perform other quality-assurance activities  In implementing this new system, it will be important for the OIG to consider how the system can assist in ensuring requirements are met and responses are received timely  Our review of VA’s information systems that track misconduct involving senior officials department-wide indicates that they may not always be held accountable for misconduct  Specifically, (1) misconduct was sometimes substantiated, but the proposed disciplinary action was not taken; (2) misconduct was sometimes substantiated, but no disciplinary action was recommended; (3) previous penalties did not have the corrective effect for officials found to have engaged in repeated acts of misconduct and who have remained in VA management positions; and (4) senior officials violated separation-of-duty policy when taking disciplinary action  VA Handbook 5021 allows the deciding official to determine the appropriate disciplinary action if one or more allegations are substantiated  However, the disciplinary action may not be more severe than what had been proposed  In several cases, misconduct was substantiated, but the proposed action was not always taken  Our review of the OAR Legacy Referral Tracking List identified 17 officials between calendar year 2011 through May 2015 with substantiated misconduct where action was proposed  However, in some of these cases, the officials were given a lesser penalty than the one proposed, while in other cases there is no evidence that action was taken  As shown in figure 3, we found that for 12 of the 17 officials with substantiated misconduct, an adverse disciplinary action (removal) was proposed  Of those 12 officials, 3 were removed, 2 received a suspension, 4 received a reprimand or admonishment, 2 were allowed to resign or retire before receiving disciplinary action, and we found no evidence of disciplinary action for the remaining individual  For the other 5 officials, actions such as counseling, admonishment, suspension, or reprimand were proposed  Of the 5 officials, 2 received the actions that were proposed, 1 received a lesser penalty than what had been proposed, 1 was allowed to retire before receiving action, and we found no evidence of the proposed action for the remaining individual  For the two officials for whom there was no evidence that disciplinary action was taken, we found no evidence within the PAID information system or personnel files that these officials received the action proposed in the OAR Legacy Referral Tracking List  Counseling was proposed for one official, and removal from the position for the other official  OAR did not provide us with evidence that the officials had received the action proposed  We also reviewed an additional 15 cases that involved a fact-finding or an AIB  Our review of these cases found that 11 out of 23 officials were associated with instances of substantiated misconduct and proposed action was recommended  For 4 of the 23 officials where the proposed action field was populated, the information within the OAR Legacy Referral Tracking List reflected the action recommended  The applicable data fields for the remaining 19 officials within the OAR Legacy Referral Tracking List were not in agreement with the action recommended, or blank  This review also identified two officials with substantiated misconduct where OAR did not provide evidence that the disciplinary action proposed was taken: Two officials were involved in a case concerning alleged whistle- blower retaliation at the Phoenix VA Health Care System  The investigative report documented that allegations were sustained  The retaliation included allegations of involuntary reassigning the whistle- blower to another position, placement of the whistle-blower on administrative leave, and lowered performance pay ratings following disclosures regarding poor patient care and nursing triage errors  Appropriate administrative action for persons identified as having engaged in retaliation was recommended  We did not find any evidence in the PAID system that these two officials involved in retaliation received disciplinary action  OAR provided documentation to show that no action was taken against one official, and was unable to provide documentation to show that the disciplinary action had been taken for the other  The official who received no action received approximately $11,500 in performance pay during a 2-year period following the allegations  OAR’s quality-review process for investigative reports does not ensure that reports with findings of substantiated misconduct include recommendations for action  Our review of OAR’s Legacy Referral Tracking List identified 70 out of 1,245 closed cases involving officials where misconduct was either substantiated, or partially substantiated, but no disciplinary action was recommended  One case involved three allegations of poor dental care provided to patients by three different senior officials  One physician cut underneath a patient’s tongue with the bur of a hand-piece drill (substantiated), another administered medication the patient was allergic to (partially substantiated), and the final senior official extracted the wrong tooth (substantiated)  We did not find any evidence in the PAID system that these senior officials received disciplinary action  Further, OAR did not provide documentation to show that any disciplinary action had been proposed or taken  The physician that cut underneath a patient’s tongue received performance pay totaling $15,000 approximately 6 days after the investigation had concluded that misconduct was substantiated  As of March 2018, two of these senior officials received performance pay, and appear to still be employed at VA  While an investigation was conducted that substantiated (or partially substantiated) the allegations, there is an increased risk that some substantiated misconduct will go unaddressed if there is no recommendation for corrective action  Our review of OAR’s Legacy Referral Tracking List indicated that some officials who had been disciplined for misconduct remained in positions where they were responsible for proposing or deciding disciplinary action for other employees  We identified 15 officials in the OAR VA-Wide Adverse Employment Action Database who received disciplinary action between 14 days to 1 year prior to proposing disciplinary action for another employee  Most of the 15 officials (12 officials) had received a suspension  We also found that five officials in the OAR Legacy Referral Tracking List had received prior disciplinary actions for offenses unrelated to the new OAR allegations  A prior history of disciplinary actions indicates that some officials may be repeat offenders for whom the previous penalties did not have the desired corrective effect  For example, 4 out of 5 officials were suspended for a different offense prior to being the subject of a new allegation  One of the four officials was suspended less than 2 months prior to being the subject of a new allegation, while another received a suspension before, and again approximately 7 months following, the OAR allegation  According to VA Handbook 5021, the deciding official must use the “Douglas” factors, which include the employee’s past disciplinary record, to determine a reasonable penalty  One of the five VA officials was eventually removed approximately 6 months after the new OAR allegation  In analyzing cases involving senior management, we noted that the OAR Legacy Referral Tracking List often did not accurately reflect the disciplinary action that was decided based on the results of the investigation  In numerous instances for the OAR Legacy Referral Tracking List, the applicable data fields indicating the proposed and final disciplinary action were blank  In these cases where the disciplinary fields were populated, the data usually did not agree  Specifically, for 32 out of the 40 records we reviewed where misconduct was substantiated, the final disciplinary action taken did not reflect the information within the OAR Legacy Referral Tracking List  When disciplinary actions are taken in response to findings of misconduct but are not entered within an appropriate information system, or are inaccurately recorded, it is more difficult to (1) monitor whether disciplinary actions have been implemented, and (2) ensure information relevant to management for making decisions is available  Further, without a prior record of misconduct or disciplinary action, senior officials who are repeat offenders may not receive the appropriate penalty required  Pursuant to the Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017, OAWP will now be responsible for receiving, reviewing, and investigating allegations of misconduct, retaliation, or poor performance involving senior officials  According to OAWP officials, their office investigates allegations of misconduct at the senior level only  OAWP officials also stated that misconduct issues that occur below the senior level will be referred to each of the three major VA administrations for investigation and resolution  In addition to the VA- Wide Adverse Employment Action and Performance Improvement Plan Database, OAWP officials stated that it has implemented two additional information systems that are used concurrently to capture case information  OAWP officials stated that they are currently working with VA Information Technology to assess options for other case-management systems that could consolidate these three information systems into one comprehensive system  VA Handbook 5021, Employee/Management Relations, states that the decision on a proposed major adverse action will be made by an official who is in a higher position than the official who proposed the action, unless the action is proposed by the Secretary  Standards for Internal Control in the Federal Government states that management should divide or segregate duties among different people  Our review of the OAR VA-Wide Adverse Employment Action Database, OAWP VA-Wide Adverse Employment Action and Performance Improvement Plan Database, and VBA data file identified examples where VA officials did not follow separation-of-duty requirements  As shown in table 14, 73 (out of an estimated 7,886) VA officials acted as both the proposing and deciding official in cases involving removals for employees found to have engaged in misconduct  Fourteen VA officials acted as both the proposing and deciding official in two or more cases  One of these 14 officials acted as both the proposing and deciding official for seven different removal cases  Further, our review of 29 VA officials found that none received disciplinary action for violating separation-of-duty policy  The systemic lack of adherence to VA’s separation-of-duty policy is reflective of a lack of controls that would allow such activity to occur  Focusing on ensuring such controls are implemented would help ensure that VA decreases the risk of abuse when officials act as both proposing and deciding officials  VA has procedures in place to ensure that allegations of misconduct are investigated, but these procedures allow VA program offices or facilities where a whistle-blower has reported misconduct to conduct the investigation  According to VA officials, investigations that are deemed necessary are occasionally ordered directly from the head of the facility or VA leadership, which takes the lead on an investigation into the allegation  Alternatively, an OIG official stated if allegations of misconduct are received by the OIG, the OIG has the option of investigating the allegation or exercising a “right of first refusal” whereby it refers allegations of misconduct to VA facilities or program offices where the allegation originated to complete an independent review and provide a response to the OIG  As shown in figure 4, the majority of contacts the OIG received (127,265 out of 133,435) from calendar years 2010 through 2014 were not investigated due to several reasons, such as insufficient evidence or lack of jurisdiction  Of those contacts that were investigated, the majority (4,208 of 6,170 investigated contacts) were not investigated by the OIG but rather were referred to facility or program offices for investigation  Whistle-blowers also have the option of reporting alleged misconduct outside VA by filing a disclosure with the OSC, and may do so if they believe there has not been a resolution to their complaint internally  If the OSC determines that there is substantial likelihood of wrongdoing, it may refer the disclosure back to the Secretary of Veterans Affairs for further investigation  According to OSC officials, as a general policy, the OSC will not refer a disclosure to the Secretary if the OIG is already conducting an investigation of that particular complaint and defers to the OIG to finalize the investigation  According to OIG officials, the OIG may, in turn, exercise its “right of first refusal” when cases are referred from the OSC  Consequently, this process can result in a disclosure that was originally made to the OSC being referred back to the facility or program office where the allegation originated  As shown in figure 4, the OSC referred 172 of 942 disclosures (18 percent) filed by VA employees back to the Secretary of Veterans Affairs for further investigation from calendar years 2010 through 2014  Of the 172 disclosures referred, VA referred 53 back to the facility or program offices where the complaint originated and 119 to the OIG  The independence of officials conducting or reviewing the results is paramount to the integrity of the process both in deed and appearance  According to VA Directive 0700, the decision whether to conduct an investigation should not be made by an official who may be a subject of the investigation, or who appears to have a personal stake or bias in the matter to be investigated  Moreover, according to OIG policy, investigations referred to VA offices must be reviewed by an official independent of and at least one level above the individual involved in the allegation  VA does not have oversight measures to ensure that all referred allegations of misconduct are investigated by an entity outside the control of the facility or program office involved in the misconduct, to ensure independence  VA OIG officials acknowledged that there have been concerns about referring cases back to the chain of command because the OIG is unsure where cases go once they are referred  The investigation of allegations of misconduct by the program office or facility where the complaint originated may present the appearance of a conflict of interest in which managers and staff at facilities may investigate themselves or other allegations where they may have a personal stake or bias in the matter to be investigated  Consequently, there may be an increased risk that the results of the investigation are minimized, not handled adequately, or questioned by the OSC or the individual who made the original allegation  According to VA Directive 0700, significant incidents occurring, and issues arising, within VA facilities or offices shall be reported and investigated as necessary to meet the informational and decision-making needs of VA  Primary responsibility in this regard rests with the chief executives of the facility or staff office involved, and with their supervisors in VA and its administrations  According to an OIG official, VA (the Secretary or a delegate) sends disclosures received from the OSC to the OIG, which may then refer to VA facility or program offices for further review and investigation  According to OSC officials, for cases that are referred to a program office, the OSC requires that the Secretary or delegate provide a report that outlines its conclusions and findings  This reporting is not required for disclosures where an ongoing OIG investigation is already under way  According to OSC officials, for each disclosure, the OSC is to review the report for statutory sufficiency and determine whether the findings of the agency head appear reasonable  The OSC is to send its final determination, report, and any comments made by the whistle-blower to the President and responsible congressional oversight committees  The OSC has raised concerns in its reports to the President about investigations conducted by VA program offices and facilities  Of the 172 whistle-blower disclosures referred by the OSC between calendar years 2010 through 2014, the Secretary of Veterans Affairs referred 53 to facility and program offices  Our review of these 53 OSC reports found that the OSC had concerns about the conclusions VA reached in 21 (40 percent) of the 53 disclosure cases  For example, the OSC found that the conclusions in some VA reports were unreasonable because VA reached its conclusion without interviewing the witness, provided shifting explanations that strained credibility and did not provide evidence of an unbiased investigation, ignored whistle-blower concerns by refusing to investigate allegations, and refused to acknowledge the impact on the health and safety of veterans seeking care after confirming problems in these areas  For disclosure cases that were referred from the OIG to facility and program offices during the 2010–2014 time frame of our review, the OIG acknowledged that these concerns arose because of a lack of communication between the department and the OIG regarding the scope of the review  At the time of our review, VA did not have a procedure in place to ensure the conclusions reached for investigations involving OSC disclosure cases are reasonable and meet the informational and decision- making needs of VA whereby all allegations are addressed  More recently, the OIG has started to communicate the scope of its reviews that involve matters referred by the OSC to the Office of the Secretary  In implementing this new process, it will be important for the Office of the Secretary to ensure that any allegations outside the purview of the OIG’s investigation are fully addressed by a departmental entity in accordance with OSC requirements  As shown in figure 4, of the 172 disclosure cases referred to VA by the OSC, a total of 119 cases were referred to the OIG  The OIG had conducted, or was already conducting, an investigation of the particular allegations for all 119 disclosures  Since these 119 disclosure cases were already under investigation by the OIG, the OSC deferred to the OIG’s investigation for these cases  A total of 37 of these 119 disclosure cases that were referred to the VA OIG were submitted to the OSC anonymously  Therefore, we were unable to conduct a review of these investigations because there was no information available to identify the individuals involved  According to Standards for Internal Control in the Federal Government, management’s ability to make informed decisions is affected by the quality of information  Accordingly, the information should be appropriate, timely, current, accurate, and accessible  The oversight body oversees management’s design, implementation, and operation of the entity’s organizational structure so that the processes necessary to enable the oversight body to fulfill its responsibilities exist and are operating effectively  Our review of the remaining 82 disclosure cases determined that the OIG does not have procedures in place to track cases that were referred from the OSC for further investigation  According to OIG officials, the OIG’s information system did not have a method in place to ensure that OSC case numbers are linked to the OIG investigative case number and final report  Consequently, the OIG was unable to produce the investigative documentation for these 82 disclosures  According to OIG officials, OSC case numbers and associated Hotline numbers are currently tracked in a spreadsheet until the implementation of a new system  The inability to locate investigative documentation prevents a third party from verifying whether the OIG examined the disclosures, whether any recommendations were addressed, or whether appropriate disciplinary action was taken for these cases  In addition, because the OSC defers to the OIG’s investigation for allegations that were already conducted, or being conducted, the OSC and individuals that made the allegations do not have documentation to demonstrate that the allegations were addressed  This information, or lack of it, has direct influence on management’s ability to make sound decisions relating to investigative matters  Pursuant to the Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017, OAWP will be responsible for recording, tracking, reviewing, and confirming implementation of recommendations from audits and investigations involving whistle-blower disclosures, including the imposition of disciplinary actions and other corrective actions contained in such recommendations  According to OAWP officials, the whistle-blower disclosure process will be similar to the current process when cases are referred to facility and program offices for investigation  OAWP will follow up on any open points with the level of leadership that is most appropriate in each case, such as the medical center or VISN director  Case details will be tracked through the three active databases that are being used concurrently  OAWP is currently working to develop an internal process that will bring the investigative communities together  For instance, OAWP would like to monitor cases that are referred to VA facility and program offices, but it does not currently have documented criteria to guide the process  According to OAWP officials, OAWP is finalizing new policies in the form of a policy manual and handbook  However, these officials were unable to provide a time frame for completion of the published guidance  Our analysis of VA data shows that individuals who filed a disclosure of misconduct with the OSC received disciplinary action, and left the agency, at a higher rate than the peer average for the rest of VA  We identified 135 disclosure cases that were received by the OSC between calendar years 2010 and 2014 and were alleging misconduct  Of the 135 disclosures, a total of 129 employees made a total of 130 disclosures nonanonymously  We compared the 129 employees who made nonanonymous disclosures to the PAID information system using the complainants’ information  As shown in table 15, on average approximately 1 percent of all employees in the VA roster received an adverse action in any given fiscal year  For the 129 nonanonymous whistle-blowers, we found that approximately 2 percent received an adverse action in the fiscal year prior to their disclosure, while 10 percent had received an adverse action in the fiscal year of their disclosure, and 8 percent received an adverse action in the year subsequent to this disclosure  While the fact that nonanonymous whistle-blowers faced higher rates of adverse action subsequent to their disclosure than the VA population as a whole is consistent with a pattern of retaliation for nonanonymous whistle-blowers, it is only an indication that retaliation could be occurring  Our analysis also showed that among employees who could be matched to the PAID end-of-year roster, attrition rates were higher for those individuals who filed a nonanonymous disclosure with the OSC  On average, approximately 9 percent of all VA employees on the end-of-year roster in one fiscal year were not on the subsequent year’s roster  In contrast, 66 percent of the 129 nonanonymous whistle-blowers did not appear in the subsequent year’s roster  Attrition rates were higher among employees who had filed a disclosure than among their peers who had not filed disclosures, for all fiscal years in our review (see table 16)  Our analysis did not confirm the reasons for disciplinary action or attrition involving any of the 129 employees who made nonanonymous disclosures to the OSC  According to VA officials, employees who have a history of poor performance or conduct may be more likely to file a disclosure with the OSC or allege misconduct, which could explain some of the disparities between whistle-blowers and other employees  However, we also could not rule out instances where retaliation by senior officials may have occurred after misconduct was disclosed  The Civil Service Reform Act of 1978, as amended, states, among other things, that federal personnel management should be free from prohibited personnel practices (PPP)  The law also authorizes the OSC to investigate allegations involving PPP that include reprisals against employees for the lawful disclosure of certain information pertaining to individuals who engage in such conduct or other wrongdoing  According to Standards for Internal Control in the Federal Government, laws and regulations may require entities to establish separate lines of communication, such as whistle-blower and ethics hotlines, for communicating confidential information  Management informs employees of these separate reporting lines, how they operate, and how they are used, and how the information will remain confidential  Reporting lines are defined at all levels of the organization and provide methods of communication that can flow down, across, up, and around the structure  Our interviews with six VA whistle-blowers who claim to have been retaliated against provided anecdotal evidence that retaliation may be occurring  Whistle-blowers we spoke to alleged that managers in their chain of command took a number of actions that were not traceable to retaliate against the whistle-blowers after they reported misconduct  These alleged actions included being reassigned to other duty locations or denied access to computer equipment necessary to complete assignments, and socially isolating these individuals from their peers, among other things  Whistle-blowers we spoke to also expressed concerns regarding the lack of guidance available to employees about how to file a disclosure through VA and the OSC  Whistle-blowers stated that employees are not provided adequate information on how to document or file a claim of misconduct or retaliation  Employees can file disclosures regarding misconduct and complaints of retaliation through multiple reporting lines  As mentioned previously, however, the OSC will generally not refer to the Secretary under its statutory process a disclosure if the OIG has conducted or is already conducting an investigation of that particular complaint  Thus, whistle-blowers may limit their chance of having an independent, non-VA entity oversee their complaint if they file a complaint with the OIG first  The Department of Veterans Affairs Accountability and Whistleblower Protection Act of 2017 requires the Secretary, in coordination with the Whistleblower Protection Ombudsman, to provide training regarding whistle-blower disclosures to each employee of VA  This information shall include, among other items, an explanation of each method established by law in which an employee may file a whistle-blower disclosure, an explanation that the employee may not be prosecuted or reprisal taken against him or her for disclosing information, and language that is required to be included in all nondisclosure policies, forms, and agreements  The Secretary shall also publish a website and display the rights of an employee making a whistle-blower disclosure  In August 2017, VA began providing additional information on its website for potential whistle-blowers who wish to report criminal or other activity to the OIG  The information provided focuses on reporting misconduct to the OIG and provides other lines of reporting established by law in which an employee may file a whistle-blower disclosure, such as directly to an immediate supervisor or the OSC  In addition, the information provided explains the process after misconduct is reported through the OIG Hotline, but does not clarify the process for referred disclosure cases received from the OSC  As mentioned previously, OIG officials stated that a disclosure made to the OSC or the OIG can be referred back to the facility or program office where the allegation originated, which may compromise confidentiality  Consequently, employees may not be aware that their information may be shared among the OSC, the OIG, OAWP, or VA facility and program offices when a disclosure is made to the OSC  Adequately communicating the investigative process to employees may alter their decision to report wrongdoing  Without a clear understanding of the lines for reporting misconduct and how they operate, whistle-blowers may be uncertain as to their options for reporting misconduct, which increases the risk that they may not report workplace misconduct  According to OSC, it has learned through its cases that OAWP has a practice of allowing VA employees, who are the subject of the allegations brought forward by whistle-blowers to review or participate in investigations, or both, which could make the whistle-blower feel uncomfortable or intimidated  This practice has led to confusion regarding the role and responsibilities of OAWP personnel  OAWP’s use of VA employees that are employed at the facility under investigation in the review of allegations creates the possibility of a conflict of interest or an appearance of a conflict of interest  For example, in a case OSC described in its comments on a draft of our report, an OAWP representative who was also associated with the human-resource office at the VISN that oversees the whistle-blower’s facility, placed the whistle- blower under oath and questioned her about issues unrelated to the referred allegations  OSC has since sought clarification of OAWP’s role and the OAWP employee’s possible connection to the VISN  While VA collects data on some types of disciplinary actions, it is limited in its ability to use those data because it does not collect all misconduct and associated disciplinary-action data through a single information system, or multiple interoperable systems  Absent a process to collect such data department-wide, VA does not have the ability to analyze and report data systematically  In addition, the data currently collected are not always reliable or useful  The inclusion of appropriate documented guidance and standardized field definitions would help to ensure VA collects reliable misconduct and associated disciplinary-action data  With high-quality information that is accurate and comprehensive, VA management would be better positioned to make knowledgeable decisions regarding the extent of misconduct occurring and how it was addressed, department-wide  VA has not ensured that program and facility human-resources personnel adhere to policy governing documentation contained within evidence files to support conclusions reached  In addition, VA often had no record of the evidence involved with the adjudication of these actions and could not verify whether these individuals received reasonable and fair due process  The absence of documentation in some files also raises the possibility that VA may not always be in compliance with its procedures for governing the adjudication of alleged employee misconduct  Additionally, ensuring that human-resources personnel adequately inform employees of their rights during the adjudication process would provide them with a reasonable opportunity to present their case when preparing their defense  VA also does not consistently adhere to OPM and NARA guidance in defining a specific retention period for adverse action files  This results in an inconsistent retention of these files across VA which complicates department-wide analysis  VA’s inconsistent adherence to the standards provided by the OIG to facilities and program offices for investigating and resolving misconduct cases increases the risk that