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



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



Report 2: 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
Report 2:  The Action Plan focuses on capacity building for security personnel in Central America and the Caribbean by Colombian security forces (both Colombian military and police)  To implement the plan, Colombia undertook several hundred activities in cooperation with Panama, Costa Rica, El Salvador, Honduras, Guatemala and the Dominican Republic, and between 2013 and 2017 trained almost 17,000 individuals (see Figure 4 )  The Colombian government notes that this program grew dramatically from 34 executed activities in 2013 to 441 activities planned for 2018  Colombia has increasingly trained military and police from other countries both under this partnership and other arrangements, including countries across the globe  According to the Colombian Ministry of Defense, around 80% of those trained were from Mexico, Central America, and the Caribbean  U S  and Colombian officials maintain that the broader effort is designed to export Colombian expertise in combating crime and terrorism while promoting the rule of law and greater bilateral and multilateral law enforcement cooperation  Critics of the effort to "export Colombian security successes" maintain that human rights concerns have not been adequately addressed  Some observers question the portion of these activities that are funded by the U S  government and want to see more transparency  In one analysis of the training, a majority of the training was provided by Colombian National Police rather than the Colombian Army, in such areas as ground, air, maritime, and river interdiction; police testimony; explosives; intelligence operations; psychological operations; and Comando JUNGLA, Colombia's elite counternarcotics police program  Other analysts praise the Colombian training and maintain that U S  assistance provided in this way has helped to improve, professionalize, and expand the Colombian military, making it the region's second largest  As that highly trained military shifts from combating the insurgency and the Colombian National Police take the dominant role in guaranteeing domestic security, Colombia may play a greater role in regional security and even in coalition efforts internationally  In September 2017, President Trump announced that he had considered designating Colombia in noncompliance with U S  counternarcotics requirements, but noted that he had not proceeded with the step in part because of Colombian training efforts to assist others in the region with combating narcotics and related crime  Colombia is a key U S  ally in the region  With diplomatic relations that began in the 19 th century following Colombia's independence from Spain, the countries have enjoyed close and strong ties  Because of Colombia's prominence in the production of illegal drugs, the United States and Colombia forged a close partnership over the past 16 years  Focused initially on counternarcotics, and later counterterrorism, a program called Plan Colombia laid the foundation for a strategic partnership that has broadened to include sustainable development, human rights, trade, regional security, and many other areas of cooperation  Between FY2000 and FY2016, the U S  Congress appropriated more than $10 billion in assistance from U S  State Department and Department of Defense (DOD) accounts to carry out Plan Colombia and its follow-on strategies  During this time, Colombia made notable progress combating drug trafficking and terrorist activities and reestablishing government control over much of its territory  Its economic and social policies have reduced the poverty rate and its security policies have lowered the homicide rate  Counternarcotics policy has been the defining issue in U S -Colombian relations since the 1980s because of Colombia's preeminence as a source country for illicit drugs  Peru and Bolivia were the main global producers of cocaine in the 1980s and early 1990s  However, successful efforts there in reducing supply pushed cocaine production from those countries to Colombia, which soon surpassed both its Andean neighbors  The FARC and other armed groups in the country financed themselves primarily through narcotics trafficking, and that lucrative illicit trade provided the gasoline for the decades-long internal armed conflict at least since the 1990s  Colombia emerged to dominate the cocaine trade by the late 1990s  National concern about the crack cocaine epidemic and extensive drug use in the United States led to greater concern with Colombia as a source  As Colombia became the largest producer of coca leaf and the largest exporter of finished cocaine, heroin produced from Colombian-grown poppies was supplying a growing proportion of the U S  market  Alarm over the volumes of heroin and cocaine being exported to the United States was a driving force behind U S  support for Plan Colombia at its inception  The evolution of Plan Colombia took place under changing leadership and changing conditions in both the United States and Colombia  Plan Colombia was followed by successor strategies such as the National Consolidation Plan, described below, and U S -Colombia policy has reached a new phase anticipating post-conflict Colombia  Announced in 1999, Plan Colombia originally was a six-year strategy to end the country's decades-long armed conflict, eliminate drug trafficking, and promote