misconduct case are not being handled appropriately  Additionally, the lack of verification of responses received to ensure documentation supports findings and recommendations has contributed to evidence that does not always meet the requirements outlined by the OIG  Finally, timely responses are not consistently provided when facility and program offices report findings to the OIG’s Hotline Division  OAR did not monitor whether substantiated instances of misconduct involving senior officials received disciplinary action  OAR’s Legacy Referral Tracking List also did not accurately reflect the disciplinary action that was decided based on the results of the investigation  When disciplinary actions are taken, in response to findings of misconduct, but are not entered within an appropriate information system, or are inaccurately recorded, it is more difficult to monitor whether disciplinary actions have been implemented in substantiated instances of misconduct involving senior officials  As demonstrated, this may result in no action being taken for substantiated misconduct or the previous penalties not having the corrective effect for repeat offenders  There is also an increased risk that substantiated misconduct will go unaddressed if there is no recommendation for corrective action  Further, VA also does not have internal controls to ensure adherence to proper separation-of-duty standards involving the removal of an employee  Such controls would minimize the risk of abuse when officials act as both proposing and deciding officials  In addition, VA does not have oversight measures to ensure that all allegations of misconduct referred by the OIG to facility and program offices are investigated by an entity outside the control of the facility or program office involved in the misconduct  The investigation of allegations of misconduct by the program office or facility where the complaint originated may present the appearance of a conflict of interest in which managers and staff at facilities may investigate themselves or other allegations where they may have a personal stake or bias in the matter to be investigated  Therefore, the risk that the results of the investigation are minimized, or not handled adequately, is increased  VA’s newly developed process to communicate the scope of its reviews that involve matters referred by the OSC to the Office of the Secretary will be important to ensure any allegations outside the purview of the OIG’s investigation are fully addressed by a departmental entity in accordance with OSC requirements  Further, the OIG’s inability to locate investigative documentation prevents a third party from verifying whether the OIG examined the disclosures, whether any recommendations were addressed, or whether appropriate disciplinary action was taken for these cases  This lack of information has direct influence on management’s ability to make sound decisions relating to investigative matters  According to OIG officials, a spreadsheet is being used for tracking case numbers associated with disclosures, but plans to implement a process within the new system  Nonanonymous whistle-blowers faced higher rates of adverse action subsequent to their disclosure than the VA population as a whole  In addition, these individuals also had attrition rates higher than their peers who had not filed a disclosure  The disparities between whistle-blowers and other employees may be an indication that retaliation by senior officials may have occurred after misconduct was disclosed  Although VA has started to provide additional information for potential whistle-blowers who wish to report criminal or other activity to the OIG, VA does not have a process to inform employees of how their information may be shared between organizations when misconduct is reported  Without a clear understanding of how the lines for reporting misconduct operate, whistle- blowers may be uncertain as to their options for reporting misconduct, increasing the risk that they may not report workplace misconduct  We are making the following 16 recommendations to VA  The Secretary of Veterans Affairs should develop and implement guidance to collect complete and reliable misconduct and associated disciplinary-action data department-wide, whether through a single information system, or multiple interoperable systems  Such guidance should include direction and procedures on addressing blank data fields, lack of personnel identifiers, and standardization among fields, and on accessibility  (Recommendation 1) The Secretary of Veterans Affairs should direct applicable facility and program offices to adhere to VA’s policies regarding employee misconduct adjudication documentation  (Recommendation 2) The Secretary of Veterans Affairs should direct the Office of Human Resource Management (OHRM) to routinely assess the extent to which misconduct-related files and documents are retained consistently with VA’s applicable documentation requirements  (Recommendation 3) The Secretary of Veterans Affairs should direct OHRM to assess whether human-resources personnel adhere to basic principles outlined in VA Handbook 5021 when informing employees of their rights during the adjudication process for alleged misconduct  (Recommendation 4) The Secretary of Veterans Affairs should adhere to OPM and NARA guidance and establish a specific record-retention period for adverse action files  In doing so, the Secretary should direct applicable administration, facility, and program offices that have developed their own record-retention schedules to then adhere to the newly established record-retention period  (Recommendation 5) The Department of Veterans Affairs (VA) Inspector General should revise its policy to include a requirement to verify whether evidence produced in senior-official case referrals demonstrates that the six elements required in VA Directive 0701 have been addressed  (Recommendation 6) The Secretary of Veterans Affairs should direct the Office of Accountability and Whistleblower Protection (OAWP) to review responses submitted by facility or program offices to ensure evidence produced in senior-official case referrals demonstrates that the six elements required in VA Directive 0701 have been addressed  (Recommendation 7) The Secretary of Veterans Affairs should direct OAWP to issue written guidance on how OAWP will verify whether appropriate disciplinary action has been implemented for all substantiated misconduct by senior officials  (Recommendation 8) The Secretary of Veterans Affairs should direct OAWP to develop a process to ensure disciplinary actions proposed in response to findings of misconduct are recorded within appropriate information systems to maintain their relevance and value to management for making decisions and take steps to monitor whether the disciplinary actions are implemented  (Recommendation 9) The Secretary of Veterans Affairs should direct OAWP to issue written guidance on how OAWP will review the disposition of accountability actions for all substantiated misconduct cases involving senior officials resulting from investigations  (Recommendation 10) The Secretary of Veterans Affairs should implement internal controls to ensure that proper adherence to separation-of-duty standards involving the removal of an employee are consistent with policy  (Recommendation 11) The Secretary of Veterans Affairs should develop oversight measures to ensure all investigations referred to facility and program offices are consistent with policy and reviewed by an official independent of and at least one level above the individual involved in the allegation  To ensure independence, referred allegations of misconduct should be investigated by an entity outside the control of the facility or program office involved in the misconduct  (Recommendation 12) The VA Inspector General, in consultation with the Assistant Secretary of OAWP, should develop a process to ensure that OSC case numbers are linked to the investigative case number and final report  (Recommendation 13) The Secretary of Veterans Affairs should direct OAWP to develop a time frame for the completion of published guidance that would develop an internal process to monitor cases referred to facility and program offices  (Recommendation 14) The Secretary of Veterans Affairs should ensure that employees who report wrongdoing are treated fairly and protected against retaliation  (Recommendation 15) The Secretary of Veterans Affairs should direct OAWP to develop a process to inform employees of how reporting lines operate, how they are used, and how the information may be shared between the OSC, the OIG, OAWP, or VA facility and program offices when misconduct is reported  (Recommendation 16) We provided a draft of this report to the Department of Veterans Affairs (VA), VA Office of Inspector General (OIG), and the Office of Special Counsel (OSC) for review and comment  In its comments, VA concurred with nine of our recommendations and partially concurred with five (see app  VI for a copy of VA’s letter)  Regarding our recommendations to the Inspector General, the OIG concurred with one recommendation and partially concurred with the other  The OIG also provided comments on our findings (see app  VII for a copy of the OIG’s letter)  We received technical comments by e-mail from OSC’s Principal Deputy Special Counsel, which we incorporated in the report as appropriate  Regarding VA’s comments, in its response to our first recommendation that the Secretary develop and implement guidance to collect complete and reliable misconduct and associated disciplinary-action data department-wide, VA concurred and outlined steps it plans to take to address our recommendations  These steps include the creation of new policies to address blank data fields, lack of personnel identifiers, lack of standardization among fields, and accessibility issues related to misconduct and associated disciplinary-action data department-wide  The target date for system implementation, dependent on approved funding and acquisition-related requirements, is January 1, 2020  On our second recommendation, that the Secretary direct applicable facility and program offices to adhere to VA’s policies regarding employee-misconduct adjudication documentation, VA concurred  It stated that a memorandum will be distributed to reiterate facility and program-office requirements to adhere to VA Handbook 5021, Employee/Management Relations, no later than October 1, 2018  VA also concurred with our third recommendation, that the Secretary direct the Office of Human Resource Management (OHRM) to routinely assess the extent to which misconduct-related files and documents are retained  According to VA, OHRM will assess, during periodic Oversight and Effectiveness Service reviews, the extent to which misconduct- related files and documents are retained  The first assessment is to be incorporated into the fiscal year 2019 Oversight and Effectiveness Service schedule no later than November 1, 2018  VA concurred with our fourth recommendation, that the Secretary direct OHRM to assess whether human-resources personnel adhere to basic principles outlined in VA Handbook 5021  VA stated that OHRM will assess, during periodic Oversight and Effectiveness Service reviews, whether human-resources and administration personnel adhere to basic principles outlined in VA Handbook 5021  The first assessment is to be incorporated into the fiscal year 2019 Oversight and Effectiveness schedule no later than November 1, 2018  In its response to our fifth recommendation, that the Secretary adhere to Office of Personnel Management (OPM) and National Archives and Records Administration (NARA) guidance and establish a specific record- retention period for adverse-action files, VA concurred and indicated that the Human Resources and Administration Assistant Secretary will establish VA guidance regarding the retention period for adverse-action files  In addition, the Human Resources and Administration Assistant Secretary is to advise applicable administration, facility, and program offices that have developed their own record-retention schedules to adhere to the newly established directive  According to VA, the directive will be established no later than November 1, 2018  VA partially concurred with our seventh recommendation, that the Secretary direct departmental heads to review responses submitted by facility or program offices to ensure evidence produced in senior-official case referrals demonstrates that the six elements required in VA Directive 0701 have been addressed  VA stated that the process described in our report pertaining to OIG findings or results will be changed to require all such reports to be submitted to OAWP  VA also indicated that it expects to publish new guidance by October 1, 2018, that will require the Office of Accountability and Whistleblower Protection (OAWP) to review responses and recommendations from facilities or program offices  Given VA’s comments, we have revised our draft recommendation to have the Secretary direct OAWP, not the department heads, to ensure evidence demonstrates that the six elements have been addressed  VA also partially concurred with our eighth recommendation, that the Assistant Secretary of OAWP review all substantiated misconduct by senior officials to verify whether disciplinary action has been implemented  VA stated that all substantiated misconduct by senior leaders in VA is handled by OAWP from intake, through investigation, working with the proposing and deciding officials  VA also stated that it expects to publish written guidance by October 1, 2018, that will clarify how OAWP will work with the appropriate servicing personnel office to ensure that the recommended disciplinary actions decided are implemented for substantiated misconduct involving senior officials  Given VA’s comments, we have revised our draft recommendation to have the Secretary of Veterans Affairs direct OAWP to issue written guidance on how OAWP will verify that appropriate disciplinary action has been implemented for all substantiated misconduct by senior officials  VA partially concurred with our ninth recommendation, that the Assistant Secretary of OAWP develop a process to ensure disciplinary actions proposed are recorded within appropriate information systems  VA stated that the VA-wide discipline tracking system currently used by OAWP will eventually be phased out  It added that once the Human Resources Information System (HRSmart) is capable of capturing and recording similar data, it will be used for this purpose  Accordingly, we have not revised our draft recommendation  VA partially concurred with our 10th recommendation, that the Assistant Secretary of OAWP assess all misconduct cases involving senior officials to ensure investigative reports with findings of substantiated misconduct include recommendations for action  According to VA, OAWP has instituted several processes since our review  VA plans to issue written guidance that outlines the process for the review and disposition of appropriate accountability actions for allegations of misconduct by senior officials by October 1, 2018  Given VA’s comments, we have revised our draft recommendation to have the Secretary of Veterans Affairs direct OAWP to issue written guidance on how OAWP will review the disposition of accountability actions for all substantiated misconduct cases involving senior officials resulting from investigations  In its response to our 11th recommendation, that the Secretary implement internal controls to ensure that separation-of-duty standards involving the removal of an employee are consistent with policy, VA concurred  It stated that it will also establish and distribute internal controls to ensure that separation-of-duty standards involving the removal of an employee are consistent with policy no later than November 1, 2018  VA partially concurred with our 12th recommendation, that the Secretary take steps to ensure independence of referred allegations of misconduct by requiring that investigations be conducted outside the control of the facility or program office involved in the misconduct  VA stated that OAWP is responsible for recording, tracking, reviewing, and confirming the implementation of recommendations from audits and investigations  However, VA did not address how it will ensure the independence of the entity responsible for conducting an investigation  As we discuss in our report, during the review OAWP officials stated that the process of referring cases of misconduct back to facilities and program offices where the misconduct occurred will continue  Accordingly, we have not revised our draft recommendation and believe implementation of it will help ensure independence  VA concurred with our 14th recommendation, that the Assistant Secretary of OAWP develop a time frame for the completion of published guidance for the development of an internal process to monitor cases referred to facility and program offices  VA provided an expected date of October 1, 2018, for publishing the internal VA guidance, with the subsequent Directive and Handbook to be published as rapidly as staff coordination permits  In its response to our 15th recommendation, that the Secretary ensure that employees who report wrongdoing are treated fairly and protected against retaliation, VA concurred  It stated that OAWP and OSC have developed a functional process to ensure whistle-blower protections are implemented, but did not indicate what the process entails  The VA Secretary has also delegated authority to the Executive Director, OAWP, to put individual personnel actions on hold if the actions appear motivated by whistle-blower retaliation  VA added that OAWP has also hired two whistle-blower program specialists specifically to increase awareness of whistle-blower protections and work with individuals that disclose employee wrongdoing to ensure individuals are treated fairly and protected from retaliation for their disclosures  VA concurred with our 16th recommendation, that the Assistant Secretary of OAWP develop a process to inform employees of how reporting lines operate  VA stated that it will provide whistle-blower training to all employees on a biennial basis, which will include the reporting lines for disclosures of wrongdoing, the manner in which disclosures flow once they are made, how information is shared among the whistle-blower entities, and what protections exists for those who disclose wrongdoing  Regarding our recommendations to the Inspector General, the OIG partially concurred with our sixth recommendation, to revise its policy to include a requirement to verify whether evidence produced in senior- official case referrals demonstrates that the six elements required in VA Directive 0701 have been addressed  The OIG indicated that VA Directive 0701 is currently being updated to require a written or electronic signature from the person preparing the responses as an attestation that the specific requirements of the directive were met  The OIG also indicated in its letter that the OIG’s Hotline staff carefully review the case response but Hotline staff are not required to request an updated response from VA to address matters not necessary to the resolution to the referral  The OIG asserted that requesting an update would detract from the resources for other important VA activities  On page 4 of the OIG’s letter, the OIG states that Hotline analysts are allowed to exercise some discretion in accepting responses that may include minor departures from the six elements  We continue to believe that, in order to have a complete response to a referral, all six elements required by the directive should be addressed  In addition, Directive 0701 does not allow for the use of professional judgement to decide which elements to include or not to include in a response  While we agree that requiring a written or electronic signature from the person preparing the responses as an attestation will help ensure that the specific requirements of the directive were met, we maintain that not requiring Hotline analysts to review responses to ensure that all elements of the directive are addressed is inconsistent with the intent of the directive  In its response to our 13th recommendation, that the OIG develop a process to ensure that an OSC case number is linked to the investigative case number and the final report, the OIG concurred  It stated that it will engage with the Executive Director of OAWP to develop a process to ensure that OSC case numbers are linked to OIG and OAWP investigative case numbers, as appropriate, and linked to any final report of investigation  In addition to its response to recommendations, the VA OIG also raised a number of concerns with our findings  Page 1 of its letter summarizes some of these concerns and then provides more detail on each concern raised, starting on page 2  Our responses to each of these detailed concerns are provided below  The OIG stated that our report does not focus on the most important cases, but focuses primarily on case referrals regarding senior officials that were not handled by the OIG because the allegations were lower risk or because of resource constraints  In addition, the OIG stated that GAO risks presenting a skewed picture of the OIG’s oversight work  We disagree with this characterization of our findings  We requested that the OIG provide us with data from the OIG’s Master Case Index (MCI) information system that would allow us to select a sample of cases, in accordance with the scope of our review  The OIG was unable to provide the requested information due to several reasons  Instead, the OIG provided data from the OIG Hotline and Office of Investigations case- management systems (subsystems within MCI) that contained a limited number of fields for analysis and 23 cases pertaining to SES misconduct that were referred to VA for investigation during GAO’s period of review  Therefore, as we discuss in the report, we were only able to review the 23 senior-official misconduct cases included in our report because the OIG was only able to provide related documentation for these cases  The OIG stated that we only reviewed a sample of just 23 case referrals from fiscal years 2011 through 2014  As described, we reviewed all 23 senior-official misconduct cases that were referred to VA for investigation that the OIG was able to provide us, not a sample  The OIG stated that our report inaccurately states that the extracts received from the MCI information system contained missing information  We disagree with this characterization of our findings  Our review included a comprehensive assessment of the reliability of the OIG’s data  To conduct this assessment, we requested an explanation of each data field to clarify when fields are normally populated and how they are used  Our findings are consistent with the information provided in response to this request  For example, the OIG’s response to our data-reliability assessment stated that the data field used to identify the type of allegations being investigated should never be blank  However, we found that field to be blank in some cases in the data that were provided to us, though the OIG asserted that the MCI information system is a relational database where each case may be associated with multiple allegations and codes  In response to the OIG’s comments on our report, we requested supporting documentation to demonstrate that the fields analyzed during our period of review did not contain missing data  The OIG provided the MCI information system user’s manual that contains detailed procedures for accessing and entering data into the MCI information system, and a compilation of various internal documents  However, the documentation did not provide evidence of the completeness of data entered into the MCI information system as part of quality-assurance reviews performed by the OIG or other designated entity  Absent evidence of data-quality reviews aimed at assessing the accuracy and completeness of data contained in the MCI information system, we did not change the conclusions based on our previous analysis  The OIG stated that our report provides incomplete information regarding sampled cases and mischaracterized one of the OIG’s case referrals in the body of the report  We disagree with this characterization of our findings  Specifically, the OIG said that we inaccurately stated that a medical center director conducted the investigation into his own alleged misconduct and found no allegations were substantiated  The synopsis included in our report clearly articulates that the medical center director was named in the allegation for having received a similar complaint involving time and attendance abuse by a physician  The medical center director, who provided the response to the OIG, was implicated in the allegation as having not addressed a similar time and attendance complaint regarding the same physician 2 years earlier  The OIG did not provide any supporting documentation to demonstrate that the alleged time and attendance abuse allegations against the physician were not substantiated  The OIG stated that our report inaccurately stated that the medical center director conducted his own investigation of himself and found no allegations were substantiated  We disagree  In response to the OIG’s comments on our report, we requested that the OIG provide additional support used to determine that the medical center director did not investigate the allegation in which he was named  The additional case documentation provided by the OIG further reaffirmed our assessment that the medical center director performed his own investigation and found no allegations were substantiated  Additional documentation provided by the OIG indicated that the OIG referred the case to the Veterans Integrated Service Network (VISN) for a response  However, documentation we examined during the course of our audit, and the documentation provided in response to our draft report, indicates that the medical center director performed the investigation of the allegations and then the results were routed through the VISN back to the OIG  The OIG stated that routing the response through the VISN should address our concerns of independence  This process does not address our concerns regarding independence because VA Directive 0701 states that all responses to Hotline case referrals must contain evidence of an independent review by an official separate from and at a higher grade than the subject / alleged wrongdoer  In this case, the name of the medical center director who signed the facility response provided to the OIG was the same individual named in the allegations  The OIG stated that the report does not provide a balanced presentation of the rigor with which the OIG reviews all incoming Hotline contacts and case responses  We disagree with this characterization of our findings  As described above, the OIG was unable to provide comprehensive data to select a sample of OIG audits, evaluations, and inspections for review due to the limitations cited  We focused on misconduct involving senior officials consistently with the scope of our review and thoroughly reviewed all 23 senior-official misconduct cases that were referred to VA for investigation, which were the only cases that the OIG was able to provide  The OIG stated that the description for one of the cases included in appendix V of the draft report was incomplete because we misunderstood the OIG’s process  We disagree with this characterization  In response to the OIG’s comments on our report, we requested additional supporting documentation  The documentation provided reaffirmed our assessment that another medical center director performed his own investigation and found no allegations were substantiated  Similar to the case described above, the medical center director completed his own investigation and then routed the response through the VISN back to the OIG  In contrast to the previous case, however, the Hotline Workgroup reviewed the response to the OIG and found it to be insufficient  Specifically, the OIG noted that the medical center director who provided the response was the subject of the complaint, despite the response being directed to the VISN, and requested clarification  The VISN informed the OIG that it is not its policy for the complainant to have any involvement in the review and data submission on a case in which the complainant is involved  The VISN stated that while this did obviously occur in this instance, it has taken steps to ensure it does not occur in the future  The supporting evidence provided for the case included in appendix V also contradicts the OIG’s previous assertion that the routing of a response through the entity with oversight (VISN) over the medical center director should have addressed GAO’s concerns of independence  The OIG stated our report provides a misrepresentation of the OIG’s failure to follow internal policies for department responses  We disagree  According to OIG statements on page 4 of the OIG’s letter, Hotline analysts are allowed to exercise some discretion in accepting responses that may include minor departures from the six elements required in VA Directive 0701  We continue to believe that in order to have a complete response to a referral, all six elements required by the directive should be addressed  On the basis of our review, the OIG does not have an effective method to ensure that cases referred to VA are reviewed in accordance with VA Directive 0701  Out of the 23 cases we reviewed, only 4 included sufficient documentation needed to support VA’s findings, and we could not identify a case that contained all six elements required in VA Directive 0701  This suggests that the current OIG review process is not adequately resolving case referrals, as asserted by the OIG’s response  In addition, VA Directive 0701 does not currently include a provision that would allow Hotline analysts to deviate from the six required elements  As stated in our report, the OSC also raised concerns regarding 40 percent of disclosure cases that were referred to VA facility and program offices  The OIG stated that much of the information in the draft report is dated and ignores system updates, specifically several key Hotline-related process improvements since 2014  Although our review began in 2015, we disagree with this characterization of our findings  In our report, we included relevant improvements to demonstrate where the OIG was able to provide support for those improvements  For example, our report discusses: (1) a new process for communicating the scope of reviews that involve matters referred by the OSC to the Office of the Secretary, (2) a description on the VA website of the process for employees who wish to report criminal or other activity to the OIG, (3) a new Enterprise Management System, and (4) a new process for receiving whistle-blower disclosures by the Secretary  In response to the OIG’s comments on our report, we requested additional documentation for any systems, practices, or personnel changes that have been implemented since 2011, including improvements to Hotline-related processes since 2014 that were not included in our report  In response, the OIG provided a copy of the OIG’s organizational chart (current as of Apr  23, 2018), described the oversight responsibilities of each OIG component, and summarized the pertinent staff positions within each component  On the basis of this documentation, we identified a new office (the Office of Special Reviews), a promotion, staff reassignments, and numerous vacancies during our review period  However, the OIG did not provide evidence of any measures to