development  The counternarcotics and security strategy was developed by the government of President Andrés Pastrana in consultation with U S  officials  Colombia and its allies in the United States realized that for the nation to gain control of drug trafficking required a stronger security presence, the rebuilding of institutions, and extending state presence where it was weak or nonexistent  Initially, the U S  policy focus was on programs to reduce the production of illicit drugs  U S  support to Plan Colombia consisted of training and equipping counternarcotics battalions in the Colombian Army and specialized units of the Colombian National Police, drug eradication programs, alternative development, and other supply reduction programs  The original 1999 plan had a goal to reduce "the cultivation, processing, and distribution of narcotics by 50%" over the plan's six-year timeframe  The means to achieve this ambitious goal were a special focus on eradication and alternative development; strengthening, equipping, and professionalizing the Colombian Armed Forces and the police; strengthening the judiciary; and fighting corruption  Other objectives were to protect citizens from violence, promote human rights, bolster the economy, and improve governance  U S  officials expressed their support for the program by emphasizing its counterdrug elements (including interdiction)  The focus on counternarcotics was the basis for building bipartisan support to fund the program in the U S  Congress because some Members of Congress were leery of involvement in fighting a counterinsurgency, which they likened to the "slippery slope" of the war in Vietnam  President George W  Bush came to office in 2001 and oversaw some changes to Plan Colombia  The primary vehicle for providing U S  support to Plan Colombia was the Andean Counterdrug Initiative, which was included in foreign operations appropriations  The Bush Administration requested new flexibility so that U S -provided assistance would back a "unified campaign against narcotics trafficking, terrorist activities, and other threats to [Colombia's] national security" due to the breakdown of peace talks between the FARC and the Pastrana government in February 2002  Congress granted this request for a unified campaign to fight drug trafficking and terrorist organizations as Members of Congress came to realize how deeply intertwined the activities of Colombia's terrorist groups were with the illicit drug trade that funded them  However, Congress prohibited U S  personnel from directly participating in combat missions  Congress placed a legislative cap on the number of U S  military and civilian contractor personnel who could be stationed in Colombia, although the cap was adjusted to meet needs over time  The current limit (first specified in the FY2015 National Defense Authorization Act, as amended) caps total military personnel at 800 and civilian contractors at 600, although numbers deployed have been far below the 1,400-person cap for years and now total fewer than 200  President Uribe (2002-2010) embraced Plan Colombia with an aggressive strategy toward the insurgent forces that prioritized citizen security  His Democratic Security Policy, implemented first in a military campaign called Plan Patriota, relied on the military to push FARC forces away from the major cities to remote rural areas and the borderlands  Like his predecessor, President Pastrana, Uribe continued to expand the Colombian military and police  He enhanced the intelligence capacity, professionalization, and coordination of the forces, in part with training provided by U S  forces  His strategy resulted in expanded state control over national territory and a significant reduction in kidnappings, terrorist attacks, and homicides  In 2007, the Uribe administration announced a shift to a "Policy of Consolidation of Democratic Security " The new doctrine was based on a "whole-of-government" approach to consolidate state presence in marginal areas that were historically neglected—vulnerable to drug crop cultivation, violence, and control by illegal armed groups  Called a strategic leap forward by then-Defense Minister Juan Manuel Santos, in 2009 the new strategy came to be called the National Consolidation Plan (see below)  Colombian support for Plan Colombia and for the nation's security program grew under Uribe's leadership  President Uribe levied a "wealth tax" to fund Colombia's security efforts, taxing the wealthiest taxpayers to fund growing defense and security expenditures  Overall U S  expenditures on Plan Colombia were only a modest portion of what Colombians spent on their own security  By one 2009 estimate, U S  expenditures were not more than 10% of what Colombians invested in their total security costs  In 2000, Colombia devoted less than 2% of its GDP to military and police expenditures and in 2010 that investment had grown to more than 4% of GDP  One assessment notes "in the end there is no substitute for host country dedication and funding" to turn around a security crisis such as Colombia faced at the beginning of the millennium  In 2008, congressional support for Plan Colombia and its successor programs also shifted  Some Members of Congress believed that the balance of programming was too heavily weighted toward security  Prior to 2008, the emphasis had been on "hard side" security assistance (to the military and police) compared with "soft side" traditional development and rule of law programs  Members debated