improve the MCI information system, case-referral processes, or relevant staff roles that were not already included in our report  As described above, the OIG was unable to provide comprehensive data to select a sample of OIG audits, evaluations, and inspections for our initial review due to the limitations cited  In response to the OIG’s comments on our report, we requested documentation related to any significant changes that have been made to the MCI information system that allows the OIG to identify all allegations of misconduct for export and analysis  The OIG provided additional information regarding overall departmental achievements that are highlighted in the OIG’s Semiannual Report to Congress, and other products from its website published between fiscal years 2011 through 2018  We recognize the OIG’s broader administrative and oversight work described in the published reports  However, this information does not address changes specifically made to the MCI information system that would enable the OIG to analyze cases pertaining to alleged misconduct by senior officials that we requested  We are sending copies of this report to the appropriate congressional committees, the Secretary of Veterans Affairs, and other interested parties  In addition, the report will be available at no charge on the GAO website at http://www gao gov  If you or your staff have any questions about this report, please contact me at (202) 512-5045 or larink@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report  Our objectives were to determine the extent to which the Department of Veterans Affairs (VA) (1) collects reliable information associated with employee misconduct and disciplinary actions that is accessible and could be used to analyze misconduct department-wide; (2) retains documentation that demonstrates VA adheres to its policies when adjudicating cases of employee misconduct; (3) ensures allegations of misconduct involving senior officials are reviewed in accordance with VA investigative standards, and these officials are held accountable; (4) has procedures to investigate whistle-blower allegations of misconduct; and the extent to which (5) data and whistle-blower testimony indicate whether retaliation for disclosing misconduct occurs at VA  For the first objective, we obtained VA employee misconduct data from 12 information systems operated by various VA components covering October 2009 through July 2017, where available  To determine the reliability of VA’s misconduct data, we analyzed the contents of the 12 information systems operated by various offices across VA  These data encompass each of the three major administrations that constitute VA— the National Cemetery Administration (NCA), Veterans Benefits Administration (VBA), and Veterans Health Administration (VHA)  We selected the information systems based on our discussions with VA officials and staff that oversee the data and, hence, identified databases capable of collecting information pertaining to either employee misconduct or disciplinary actions  Data fields were selected based on whether they would provide beneficial information to better understand the disciplinary process  VA’s Personnel and Accounting Integrated Data (PAID) system, which was developed to track payroll actions, contains information about adverse disciplinary actions that affect employee salary department-wide  We obtained an extract of all adverse disciplinary actions from the PAID system  We assessed the reliability of each system for the purposes of identifying and tracking misconduct cases  To do this, we performed electronic tests on 12 information systems to determine the completeness and accuracy of the fields contained in the data files  We also submitted to the overseeing offices for all 12 information systems general data-quality questions regarding the purpose of the data, their structure, definitions and values for certain fields, automated and manual data-quality checks to ensure the accuracy of the data, and limitations  As discussed further, the data were generally not reliable for a department-wide assessment of all misconduct and disciplinary actions due to the lack of completeness and compatibility of the data across all information systems  VA staff could not confirm whether some of the missing data we identified were artifacts of the database extraction process VA used to assemble the data files we used in our review  Despite challenges with aspects of the data, we found the data sufficiently reliable for conducting analysis where fields were populated and field definition concurrence was obtained by program offices  For the second objective, we selected a generalizable stratified random sample of 544 misconduct cases from October 2009 through May 2015  Where available, we reviewed the employees’ disciplinary-action files and Electronic Official Personnel Folders to determine the extent to which VA’s actions were consistent with disciplinary policy outlined in VA Handbook 5021, Employee/Management Relations  These data encompass each of the three major administrations that constitute VA— NCA, VBA, and VHA  We determined the data to be sufficiently reliable for analysis of disciplinary actions affecting salary that resulted from misconduct that was not reported to supervisors directly from employees  Accordingly, our sample only includes misconduct cases that resulted in a change in salary or were reported to departmental organizations within the 12 information systems selected  We developed a data-collection instrument to document the results of our case reviews  We revised our data-collection instrument to address issues found during the course of our analysis, and developed a companion document that outlined the decision rules for reviewing cases  We also designated two primary reviewers to ensure the decision rules were consistently applied across all cases  Our review of laws and regulations revealed that disciplinary rules sometimes vary depending on whether employees fall under Title 5, Title 38, or hybrid Title 5 and Title 38 hiring authority  To minimize confusion associated with these differences, we incorporated criteria into our data- collection instrument  In addition, we were unable to obtain complete case information for 25 percent of the cases  For these cases, we obtained direct access to the Office of Personnel Management’s (OPM) Electronic Official Personnel Folders system to attempt to recover some of the missing information  Ultimately, we were unable to complete our review for 10 percent of cases in our sample because of missing files  In addition to reporting missing case information, we used our generalizable analysis results to project VA-wide figures for several data elements that were not in compliance with VA policy  Unless otherwise noted, estimates in this report have a margin of error of +/-7 4 percentage points or less for a 95 percent confidence interval  For the third objective, we analyzed data from the Office of Accountability Review (OAR) Legacy Referral Tracking List and VA Office of Inspector General (OIG) case-referral and investigative case-management systems, and we selected cases for in-depth review  We selected these two systems based on discussions with VA officials who were knowledgeable with databases that have the capacity to track misconduct information pertaining to senior officials  The OAR Legacy Referral Tracking List comprises referrals from January 2011 through May 2015  The OIG provided 23 case-referral files involving senior officials from calendar years 2011 through 2014  As part of our review of the OIG case files, we evaluated specific data elements contained in VA’s response documents using VA policy for referring and reviewing misconduct cases  We assessed the reliability of the OAR Legacy Referral Tracking List and OIG case-management systems for the purposes of identifying and tracking misconduct cases  To do this, we performed electronic tests on each database to determine the completeness and accuracy of the fields contained in the data files, including senior-official indicators  Where feasible, we opted to match individual datasets to PAID to determine whether disciplinary actions were administered as prescribed  We also submitted to OAR and the OIG general data-quality questions regarding the purpose of the data, their structure, definitions and values for certain fields, automated and manual data-quality checks to ensure the accuracy of the data, and limitations  On the basis of this information, we found the OAR data to be sufficiently reliable for conducting analysis where fields were sufficiently populated  For the OAR data, we matched the persons of interest to adverse-action files from PAID to determine whether adverse disciplinary actions were administered as prescribed during the available time frame (January 2011 through May 2015)  We also obtained VA’s response documents for the 23 case-referral files provided by the OIG to evaluate whether VA was adhering to its own policy for referring and reviewing misconduct cases  Through our OAR Legacy Referral Tracking List analysis, we identified illustrative case examples of misconduct involving senior officials  Further, based on our evaluation of the 23 OIG case referrals using VA’s referral policy, we developed several illustrative case examples  For the fourth objective, we interviewed senior officials from VA and the OSC responsible for investigating whistle-blower complaints  We obtained the OSC’s procedures for referring disclosure complaints and VA’s policy for investigating these complaints once received at the agency  In addition, we obtained whistle-blower disclosure data from the Office of Special Counsel (OSC) covering calendar years 2010 through 2014  To determine the reliability of the data, we conducted electronic testing and traced data elements to source documentation  We determined the data to be sufficiently reliable to identify the total number of cases that were investigated by the OIG, or referred to facility and program offices  We also observed a course to assess VA’s training provided to VA employees conducting investigations  We identified 135 OSC disclosure cases for analysis based on two criteria: (1) they contained at least partial complainant information (i e , the allegations were not anonymously reported or could be identified with supplemental information) and (2) they contained an indicator that the case had been closed by the OSC pending an ongoing investigation by VA or the OIG  These cases represent the universe of VA disclosures accepted by the OSC  Of the 135 disclosure cases referred to VA, 53 cases were referred to VA facility and program offices for further investigation  The remaining 82 disclosure cases indicated that they were investigated by the OIG  We reviewed the results of OSC’s assessment of investigative documentation developed by VA for these whistle-blower disclosure cases  For the fifth objective, we analyzed the 135 whistle-blower disclosure cases obtained from the OSC  These cases represent the universe of VA disclosures accepted by the OSC from calendar years 2010 through 2014, which were investigated by VA  We obtained an extract of year-end rosters from the PAID system as of September for fiscal years 2010 through 2014, with a final extract through May 30, 2015  Finally, we interviewed representatives from whistle-blower advocacy groups, as well as established whistle-blowers who disclosed wrongdoing or retaliation at VA and who were referred to us by one advocacy group  Of the 135 disclosures received by the OSC, a total of 129 employees made a total of 130 disclosures nonanonymously  For these 130 disclosure cases, we reviewed OSC and OIG investigative reports, as well as PAID roster files, to gather additional information to perform analysis of potential retaliation  We also interviewed six individual whistle- blowers with formal disclosure cases accepted by the OSC, indicating that the OSC had previously reviewed the case and determined that it contained sufficient evidence and merit to warrant further investigation  Our analysis of potential retaliation comprised two parts  First, we compared the 129 employees associated with the selected OSC cases to the PAID rosters using the complainants’ information to determine whether employees associated with the selected OSC cases were more likely to leave the agency  We identified the overall count and proportion (across years) of roster-matched employees who made a disclosure between fiscal years 2010 through 2014 but were not employed at VA the following fiscal year  Second, to determine whether employees associated with the selected OSC cases were more likely to receive disciplinary action, we also calculated the yearly totals and proportion of roster-matched employees identified above for whom a record existed in the PAID disciplinary action information system  We did this by comparing the proportion of employees who received one or more disciplinary actions in the year prior to the appearance in the roster, in the same fiscal year as the roster, and in the subsequent fiscal year  We also completed this analysis utilizing the PAID roster file to determine the yearly proportion of all VA employees who left the agency  On the basis of the results of our analysis, we reported by fiscal year the percentage of whistle-blowers that received disciplinary action or left VA at a higher rate than the overall VA population following a disclosure  To address all objectives, we interviewed senior officials from VA’s major components responsible for investigating and adjudicating cases of employee misconduct  We also reviewed standard operating procedures, policy statements, and guidance for staff charged with investigating and adjudicating allegations of employee misconduct  We conducted this performance audit from January 2015 to May 2018 in accordance with generally accepted government auditing standards  Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives  We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives  This data file is designed to track referrals made to OAR, including allegations of misconduct related to senior officials  Through our analysis of this spreadsheet, we identified 11 fields out of 92 that were missing information that could be used to analyze misconduct  Complainant #1 (First Name) (20 percent of 1,245 blank)— According to OAR, this field is populated when there is a known complainant for a matter  Some matters referred to OAR may be anonymously disclosed and not contain complainant information  This file also contains a case-origin field that specifies whether a case was anonymous  Our review of both the complainant and case-origin field indicated that only 11 percent of the complaints were generated from an anonymous source, and the remaining records should have included a complainant name  Disciplinary Action (96 percent of 1,245 blank)—This field should be populated to indicate whether a disciplinary action was taken after the completion of an investigation  Grade (97 percent of 1,245 blank)—According to OAR, this field should be populated with the grade of the Person of Interest (POI), if known  Our review of this field indicated that 97 percent were blank, therefore we were unable to analyze the variation in grade level for officials who were the subject of complaints  OAR Action (77 percent of 1,245 blank)—According to OAR, this field should be populated as an internal reference to describe what stage in the administrative process the matter was in when received  The lack of information did not allow for analysis of the types of actions taken for each case  Person of Interest (POI) (47 percent of 1,245 blank)—This field specifies the first and last name of the Department of Veterans Affairs (VA) employee who is the subject of an allegation  POI (Person of Interest) Last Name 1–5 (51 to 99 percent of 1,245 blank)—This field specifies the last name of VA employee who is the subject of an allegation  There are a total of five person-of-interest (POI) fields for each matter  According to OAR, blank POI fields occur when the case has fewer than five POIs or the POI was not specified in the matter referred  Our review of the five POI fields indicated that more than half of the records did not contain at least one POI because no individual was specified  The lack of information did not allow for further investigation of senior-level officials involved in misconduct  Proposed Action (97 percent of 1,245 blank)—According to OAR, this field should be populated to notify OAR staff if any disciplinary action was proposed  Our review of this field indicated that 97 percent were blank, suggesting that very few high-level officials received corrective action, or the field was not consistently completed for each record  Due to the large share of blank values, the data posed limitations when analyzing how many senior officials received corrective action as a result of a complaint  This data file is designed to track misconduct and disciplinary actions taken against VA employees  Through our analysis of this spreadsheet, we identified 9 fields out of 21 that were missing information that could be used to analyze misconduct  Action Taken (3 percent of 9,851 blank)—According to OAR, this field should be populated with the action that the deciding official takes, with the exception of pending actions  If there is a pending action, this field will remain blank  Our review of the action-taken field found three records that were annotated as a “pending decision” within this field, which indicates that there is an option for entering information into this field when there is an action pending and the field should never be blank  Admin Leave (30 percent of 9,851 blank)—According to OAR, this field should be populated if an employee is placed on administrative leave while an adverse action is pending  If an employee is not placed on administrative leave, the field may be left blank  Our review of the admin-leave field found that about 66 percent of the records were annotated as “no” within this field, which indicates that there is an option for entering information into this field when an employee was not placed on administrative leave  Date Proposed (11 percent of 9,851 blank)—According to OAR, this field is used when an adverse action is proposed for an employee  There are some actions that are not proposed, such as probationary terminations or admonishments that may be taken without being proposed, and therefore result in this field being blank  Our analysis found that about 95 percent of these records containing blank proposed date fields also had an entry in the proposed adverse-action field, which contained such entries as removals, suspensions, and demotions that require a proposed date  Deciding Official (14 percent of 9,851 blank)—According to OAR, this field should be populated with the name of the official who issued the action taken  Effective Date (5 percent of 9,851 blank)—According to OAR, this field should be populated with the date of the action taken  Some entries will not have an effective date if an entry is pending decision  Also, if no action is taken, the decision was counseling, or the proposed action was rescinded, this field may not have an effective date  Our review found that about 14 percent of the cases that included adverse actions, such as a suspension, removal, reassignment, or demotion, and that should have included a date of action, were blank  Offense 2 and 3 (79 and 95 percent of 9,851 blank)—According to OAR, this field tracks the second- and third-most-significant charge against the employee when applicable  Proposing Official (16 percent of 9,851 blank)—According to OAR, this field should be populated with the name of the official who makes the proposed adverse action  Instances where a proposing official has left the agency at the time of entry and could not be found in the lookup feature that relies on the e-mail global address list may produce blank fields  Also, disciplinary actions that were taken without proposal would not have a proposing official  In these instances, the human-resources specialists who enter the actions are instructed to include the name in the other-comments box  Our review of these records indicated that a majority of records lacking an entry in the proposing official field also lacked an annotation in the other- comments field to accurately identify the proposing official  Settlement (14 percent of 9,851 blank)—According to OAR, this field tracks whether a settlement agreement occurred  This data file is designed to collect allegations of criminal activity, waste, abuse, and mismanagement received by the OIG Hotline Division  Through our analysis of this information system, we identified one field out of seven that was missing information that could be used to analyze misconduct  Nature of Complaint (54 percent of 896 blank)—According to the OIG, this field should contain a brief description of the issue that most closely matches the allegation  Each case can have more than one nature of complaint and corresponding administrative action, if any  OIG officials stated that this field identifies the type of allegations being investigated and should never be blank  Our review of these cases found that over half of the cases involving the OIG contained entries for administrative action taken, but the nature-of-complaint fields corresponding to these actions were blank  This data file is designed to track misconduct and disciplinary action taken against VBA employees  Through our analysis of this spreadsheet, we identified 3 fields out of 20 that were missing information that could be used to analyze misconduct  Alleged Offense 2 and 3 (92 and 99 percent of 1,375 blank)— According to VBA officials, this field should be populated if an individual is charged with multiple offenses, or has additional offenses in the same reporting period  In most instances, there is typically only one offense at the time of reporting  Sustained (52 percent of 1,375 blank)—According to VBA, this field should be populated if an offense is sustained at the time of reporting  This data file is designed to track all allegations of misconduct and associated disciplinary actions taken against VA employees  Through our analysis of this spreadsheet, we identified 8 fields out of 34 that were missing information that could be used to analyze misconduct  Deciding Official (3 percent of 5,571 blank)—According to OAWP, this field should be populated with the name of the official who makes the decision for adverse action  Detail Position (89 percent of 5,571 blank)—According to OAWP, this field should be populated with the position an employee was detailed to if removed from official position  Offense 2 and 3 (69 and 91 percent of 5,571 blank)—According to OAWP, this field tracks the most-significant charges against the employee  If there are fewer than three charges, these fields are left blank  Offense 1 Sustained (14 percent of 5,571 blank)—According to OAWP, this field should be populated if an individual’s first offense has been sustained  Offense 2 and 3 Sustained (73 and 91 percent of 5,571 blank)— According to OAWP, these fields should be populated if an individual’s second and third offenses have been sustained  The majority of cases only involve one offense  Proposing Official (9 percent of 5,571 blank)—According to OAWP, this field should be populated with the name of the official who makes the proposed adverse action  This data file tracks Equal Employment Opportunity (EEO) discrimination complaints  Through our analysis of this information system, we identified 1 field out of 66 that did not have standardization that could be useful to analyze misconduct  Employment—We found that the values for this field were not mutually exclusive, or independent of one another  For example, this field includes two distinct categories of information: employment status, such as full time or part time; and hiring authority, such as Title 5 or Title 38  This method of storing information resulted in undercounting each of the separate values due to the system’s failure to account for expected overlap  For instance, an employee could be both a full-time and Title 5 employee and the field only tracks one or the other  ORM officials stated that this field has since been modified to capture more options to account for the overlap  This data file is designed to track misconduct and disciplinary actions taken against Department of Veterans Affairs (VA) employees  Through our analysis of this spreadsheet, we identified 1 field out of 21 that did not have standardization that could be useful to analyze misconduct  Position—We found the VA-Wide Adverse Employment Action Database contained variations within this field, such as multiple values for the “Cemetery Caretaker” position name  According to OAR, this field is a free-text field, and the office conducts manual searches to review and analyze position titles when needed  Our review found that the different variations in position titles made it difficult to successfully determine the frequency and nature of allegations by position  This is an information system designed to collect allegations of criminal activity, waste, abuse, and mismanagement received by the OIG Hotline Division  Through our analysis of this data file, we identified 1 field out of 7 that did not have standardization that could be useful to analyze misconduct  Nature of Complaint—Our review of the Master Case Index file found variations of similar values in this field  For example, this field contained 21 different claim types pertaining to similar types of fraud, which made it difficult to assess the frequency and nature of claims entered into the system  OIG officials stated that they do not attempt to account for these variations or assess the frequency of use because they are assigned based on a “best match” to the allegations of the case  This data file is designed to track misconduct and disciplinary action taken against VBA employees  Through our analysis of this spreadsheet, we identified 1 field out of 20 that did not have standardization that could be useful to analyze misconduct  Position—Our review found some duplication and overlapping values among this field  For example, the position title for “service representative” contained 21 similar categories with numerous variations in spelling (i e , Veteran Service Representative vs  Veterans Service Representative, and Rating Veteran Service Representative vs  Rating Veterans Service Representative)  We were unable to verify the number of distinct positions due to the lack of standardization within this field  This data file is a tracking spreadsheet for monitoring misconduct and disciplinary action workload  Through our analysis of this spreadsheet, we identified 5 fields out of 12 that did not have standardization that could be useful to analyze misconduct  Action Proposed/Decided/Taken—We were unable to analyze this data field because the action taken was tracked in one single field and updated with the most-recent action, rather than each distinct action being entered in a separate field  Consequently, we were not able to distinguish those cases where corrective action may have been taken, to verify whether the corrective action had been implemented  Current Status—We were unable to analyze this data field because it was not a standardized field  For example, we were unable to determine the total number of cases that were closed, open, or pending due to the variations in the data field (e g , Open, open, open – pending, open-pending)  Full Name of Employee, Grievant, Appellant, Complainant, Non- Employee—We were unable to distinguish whether the individual filing a complaint was an employee, grievant, appellant, complainant, or nonemployee because the information entered into this single field only provided the employee’s full name and did not provide a distinction as to which category the record was assigned, as indicated by the field name  NCA Facility—We were unable to analyze this data field because it was not a standardized field  For example, we were unable to run demographic information on the different facilities involved because this field contained erroneous information  Examples of erroneous information included the name of the Memorial Service Network in one case, and the region, rather than the facility name, in another  Supervisor Name—We were unable to analyze this data field because it was not a standardized field  For example, we were unable to determine the total number of supervisors that were associated with each case due to the variations in the names entered within this field, which included misspelled first or last names, addition/omission of middle initials, or no first name  This data file is a tracking spreadsheet for all allegations received by the VA Secretary regarding misconduct, patient care, or other wrongdoing  Through our analysis of this spreadsheet, we identified 1 field out of 9 that did not have standardization that could be useful to analyze misconduct  Subject—Our review of this tracking spreadsheet found over 380 different possible categories that could be assigned to one record  These categories contained a significant number of variations  For example, we found 38 different categories that contained possible EEO-related issues such as “EEO/Whistleblower,” “Potential EEO,” and “EEO Violations ” We were unable to distinguish the different subject categories for this field due to the lack of standardization  CSRT officials stated that ExecVA reports contain only data corresponding to specific search criteria  This is an information system for tracking allegations of misconduct at all VA facilities that include violation of law and misdemeanors  Through our analysis of this data file, we identified 3 fields out of 29 that did not have standardization that could be useful to analyze misconduct  Classification—We found that this field contained at least three different variations of assault categories (i e , assault, assault-other, and assault-aggravated)  VAPS officials stated that this field is determined and entered by the user  Crime Type—We found this field contained at least five different variations of alcohol-consumption categories, such as “entering premises under the influence” and “alcohol – under the influence ” VAPS officials stated that this field is determined and entered by the user  Final Disposition—We found this field contained at least two different variations of charge type (i e , charged, charged – Issued Ticket), six different variations of open type (for example, open/referred to Court, open/cvb), and two different variations of closed type (i e , closed, case closed)  VAPS officials stated that this field is determined and entered by the user  This data file is designed to track all allegations of misconduct and associated disciplinary actions taken against VA employees  Through our analysis of this spreadsheet, we identified 1 field out of 34 that did not have standardization that could be useful to analyze misconduct  Position Title—We found this field contained at least 15 different variations of Registered Nurse, such as “Registered Nurse,” “Staff RN,” and “RN ” Allegations surrounding inadequate staffing, patient care, and safety at a Department of Veterans Affairs (VA) emergency room were investigated by the medical center director of the facility  The medical center director found that the inadequate patient care and safety issue was unsubstantiated based on a review of patient safety incidents for the last 6 months  The medical center director did not provide a copy