if the roughly 75%/25% mix should be realigned  Since FY2008, Congress has reduced the proportion of assistance for security-related programs and increased the proportion for economic and social aid  As Colombia's security situation improved and Colombia's economy recovered, the United States also began turning over to Colombians operational and financial responsibility for efforts formerly funded by the U S  government  The Colombian government "nationalized" the training, equipping, and support for Colombian military programs, such as the counterdrug brigade, Colombian Army aviation, and the air bridge denial program  U S  funding overall began to decline  The nationalization efforts were not intended to end U S  assistance, but rather to gradually reduce it to pre-Plan Colombia levels, adjusted for inflation  A key goal of Plan Colombia was to reduce the supply of illegal drugs produced and exported by Colombia but the goals became broader over time  Bipartisan support for the policy existed through three U S  Administrations—President Bill Clinton, President George W  Bush, and President Barack Obama  Plan Colombia came to be viewed by some analysts as one of the most enduring and effective U S  policy initiatives in the Western Hemisphere  Some have lauded the strategy as a model  In 2009, William Brownfield, then-U S  Ambassador to Colombia, described Plan Colombia as "the most successful nation-building exercise that the United States has associated itself with perhaps in the last 25-30 years " Other observers, however, were critical of the policy as it unfolded  Many in the NGO and human rights community maintained the strategy, with its emphasis on militarization and security, was inadequate for solving Colombia's persistent, underlying problems of rural violence, poverty, neglect and institutional weakness  Nevertheless, it appears that improvements in security conditions have been accompanied by substantial economic growth and a reduction in poverty levels over time  The National Consolidation Plan first launched during the Uribe Administration, (renamed the National Plan for Consolidation and Territorial Reconstruction), was designed to coordinate government efforts in regions where marginalization, drug trafficking, and violence converge  The whole-of-government consolidation was to integrate security, development, and counternarcotics to achieve a permanent state presence in vulnerable areas  Once security forces took control of a contested area, government agencies in housing, education, and development would regularize the presence of the state and reintegrate the municipalities of these marginalized zones into Colombia  The plan had been restructured several times by the Santos government  The United States supported the Colombian government's consolidation strategy through an inter-agency program called the Colombia Strategic Development Initiative (CSDI)  CSDI provided U S  assistance to "fill gaps" in Colombian government programming  At the U S  Embassy in Colombia, CSDI coordinated efforts of the U S  Agency for International Development (USAID), the State Department's Narcotics Affairs Section, the U S  Military Group, and the Department of Justice to assist Colombia in carrying out the consolidation plan by expanding state presence and promoting economic opportunities in priority zones  It combined traditional counternarcotics assistance for eradication, interdiction, alternative development, and capacity building for the police, military, and justice sector institutions with other economic and social development initiatives  As the peace agreement between the FARC and the government moved forward into implementation, the focus of U S  assistance to Colombia has shifted again  With a foundation of the work done to advance consolidation, U S  assistance has begun to aid in post-conflict planning and support Colombia's transition to peace by building up democratic institutions, protecting human rights and racial and ethnic minorities, and promoting economic opportunity  USAID's country cooperation strategy for 2014-2018 anticipated the Colombian government reaching a negotiated agreement with the FARC, but remained flexible if an agreement was not signed  It recognized early implementation efforts, especially in the first 24 months after signature, would be critical to demonstrate or model effective practices  In the next five years, it envisioned Colombia evolving from aid recipient to provider of technical assistance to neighbors in the region  Consolidating state authority and presence in the rural areas with weak institutions remains a significant challenge following the FARC's disarmament in the summer of 2017  Reintegration of the FARC and possibly other insurgent forces, such as the ELN, will be expensive and delicate  In particular, critics of the consolidation efforts of the Colombian government maintain that the Santos administration often lacked the commitment to hand off targeted areas from the military to civilian-led development and achieve locally led democratic governance  Consolidation efforts suffered from low political support, disorganization at the top levels of government, and failure to administer national budgets effectively in more remote areas, among other challenges  In August 2018, shortly after President Duque took office, USAID announced a framework of priorities for U S  economic development assistance to Colombia  Some of these priorities include promoting and supporting a