of her report review to support this conclusion  She also indicated that an external consultant was hired to assess staffing issues, and found generally that improvements could be made for staffing to address surge capacity  The director stated the medical center was in the process of implementing the recommendations made by the consultant, but her response did not discuss the specific improvements planned or include the external consultant’s report  A fact-finding was performed by a panel comprised of VA Connecticut Healthcare System officials in response to alleged violations of law, gross mismanagement, and waste of funds that included the improper billing of services for a Las Vegas conference and paying contracts through a VA nonprofit corporation to handle such expenditures  The allegations specifically requested a cost-benefit analysis for the conference location  The response received from the program office stated that an outside accounting firm performs an annual financial audit of the VA nonprofit corporation and found no material issues  Neither a copy of the annual financial audit nor a cost-benefit analysis was provided in the response as support  Additionally, the response did not address allegations regarding the status of several essential positions vacated over the prior 3 years  Allegations involved time-and-attendance abuse by a physician who was accused of not responding to calls from peers or coming into the clinic, in favor of his private practice  According to the complainant, physician assistants (PA) examine the physician’s patients at the clinic for him  The medical center director, who was also named in the allegation as having received a similar complaint against the physician 2 years earlier, reviewed the case against the physician and himself  The medical center director’s response claimed that the location indicated in the allegation was not a private practice, but rather a location where the physician reviews medical records and sometimes serves as an expert witness  He did not provide evidence to support his claim  The medical center director also stated that he had not received any reports against the physician for missed calls or clinics and that PAs are expected to participate in these activities  However, he did not provide the physician’s work log, or the PA position descriptions showing that they are allowed to perform these functions autonomously  Finally, the medical center director claimed he did not recall the allegation made against the physician 2 years prior and neither formally substantiated nor disproved the current allegations against the physician  No recommendations were made  The medical center director was accused of hiring an unqualified individual to a Quality Manager position due to their romantic relationship  The response received from the human-resources consultant noted that it was unusual to find a Nurse II manager with only an associate’s degree, but was not illegal, and the employee was qualified based on prior experience  Concerns were also raised concerning the medical center director’s use of over $400 in government funds to “soundproof” the Quality Manager’s office, including having panels attached to one wall and the hollow office door replaced with a solid door  The Chief of Engineering Services was interviewed regarding the request and stated it was an odd request, and the first time he was asked to soundproof an administrative employee’s office  The response provided by the program office did not address why the director used government funds to soundproof the Quality Manager’s office  The response provided also did not address whether recommendations that the Quality Manager’s retention allowance be reviewed for compliance and that she be counseled for appropriate office dress code were implemented  The medical center director was alleged to have misrepresented a plan to track and provide mental-health services to veterans in non-VA hospitals and created a hostile work environment against African-American veterans and employees  The medical center director investigated the allegations against himself and provided a response that was eventually submitted late to the OIG  His response indicated that a review was completed and all allegations were unsubstantiated  Several documents provided with his response showed that only 12 contacts were made to veterans with mental-health care needs during the requested 24-month period, the percentage of patients experiencing wait times greater than 14 days before receiving mental-health services averaged 18 percent, and two veteran suicides occurred  The medical center director did not address allegations of creating a hostile work environment for African American veterans and employees  The medical center director improperly reannounced a vacancy in order to hire an individual with whom he allegedly had a close personal relationship to an Assistant Director position  He also requested the master key to the facility be issued to her against regulations  The allegation involving the master key was substantiated, but the Deputy Under Secretary who conducted the investigation stated that while there was no record of the key being returned, the key was returned and the general engineer brought the facility into compliance with VA regulations  Nonetheless, the Deputy Under Secretary found that a master key was issued in violation of policy, but no recommendations were made to the medical center director for corrective action  Allegations involved false patient wait-time documentation and abuse of authority  Specifically, a medical center director instructed staff to falsify patient wait times between follow-up appointments in order to meet VA’s 14-day timeliness metric  The investigation concluded that the false documentation allegation was substantiated, but attributed the cause to staff not understanding how to enter a follow-up appointment date into the system  It was also concluded that the correction of several hundred dates in the system improved the performance of the department for the national wait-time metric  However, no documentation was provided to (1) prove the medical center director had not abused his authority by instructing staff to review wait times greater than 14 days to determine how they could be reduced, and (2) support the conclusion that the original wait times were entered in error  In addition to the contact above, Dave Bruno (Assistant Director), Erica Varner (Analyst in Charge), Hiwotte Amare, Chris Cronin, Carrie Davidson, Ranya Elias, Colin Fallon, Mitch Karpman, Grant Mallie, Anna Maria Ortiz, Sabrina Streagle, Reed Van Beveren, and April Van Cleef made key contributions to this report 


Report 2: The issue of who gets disciplined and why is complex  Studies we reviewed suggest that implicit bias—stereotypes or unconscious associations about people—on the part of teachers and staff may cause them to judge students’ behaviors differently based on the students’ race and sex  Teachers and staff sometimes have discretion to make case- by-case decisions about whether to discipline, and the form of discipline to impose in response to student behaviors, such as disobedience, defiance, and classroom disruption  Studies show that these decisions can result in certain groups of students being more harshly disciplined than others  Further, the studies found that the types of offenses that Black children were disciplined for were largely based on school officials’ interpretations of behavior  For example, one study found that Black girls were disproportionately disciplined for subjective interpretations of behaviors, such as disobedience and disruptive behavior  A separate study used eye-tracking technology to show that, among other things, teachers gazed longer at Black boys than other children when asked to look for challenging behavior based on video clips  The Department of Health and Human Services (HHS) reported that this research has highlighted implicit bias as a contributing factor in school discipline and may shed some light on the persistent disparities in expulsion and suspension practices, even though the study did not find that teacher gazes were indicative of how they would discipline students  Children’s behavior in school may be affected by health and social challenges outside the classroom that tend to be more acute for poor children, including minority children who experience higher rates of poverty  Research shows that experiencing trauma in childhood may lead to educational challenges, such as lower grades and more suspensions and expulsions; increased use of mental health services; and increased involvement with the child welfare and juvenile justice systems, according to HHS’s Substance Abuse and Mental Health Services Administration (SAMHSA)  Further, a substantial share of children nationwide are estimated to have experienced at least one trauma, referred to as an adverse childhood experience (ACE), according to the National Survey of Children’s Health  Additionally, as we recently reported, there has been an increase in certain mental health issues within the school age population  For example, from 2005 to 2014, the suicide rate of youth ages 15 to 19 rose slightly, with older youth having a much higher rate of suicide than younger youth, and since 2007, the percentage of youth ages 12-17 experiencing a major depressive episode increased  About 50 million students were enrolled in K-12 public schools during the 2013-14 school year, according to the CRDC  About 90 percent of students attended traditional public schools; the remainder were enrolled at public charters, magnets, and other types of schools (see table 1)  About half of all public school students were White and the other half fell into one of several minority groups, with Hispanic and Black students being the largest minority groups (see fig  1)  The number of boys and girls in public schools was almost evenly split  A larger percentage of boys were students with disabilities  Nearly half of all public school students went to schools where 50 percent or more of the students were low-income, and about a quarter went to schools where 75 percent or more of the students were low-income (see table 2)  Discipline of students dropped between 2011-12 and 2013-14 over the six broad categories of discipline reported in Education’s CRDC, which were (1) out-of-school suspensions, (2) in-school suspensions, (3) referrals to law enforcement, (4) expulsions, (5) corporal punishment, and (6) school- related arrests  For example, in school year 2011-12 about 3 4 million (or 6 9 percent) of K-12 public school students were suspended out-of-school at least once, and in school year 2013-14 these suspensions fell to about 2 8 million (or 5 7 percent)  Other disciplinary actions affected a much smaller portion of the student body—specifically, less than 0 5 percent of all K-12 public school students were expelled, referred to law enforcement, had a school-related arrest, or experienced corporal punishment in 2013-14, according to Education’s reported data  Education’s Office for Civil Rights and Justice’s Civil Rights Division are responsible for enforcing a number of civil rights laws, which protect students from discrimination on the basis of certain characteristics (see table 3)  As part of their enforcement responsibilities, both agencies conduct investigations in response to complaints or reports of possible discrimination  Education also carries out agency-initiated investigations, which are called compliance reviews and which target problems that Education has determined are particularly acute  Education may also withhold federal funds if a recipient is determined to be in violation of the civil rights laws and the agency is unable to reach agreement with the parties involved  In addition, Justice has the authority to file suit in federal court to enforce the civil rights of students in public education  Education and Justice have also issued guidance to assist public schools in meeting their obligations under federal law to administer school discipline without unlawfully discriminating against students on the basis of race, color, or national origin  According to the guidance, public schools are prohibited by federal law from discriminating in the administration of student discipline based on protected characteristics  Further, Education and Justice have noted in their guidance that disciplinary policies and practices can result in unlawful discrimination based on race, for example, in two ways: first, if students are intentionally subject to different treatment on account of their race; and second, if a policy is neutral on its face but has a disproportionate and unjustified effect on students of a particular race, referred to as disparate impact  According to Education and Justice guidance, significant and unexplained racial disparities in student discipline give rise to concerns that schools may be engaging in racial discrimination that violates federal civil rights laws; however, data showing such disparities, taken alone, do not establish whether unlawful discrimination has occurred  Two significant, recently enacted laws include provisions related to school discipline: the Every Student Succeeds Act (ESSA) and the Child Care and Development Block Grant Act of 2014 (CCDBG Act of 2014)  ESSA, enacted in December 2015, amended Title I program requirements to allow states’ accountability systems to use multiple indicators of success, which can include measures of school climate and safety  As we previously reported in 2017, some states were considering measures related to suspension rates or school attendance  Additionally, ESSA amended the Elementary and Secondary Education Act of 1965 to authorize the Student Support and Academic Enrichment Program, under which school districts may use grant funding to, among other things, design and implement a locally-tailored plan to reduce exclusionary discipline practices in elementary and secondary schools  These grants also allow the use of funding to expand access to school- based mental health services, including counseling  In addition, the CCDBG Act of 2014 allows states to use certain funds to support the training and professional development of child care workers through activities such as behavior management strategies and training that promote positive social and emotional development and reduce challenging behaviors, including reducing expulsions of young children for those behaviors  Black students, boys, and students with disabilities were disproportionately disciplined in K-12 public schools, according to our analysis of Education’s most recent CRDC data  This pattern of disproportionate discipline persisted regardless of the type of disciplinary action, level of school poverty, or type of public school these students attended  Across each disciplinary action, Black students, boys, and students with disabilities experienced disproportionate levels of discipline  Black students were particularly overrepresented among students who were suspended from school, received corporal punishment, or had a school- related arrest (see fig  2)  For example, Black students represented 15 5 percent of all public school students and accounted for 39 percent of students suspended from school, an overrepresentation of about 23 percentage points  Differences in discipline were particularly large between Black and White students  Although there were approximately 17 4 million more White students than Black students attending K-12 public schools in 2013-14, nearly 176,000 more Black students than White students were suspended from school that school year  See appendix IV, table 12 for additional data on the disciplinary experiences of different racial or ethnic groups  For example, American Indian and Alaska Native students had higher than average rates of receiving each of the six disciplinary actions  This pattern of disproportionate discipline affected both Black boys and Black girls—the only racial group for which both sexes were disproportionately disciplined across all six actions  For example, Black girls were suspended from school at higher rates than boys of multiple racial groups and every other racial group of girls (see fig  3)  Further, boys as a group were overrepresented, while girls were underrepresented among students disciplined across each action  Specifically, boys accounted for just over half of all public school students, but were at least two-thirds of students disciplined across each of the six actions, according to our analysis of Education’s school year 2013-14 data  Boys were particularly overrepresented among students who received corporal punishment, by about 27 percentage points (see fig  4)  These kinds of disparities presented as early as pre-school (see sidebar)  Additional information about discipline for pre-school students is in appendix IV, table 17  Regardless of the level of school poverty, Black students, boys, and students with disabilities were suspended from school at disproportionately higher rates than their peers (see fig  6)  This was particularly acute for Black students in high-poverty schools, where they were overrepresented by nearly 25 percentage points in suspensions from school  This pattern persisted across all six disciplinary actions, as well  A similar pattern emerged for boys and students with disabilities  However, unlike Black students, boys and students with disabilities were particularly overrepresented among students suspended from low-poverty public schools (poverty less than 25 percent)  Effect of School Poverty on Discipline GAO used a regression model to examine the independent effect of school poverty on discipline in school year 2013-14  The model showed that increases in the percentage of low-income students in a school were generally associated with significantly higher rates for each of the six disciplinary actions GAO reviewed (in-school and out-of-school suspensions, referrals to law enforcement, expulsions, corporal punishment, and school- related arrests)  In these schools, boys and students with disabilities were overrepresented by approximately 24 and 20 percentage points, respectively  See appendix IV, table 14 for more information on discipline by the poverty level of the school  In addition, see sidebar for regression results that were relevant to poverty and school discipline  Full results from our regression model are in appendix I, table 10  Regardless of the type of public school a student attended—traditional, magnet, charter, alternative, or special education—Black students, boys, and students with disabilities were disciplined at disproportionately higher rates than their peers, with few exceptions (see fig  7)  For example, Black students were disproportionately suspended from all types of public schools, and this was particularly acute in charter schools  That is, although they represented about 29 percent of all students in charter schools, Black students accounted for more than 60 percent of the students suspended from charter schools (about 32 percentage points higher than their representation in those schools)  Boys and students with disabilities were particularly overrepresented among students suspended from traditional public schools (roughly 19 and 14 percentage points, respectively, above their representation in traditional public schools)  Effect of School Type on Discipline GAO used a regression model to examine the independent effect of attending different types of public schools on disciplinary outcomes  The model showed several significant associations between school type and the likelihood of receiving discipline  For example, attending an alternative school was associated with a significantly higher likelihood of being suspended (in-school or out-of-school), expelled, referred to law enforcement, or arrested for a school-related incident, compared to attending a traditional public school  The model also showed that students were significantly less likely to be suspended (in-school or out-of-school) if they attended a magnet, charter, or special education school as compared to a traditional public school  We found a few exceptions to the general pattern of Black students, boys, and students with disabilities receiving disproportionately high rates of discipline by school type  For example, Black students attending special education schools did not receive corporal punishment at disproportionate levels  See appendix IV, table 15 for additional information on discipline by the type of public school  In addition, see sidebar for regression results that were relevant to school type and school discipline  Full results from our regression model are in appendix I, table 10  We also found a regional component to discipline in public schools  For example, corporal punishment generally occurred in southern states  See appendix II for maps showing the rates of disciplinary actions by public school district  We spoke with school officials at five school districts about how they are addressing discipline, including challenges they face in responding to student conduct given the complex issues influencing student behavior  Several school officials noted a range of issues, including complex issues such as the effects of poverty, mental health issues, and family dysfunction, that they said contributed to behavior that leads to discipline (see fig  8)  For example, officials at a high-poverty Georgia high school said that their students have additional responsibilities, such as raising or watching siblings or working to support their family, which may cause students to be late to, or skip, class  This observation is consistent with our recent report on child well-being, which cited research showing that children in poverty are more likely to face academic and social challenges than their peers, and with our analysis of CRDC data, which showed that rates of chronic absenteeism (being absent 15 or more days in a school year), were higher in high-poverty schools  See appendix IV, table 19 for detailed data on chronic absenteeism  At one high school in Georgia, officials said that attendance issues were the reason for a majority of disciplinary actions at their school  They said that if students were repeatedly late to school or did not get to their next class within the set amount of time, students could amass enough infractions to warrant suspension from school  In contrast, an official at an elementary school in Georgia said that they usually do not discipline their students for being late to school, as they have found that it was often due to circumstances beyond the child’s control  According to several school officials, some groups such as homeless youth, American Indian, or Lesbian, Gay, Bisexual, Transgender, or Questioning (LGBTQ) students have had greater attendance problems than others  For example, education officials in California said that homeless and foster youth frequently miss school because of all the transitions and instability in their lives  In a school in Texas, officials also reported attendance issues with students who are homeless or in foster care because they lack transportation and clothing  Similarly, we previously reported that American Indian students face school attendance challenges, including access to reliable transportation  In addition, American Indian and Alaska Native students had the highest rates of chronic absenteeism in school year 2013-14, compared to students of other races, according to our analysis of CRDC data (see appendix IV)  LGBTQ students are at a high risk of suicide and other emotional issues during adolescence, and often feel disconnected from their peers and families, according to county education officials in California  According to these officials, this can contribute to attendance problems  Officials in our five selected school districts also described what they perceived as a growing trend of behavioral challenges or provided examples related to mental health and trauma, such as increased anxieties, thoughts of and attempts at suicide, and depression among students  For example, state education officials in Georgia said they viewed a growing number of their students as being “trauma complex ” Officials at one school in Massachusetts said that they involve the mental health clinicians or social worker for additional support when students are dealing with traumatic experiences, depression, or are struggling to self- regulate  Further, officials at another school in Massachusetts said that many of their students have experienced trauma and this may lead to more aggressive behaviors at the elementary school level, and to more self-destructive behaviors at the middle school level  Specifically, these officials said that children who have experienced trauma may kick, bite, and punch others when they are younger and cut themselves or become suicidal when older  Similarly, officials at a school in Texas said that they have seen a growth in suicidal ideation and self-harm among the students  Some school officials also said that they felt ill-equipped or that schools lacked resources to deal with the increase in students with mental health issues and the associated behaviors  School officials in all five of the selected states also said that social media results in conflicts or related behavioral incidents among students, such as related bullying and arguments  Officials at a school in Georgia said that social media arguments can cause students who were not part of the original situation to be pulled in, creating classroom disruptions that end in discipline for a larger group  Moreover, officials in a North Dakota middle school said that disagreements on social media last for longer periods of time  They said that social media has also been used to facilitate the purchase of illegal drugs, which can result in students being arrested in school and expelled  Use of Corporal Punishment in School for Five Selected States California, Massachusetts, and North Dakota: Corporal punishment in schools is prohibited  Texas: If a school district adopts a policy to permit corporal punishment, school staff may use corporal punishment unless the student’s parent has provided a written, signed statement prohibiting it  None of the schools GAO visited used corporal punishment, according to officials  Georgia: Boards of education are authorized to determine policies related to corporal punishment, including allowing school staff, at their discretion, to administer corporal punishment in order to maintain discipline  However, none of the schools GAO visited used corporal punishment, according to officials  School district officials from three of the five selected districts we visited stated that officials at individual schools generally have a lot of discretion in determining what discipline a student receives  In several schools, officials said they often try other avenues first to address behavior, such as detention, alerting or having a discussion with the parent, or taking away certain privileges such as making the student eat lunch with the teacher instead of with their friends  However, for certain offenses, officials in most districts said that discipline was automatically more severe  Gun possession, for example, prompts an automatic expulsion at most of the school districts we visited  In another example, school district officials in Texas said drug-related incidents, physical assault of a teacher or student, or extreme sexual behaviors can result in a student being placed in an alternative school  School officials at one alternative school we visited stated that 80 to 90 percent of their students are there due to drug-related incidents  Officials in several of the school districts said their districts had School Resource Officers who only become involved in school disciplinary issues when requested by school administrators  In a Texas high school with over 3,800 students, a school official said School Resource Officers patrol school grounds, monitor gang activity, and may become involved when there are illegal drug issues  Officials also said that School Resource Officers sometimes provide trainings for students, parents, or school staff on subjects such as safety, good decision making, substance abuse, and peer pressure  Further, although corporal punishment was legal in two of the five states we visited (see sidebar), the school district officials with whom we spoke in those states said it was not used anymore in their districts  Our analysis of schools nationwide using school year 2013-14 data showed that corporal punishment tended to be most prevalent in southern states (see maps in appendix II)  While there is no one-size-fits-all solution to addressing challenging student behavior, or to the evident disparities in discipline for certain student groups, officials in two school districts we visited told us they recognize the importance of finding alternatives to discipline that unnecessarily removes children from the learning environment  Some school officials said they have begun to specifically address disparities for certain student groups  Officials in all selected school districts reported they are implementing efforts to better address student behavior or reduce the use of exclusionary discipline  For example, officials in all school districts said that they are implementing alternative discipline models that emphasize preventing challenging student behavior and focus on supporting individuals and the school community, such as positive behavioral interventions and supports (PBIS), restorative justice practices, and social emotional learning (SEL) (see sidebar)  For example, officials at a selected school district in Texas said they have implemented a classroom management model that uses positive behavior techniques  Texas state law allows schools to develop and implement positive behavior programs as disciplinary alternatives for very young students  This was also true in California, where state law specifically lists suggested alternatives to suspension, including restorative justice, a positive behavior support approach with tiered interventions, and enrollment in programs that teach positive social behavior or anger management  Examples of Alternatives to Discipline that Removes Students from the Classroom Positive Behavioral Interventions and Supports (PBIS): A school-wide framework that focuses on positive behavioral expectations  By teaching students what to do instead of what not to do, the school can focus on the preferred behaviors  All of the selected school districts used some form of positive behavioral intervention and supports  One school official told us that PBIS has significantly reduced their discipline referral numbers and provided teachers more tools to get behavior situations under control  Restorative Justice Practices: This approach focuses on repairing harm done to relationships and people  The aim is to teach students empathy and problem-solving skills that can help prevent inappropriate behavior in the future  For example, according to officials we interviewed at one school, their restorative practices help students take ownership of their actions and work collaboratively to restore relationships that may have been strained  Officials at another school said schools use mediation techniques as alternatives to suspensions  Social and Emotional Learning (SEL): SEL enhances students’ abilities to deal effectively and ethically with daily tasks and challenges  SEL integrates the following five core competencies: self-awareness, self- management, social awareness, relationship skills, and responsible decision making  At a school implementing this model, officials said that they are strengthening their SEL program to improve the whole child instead of treating discipline and mental and behavioral health separately  With regard to directly addressing disparities in school discipline, officials at one school district in California said they created a new leadership team for equity, culture, and support services, and developed a district- wide equity plan that includes mandatory training on implicit bias for principals  Officials from that district also said they had recently changed a policy to increase the consistency of discipline actions across the district’s schools  Similarly, officials at a school district in Massachusetts reported they were working to build awareness among school leadership to address racial bias and the achievement gap through multiyear trainings  Officials we spoke with at a school within that district said they conduct trainings for staff on implicit bias and other related issues to reduce school discipline disparities  As some of the schools and districts we visited have begun implementing alternative discipline models and efforts to reduce the use of exclusionary discipline in recent years, we heard from officials in two districts that there has been difficulty with implementation due to limited resources, staffing turnover, and resistance on the part of some parents  During our visits to schools, we observed classroom spaces that school officials used to manage student behavior, including through various alternative approaches to discipline (see fig  9)  Officials in two school districts said they are moving away from exclusionary discipline because it decreases the amount of academic instruction  Officials at one school district in Georgia said that the district had a history of overusing exclusionary discipline and they understood that schools cannot “suspend their way out of behavioral and discipline issues ” Officials at that district said they are currently rolling out PBIS to their schools, although progress has been slow  While they said discipline rates have decreased and they have received fewer parent and staff complaints, change is difficult because of limited resources, staff turnover, and some resistance to alternative discipline versus punitive discipline on the part of both some school staff and parents  State education officials in all five states said that changes to state law were made or considered related to school discipline in the past several years  For example, California officials said that state law now prohibits suspensions and expulsions for children in grades K-3 for willful defiance  For all ages suspensions may only be used when other means of correction fail to bring about proper conduct  Similarly, Massachusetts law requires that during a student meeting or a hearing to decide disciplinary consequences for a student, school administrators consider ways to re-engage students in the learning process and that expulsion only be used after other remedies and consequences have failed  Massachusetts also revised its state law effective July 2014 to require that schools provide educational services for expelled students  Georgia state law includes a preference for reassignment of disruptive students to alternative educational settings in lieu of suspending or expelling such students  In addition, most of the selected states plan to include school discipline or absenteeism as measures of school quality in their state ESSA Title I plans (see sidebar)  According to administrative data from Education, the Office for Civil Rights (OCR) resolved over 2,500 K-12 school discipline cases between 2011 and summer 2017 through several means, including voluntary resolution (leading to agreed-upon actions and subsequent monitoring), dismissal, or closure due to insufficient evidence  These cases stemmed both from external complaints and reviews self-initiated by Education  When we analyzed a non-generalizable sample of resolved cases, we found that most of them focused on alleged racial discrimination or disability status  In the four cases we selected for more in-depth review, the school districts agreed to address discipline issues by, for example, designating a discipline supervisor, training staff, revising district policies, holding student listening sessions, and regularly reviewing data to identify disparities (see case descriptions below)  Some of these remedies are designed to reduce exclusionary discipline or improve overall school climate, and others are more directly focused on addressing disparities in school discipline  For example, having school leadership regularly review data, particularly when disaggregated by race and other student characteristics, would increase awareness of disparities  Education Case 1: Race and Exclusionary Discipline in a Mississippi School District  OCR’s 2014 investigation of the Tupelo Public School District found that Black students were disproportionately disciplined in nearly all categories of offenses  These commonly included subjective behaviors like disruption, defiance, disobedience, and “other misbehavior as determined by the administration ” The consequences for “other misbehavior” in high school could be severe, ranging from detention to referral to an alternative school  Once at the alternative school, students were searched thoroughly each day upon entry, escorted by security officers when changing classes, and not allowed to carry purses or book bags  OCR concluded that the district’s discipline codes afforded administrators broad discretion, and found different treatment of Black students when looking at specific disciplinary records  For example, among several students who were disciplined for the first offense of using profanity, Black students were the only ones who were suspended from school, while White students received warnings and detention for substantially similar behavior  To address these issues, the district entered into a voluntary resolution agreement whereby it committed to taking specific actions to ensure that all students have an equal opportunity to learn in school  It agreed, among other things, to revise its student discipline policies, practices, and procedures to include clear and objective definitions of misconduct, eliminate vague and subjective offense categories, and describe criteria for selection within the range of possible penalties when imposing sanctions  The district also agreed to require that alternatives to suspension and other forms of exclusionary discipline be considered in all cases except where immediate safety of students or staff is threatened, and where the behavior in question is such that the disruption to the educational environment can only be remedied by removal, or where the student’s removal is a result of the district’s progressive discipline policy  Education Case 2: Disability and Restraint & Seclusion in a Non- Public California School  This 2016 OCR investigation focused on restraint and seclusion of a student with disabilities who was placed at the non-public school with which Oakland Unified School District contracted to provide the student with certain services, including developing and implementing behavior intervention plans  OCR found the use of prone restraint on this student to be severe, persistent, and pervasive: staff held the student face-down 92 times over a period of 11 months, with the longest duration of a single face-down restraint being 93 minutes  Examples of behaviors that led to the use of restraint included disruptive behavior, not following directions, pushing desks, and ripping up assignments  Staff said that the student wanted to be disciplined and understood prone restraint to be disciplinary  OCR determined that the district allowed the student to be treated differently for non-dangerous behavior on the basis of disability  The district entered into a resolution agreement, committing to resolve these issues by offering individual relief to the student—arranging for an evaluation of the student for adverse effects of the restraint and seclusion, with recommendations for addressing areas of harm—and implementing district-wide policy changes related to restraint and seclusion  The latter included establishing a protocol for responding to any contracted non-public schools’ reports of restraining or secluding district students, and providing training on positive interventions  Excerpt from Christian County, KY Case An African American 10th grader was assigned 1-day out-of-school suspension for skipping school  In comparison, a white 12th grader was assigned a conference with the principal for skipping school  The African American student had 19 previous disciplinary referrals, while the white student had 28 previous disciplinary referrals  Education reported that it would be difficult for the district to demonstrate how excluding a student from attending school in response to the student’s efforts to avoid school meets an important educational goal  Education Case 3: Race and Exclusionary Discipline in a Kentucky School District  In this 2014 case, OCR found that Christian County School District disciplined Black students more frequently or harshly than similarly situated White students  Specifically, Black students were more than 10 times more likely than White students to receive out-of-school suspension for disorderly conduct, and Black students were more likely to be assigned to an “Isolated Classroom Environment” when discipline was for a violation that afforded discretion  OCR also found that the district’s discipline code did not define 61 types of violations, including ones that involve interpretation, such as disorderly conduct, failure to follow directions, deliberate classroom disruption, and profanity  OCR found that administrators had wide discretion in determining the consequences for such actions, and noted that the discipline code allowed for virtually every type of sanction, including expulsion, for each type of violation  OCR also found inconsistencies in treatment of students in different racial groups when looking at individual records (see sidebar)  Although district officials said they were aware of the higher rates of discipline for Black students, OCR found that there were no safeguards to ensure that discretion would be exercised in a nondiscriminatory manner  To resolve these issues, the district agreed to ensure as much as possible that misbehavior is addressed in a way that avoids exclusionary discipline, collaborate with experts on research-based strategies to prevent discrimination in discipline, and provide support services to decrease behavioral difficulties, among other things  Education Case 4: Race and Informal Removals in a California Charter School  In this 2015 case, OCR investigated whether Black students were disproportionately disciplined at a charter school which emphasizes Hmong culture and language  The complaint noted that the student’s parents had been asked to take him home on a few occasions because he was disruptive in class  School administrators confirmed the practice of “early dismissal” in response to misbehavior, but said they did not consider the dismissal to be disciplinary  Because the school did not maintain records of these removals, OCR was unable to determine if the student was subjected to discriminatory discipline  However, OCR noted that the practice of removing students from school for disciplinary reasons without appropriate recordkeeping and due process makes it almost impossible for the school to assess whether it is fully meeting its duty of ensuring nondiscrimination with respect to discipline  To resolve these issues, the school agreed, among other things, to revise its discipline policies, provide due process and alternatives to exclusionary discipline, and clearly prohibit the kinds of informal suspensions that OCR observed  Justice also investigates discrimination in school discipline based on complaints filed under federal civil rights statutes and as part of monitoring desegregation orders  Three recently-resolved cases investigated exclusionary discipline or restraint and seclusion for students of color and those with disabilities (see case descriptions below)  Justice Case 1: Race and Exclusionary Discipline in an Arkansas School District  This Justice case, originally stemming from a desegregation order, focused on whether the Watson Chapel School District was discriminating against Black students in its administration of school discipline  Justice found that the district suspended and expelled Black students at significantly higher rates than White students, and that district policies and procedures were responsible for this difference  The parties signed a Consent Order in 2016, under which the school district agreed to implement positive interventions and supports, transition away from exclusionary discipline, revise the code of conduct to list specific levels of disciplinary infractions and consequences, prohibit corporal punishment, establish a memorandum of agreement with any law enforcement agency that supplies school resource officers, and provide training to staff  In addition, the district agreed to provide due process before students receive out-of-school suspensions, expulsions, or referrals to the alternative education program because of disruptive behavior  Justice Case 2: Race and Disability in a Maryland School District  Justice investigated complaints that discipline policies in the Wicomico County Public School District resulted in the discriminatory suspension of Black and Latino students and students with disabilities  After the investigation, Justice and the district negotiated and entered into a voluntary out-of-court settlement agreement in January 2017  The district agreed to hire a consultant to implement positive behavioral interventions and supports and restorative practices, revise the code of conduct to include objective definitions of behavioral infractions and incorporate alternatives to exclusionary discipline, establish clear guidelines for when law enforcement intervention is appropriate, and provide appropriate due process procedures  Justice Case 3: Race and Restraint & Seclusion in a Kentucky School District  This 2017 Justice case investigated whether Covington Independent Schools’ disciplinary practices, including the use of exclusionary discipline, restraint, and seclusion, discriminated on the basis of race, national origin, or disability  The parties agreed to negotiate a settlement agreement under which the district agreed to develop a process to regularly identify students who disproportionately had disciplinary referrals, with a focus on offenses that may be the result of unaddressed behavioral needs such as disruptive behavior or aggression, defiance, and being “beyond control ” The district also agreed to discontinue the use of “calm rooms” (where students are isolated during an episode of misbehavior) and prohibit the use of physical restraint except in the case of imminent danger that could not be addressed through de-escalation techniques  The district agreed to adopt an intervention procedure to meet the needs of students with disabilities who may need support beyond the standard discipline policies  In addition, if parents of students with disabilities were asked to come to the school to become involved in an ongoing instance of misbehavior, the district could no longer require the parent to take the student home unless the student had been assigned an out-of-school suspension or expulsion  Education and Justice collaborated on a “Rethink Discipline” campaign in 2014 to address what they viewed as widespread overuse of suspensions and expulsions  This awareness campaign included comprehensive guidance to help states and schools implement alternatives to exclusionary discipline, reduce discrimination, and identify root causes of disparities (see sidebar)  The agencies have also collaborated to provide guidance encouraging school districts that use school resource officers to formalize partnerships with local law enforcement agencies and clarify that school resource officers should not administer discipline in schools  Education has also issued special guidance related to the discipline of students with disabilities, including an explanation of the requirement to provide appropriate strategies to address behavior in students’ individualized education programs (IEPs)  This guidance stated that when a student with a disability is regularly sent home early from school for behavior reasons, it is likely that the child’s opportunity to make progress in the general education curriculum is significantly impeded (see sidebar)  The guidance states that being sent home regularly in this way constitutes a disciplinary removal, which comes with statutory reporting obligations and other considerations  For further information on available federal guidance related to discipline in public schools, see appendix III  available could result in an inappropriately restrictive placement  demonstrates that disciplinary measures such as short-term removals from the current placement (e g , suspension), or other exclusionary disciplinary measures that significantly impede the implementation of the individualized education program (IEP), generally do not help to reduce or eliminate reoccurrence of the misbehavior  Education and other federal entities have also awarded grants and established special initiatives related to student behavior and school discipline, many of which started around the same time as the federal Rethink Discipline campaign and were designed to be complementary  For example, Education awarded about $130 million from 2014-2016 to states and school districts through the School Climate Transformation Grant, which was established in 2014 to support districts taking steps to improve behavioral outcomes  According to Education, nearly 3,000 schools have worked to implement these behavioral support systems through the grant, and preliminary outcomes data have shown increased student attendance and fewer disciplinary referrals  In addition, Education awarded about $68 million for fiscal years 2015-2019 to over 20 school districts under Project Prevent—a grant to promote conflict resolution skills in students, particularly when they have been exposed to pervasive violence  According to the districts’ grant summary documents, these districts have experienced nearly 10,000 fewer violent behavioral incidents and have provided access to mental health services for over 5,000 students  Justice’s research arm, the National Institute of Justice, also started the Comprehensive School Safety Initiative in 2014 and has since provided about $84 million to fund nearly 40 research projects and interventions that address school discipline and safety, such as implementing restorative practices and studying the root causes of the school-to-prison pipeline  More recently, Education collaborated with HHS to fund the Pyramid Equity Project for early learning programs, which is designed to address implicit bias in school discipline, implement culturally responsive practices in addressing student behavior, and use data systems to understand equity issues  For ongoing technical assistance related to student behavior and school discipline, Education sponsors centers on supportive learning environments, improving student engagement and attendance, and implementing positive behavioral interventions and supports (PBIS)  For example, the National Center on Safe Supportive Learning Environments provides information and resources on addressing school discipline, mental health, substance abuse, physical safety, student engagement, and other related issues  Justice funds a technical assistance center on school-justice partnerships that works to enhance collaboration among schools, mental and behavioral health specialists, and law enforcement officials  This center recently published a bulletin on the intersection of exclusionary school discipline and the juvenile justice system, which offers tips for judges who handle school-related cases and information on successful efforts to reduce the number of school-based referrals to law enforcement  For a list of other technical assistance centers related to student behavior or discipline, see appendix III  Lastly, to help identify discipline disparities among the nation’s schools, Education collects comprehensive data on school discipline every other year through the CRDC  The agency publicly releases highlights from these data through their “First Look” documents and in annual reports, which typically focus on a limited number of disciplinary actions (primarily suspensions) and student demographics (usually race and disability status)  Education’s public analyses of school discipline data have not included school characteristics like poverty level or type of school  Education encourages districts and schools to disaggregate their data by various student demographics and examine it for disparities  In addition, Education’s Office of Special Education and Rehabilitative Services recently examined racial and ethnic disparities for students with disabilities using data collected under IDEA, Part B  This IDEA report provides the public with information on whether districts had significant disproportionality on the basis of race or ethnicity in the discipline of students with disabilities  We provided a draft of this report to the Departments of Education and Justice for review and comment  These agencies provided technical comments, which we incorporated as appropriate  We also provided selected draft excerpts relevant to officials we interviewed in state agencies, school districts, and school officials  We received technical comments from those officials in four of our five selected states, which we incorporated as appropriate  As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date  At that time, we will send copies to the appropriate congressional committees, the Secretary of Education, the Secretary of Health and Human Services, the Attorney General, and other interested parties  In addition, the report will be available at no charge on the GAO website at http://www gao gov  If you or your staff have any questions about this report, please contact me at (617) 788-0580 or nowickij@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report  GAO staff who made key contributions to this report are listed in appendix V  The objectives of this report were to examine (1) the patterns in disciplinary actions among public schools, (2) the challenges selected school districts reported with student behavior and how they are approaching school discipline, and (3) the actions the Department of Education (Education) and the Department of Justice (Justice) have taken to identify and address any disparities or discrimination in school discipline  To conduct this work we (1) analyzed federal discipline data by student demographics and school characteristics; (2) visited five school districts to provide illustrative examples of approaches to school discipline; and (3) interviewed federal agency officials and reviewed agency documentation, federal laws, regulations and policies, selected state laws, and a selection of resolved school discipline cases  To inform all aspects of our work, we interviewed representatives from several nonfederal civil rights organizations and advocacy organizations that represent parents and families, individuals with disabilities, and people from specific racial or ethnic backgrounds, such as Hispanic, African-American, and American Indian communities  We also met with academic subject matter experts to discuss issues related to school discipline, including disparities in school discipline and initiatives intended to reduce exclusionary discipline  In addition, we reviewed two dozen articles containing research that had been published since 2010 to further understand the context of school discipline issues and programs  We evaluated the methods used in the research and eliminated the research if we felt the methods were not appropriate or rigorous  The following sections contain detailed information about the scope and methodology for this report  To determine the patterns in disciplinary actions among public schools, we used Education’s Civil Rights Data Collection (CRDC) to analyze discipline data from all public schools by student demographics (e g , race, sex, disability) and school characteristics (e g , school type, such as charter or magnet school)  Our analyses of this data, taken alone, do not establish whether unlawful discrimination has occurred  The CRDC is a biennial survey that is mandatory for every public school and district in the United States  Conducted by Education’s Office for Civil Rights, the survey collects data on the nation’s public schools (pre-K through 12th grade), including disciplinary actions as well as student characteristics and enrollment, educational and course offerings, and school environment, such as incidents of bullying  CRDC data are self-reported by districts and schools, and consequently there is potential for misreporting of information  In school years 2011-12 and 2013-14, the CRDC collected data from nearly every public school in the nation (approximately 17,000 school districts, 96,000 schools, and 50 million students in school year 2013-14)  Using the public-use data file of the CRDC, we focused our analysis primarily on data for school year 2013- 14, the most recent data available at the time of our analysis  We also compared disciplinary data from school years 2011-12 and 2013-14 to analyze how discipline may have changed over that period  The 2013-14 CRDC collected data on six broad types of disciplinary actions: (1) out-of-school suspensions, (2) in-school suspensions, (3) referrals to law enforcement, (4) expulsions, (5) corporal punishment, and (6) school-related arrests  The CRDC did not collect data on less severe forms of discipline, such as detentions, Saturday school, or removing privileges to engage in extracurricular activities, such as athletic teams or field trips  As shown in table 4, we combined related variables for out-of- school suspension and expulsion; we also provide a crosswalk of discipline variables used in this report and those captured in the CRDC  For each of the six disciplinary actions in our review, we examined discipline counts and rates both overall and disaggregated by student demographic characteristics  Specifically, we examined counts and rates for each disciplinary action by student sex (boy or girl), race or ethnicity (see table 5), disability status (students with or without disabilities), and English Language Learners  Using the CRDC, we also examined race and sex intersectionally, for example, disciplinary rates for Black boys or White girls  In order to analyze discipline counts and rates by the poverty level of the school, we pulled in data on free or reduced-price lunch eligibility from the 2013-14 Common Core of Data (CCD), and matched it to schools in the 2013-14 CRDC, which did not collect eligibility data  The CCD is administered by Education’s National Center for Education Statistics, and annually collects nonfiscal data about all public schools in the nation  A student is generally eligible for free or reduced-price lunch based on federal income eligibility guidelines that are tied to the federal poverty level and the size of the family  State education agencies supply these data for their schools and school districts  We then sorted schools into quartiles based on the percentage of students eligible for free or reduced-price lunch as follows: 0 to 25 percent, 25 1 to 49 9 percent, 50 to 74 9 percent, and 75 to 100 percent (see table 6)  The poverty thresholds and measure of poverty discussed here and throughout this report were commonly used in the literature and also aligned with how Education analyzed its data  To analyze discipline counts and rates by the type of public school a student attended, we sorted schools into mutually exclusive categories and reviewed disciplinary data by student demographic information  The 2013-14 CRDC allowed schools to self-identify as special education, magnet, charter, and alternative schools (see table 7)  The categories of public schools in the CRDC were not mutually exclusive; that is, schools could select multiple school types to describe their school, such as a charter school that was also an alternative school  To create mutually exclusive categories for analytical purposes, we applied the following criteria: Alternative school: all schools that selected “alternative” as the school type in the CRDC, even if they selected other types as well  Special education school: schools that selected “special education” as the school type in the CRDC, except those schools that also selected the alternative school type  Charter school: schools that selected “charter” as the school type in the CRDC, except those schools that also selected the alternative school type and/or the special education school type  Magnet school: schools that selected “magnet” as the school type in the CRDC, except those schools that also selected the alternative school type, the special education school type, and/or the charter school type  Traditional school: schools that did not select any other school type in the CRDC  Table 8 provides the breakdown of students and schools captured in the 2013-14 CRDC after applying these criteria  For each of our school discipline analyses, we also examined disparities in disciplinary rates by student demographics  Specifically, we compared each student groups’ representation among students disciplined to their representation in the overall student population  For example, if boys accounted for 50 percent of all K-12 public school students, but represented 75 percent of students that received a given disciplinary action, then boys would be overrepresented among students that received that type of discipline by 25 percentage points  We also compared disciplinary rates across student groups and similarly examined disparities based on school poverty level and school type for all students  We also analyzed CRDC data on discipline of pre-school students  The disciplinary data for pre-school students that was collected in the CRDC for school year 2013-14 was different than disciplinary data collected for K-12 students  Specifically, data on pre-school discipline was limited to out-of-school suspensions and expulsions  Findings from our analysis of pre-school discipline data are included where applicable in the report and additional data are provided in appendix IV, table 17  In addition to analyzing data on school discipline, we also analyzed data on chronic absenteeism, which was defined as students who were absent 15 or more days during the school year for any reason, which could include for suspensions and expulsions  The CRDC also collected data on instances in which students were restrained—both physically and mechanically—or secluded at school  Education has provided a resource document with principles to school districts that indicates restraint and seclusion should only be used in instances where a student’s “behavior poses imminent danger of serious physical harm to self or others,” and should never be used as punishment or discipline  However, multiple sources, including civil rights complaints filed with Education, news stories, and other reports have alleged that these practices have been used in response to student misbehavior, in particular for students with disabilities  We included data on chronic absenteeism and restraint and seclusion in our analyses, and present related