whole-of-government strategy to include the dismantling of organized crime; increasing the effectiveness of Colombia's security and criminal justice institutions; promoting enhanced prosperity and job creation through trade; improving the investment climate for U S  companies; and advancing Colombia's capacity to strengthen governance and transition to sustainable peace, including reconciliation among victims, ex-combatants, and other citizens  The U S  Congress initially approved legislation in support of Plan Colombia in 2000, as part of the Military Construction Appropriations Act of 2001 ( P L  106-246 )  Plan Colombia was never authorized by Congress, but it was funded annually through appropriations  From FY2000 through FY2016, U S  funding for Plan Colombia and its follow-on strategies exceeded $10 billion in State Department and Defense Department programs  From FY2000 to FY2009, the United States provided foreign operations assistance to Colombia through the Andean Counterdrug Program (ACP) account, formerly known as the Andean Counterdrug Initiative, and other aid accounts  In FY2008, Congress continued to fund eradication and interdiction programs through the ACP account, but funded alternative development and institution building programs through the Economic Support Fund (ESF) account  In the FY2010 request, the Obama Administration shifted ACP funds into the International Narcotics Control and Law Enforcement (INCLE) account  Since FY2008, U S  assistance has gradually declined because of tighter foreign aid budgets and nationalized Plan Colombia-related programs  In FY2014, in line with other foreign assistance reductions, funds appropriated to Colombia from State Department accounts declined to slightly below $325 million  In FY2015, Congress appropriated $300 million for bilateral assistance to Colombia in foreign operation  The FY2016 Omnibus Appropriations bill ( P L  114-113 ) provided Colombia from U S  State Department and U S  Agency for International Development accounts, slightly under $300 million, nearly identical to that appropriated in FY2015 (without P L  480, the Food for Peace account, the total for FY2016 was $293 million as shown in Table 1 )  In FY2017, Congress funded a program the Obama Administration had proposed called "Peace Colombia" to re-balance U S  assistance to support the peace process and implementation of the accord  In May 2017, Congress approved a FY2017 omnibus appropriations measure, the Consolidated Appropriations Act, 2017 ( P L  115-31 ), which funded the various programs of Peace Colombia at $391 3 million  In the FY2017 legislation, Congress appropriated the following: The ESF account increased to $187 million (from $134 million in FY2016) to build government presence, encourage crop substitution to replace drug crops, and provide other assistance to conflict victims, including Afro-Colombian and indigenous communities  However, only $180 million was subsequently allocated  INCLE funding increased to $143 million with a focus on manual eradication of coca crops, support for the Colombian National Police, and judicial reform efforts  INCLE funding also included $10 million for Colombian forces' training to counterparts in other countries  $38 5 million in Foreign Military Financing (FMF); and $21 million in Nonproliferation, Anti-Terrorism, Demining, and Related Programs (NADR), which was a relatively large increase from under $4 million in FY2016 to focus on the demining effort  How the Trump Administration will engage with the issues of supporting post-conflict stability in Colombia has not been clearly defined by either the State Department or other executive departments  For example, the Trump Administration's proposed foreign aid budget for FY2018 would have reduced assistance to Colombia to $251 million  However, the FY2018 omnibus appropriations measure, approved by Congress in March 2018 ( P L  115-114 ), again included $391 3 million to support Colombia's transition to peace  The Trump Administration's FY2019 budget request for Colombia is $265 million, approximately a 32% reduction from the $391 3 million appropriated by Congress in FY2018  However, the House and Senate appropriations bills, H R  6385 and S  3108 , again would support the funding level of $391 3 million  The FY2019 Administration request would reduce post-conflict recovery programs and place greater emphasis on counternarcotics and security  Below, Table 1 provides account data from the annual international affairs congressional budget justification documents  The information about DOD-funded programs was provided to the Congressional Research Service by DOD analysts in December 2015 and October 2017 (and has not been updated)  The breakout of DOD assistance to Colombia is shown in Table 2     Colombia also has received additional U S  humanitarian funding to help it cope with more than 1 million Venezuelan migrants  As of September 30, 2018, U S  government humanitarian funding for the Venezuela response totaled approximately $96 5 million for both FY2017 and FY2018 combined, of which $54 8 million was for Colombia  (Humanitarian funding is drawn primarily from the global humanitarian accounts in annual Department of State/Foreign Operations appropriations acts ) In addition, the U S  Navy hospital ship USNS Comfort is on an 11-week medical support mission deployed through the end of 2018 to work with government partners, in part to assist with arrivals from Venezuela  In Colombia, the U S  