findings in appendix IV, tables 18 and 19  We determined that the data we used from the CRDC and CCD were sufficiently reliable for the purposes of this report by reviewing technical documentation, conducting electronic testing, and interviewing officials from Education’s Office for Civil Rights and National Center for Education Statistics  For our analysis of the 2013-14 CRDC, we used the final data file that was publicly available as of June 2017 because it corrected errors in the original data previously submitted by several school districts  We conducted a generalized linear regression using the 2013-14 CRDC and CCD data to explore whether and to what extent certain school-level characteristics were associated with higher rates of each disciplinary action  Such a model allowed us to test the association between a given school characteristic and the percentage of students receiving a given disciplinary action, while holding other school characteristics constant  We selected different school characteristics (our independent variables) for the regression based on factors that Education’s Office for Civil Rights and other researchers have identified as potential drivers of school discipline rates (our dependent, or outcome variables)  Table 9 lists the variables we included in our regression model  We conducted a separate regression for each of the six disciplinary actions listed as an outcome variable  We excluded some schools from our regression model  Specifically, we excluded schools that met one or more of the following criteria: Data were not available in both the CRDC and CCD data sets, and therefore we were unable to determine the percentage of students eligible for free or reduced-price lunch in these schools or whether these schools were located in rural, suburban, or urban areas  School was listed as “ungraded” in the CRDC because we could not determine if these schools offered grade 6 or above  School only offered pre-school because pre-school disciplinary data were reported separately and differently than K-12 disciplinary data in the CRDC  School identified as a juvenile justice facility in the CRDC  In the 2013-14 CRDC, schools could identify as a juvenile justice facility, and select one of the other school types in our analysis (i e , traditional, magnet, charter, alternative, and special education schools)  Due to this overlap, and because it is reasonable to expect discipline within a juvenile justice facility could function differently than discipline in other schools, we excluded these schools from our regression model  School had less than 10 students enrolled because in smaller schools minor fluctuations in the numbers of students receiving a given disciplinary action could have a large effect on disciplinary rates  In the 2013-14 data, these exclusions reduced the total number of public schools in our regression model from a universe of 95,507 public schools to 86,769 public schools  All regression models are subject to limitations and for this model the limitations included: Data we analyzed were by school rather than student  Consequently, we were not able to describe the association between our independent variables and a student’s rate of different disciplinary actions, while controlling for characteristics of an individual student, such as sex, race or ethnicity, disability status, or grade level  Instead, the school-level nature of the CRDC data limited our description of the associations between school characteristics and disciplinary rates to whether there was an increase, decrease, or no effect on disciplinary rates for schools with a given characteristic, controlling for other characteristics of the entire school’s population, such as percent of students who are boys or are Black  Some variables that may be related to student behavior and discipline are not available in the data  For example, in this context, it could be that parent education or household type (single- versus multiple- headed household) could be related to student behaviors, such as those that lead to receiving the six disciplinary actions we analyzed  Results of our analyses are associational and do not imply a causal relationship because, for example, CRDC data were not gathered by a randomized controlled trial, where students would be randomized to attend schools with certain characteristics  Typically, a generalized linear regression model provides an estimated incidence rate ratio, where a value greater than one indicates a higher or positive association, in this case, between the disciplinary outcome and the independent variable of interest, such as being a charter school or having a higher percentage of Black students  An estimated incidence rate ratio less than one indicates a lower incidence of a given disciplinary action when a factor is present  Given the limitations of our model as described above, we present the results of our regression model in table 10 by describing the direction of the associations, rather than an estimated rate (incidence) of disciplinary outcomes  For categorical variables in table 10, we provided the comparison school characteristic in brackets and italics  For example, the results in this table should be interpreted as students attending alternative schools were significantly more likely than students attending traditional schools to be suspended out of school  For continuous variables (i e , those starting with “Percent”), the results in this table should be interpreted as the likelihood of receiving a given disciplinary action as the percentage of students in the school with a given characteristic increased  For example, as the percentage of students eligible for free or reduced- price lunch increased, we found that the likelihood of receiving each of the six disciplinary actions also increased  It should be noted that interactions (i e , where we combine both race and sex variables) should be interpreted differently than other variables in table 10  Though an interaction may be “negative,” it does not necessarily imply that the group presented in the interaction was significantly less likely to receive the given disciplinary action because interactions are interpreted relative to the main effect of each variable in the interaction  For example, as shown in table 10, the interaction for percentage of Black boys was negative for out-of-school suspensions; however, the estimated incidence of out-of-school suspensions for a school with a higher than average percentage of Black students and a higher than average percentage of boys was positive  Since the contribution for an interaction coefficient is relative, in this example the contribution of the main effects outweighed that of the interaction, resulting in a positive effect altogether, despite the negative interaction  To obtain information on how selected school districts are addressing discipline issues, including any challenges they face in doing so, we selected five school districts to serve as illustrative examples  To select school districts, we used CRDC data to sort school districts into categories based on district size; the presence of disparities in out-of- school suspension rates for boys, Black students, or students with disabilities; and whether the out-of-school suspension rate was increasing or decreasing between the two most recent CRDC collections  With regard to size, we collapsed several categories that Education has previously used into three groupings, each with roughly one-third of all students attending public schools in school year 2013-14: Large School District: 25,000 or more students (34 7% of all students in 2013-14) Medium School District: 5,000 to 24,999 students (33 2% of all students in 2013-14) Small School District: Less than 5,000 students (32 1% of all students in 2013-14) Further, we focused on out-of-school suspensions for selection purposes because this disciplinary action was one of the most frequently reported disciplinary actions employed by schools in Education’s two most recent data collection efforts on the issue (2011-12 and 2013-14 CRDC)  Moreover, out-of-school suspensions are an exclusionary disciplinary action; that is, they remove or exclude students from the usual instructional or learning environment  Selecting districts with a range of out-of-school suspension rate was intended to generate a mix of districts that commonly use exclusionary discipline, as well as those that may employ alternatives  For site selection, we used out-of-school suspension data in two ways  First, we excluded districts that did not have a disparity in out-of-school suspension rates for Black students, boys, or students with disabilities  Prior GAO work and Education’s data showed that these groups were particularly vulnerable to discipline disparities, and the purpose of this research objective was to understand district efforts to identify and address such disparities  Second, we grouped school districts by whether their out-of-school suspension rate increased or decreased between 2011-12 and 2013-14  Exploring school districts that changed in different ways over time was intended to help us identify successful efforts to reduce suspensions as well as challenges districts face in addressing disparate discipline  Using the above criteria, we grouped school districts into the following categories: Category 1 and 2: Large school district and out-of-school suspension rate that increased (or decreased) from 2011-12 to 2013-14 Category 3 and 4: Medium school district and out-of-school suspension rate that increased (or decreased) from 2011-12 to 2013- 14 Category 5 and 6: Small school district and out-of-school suspension rate that increased (or decreased) from 2011-12 to 2013-14  After sorting school districts into the above categories, we randomized the list within each category to improve the methodological rigor of selecting school districts  In addition, we applied a series of post-checks to our list of districts in each grouping to ensure we had appropriate variety to consider other key factors in school discipline  Specifically, we checked for variety in: types of public schools in the district, geographic diversity both in terms of region of the country and use of corporal punishment in the district, and use of restraint or seclusion in the district  To select specific districts, we started with the district in each category that was at the top of the randomized list and then applied the above post-checks  We then conducted outreach to district superintendents or their designees via telephone and email to obtain their agreement to participate in this review  When school districts were unresponsive to our outreach or unwilling to participate, we contacted additional districts that had similar characteristics in order to achieve variety in our final selections  This resulted in the selection of five schools districts, one each in California, Georgia, Massachusetts, North Dakota, and Texas (see table 11)  We visited each district and interviewed district-level officials involved in school discipline and school climate initiatives  These officials included superintendents, assistant superintendents, program managers, and directors of applicable district departments (e g , student support services and special education)  We also reviewed district-level discipline data, school district discipline policies, and relevant state laws related to school discipline to better understand the local context in each selected district  In the five districts we visited, we also interviewed officials at a total of 19 schools  At each school, we typically met with principals and/or assistant principals, and in some instances, spoke with other personnel at the school, such as counselors, attendance coordinators, school resource officers (i e , law enforcement officers), and teachers  In each district, we selected a variety of schools to visit based on grade level, school type, and disciplinary data  For each selected district, we also interviewed officials from the state educational agency that oversees that district to better understand the statewide context around discipline, such as state laws that may affect district disciplinary policies, statewide initiatives related to discipline, and state-level monitoring of district-level disciplinary actions  In California, we also met with the county office of education that oversees the district we selected because, in that state, counties have a primary role in the local school district accountability structure  Because we selected these school districts judgmentally, we cannot generalize the findings about these districts’ approaches to discipline, and the challenges they face, to all school districts and schools nationwide  To determine the extent to which, and in what ways, Education and Justice are identifying and addressing discipline disparities and discrimination, we interviewed agency officials at headquarters and regional offices, reviewed agency documentation and administrative data, reviewed federal laws and regulations, and reviewed a non-generalizable sample of seven recently resolved school discipline investigations undertaken by Education and Justice (which we refer to as cases)  With both agencies, we interviewed officials about each agency’s responsibilities with respect to federal civil rights laws and regulations, as well as the actions the agencies took to enforce them  We also discussed each agency’s guidance, support to school districts on these issues (e g , grants and technical assistance), and data collection activities  In addition, we collected and reviewed relevant agency procedures and guidance documents  We also requested and reviewed Education’s data on the number of civil rights complaints received and cases related to school discipline investigated from 2011 to August 2017 to better understand the scope of the agency’s efforts  Education provided these data from their internal database, where investigators categorized cases as being related to school discipline  We assessed the reliability of this source through discussion with knowledgeable officials and reviewing key documents and determined the data to be reliable for our purposes  To select resolved school discipline cases to review, we searched Education’s and Justice’s respective online repositories of resolved investigations and compliance reviews, as well as Education’s annual reports, to create a list of resolved cases related to school discipline  We then narrowed the list to cases resolved in approximately the past 3 years (from 2014 to May 2017) and excluded long-standing cases that were opened several decades ago to help ensure the information in the cases reflected recent policies and practices in each agency  We also excluded cases regarding institutions of higher education because they were outside the scope of this review  This resulted in a list of 12 relevant resolved cases—9 for Education and 3 for Justice  From this list, we selected 7 cases to review in depth to better understand Education’s and Justice’s investigatory processes and resolutions with regard to school discipline cases in pre-K through 12th grade, and to provide illustrative examples in our report  We selected 4 cases from Education that provided a mix of the type of alleged discrimination (e g , race or disability) and type of discipline (e g , suspension, expulsion, arrest, etc )  We selected all 3 relevant cases from Justice  For each case, we reviewed the type of investigation (complaint investigation or compliance review); the reason for the investigation; any applicable findings or recommendations; and the ultimate resolution of the investigation, such as a voluntary agreement with the school district or remedies to address findings  In all instances, we are presenting Education’s and Justice’s findings and do not reach any independent conclusions regarding the cases  We conducted this performance audit from November 2016 to March 2018 in accordance with generally accepted government auditing standards  Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives  We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives  This appendix contains maps showing rates of disciplinary actions by school district for each of the six disciplinary actions captured in the Department of Education’s Civil Rights Data Collection for school year 2013-14  Funded by Department of Education (Education): National Center on Safe Supportive Learning Environments: offers information and technical assistance focused on improving student supports and academic enrichment  This includes resources on using positive approaches to discipline, as well as promoting mental health for students and ensuring the safety and effectiveness of physical learning environments  https://safesupportivelearning ed gov/  National Student Attendance, Engagement, and Success Center: a center that disseminates evidence-based practices and facilitates communities of practice to help students attend school every day, be engaged in school, and succeed academically, so that they graduate high school prepared for college, career, and civic life  It offers webinars on identifying the root causes of chronic absence, linking school climate and exclusionary discipline to absenteeism, and improving attendance for vulnerable students  http://new every1graduates org/nsaesc/ National Technical Assistance Center for the Education of Neglected or Delinquent Children and Youth: provides technical assistance to state agencies with Title I, Part D programs and works to improve education services for children and youth who are neglected, delinquent, or at risk  This includes running the Supportive School Discipline Communities of Practice, which brings together education and justice leaders for knowledge-sharing events and offers webinars on discipline initiatives such as restorative practices  https://www neglected-delinquent org/ Positive Behavioral Interventions and Supports Technical Assistance Center: funded by Education’s Office of Special Education Programs, this center supports implementation of a multi- tiered approach to social, emotional and behavior support  In addition, it offers resources on cultural responsiveness, addressing discipline disproportionality, and interconnecting mental health with behavior support systems, among other issues  https://www pbis org/  Funded by Department of Health and Human Services (HHS): Center of Excellence for Infant and Early Childhood Mental Health Consultation: supports states, tribes, and communities in promoting mental health and school readiness  It provides training to leaders in early childhood education around mental health and school readiness issues  https://www samhsa gov/iecmhc Center for School Mental Health: works to strengthen policies and programs in school mental health to improve learning and promote success for youth  This center is supported in full by HHS’s Maternal and Child Health Bureau, Division of Child, Adolescent and Family Health Adolescent Health Branch in the Health Resources and Service Administration  http://csmh umaryland edu/ National Center for Trauma-Informed Care and Alternatives to Seclusion and Restraint: works to develop approaches to eliminate the use of seclusion, restraints, and other coercive practices and to further advance the knowledge base related to implementation of trauma-informed approaches  https://www samhsa gov/nctic National Child Traumatic Stress Network: works to improve access to care, treatment, and services for children and adolescents exposed to traumatic events  The group provides a comprehensive focus on childhood trauma by collaborating with the health, mental health, education, law enforcement, child welfare, juvenile justice, and military family service systems  http://nctsn org/ National Resource Center for Mental Health Promotion and Youth Violence Prevention: offers resources and technical assistance to states, tribes, territories, and local communities to promote overall child wellness and prevent youth violence  http://www healthysafechildren org/ Now Is the Time Technical Assistance Center: provides national training and technical assistance to recipients of the Healthy Transitions (youth access to mental health) and Project Advancing Wellness and Resilience Education (AWARE) grants  https://www samhsa gov/nitt-ta/about-us Funded by Department of Justice (Justice): School-Justice Partnership National Resource Center: provides trainings and webinars, and partners with stakeholders in the law enforcement, juvenile justice, mental health, and public education arenas  The National Council of Juvenile and Family Court Judges operates this center  https://schooljusticepartnership org/ Office of Juvenile Justice and Delinquency Prevention (OJJDP) This appendix contains several tables that show the underlying data used throughout this report, as well as additional analyses we conducted using the Department of Education’s Civil Rights Data Collection (CRDC) and Common Core of Data (CCD) for school year 2013-14  Our analyses of Education’s data, as reflected in these tables, taken alone, do not establish whether unlawful discrimination has occurred  The following tables and information are included in this appendix: Table 12: students who received disciplinary actions captured in the CRDC, disaggregated by student sex, race or ethnicity, and English Language Learner status  Table 13: students with or without disabilities who received disciplinary actions captured in the CRDC, disaggregated by student sex and race or ethnicity  Table 14: students who received disciplinary actions captured in the CRDC, disaggregated by the poverty level of the school and other student characteristics  Table 15: students who received disciplinary actions captured in the CRDC, disaggregated by the type of public school and other student characteristics  Table 16: students who received disciplinary actions captured in the CRDC, disaggregated by the grades offered in the school and other student characteristics  Table 17: pre-school students who were suspended from school, disaggregated by student sex and race or ethnicity, as well as the poverty level of school and the type of public school  Table 18: students who were restrained—mechanically or physically—or secluded, disaggregated by student sex, race or ethnicity, and disability status as well as the poverty level of school and the type of public school  Table 19: students who were chronically absent, disaggregated by student sex, race or ethnicity, and disability status, as well as the poverty level of school and the type of public school  Table 20: schools that reported having access to a school counselor or sworn law enforcement officer, disaggregated by the poverty level of school and the type of public school  Table 21: students disciplined for harassment or bullying, disaggregated by student sex, race or ethnicity, and disability status  In addition to the contact named above, Sherri Doughty (Assistant Director), Amy Moran Lowe (Analyst-in-Charge), James Bennett, Holly Dye, Aaron Karty, Jean McSween, John Mingus, James Rebbe, Sonya Vartivarian, and David Watsula made key contributions to this report  Also contributing were Johana Ayers, Deborah Bland, Irina Carnevale, Caitlin Croake, Vijay D’Souza, Gretta Goodwin, Gloria Hernandez-Saunders, Reginald Jones, DuEwa Kamara, John Karikari, Ted Leslie, Sheila R  McCoy, Brittni Milam, Cady Panetta, Moon Parks, Caroline Prado, Steven Putansu, Maria Santos, Margie K  Shields, Ruth Solomon, Alexandra Squitieri, and Barbara Steel-Lowney 

ground_truth: VA provides services and benefits to veterans through hospitals and other facilities nationwide. Misconduct by VA employees can have serious consequences for some veterans, including poor quality of care. GAO was asked to review employee misconduct across VA. This report reviews the extent to which VA (1) collects reliable information associated with employee misconduct and disciplinary actions, (2) adheres to documentation-retention procedures when adjudicating cases of employee misconduct, (3) ensures allegations of misconduct involving senior officials are reviewed according to VA investigative standards and these officials are held accountable, and (4) has procedures to investigate whistle-blower allegations of misconduct; and the extent to which (5) data and whistle-blower testimony indicate whether retaliation for disclosing misconduct occurs at VA. GAO analyzed 12 information systems across VA to assess the reliability of misconduct data, examined a stratified random sample of 544 misconduct cases from 2009 through 2015, analyzed data and reviewed cases pertaining to senior officials involved in misconduct, reviewed procedures pertaining to whistle-blower investigations, and examined a nongeneralizable sample of whistle-blower disclosures from 2010 to 2014. The Department of Veterans Affairs (VA) collects data related to employee misconduct and disciplinary actions, but fragmentation and data-reliability issues impede department-wide analysis of those data. VA maintains six information systems that include partial data related to employee misconduct. For example, VA's Personnel and Accounting Integrated Data system collects information on disciplinary actions that affect employee leave and pay, but the system does not collect information on other types of disciplinary actions. The system also does not collect information such as the offense or date of occurrence. GAO also identified six other information systems that various VA administrations and program offices use to collect specific information regarding their respective employees' misconduct and disciplinary actions. GAO's analysis of all 12 information systems found data-reliability issues—such as missing data, lack of identifiers, and lack of standardization among fields. Without collecting reliable misconduct and disciplinary action data on all cases department-wide, VA's reporting and decision making on misconduct are impaired. VA inconsistently adhered to its guidance for documentation retention when adjudicating misconduct allegations, based on GAO's review of a generalizable sample of 544 out of 23,622 misconduct case files associated with employee disciplinary actions affecting employee pay. GAO estimates that VA would not be able to account for approximately 1,800 case files. Further, GAO estimates that approximately 3,600 of the files did not contain required documentation that employees were adequately informed of their rights during adjudication procedures—such as their entitlement to be represented by an attorney. The absence of files and associated documentation suggests that individuals may not have always received fair and reasonable due process as allegations of misconduct were adjudicated. Nevertheless, VA's Office of Human Resource Management does not regularly assess the extent to which files and documentation are retained consistently with applicable requirements. VA did not consistently ensure that allegations of misconduct involving senior officials were reviewed according to investigative standards and these officials were held accountable. For example, based on a review of 23 cases of alleged misconduct by senior officials that the VA Office of Inspector General (OIG) referred to VA facility and program offices for additional investigation, GAO found VA frequently did not include sufficient documentation for its findings, or provide a timely response to the OIG. In addition, VA was unable to produce any documentation used to close 2 cases. Further, OIG policy does not require the OIG to verify the completeness of investigations, which would help ensure that facility and program offices had met the requirements for investigating allegations of misconduct. Regarding senior officials, VA did not always take necessary measures to ensure they were held accountable for substantiated misconduct. As the figure below shows, GAO found that the disciplinary action proposed was not taken for 5 of 17 senior officials with substantiated misconduct. As a result of June 2017 legislation, a new office within VA—the Office of Accountability and Whistleblower Protection—will be responsible for receiving and investigating allegations of misconduct involving senior officials. VA has procedures for investigating whistle-blower complaints, but the procedures allow the program office or facility where a whistle-blower has reported misconduct to conduct the investigation. According to the OIG, it has the option of investigating allegations of misconduct, or exercising a “right of first refusal” whereby it refers allegations of misconduct to the VA facility or program office where the allegation originated. VA does not have oversight measures to ensure that all referred allegations of misconduct are investigated by an entity outside the control of the facility or program office involved in the misconduct, to ensure independence. As a result, GAO found instances where managers investigated themselves for misconduct, presenting a conflict of interest. Data and whistle-blower testimony indicate that retaliation may have occurred at VA. As the table below shows, individuals who filed a disclosure of misconduct with the Office of Special Counsel (OSC) received disciplinary action at a much higher rate than the peer average for the rest of VA in fiscal years 2010–2014. Additionally, GAO's interviews with six VA whistle-blowers who claim to have been retaliated against provided anecdotal evidence that retaliation may be occurring. These whistle-blowers alleged that managers in their chain of command took several untraceable actions to retaliate against the whistle-blowers, such as being denied access to computer equipment necessary to complete assignments. GAO makes numerous recommendations to VA to help enhance its ability to address misconduct issues (several of the recommendations are detailed on the following page). GAO recommends, among other things, that the Secretary of Veterans Affairs develop and implement guidance to collect complete and reliable misconduct and disciplinary-action data department-wide; such guidance should include direction and procedures on addressing blank fields, lack of personnel identifiers, and standardization among fields; direct applicable facility and program offices to adhere to VA's policies regarding misconduct adjudication documentation; direct the Office of Human Resource Management to routinely assess the extent to which misconduct-related files and documents are retained consistently with applicable requirements; direct the Office of Accountability and Whistleblower Protection (OAWP) to review responses submitted by facility or program offices to ensure evidence produced in senior-official case referrals demonstrates that the required elements have been addressed; direct OAWP to issue written guidance on how OAWP will verify whether appropriate disciplinary action has been implemented; and develop procedures to ensure (1) whistle-blower investigations are reviewed by an official independent of and at least one level above the individual involved in the allegation, and (2) VA employees who report wrongdoing are treated fairly and protected against retaliation. GAO also recommends, among other things, that the VA OIG revise its policy and require verification of evidence produced in senior-official case referrals. VA concurred with nine recommendations and partially concurred with five. In response, GAO modified three of the recommendations. The VA OIG concurred with one recommendation and partially concurred with the other. GAO continues to believe that both are warranted.

prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 2.