response aims to help the Venezuelan arrivals as well as the local Colombian communities that are hosting them  In addition to humanitarian assistance, the United States is providing $37 million in bilateral assistance to support medium- and longer-term efforts by Colombia  Some Members of Congress have been deeply concerned about human rights violations in Colombia—especially those perpetrated by any recipients or potential recipients of U S  assistance  In Colombia's multisided, 50-year conflict, the FARC and ELN, the paramilitaries and their successors, and Colombia's security forces have all committed serious violations  Colombians have endured generations of noncombatant killings, massacres, kidnappings, forced displacements, forced disappearances, land mine casualties, and acts of violence that violate international humanitarian law  The extent of the crimes and the backlog of human rights cases to be prosecuted have overwhelmed the Colombian judiciary, which some describe as "inefficient" and overburdened  The United Nations and many human rights groups maintain that although some prosecutions have gone forward, most remain unresolved and the backlog of cases has been reduced slowly  In addition to the problem of impunity for such serious crimes, continued violations remain an issue  Since 2002, Congress has required in the annual foreign operations appropriations legislation that the Secretary of State certify annually to Congress that the Colombian military is severing ties to paramilitaries and that the government is investigating complaints of human rights abuses and meeting other human rights statutory criteria  (The certification criteria have evolved over time  ) For several years, certification was required before 30% of funds to the Colombian military could be released  The FY2014 appropriations legislation requires that 25% of funding under the Foreign Military Financing (FMF) program be held back pending certification by the Secretary of State  Some human rights groups have criticized the regular certification of Colombia, maintaining that evidence they have presented to the State Department has contradicted U S  findings  However, even some critics have acknowledged the human rights conditions on military assistance to Colombia to be "a flawed but useful tool" because the certification process requires that the U S  government regularly consult with Colombian and international human rights groups  Critics acknowledge that over time, conditionality can improve human rights compliance  Additional tools for monitoring human rights compliance by Colombian security forces receiving U S  assistance are the so-called "Leahy Law" restrictions, which Congress first passed in the late 1990s prior to the outset of Plan Colombia  First introduced by Senator Patrick Leahy, these provisions deny U S  assistance to a foreign country's security forces if the U S  Secretary of State has credible information that such units have committed "a gross violation of human rights " The provisions apply to security assistance provided by the State Department and DOD  The Leahy Law under the State Department is authorized by the Foreign Assistance Act (FAA) of 1961, as amended, and is codified at 22 U S C  2378d (§520M of the FAA)  The DOD Leahy provisions, which for years applied just to DOD training, now include a broader range of assistance, as modified in the FY2014 appropriations legislation  The provision related to the Leahy Laws for DOD assistance is codified at 10 U S C  362, and prohibits "any training, equipment, or other assistance," to a foreign security force unit if there is credible information that the unit has committed a gross violation of human rights  Both the State Department and DOD Leahy provisions require the State Department to review and clear—or vet—foreign security forces to determine if any individual or unit is credibly believed to be guilty of a gross human rights violation  Leahy vetting is typically conducted by U S  embassies and State Department headquarters  Reportedly on an annual basis about 1% of foreign security forces are disqualified from receiving assistance under the Leahy provisions, although many more are affected by administrative issues and are denied assistance until those conditions are resolved  Tainted security force units that are denied assistance may be remediated or cleared, but the procedures for remediation differ slightly between the DOD and State (or FAA) provisions  Because of the large amount of security assistance provided to Colombian forces (including the military and police), the State Department reportedly vets more candidates for assistance in Colombia than in any other country  In the late 1990s, poor human rights conditions in Colombia were a driving concern for developing the Leahy Law provisions  The U S  Embassy in Bogotá, with nearly two decades of experience in its vetting operations, has been cited as a source of best practices for other embassies seeking to bring their operations into compliance or enhance their performance  State Department officials have cited Colombia as a model operation that has helped Colombia to improve its human rights compliance  However, some human rights organizations are critical of the Leahy vetting process in Colombia, and cite the prevalence of extrajudicial executions allegedly committed by Colombian military units as evidence that these restrictions on U S  assistance have failed to remove human rights violators from the Colombian