Report 1: During World War II and then again after the outbreak of fighting in Korea, Congress found that the existence of thousands of small business concerns was being threatened by war-induced shortages of materials coupled with an inability to obtain defense contracts or financial assistance  Concerned that many small businesses might fail without government assistance, in 1953, Congress passed and President Dwight Eisenhower signed into law the Small Business Act (P L  83-163), which authorized the Small Business Administration (SBA)  The act specifies that it is the declared policy of Congress to promote the interests of small businesses to "preserve free competitive enterprise " Congress specified that one of the ways to preserve free competitive enterprise was to insure that small businesses received a "fair proportion" of federal contracts and subcontracts: It is the declared policy of the Congress that the Government should aid, counsel, assist, and protect, insofar as is possible, the interests of small-business concerns in order to preserve free competitive enterprise, to insure that a fair proportion of the total purchases and contracts or subcontracts for property and services for the Government (including but not limited to contracts or subcontracts for maintenance, repair, and construction) be placed with small-business enterprises, to insure that a fair proportion of the total sales of Government property be made to such enterprises, and to maintain and strengthen the overall economy of the Nation  Congress indicated that its intent in supporting small businesses was not to "favor small business at the expense of its larger competitors  Our only purpose in supporting the creation and effective operation of the SBA is to equalize the scales when necessary to guarantee the continued vigor of our competitive free enterprise system " More recently, a House committee report indicated that the primary rationale for small business contracting programs is the positive economic benefits they provide, as well as assisting small businesses overcome the complexities of the system  The economic benefits of these programs can be seen in two primary areas—market competition and local economic development  First, [these] programs … are designed to increase and diversify small contractors with the intent of expanding the federal supplier base  This leads to increased competition, which results in higher quality, greater product variety, and lower prices  Second, these contracting initiatives lower barriers to entry in a wide range of markets for small businesses  This provides greater market access for small firms' goods and services  From an economic perspective, such access is critical to generating positive macroeconomic benefits, including higher job creation, wage growth, and greater income distribution  Over the years, Congress has approved legislation to support small business in various ways  For example, the SBA administers several types of programs to support small businesses, including loan guaranty and venture capital programs to enhance small business access to capital; contracting programs to increase small business opportunities in federal contracting; direct loan programs for businesses, homeowners, and renters to assist their recovery from natural disasters; and small business management and technical assistance training programs to assist business formation and expansion  In recent years, congressional interest in these programs has increased, primarily because assisting small businesses is viewed as a means to stimulate economic activity and create jobs  This report describes the various federal programs, requirements, procurement officers, and procurement offices involved in promoting federal contracting and subcontracting with small businesses, small disadvantaged businesses (SDBs), SDBs participating the SBA's "8(a) Program," Historically Underutilized Business Zone (HUBZone) small businesses, women-owned small businesses (WOSBs), and service-disabled veteran-owned small businesses (SDVOSBs)  The SBA administers many, but not all, of these programs  It examines the following federal requirements and authorities in promoting contracting and subcontracting with small businesses: 1  The requirement that federal agencies generally reserve contracts that have an anticipated value greater than the micro-purchase threshold (currently $10,000) but not greater than the simplified acquisition threshold (currently $250,000) exclusively for small businesses unless the contracting officer is unable to obtain offers from two or more small businesses that are competitive with market prices and the quality and delivery of the goods or services being purchased  2  The establishment of small business procurement goals, both government-wide and agency specific, to promote the awarding of contracts to small businesses  3  The requirement that federal agencies generally set aside contracts that have an anticipated value exceeding the simplified acquisition threshold exclusively for small businesses when there is a reasonable expectation that offers will be obtained from at least two responsible small businesses offering the products of different small businesses (Rule of Two) and the award will be made at a fair market price  4  The authority provided federal agencies to make sole source awards to small businesses when the award could not otherwise be made (e g , only a single source is available, under urgent and compelling circumstances)  5  The authority provided federal agencies to set aside contracts for, or grant other contracting preference to, specific types of small businesses (e g , 8(a) small businesses, HUBZone small businesses, WOSBs, and SDVOSBs)  It discusses the SBA's oversight and responsibilities concerning the small business goaling program, small business mentor-protégé programs, the 7(j) management and training program, and the surety bond guaranty program  It also discusses the role of the Office of Small and Disadvantaged Business Utilization (OSDBU), located in each federal agency, in promoting contracting with small businesses, and examines the role and responsibilities of various federal procurement officers, including procurement center representatives, commercial market representatives, and business opportunity specialists, in promoting small business contracting opportunities  This report concludes with a brief discussion of the strong bipartisan support for small business contracting programs  However, that does not mean that these programs face no opposition, or that issues have not been raised concerning the impact and operations of specific programs  For example, small business advocates note that implementing regulations in the Federal Acquisition Regulation (FAR) narrow the reach (and impact) of some small business contracting preferences by excluding specific types of contracts, such as those listed in the Federal Supply Schedules, from FAR requirements pertaining to small business contracting  Advocates want the federal government to enact policies that reduce or eliminate exclusions that narrow the reach of small business contracting preferences  Critics have questioned some of these programs' effectiveness, in terms of promoting both small business opportunities to win federal contracts and a more diversified, robust economy  With a few exceptions, businesses interested in bidding on a federal contract must obtain a Dun & Bradstreet Data Universal Numbering System (DUNS) number (i e , a unique nine-digit identification number) for each of the business's physical locations, and register with the federal government's System for Award Management (SAM)  SAM is used by government agencies for several purposes, including to find contractors  Businesses also must match their products and services to a North American Industry Classification System (NAICS) code  Businesses generally have a primary NAICS code, and may have multiple NAICS codes if they sell multiple products and services  Businesses that identify themselves as a small business in SAM must (1) meet the Small Business Act's definition of a small business and (2) not exceed size standards established, and updated periodically, by the SBA  The Small Business Act defines a small business as one that is organized for profit; has a place of business in the United States; operates primarily within the United States or makes a significant contribution to the U S  economy through payment of taxes or use of American products, materials, or labor; is independently owned and operated; and is not dominant in its field on a national basis  The business may be a sole proprietorship, partnership, corporation, or any other legal form  The Small Business Act authorizes the SBA to establish size standards to ensure that only small businesses are provided SBA assistance  The SBA currently uses two types of size standards to determine SBA program eligibility: industry-specific size standards and alternative size standards , for some lending and venture capital investment programs based on the applicant's maximum tangible net worth and average net income after federal taxes  The SBA's industry-specific size standards are used to determine eligibility for federal small business contracting purposes  The SBA determines if a business is small by comparing that business's economic characteristics (typically number of employees or average annual receipts) to size standards listed in the SBA's Table of Small Business Size Standards   The table has size standards for 1,036 industrial classifications in the North American Industrial Classification System  Businesses that exceed the applicable size standard for their primary industry do not meet the requirement of being small  The SBA's size standards are designed to (1) encourage competition within each industry and (2) ensure that SBA assistance is provided only to firms that are not dominant in their field on a national basis  The size standards are derived through an assessment of four economic factors: (1) the average firm size, (2) the average assets size as a proxy of start-up costs and entry barriers, (3) the four-firm concentration ratio (the cumulative share of total industry receipts of that industry's four biggest firms) as a measure of industry competition, and (4) the size distribution of firms  The SBA also considers the ability of small businesses to compete for federal contracting opportunities and, when necessary, several secondary factors "as they are relevant to the industries and the interests of small businesses, including technological change, competition among industries, industry growth trends, and impacts of size standard revisions on small businesses " Historically, the SBA has used the number of employees to determine if manufacturing and mining companies are small (ranging from fewer than 50 employees for some industries to fewer than 1,500 employees for others) and average annual receipts for most other industries (ranging from no more than $1 million for some industries to no more than $40 million for others)  To make it easier to determine if an offeror meets the SBA's definition of a small business, prior to soliciting bids, federal agencies are required to classify a product or service being acquired in only one (NAICS code) industry, "whose definition best describes the principal nature of the product or service being acquired even though for other purposes it could be classified in more than one " When acquiring a product or service that could be classified in two or more industries with different size standards, contracting officers must "apply the size standard for the industry accounting for the greatest percentage of the contract price " If a solicitation calls for more than one item and allows offers to be submitted on any or all of the items, "an offeror must meet the size standard for each item it offers to furnish " If a solicitation calling for more than one item requires offers on all or none of the items, "an offeror may qualify as a small business by meeting the size standard for the item accounting for the greatest percentage of the total contract price " With several notable exceptions (e g , HUBZone small businesses, SBA 8(a) program participants, and veteran-owned small businesses [VOSBs] and SDVOSBs seeking contracts with the Department of Veterans Affairs), businesses generally self-certify their status as small when they register their business in the SAM database  The contracting officer is required to accept an offeror's representation in a specific bid or proposal that it is a small business unless "(1) another offeror or interested party challenges the concern's small business representation or (2) the contracting officer has a reason to question the representation " If an offeror's small business status is challenged, the contracting officer is generally not allowed to award the contract until the SBA has made a size determination or 15 business days after the SBA receives the protest, whichever occurs first  The SBA's Office of Government Contracting Area Office (Area Office) serving the area in which the headquarters of the offeror is located initially reviews the protest  The Area Office is required, by regulation, to determine the offeror's size status within 15 business days after receipt of the protest, or "within any extension of time granted by the contracting officer " If the SBA does not make a determination within the required time, the contracting officer "may award the contract after determining in writing that there is an immediate need to award the contract and that waiting until SBA makes its determination will be disadvantageous to the government " An appeal of the Area Office's decision may be filed with the SBA's Office of Hearings and Appeals (OHA)   If the OHA accepts the appeal for consideration and finds the protested concern to be ineligible for award, the contracting officer must "terminate the contract unless termination is not in the best interests of the government, in keeping with the circumstances described in the [aforementioned] written determination  However, the contracting officer shall not exercise any options or award further task or delivery orders " Furthermore, a concern cannot become eligible for a specific award after the SBA has determined that it is not a small business, even if the concern takes action to meet the definition of a small business  The SBA or the federal agency may suspend or debar a firm from future government contracts for misrepresenting its size status  In addition, individuals that knowingly misrepresent a business's size to secure a federal contract can be subject to civil and criminal penalties  15 U S C  §644(e)(1) states, "To the maximum extent practicable, procurement strategies used by a Federal department or agency having contracting authority shall facilitate the maximum participation of small business concerns as prime contractors, subcontractors, and suppliers " To accomplish this goal, FAR regulations (FAR §19 202-1) require contracting officers, when applicable, to take the following actions prior to awarding a federal contract: 1  "Divide proposed acquisitions of supplies and services (except construction) into reasonably small lots (not less than economic production runs) to permit offers on quantities less than the total requirement " 2  "Plan acquisitions such that, if practicable, more than one small business concern may perform the work, if the work exceeds the amount for which a surety may be guaranteed by the SBA against loss under 15 U S C  §694b [generally $6 5 million, or $10 million if the contracting officer certifies that the higher amount is necessary] " 3  "Ensure that delivery schedules are established on a realistic basis that will encourage small business participation to the extent consistent with the actual requirements of the Government " 4  "Encourage prime contractors to subcontract with small business concerns [primarily through the agency's role in negotiating an acceptable small business subcontracting plan with prime contractors on contracts anticipated to exceed $700,000 or $1 5 million for construction contracts] " 5  "Provide a copy of the proposed acquisition package to the SBA procurement center representative [PCR, duties are described later]" for his or her review, comment and recommendation, or, if a PCR is not assigned, to the SBA Area Office serving the area in which the procuring activity is located "at least 30 days prior to the issuance of the solicitation if (i) The proposed acquisition is for supplies or services currently being provided by a small business and the proposed acquisition is of a quantity or estimated dollar value, the magnitude of which makes it unlikely that small businesses can compete for the prime contract; (ii) The proposed acquisition is for construction and seeks to package or consolidate discrete construction projects and the magnitude of this consolidation makes it unlikely that small businesses can compete for the prime contract; or (iii) The proposed acquisition is for a consolidated or bundled requirement … The contracting officer shall provide all information relative to the justification for the consolidation or bundling, including the acquisition plan or strategy and if the acquisition involves substantial bundling, the information identified in [FAR] 7 107-4  The contracting officer shall also provide the same information to the agency Office of Small and Disadvantaged Business Utilization [duties are described later] " 6  "Provide a statement explaining why the (i) Proposed acquisition cannot be divided into reasonably small lots (not less than economic production runs) to permit offers on quantities less than the total requirement; (ii) Delivery schedules cannot be established on a realistic basis that will encourage small business participation to the extent consistent with the actual requirements of the government; (iii) Proposed acquisition cannot be structured so as to make it likely that small businesses can compete for the prime contract; (iv) Consolidated construction project cannot be acquired as separate discrete projects; or (v) Consolidation or bundling is necessary and justified " 7  "Process the 30-day notification concurrently with other processing steps required prior to the issuance of the solicitation " 8  "If the contracting officer rejects the SBA procurement center representative's recommendation … document the basis for the rejection and notify the SBA procurement center representative [who (as described later) may appeal the rejection to the chief of the contracting office and, ultimately, to the agency head] " The SBA may assign one or more procurement center representatives (PCRs) to any contracting activity or contract administration office to implement the SBA's policies and programs  The SBA currently has 49 PCRs located in the SBA's six Area Offices  PCRs are required to comply with the contracting agency's directives governing the conduct of contracting personnel and the release of contract information  PCR duties include the following: Review proposed acquisitions to recommend "the setting aside of selected acquisitions not unilaterally set aside by the contracting officer;" new qualified small business sources; and the feasibility of breaking out components of the contract for competitive acquisitions  Review proposed acquisition packages  If the PCR (or, if a PCR is not assigned, the SBA Area Office serving the area in which the procuring activity is located) "believes that the acquisition, as proposed, makes it unlikely that small businesses can compete for the prime contract," the PCR can recommend any alternate contracting method that he or she "reasonably believes will increase small business prime contracting opportunities " The recommendation must be made to the contracting officer within 15 days after the package's receipt  Recommend small businesses "for inclusion on a list of concerns to be solicited in a specific acquisition " Appeal to the contracting office's chief "any contracting officer's determination not to solicit a concern recommended by the SBA for a particular acquisition, when not doing so results in no small business being solicited " This appeal may be further appealed to the agency head  Conduct periodic reviews of the agency's contracting activity, including the agency's assessment of any required small business subcontracting plan, "to ascertain whether the agency is complying with the small business policies in this regulation " Sponsor and participate in conferences and training "designed to increase small business participation in the contracting activities of the office " Every federal agency (except the SBA) that has procurement powers is required to have an OSDBU, whose director, by statute, reports directly to the head of the agency and has supervisory authority over agency staff performing certain procurement functions  The OSDBU's primary responsibility is to ensure that small businesses, SDBs, WOSBs, SDVOSBs, and HUBZone small businesses are treated fairly and that they have an opportunity to compete and be selected for a fair amount of the agency's contract dollars  Among its statutory responsibilities are the following: "Identify proposed solicitations that involve significant bundling of contract requirements, and work with the agency acquisition officials and the Administration to revise the procurement strategies for such proposed solicitations where appropriate to increase the probability of participation by small businesses as prime contractors, or to facilitate small business participation as subcontractors and suppliers, if a solicitation for a bundled contract is to be issued " Assist small businesses "to obtain payments, required late payment interest penalties, or information regarding payments due to the concern from an executive agency or a contractor " Assign "a small business technical adviser to each office to which the SBA has assigned" a PCR  The small business technical advisor "shall be a full-time employee of the procuring activity, well qualified, technically trained and familiar with the supplies or services purchased at the activity; and whose principal duty shall be to assist" the PCR  Provide the agency's "Chief Acquisition Officer and senior procurement executive … with advice and comments on acquisition strategies, market research, and justifications [related to limitations on the consolidation of contracts as a means to provide small businesses appropriate opportunities to participate as prime contractors and subcontractors] " Provide training to small businesses and contract specialists, provided that the training does not interfere with the director carrying out his or her other responsibilities  Ensure that a small business that notifies the PCR prior to a contract's award that "a solicitation, request for proposal, or request for quotation unduly restricts [its] ability … to compete for the award … is aware of other resources and processes available to address unduly restrictive provisions … even if such resources and processes are provided by such agency, the Administration, the Comptroller General, or a Department of Defense (DOD) procurement technical assistance program [described below] " Review all subcontracting plans "to ensure that the plan provides maximum practicable opportunity for small business concerns to participate in the performance of the contract to which the plan applies " In accordance with P L  109-163 , the National Defense Authorization Act of 2006, the DOD renamed its OSDBU the Office of Small Business Programs (OSBP)  The act also redesignated the Army, Navy, and Air Force's OSDBUs to OSBPs of the Department of the Army, Navy, and Air Force, respectively  At the agency level, procurement department heads (sometimes titled senior procurement executive ) are responsible for implementing small business programs at their agencies, including achieving program goals  In general, procurement department staff who work on small business issues (often titled small business specialists ) coordinate with OSDBU directors on their agencies' small business programs  Chief acquisition officers provide a focal point for acquisition in agency operations  Their key functions include "monitoring and evaluating agency acquisition activities, increasing the use of full and open competition, increasing performance-based contracting, making acquisition decisions, managing agency acquisition policy, acquisition career management, acquisition resources planning, and conducting acquisition assessments " The SBA must assign a breakout procurement center representative (breakout PCR) to each major procurement center  A major procurement center is, in the opinion of the SBA Administrator, a procurement center that purchases substantial dollar amounts of other than commercial items, and has the potential to incur significant savings as a result of the placement of a breakout PCR  The breakout PCR advocates for (1) the appropriate use of full and open competition, and (2) the breakout of items, "when appropriate and while maintaining the integrity of the system in which such items are used " The breakout PCR is in addition to the PCR  When a breakout PCR is assigned, the SBA must assign at least two co-located small business technical advisors  SBA breakout PCRs and technical advisors must comply with the contracting agency's directives governing the conduct of contracting personnel and the release of contract information  The SBA must obtain security clearances for its breakout PCRs and technical advisors as required by the contracting agency  The SBA has four commercial market r epresentatives who, among other duties, help prime contractors find small businesses that are capable of performing subcontracts; provide counseling on the contractor's responsibility to maximize subcontracting opportunities for small businesses; and conduct periodic reviews of contractors awarded contracts requiring an acceptable subcontracting plan that provides small businesses "the maximum practicable opportunity to participate in contract performance consistent with its efficient performance" (generally any solicitation to perform a contract that is expected to exceed $700,000 ($1 5 million for construction) and that has subcontracting possibilities)  The SBA's business opportunity s pecialists provide, among other duties, guidance, counseling, and referrals for assistance with technical, management, financial, or other matters intended to improve the competitive viability of SBA 8(a) program participants  They provide 8(a) program participants comprehensive assessments of the firm's strengths and weaknesses; monitor and document their compliance with 8(a) program requirements; advise them on compliance with contracting regulations after the award of a 8(a) program contract or subcontract; review and monitor their compliance with mentor-protégé agreements; represent the interests of the SBA Administrator and small businesses in the award, modification, and administration of 8(a) program contracts and subcontracts; and report fraud or abuse involving the 8(a) program  The Small Business Procurement Advisory Council (SBPAC), whose members are composed of the SBA Administrator (or his or her designee), the director of the Minority Business Development Agency, and the head of each OSDBU in each federal agency having procurement powers, has the following statutory duties: 1  Develop positions on proposed procurement regulations affecting the small business community  2  Submit comments reflecting such positions to appropriate regulatory authorities  3  Conduct reviews of each OSDBU to determine the office's compliance with its statutory requirements  4  Identify best practices for maximizing small business utilization in federal contracting that may be implemented by federal agencies having procurement powers  5  Submit annually, to the House Committee on Small Business and Senate Committee on Small Business and Entrepreneurship, a report describing (1) the comments submitted to appropriate regulatory authorities, including any outcomes related to the comments; (2) the results of its review of each OSDBU ; and (3) best practices identified for maximizing small business contracting   The Defense Logistic Agency's Procurement Technical Assistance Program (PTAC) helps "businesses pursue and perform under contracts with the Department of Defense, other federal agencies, state and local governments and with government prime contractors  Most of the assistance the PTACs provide is free  PTAC support to businesses includes registration in systems such as the System for Award Management (SAM), identification of contract opportunities, and help in understanding requirements and in preparing and submitting bids " The Competition in Contracting Act of 1984 generally requires "full and open competition" for government procurement contracts  However, various provisions of the Small Business Act authorize or, in some cases, require federal agencies to provide for other than "full and open competition through the use of competitive procedures" when contracting with small businesses  For example, as mentioned previously, federal agencies are generally required to reserve contracts that have an anticipated value greater than the micro-purchase threshold (currently $10,000), but not greater than the simplified acquisition threshold (currently $250,000) exclusively for small businesses unless the contracting officer is unable to obtain offers from two or more small businesses that are competitive with market prices and the quality and delivery of the goods or services being purchased  In addition, federal agencies are generally required to set aside contracts that have an anticipated value exceeding the simplified acquisition threshold exclusively for small businesses when there is a reasonable expectation by the contracting officer that offers will be obtained by at least two responsible small businesses offering the products of different small businesses (Rule of Two) and the award will be made at a fair market price; may similarly set aside contracts exceeding the simplified acquisition threshold for competition reserved for specific types of small businesses (e g , 8(a) small businesses, HUBZone small businesses, WOSBs and SDVOSBs); may enter into negotiations directly with particular types of small businesses (e g , a sole source award) when the award could not otherwise be made (e g , only a single source is available or under urgent and compelling circumstances); and are required to grant HUBZone small businesses a price evaluation preference of not more than 10% in open and unrestricted competitions  Several SBA programs assist small businesses in obtaining and performing federal contracts and subcontracts  These include various prime contracting programs; subcontracting programs; and other assistance (e g , contracting technical training assistance and oversight of the federal small business goaling program and the Surety Bond Guarantee program)  Several contracting programs allow small businesses to compete only with similar firms for government contracts or receive sole source awards in circumstances in which such awards could not be made to other firms  These programs provide small businesses an opportunity to win government contracts without having to compete against larger and more experienced companies  The 8(a) Minority Small Business and Capital Ownership Development Program (named for the section of the Small Business Act from which it derives its authority) provides business development assistance to businesses owned and controlled by persons who are socially and economically disadvantaged  African Americans, Hispanics, Native Americans (including American Indians, Eskimos, Aleuts, and Native Hawaiians), Asian-Pacific Americans, and Subcontinent Asian Americans are presumed to be socially and economically disadvantaged  Other individuals can also qualify as socially and economically disadvantaged on a case-by-case basis  To be considered economically disadvantaged, an individual's net worth, excluding ownership interest in the 8(a) firm and equity in his or her primary personal residence, must be less than $250,000 at the time of application to the 8(a) Program, and less than $750,000 thereafter  Federal agencies are authorized to award contracts for goods or services, or to perform construction work, to the SBA for subcontracting to 8(a) firms  The SBA is authorized to delegate the function of executing contracts to the procuring agencies and often does so  Once the SBA has accepted a contract for the 8(a) Program, the contract is awarded through either a set-aside or on a sole source basis, with the contract amount generally determining the acquisition method used  When the contract's anticipated total value, including any options, is less than $4 million ($7 million for manufacturing contracts), the contract is normally awarded without competition (as a sole source award)  In contrast, when the contract's anticipated value exceeds these thresholds, the contract generally must be awarded via a set-aside with competition limited to 8(a) firms so long as there is a reasonable expectation that at least two eligible and responsible 8(a) firms will submit offers and the award can be made at fair market price  The SBA also provides technical assistance and training to 8(a) firms  Firms may participate in the 8(a) Program for no more than nine years  In FY2017, the federal government awarded $27 2 billion to 8(a) firms  $16 4 billion was awarded with an 8(a) preference ($8 billion through an 8(a) set-aside and $8 4 billion through an 8(a) sole source award); $4 8 billion was awarded to an 8(a) firm in open competition with other firms; and $6 billion was awarded with another small business preference (e g , set-asides and sole source awards for small businesses generally and for HUBZone firms, women-owned small businesses, and service-disabled veteran-owned small businesses)  This program assists small businesses located in Historically Underutilized Business Zones (HUBZones) through set-asides, sole source awards (so long as the award can be made at a fair and reasonable price, and the anticipated total value of the contract, including any options, is below $4 million, or $7 million for manufacturing contracts) and price evaluation preferences (of up to 10%) in full and open competitions  The HUBZone program targets assistance to small businesses located in areas with low income, high poverty, or high unemployment


Report 2:  To be certified as a HUBZone small business, at least 35% of the small business's employees must generally reside in a HUBZone  In FY2017, the federal government awarded $7 53 billion to HUBZone-certified small businesses  $1 90 billion was awarded with a HUBZone preference ($1 49 billion through a HUBZone set-aside, $65 3 million through a HUBZone sole source award, and $346 9 million through a HUBZone price-evaluation preference); $1 53 billion was awarded to HUBZone-certified small businesses in open competition with other firms; and $4 10 billion was awarded with another small business preference (e g , set-asides and sole source awards for small businesses generally and for 8(a), women-owned, and service-disabled veteran-owned small businesses)  This program allows agencies to set aside contracts for SDVOSBs  Also, federal agencies may award sole source contracts to SDVOSBs so long as the award can be made at a fair and reasonable price, and the anticipated total value of the contract, including any options, is below $4 million ($6 5 million for manufacturing contracts)  For purposes of this program, veterans and service-related disabilities are defined as they are under the statutes governing veterans affairs  In FY2017, the federal government awarded $18 2 billion to SDVOSBs  $6 8 billion was awarded through a SDVOSB set-aside award; $4 3 billion was awarded to a SDVOSB in open competition with other firms; and $7 1 billion was awarded with another small business preference (e g , set-asides and sole source awards for small businesses generally and for HUBZone firms, 8(a) firms, and WOSBs)  Under this program, contracts may be set aside for economically disadvantaged WOSBs in industries in which women are underrepresented and substantially underrepresented  Federal agencies may award sole source contracts to WOSBs so long as the award can be made at a fair and reasonable price, and the anticipated total value of the contract, including any options, is below $4 million ($6 5 million for manufacturing contracts)  In FY2017, the federal government awarded $21 3 billion to WOSBs  $648 9 million was awarded with a WOSB preference ($580 5 million through a WOSB set-aside and $68 4 million through a WOSB sole source award); $7 0 billion was awarded to a WOSB in open competition with other firms; and $13 7 billion was awarded with another small business preference (e g , set-asides and sole source awards for small businesses generally and for HUBZone firms, 8(a) firms, and SDVOSBs)  Federal contracting officers are required to provide the SBA's PCR (or, if a PCR is not assigned, the SBA Area Office serving the procuring activity area) a "reasonable period of time" to review any solicitation requiring submission of a small business subcontracting plan and to submit advisory findings before the solicitation is issued  The PCR's advisory comments regarding the small business subcontracting plan's acceptability must be submitted, in writing, to the appropriate contracting officer within five working days after the plan's receipt  As mentioned previously, the SBA's commercial market representatives help prime contractors find small businesses to perform subcontracts; counsel contractors on their responsibility to maximize subcontracting opportunities for small businesses; and conduct periodic reviews, often in concert with a SBA PCR, of contractors awarded contracts that require an acceptable small business subcontracting plan  Federal agencies may also set aside contracts or make sole source awards to small businesses not participating in any other program under certain conditions  The Department of Transportation's (DOT's) Disadvantaged Business Enterprise (DBE) Program originally began in 1980 as a minority/women's business enterprise program "established by regulation under the authority of Title VI of the Civil Rights Act of 1964 and other nondiscrimination statutes that apply to DOT financial assistance programs " Congress has reauthorized the DBE program several times since its inception; most recently in P L  114-94 , the Fixing America's Surface Transportation Act (FAST-Act)  The FAST-Act provides, that, except to the extent the Secretary of Transportation determines otherwise, not less than 10% of the amounts made available for any program under Titles I (federal-aid highways), II (innovative project finance), III (public transportation) and VI (innovation) of the act and 23 U S  Code 403 (highway safety research and development), shall be expended with DBEs  DOT also has a separate DBE program for airport concessions  A DBE is a for-profit small business owned and controlled by socially and economically disadvantaged individuals  Eligibility for the DBE program differs somewhat from the 8(a) program  For example, under the DBE program, women are presumed to be socially and economically disadvantaged individuals  Also, to be regarded as economically disadvantaged, an individual must have a personal net worth (excluding ownership interest in the firm and equity in his or her primary personal residence) that does not exceed $1 32 million  The DBE must also meet SBA size criteria and have average annual gross receipts not exceeding $23 98 million  Size limits for the airport concessions DBE program are higher  The DBE program's eight objectives are to 1  ensure nondiscrimination in the award and administration of DOT-assisted contracts in the department's highway, transit, and airport financial assistance programs; 2  create a level playing field on which DBEs can compete fairly for DOT-assisted contracts; 3  ensure that the department's DBE program is narrowly tailored in accordance with applicable law; 4  ensure that only firms that fully meet the program's eligibility standards are permitted to participate as DBEs; 5  help remove DBE-participation barriers in DOT-assisted contracts; 6  promote the use of DBEs in all types of federally-assisted contracts and procurement activities conducted by recipients; 7  assist the development of firms that can compete successfully in the marketplace outside the DBE program; and 8  provide appropriate flexibility to recipients of federal financial assistance in establishing and providing opportunities for DBEs  Other federal programs promote subcontracting with small disadvantaged businesses (SDBs)  SDBs include 8(a) participants and other small businesses that are at least 51% unconditionally owned and controlled by socially or economically disadvantaged individuals or groups  Individuals owning and controlling non-8(a) SDBs may have net worth of up to $750,000 (excluding ownership interests in the SDB firm and equity in their primary personal residence)  Otherwise, however, SDBs must generally satisfy the same eligibility requirements as 8(a) firms, although they do not apply to the SBA to be designated SDBs in the same way that 8(a) firms do  Federal agencies must negotiate "subcontracting plans" with the apparently successful bidder or offeror on eligible prime contracts prior to awarding the contract  Subcontracting plans set goals for the percentage of subcontract dollars to be awarded to SDBs, among others, and describe efforts that will be made to ensure that SDBs "have an equitable opportunity to compete for subcontracts " Federal agencies may also consider the extent of subcontracting with SDBs in determining to whom to award a contract or give contractors "monetary incentives" to subcontract with SDBs  As of February 11, 2019, the SBA's Dynamic Small Business Search database included 2,538 SBA-certified SDBs and 100,595 self-certified SDBs  The SBA's 7(j) Management and Technical Assistance program provides "a wide variety of management and technical assistance to eligible individuals or concerns to meet their specific needs, including: (a) counseling and training in the areas of financing, management, accounting, bookkeeping, marketing, and operation of small business concerns; and (b) the identification and development of new business opportunities " Eligible individuals and businesses include "8(a) certified firms, SDBs, businesses operating in areas of high unemployment, or low income or firms owned by low income individuals " In FY2017, the 7(j) Management and Technical Assistance program assisted 4,100 small businesses  The SBA's Surety Bond Guarantee program aims to increase small businesses' access to federal, state, and local government contracting, as well as private-sector contracts, by guaranteeing bid, performance, and payment bonds for small businesses that cannot obtain surety bonds through regular commercial channels  The program guarantees individual contracts of up to $6 5 million and up to $10 million if a federal contracting officer certifies that such a guarantee is necessary  The SBA's guarantee ranges from not to exceed 80% to not to exceed 90% of the surety's loss if a default occurs  In FY2017, the SBA guaranteed 10,397 bid and final surety bonds with a total contract value of more than $6 3 billion  A surety bond is a three-party instrument between a surety (someone who agrees to be responsible for the debt or obligation of another), a contractor, and a project owner  The agreement binds the contractor to comply with the terms and conditions of a contract  If the contractor is unable to successfully perform the contract, the surety assumes the contractor's responsibilities and ensures that the project is completed  The surety bond reduces the risk associated with contracting  Surety bonds are meant to encourage project owners to contract with small businesses that may not have the credit history or prior experience of larger businesses and may be at greater risk of failing to comply with the contract's terms and conditions  Surety bonds are important to small businesses interested in competing for federal contracts because the federal government requires prime contractors—prior to the award of a federal contract exceeding $150,000 for the construction, alteration, or repair of any building or public work of the United States—to furnish a performance bond issued by a surety satisfactory to the contracting officer in an amount that the officer considers adequate to protect the government  Small business mentor-protégé programs typically seek to pair new businesses with more experienced businesses in mutually beneficial relationships  Protégés may receive financial, technical, or management assistance from mentors in obtaining and performing federal contracts or subcontracts, or serving as suppliers under such contracts or subcontracts  Mentors may receive credit toward subcontracting goals, reimbursement of certain expenses, or other incentives  The federal government currently has several mentor-protégé programs to assist small businesses in various ways  The 8(a) Mentor-Protégé Program is a government-wide program designed to assist small businesses "owned and controlled by socially and economically disadvantaged individuals" participating in the SBA's Minority Small Business and Capital Ownership Development Program (commonly known as the 8(a) program) in obtaining and performing federal contracts  For that purpose, mentors may (1) form joint ventures with protégés that are eligible to perform federal contracts set aside for small businesses; (2) make certain equity investments in protégé firms; (3) lend or subcontract to protégé firms; and (4) provide technical or management assistance to their protégés  The SBA's A ll S mall B usiness Mentor-Protégé Program is a government-wide mentor-protégé program for all small business concerns, consistent with the SBA's mentor-protégé program for participants in the SBA's 8(a) Business Development program  The Department of Defense (DOD) Mentor-Protégé Program , in contrast, is agency-specific  It assists various types of small businesses and other entities in obtaining and performing DOD subcontracts and serving as suppliers on DOD contracts  Mentors may (1) make advance or progress payments to their protégés that DOD reimburses; (2) award subcontracts to their protégés on a noncompetitive basis when they would not otherwise be able to do so; (3) lend money to or make investments in protégé firms; and (4) provide or arrange for other assistance  Other agencies also have agency-specific mentor-protégé programs to assist various types of small businesses or other entities in obtaining and performing subcontracts under agency prime contracts  The Department of Homeland Security (DHS), for example, has a mentor-protégé program wherein mentors may provide protégés with rent-free use of facilities or equipment, temporary personnel for training, property, loans, or other assistance  Because these programs are not based in statute, unlike the SBA and DOD programs, they generally rely upon preexisting authorities (e g , authorizing use of evaluation factors) or publicity to incentivize mentor participation  Currently, more than 1,200 mentor-protégé agreements are in place, even though there are issues with the accuracy and thoroughness of some federal agency records  Since 1978, federal agency heads have been required to establish federal procurement goals, in consultation with the SBA, "that realistically reflect the potential of small business concerns and small business concerns owned and controlled by socially and economically disadvantaged individuals" to participate in federal procurement  Each agency is required, at the conclusion of each fiscal year, to report its progress in meeting the goals to the SBA  In 1988, Congress authorized the President annually to establish government-wide minimum participation goals for procurement contracts awarded to small businesses and small businesses owned and controlled by socially and economically disadvantaged individuals  Congress required the government-wide minimum participation goal for small businesses to be "not less than 20% of the total value of all prime contract awards for each fiscal year" and "not less than 5% of the total value of all prime contract and subcontract awards for each fiscal year" for small businesses owned and controlled by socially and economically disadvantaged individuals  Each federal agency was also directed to "have an annual goal that presents, for that agency, the maximum practicable opportunity for small business concerns and small business concerns owned and controlled by socially and economically disadvantaged individuals to participate in the performance of contracts let by such agency " The SBA was also required to report to the President annually on the attainment of the goals and to include the information in an annual report to Congress  The SBA negotiates the goals with each federal agency and establishes a small business eligible baseline for evaluating the agency's performance  The agency head is required to "make consistent efforts to annually expand participation by small business concerns from each industry category " If the SBA and the agency cannot agree on the goals, the agency may submit the case to the Office of Management and Budget (OMB) Office of Federal Procurement Policy (OFPP) for resolution  The small business eligible baseline excludes certain contracts that the SBA has determined do not realistically reflect the potential for small business participation in federal procurement (such as those awarded to mandatory and directed sources), contracts funded predominately from agency-generated sources (i e , non-appropriated funds), contracts not covered by the FAR, acquisitions on behalf of foreign governments, and contracts not reported in the Federal Procurement Data System – Next Generation, or FPDS-NG (such as government procurement card purchases and contracts valued less than $10,000)  These exclusions typically account for 18% to 20% of all federal prime contracts each year  The SBA then evaluates the agencies' performance against their negotiated goals annually, using FPDS-NG data, managed by the U S  General Services Administration (GSA), to generate the small business eligible baseline  This information is compiled into the official Small Business Goaling Report, which the SBA releases annually  Each agency that fails to achieve any proposed prime or subcontract goal is required to submit a justification to the SBA on why it failed to achieve a proposed or negotiated goal with a proposed plan of corrective action  Agencies can take credit in every category that is applicable to the recipient of the contract  For example, "when counting goaling achievements, a contract awarded to a service-disabled Veteran-Owned Woman-Owned Small Business would be counted toward the Small Business (SB) goal, the Service-Disabled Veteran-Owned Small Business (SDVOSB) goal and the Women-Owned Small Business (WOSB) goal  However, these category counts are not summed to triple the total count  The Sum of Parts Does Not Equal the Whole (italics in original) " Over the years, federal government-wide procurement goals have been established for small businesses generally ( P L  100-656 , the Business Opportunity Development Reform Act of 1988, and P L  105-135 , the HUBZone Act of 1997—Title VI of the Small Business Reauthorization Act of 1997); small businesses owned and controlled by socially and economically disadvantaged individuals ( P L  100-656 ); women ( P L  103-355 , the Federal Acquisition Streamlining Act of 1994); small businesses located within a HUBZone ( P L  105-135 ); and small businesses owned and controlled by a service-disabled veteran ( P L  106-50 , the Veterans Entrepreneurship and Small Business Development Act of 1999)  The current federal small business procurement goals are at least 23 0% of the total value of all small business eligible prime contract awards to small businesses for each fiscal year; 5 0% of the total value of all small business eligible prime contract awards and subcontract awards to small disadvantaged businesses (including participants in the SBA's 8(a) Program) for each fiscal year; 5 0% of the total value of all small business eligible prime contract awards and subcontract awards to women-owned small businesses; 3 0% of the total value of all small business eligible prime contract awards and subcontract awards to HUBZone small businesses; and 3 0% of the total value of all small business eligible prime contract awards and subcontract awards to service-disabled veteran-owned small businesses  There are no punitive consequences for not meeting these goals  However, the SBA's Small Business Goaling Report is distributed widely, receives media attention, and serves to heighten public awareness of the issue of small business contracting  For example, agency performance as reported in the SBA's Small Business Goaling Report is often cited by Members during their questioning of federal agency witnesses during congressional hearings  As shown in Table 1 , the FY2017 Small Business Goaling Report , using FPDS-NG data, indicates that federal agencies met the federal procurement goal for small businesses generally, small disadvantaged businesses, and service-disabled veteran-owned small businesses in FY2017  Table 1 also provides, for comparative purposes, the percentage of total reported federal contracts (without exclusions) awarded to those small businesses in FY2017  Before awarding a federal contract, the contracting officer must affirmatively determine that the business is responsible to perform the contract  If the contracting officer determines that an apparent successful small business offeror lacks certain elements of responsibility (e g , is unable to fulfill the requirements of a specific government procurement because it lacks capability, competency, capacity, credit, integrity, perseverance, tenacity, or limitations on subcontracting), the officer is required to refer the matter in writing to the SBA for review and a possible Certificate of Competency (COC), even if the next acceptable offer is also from a small business  The COC certifies in writing that the small business meets all required elements of responsibility for the purpose of receiving and performing a specific government contract  The "COC program empowers the SBA to certify to contracting officers as to all elements of responsibility of any small business concern to receive and perform a specific government contract  The COC program does not extend to questions concerning regulatory requirements imposed and enforced by other federal agencies " As mentioned previously, the SBA's commercial market representatives conduct periodic compliance reviews of contractors awarded contracts that require an acceptable small business subcontracting plan  In addition, once the contract is completed, federal agencies are required to pay the contractor on a timely basis and pay interest penalties for late payments  Under specified circumstances, federal agencies may also pay contractors before the contract's payment's due date  The periodic compliance review can take place on-site, at the contracting agency, or virtual  Materials that may be reviewed include the contractor's contract files, correspondence that is directly or indirectly related to the contract, IT systems, subcontracting methods, and procedures  Contractors are selected randomly for audit  The SBA may enter into agreements with other federal agencies to conduct these assessments  The compliance report includes compliant and non-compliant items found during the assessment of the contractor's subcontracting activities and a rating indicating the contractor's level of compliance or non-compliance, ranging from unsatisfactory to outstanding  If any deficiencies are found, the contractor is required to submit, within 30 days of the compliance review rating letter date, a corrective action plan (CAP)  The CAP is submitted to the SBA Area Office via email, or any method designated by the SBA  The commercial market representative conducts a follow-up compliance report within six months to a year of the date the SBA acknowledges receipt of the contractor's CAP to ensure that corrective actions have been taken to eliminate the deficiencies  The SBA keeps the federal agency that awarded the contract informed of the contractor's adherence to correcting the deficiencies  If the contractor refuses to provide or address all deficiencies in the CAP, a delinquent CAP letter is sent advising the contractor that it has 15 days from the letter's date to comply with federal regulations  If an acceptable CAP is not received in the allotted time frame the case is escalated to the SBA's subcontracting program manager who informs the SBA's Office of Government Contracting director and works with the SBA's Office of General Counsel and the federal agency that awarded the contract for resolution or to begin accessing liquidated damages  Once a contract is awarded, federal agencies are generally required to pay interest to prime contractors on any invoice payments the agency fails to make by the date(s) specified in the contract, or within 30 days of receipt of a proper invoice for the amount due if no date is specified in the contract  Similar requirements exist for prime contractors in paying subcontractors on construction contracts  These requirements are especially important for small businesses in the construction industry  Specifically, every construction contract awarded by a federal agency must contain clauses obligating the prime contractor to (1) pay the subcontractor for "satisfactory performance" under the subcontract within seven days of receiving payment from the agency and (2) pay interest on any amounts that are not paid within the proper time frame  The contract must also obligate the prime contractor to include similar payment and interest penalty terms in its subcontracts, as well as require its subcontractors to impose these terms on their subcontractors  This latter provision ensures that the payment and interest penalty requirements flow down to all tiers of construction subcontractors  In addition, required subcontracting plans must incorporate terms obligating the prime contractor to notify the agency awarding the contract in writing if a subcontractor is paid a reduced price for goods supplied or services completed under the contract, or if payment is made to the subcontractor more than 90 days past due  The prime contractor must include the reason for the reduction in payment or failure to pay a subcontractor within 90 days  If the contracting officer for a covered contract (a contract that requires an acceptable subcontracting plan) determines that a prime contractor has a history of unjustified, untimely payments to contractors, the contracting officer shall record the contractor's identity, describe the circumstances under which the contractor may be determined to have a history of unjustified, untimely payments to subcontractors, and include the contractor's identity in, and make publicly available through, the Federal Awardee Performance and Integrity Information System, or any successor  This information is used by federal agencies to "evaluate the business ethics and quality of prospective contractors competing for Federal contracts and to protect taxpayers from doing business with contractors that are not responsible sources " Federal agencies are permitted to make an accelerated payment up to seven days before the required payment date in a federal contract, or earlier if the agency deems it necessary on a case-by-case basis if, after receiving a proper invoice, it is in the best interest of the government, and any of the following is true: the invoice in under $2,500; the payment is to a small business; or the payment is related to an emergency, disaster, or military deployment  In addition, the Secretary of Defense is required, to the fullest extent permitted by law, to establish an accelerated payment date for its small business prime contractors, with a goal of 15 days after receipt of a proper invoice for the amount due if a specific payment date is not established by contract  The Secretary of Defense is also required to establish, to the fullest extent permitted by law, an accelerated payment date for its prime contractors that subcontract with small businesses, with a goal of 15 days after receipt of a proper invoice for the amount due if a specific payment date is not established by contract and the prime contractor agrees to make payments to the subcontractor "in accordance with the accelerated payment date, to the maximum extent practicable, without any further consideration from or fees charged to the subcontractor " The small business contracting programs described in this report generally have strong bipartisan support  However, that does not mean that these programs face no opposition or that issues have not been raised concerning the impact or operations of specific programs  For example, small business advocates seek policies that reduce or eliminate exclusions that narrow the reach of small business contracting preferences, want the SBA to use the total value of all prime contract awards in the Small Business Goaling Report, and want the SBA to use a more discerning methodology for awarding performance grades to federal agencies in meeting its small business contracting goals  Critics have questioned some of these programs' effectiveness, in terms of both promoting small business opportunities to win federal contracts and a more diversified, robust economy  Many observers judge the relative success or failure of federal efforts to enhance small business contracting opportunities by whether the federal government and individual federal agencies meet the procurement goals in the annual Small Business Goaling Report  In recent years, the federal government has generally succeeded in meeting the government-wide goals of awarding 23% of the total value of all small business eligible prime contract awards to small businesses generally, 5% to SDBs, and 3% to SDVOSBs  However, it has had difficulty meeting the goals of 5% to WOSBs and 3% to HUBZone small businesses  The Small Business Goaling Report is the most convenient measure available to compare federal small business contracting performance over time, but it has limitations  For example, the report does not include all federal contracts, because some are not deemed to be small business eligible and others are not recorded in the FPDS-NG  In addition, the report does not evaluate the effect these contracts have on small businesses, industry competitiveness, or the overall economy  As one group of researchers has argued, the entire goal-setting process … is geared to measuring the dollars and contracts awarded to small business, and pays little attention to the effect that access to government contracts has on small business starts, growth, and wealth generation  Results of the program are also hard to isolate, difficult to measure, and generally not judged against the next best or other alternative policies [emphasis in original]  Comprehensive studies examining the effect of small business contracting preferences on small business startups, growth, wealth generation, and industry competitiveness may prove useful for congressional oversight  In the meantime, although the Small Business Goaling Report has its limitations, it can help policymakers identify programs most in need of examination  For example, the SBA has announced that it is focusing additional efforts on promoting the HUBZone program to federal contracting officials, primarily due to the continuing difficulties federal agencies have had in meeting the 3% goal for HUBZone small businesses 

ground_truth: Research has shown that students who experience discipline that removes them from the classroom are more likely to repeat a grade, drop out of school, and become involved in the juvenile justice system. Studies have shown this can result in decreased earning potential and added costs to society, such as incarceration and lost tax revenue. Education and Justice are responsible for enforcing federal civil rights laws that prohibit discrimination in the administration of discipline in public schools. GAO was asked to review the use of discipline in schools. To provide insight into these issues, this report examines (1) patterns in disciplinary actions among public schools, (2) challenges selected school districts reported with student behavior and how they are approaching school discipline, and (3) actions Education and Justice have taken to identify and address disparities or discrimination in school discipline. GAO analyzed discipline data from nearly all public schools for school year 2013-14 from Education's Civil Rights Data Collection; interviewed federal and state officials, as well as officials from a total of 5 districts and 19 schools in California, Georgia, Massachusetts, North Dakota, and Texas. We selected these districts based on disparities in suspensions for Black students, boys, or students with disabilities, and diversity in size and location. We also reviewed federal laws and a non-generalizable sample of seven recently resolved federal school discipline investigations (selected in part based on the type of alleged discrimination). We incorporated technical comments from the agencies as appropriate. Black students, boys, and students with disabilities were disproportionately disciplined (e.g., suspensions and expulsions) in K-12 public schools, according to GAO's analysis of Department of Education (Education) national civil rights data for school year 2013-14, the most recent available. These disparities were widespread and persisted regardless of the type of disciplinary action, level of school poverty, or type of public school attended. For example, Black students accounted for 15.5 percent of all public school students, but represented about 39 percent of students suspended from school—an overrepresentation of about 23 percentage points (see figure). Officials GAO interviewed in all five school districts in the five states GAO visited reported various challenges with addressing student behavior, and said they were considering new approaches to school discipline. They described a range of issues, some complex—such as the effects of poverty and mental health issues. For example, officials in four school districts described a growing trend of behavioral challenges related to mental health and trauma. While there is no one-size-fits-all solution for the issues that influence student behavior, officials from all five school districts GAO visited were implementing alternatives to disciplinary actions that remove children from the classroom, such as initiatives that promote positive behavioral expectations for students. Education and the Department of Justice (Justice) documented several actions taken to identify and address school discipline issues. For example, both agencies investigated cases alleging discrimination. Further, to help identify persistent disparities among the nation's schools, Education collects comprehensive data on school discipline every other year through its Civil Rights Data Collection effort.