military  A human rights nongovernmental organization, Fellowship of Reconciliation, has published reports alleging an association between false positive killings and Colombian military units vetted by the State Department to receive U S  assistance  However, some have questioned the group's methodology  Some human rights organizations contend that the U S  government has tolerated abusive behavior by Colombian security forces without taking action or withholding assistance  Measured exclusively in counternarcotics terms, Plan Colombia has been a mixed success  Colombia remains the dominant producer of cocaine and in the DEA's National Drug Threat Assessment for 2017 continued to be the source for 95% of cocaine seized in the United States  Enforcement, eradication, and improved security squeezed production in Colombia, so that in 2012, Peru reemerged as the global leader in cocaine production, surpassing Colombia, for a year or so  In the early 2000s, given Colombia's predominance as the source of cocaine destined for U S  markets and its status as the second-largest producer of heroin consumed in the United States, eradication of coca bush and opium poppy (from which heroin is derived) was an urgent priority and became the preferred tool for controlling the production of these drugs  Another critical component of the drug supply reduction effort was alternative development programs funded by the U S  Agency for International Development (USAID) to assist illicit crop cultivators with transitioning to licit crop production and livelihoods  Analysts have long debated how effective Plan Colombia and its follow-on strategies were in combating illegal drugs  Although Plan Colombia failed to meet its goal of reducing the cultivation, processing, and distribution of illicit drugs by 50% in its original six-year time frame, Colombia has sustained significant reductions in coca cultivation in recent years  According to U S  estimates, cultivation of coca declined from 167,000 hectares in 2007 to 78,000 hectares in 2012  (Poppy cultivation declined by more than 90% between 2000 and 2009 ) According to U S  government estimates, Colombia's potential production of pure cocaine fell to 170 metric tons in 2012, the lowest level in two decades  However, it started to rise slightly in 2013, and more dramatically in 2014 through 2016  In those years, cultivation of coca and production of cocaine grew significantly in part due to ending the aerial eradication of coca crops  In 2015, following a U N  agency determination that the herbicide used to spray coca crops was probably carcinogenic, Colombia's minister of health determined that aerial eradication of coca was not consistent with requirements of Colombia's Constitutional Court  In 2016, as noted above, the U S  DEA reported that 95% of cocaine seized in the United States originated in Colombia  According to U S  Office of National Drug Control Policy, Colombia in 2017 cultivated an unprecedented 209,000 hectares of coca, from which cocaine is derived, capable of generating 921 metric tons of cocaine  The United Nations estimates for 2017, which typically differ in quantity but follow the same trends as U S  estimates, maintained that Colombia's potential production of cocaine reached nearly 1,370 metric tons, 31% above its 2016 estimate  Even with Colombia's economic stability and improving security, cocaine exports (primarily to the U S  market) remain a major concern for U S  lawmakers  However, in drug interdiction, Colombia has set records for many years and is considered a strong and reliable U S  partner  The United Nations Office on Drugs and Crime ( Table 4 ), shows Colombia cultivating 146,000 hectares of coca in 2016, a 52% increase over 2015 and another increase to 171,000 hectares, a 17% increase, in 2017  Although cocaine seizures were quite high in both years, the interdiction of cocaine was insufficient to counter the large increases in production  Both manual eradication and aerial eradication were central components of Plan Colombia to reduce coca and poppy cultivation  Manual eradication is conducted by teams, usually security personnel, who uproot and kill the plant  Aerial eradication involves spraying the plants from aircraft with an herbicide mixture to destroy the drug crop, but it may not kill the plants  In the context of Colombia's continuing internal conflict, manual eradication was far more dangerous than aerial spraying  U S  and Colombian policymakers recognized the dangers of manual eradication and, therefore, employed large-scale aerial spray campaigns to reduce coca crop yields, especially from large coca plantations  Colombia is the only country globally that aerially sprayed its illicit crops, and the practice has been controversial for health and environmental reasons, resulting in a Colombian decision to end aerial eradication in 2015  Since 2002, as a condition of fully funding the spraying program, Congress has regularly directed the State Department, after study and consultation with the U S  Environmental Protection Agency and other relevant agencies, to certify that the spraying did not "pose unreasonable risks or adverse effects to humans or the environment " This certification requirement was included most years in the annual foreign operations appropriations legislation  Some analysts have also raised questions about the monetary and collateral costs of aerial eradication compared with other drug supply control strategies, its effectiveness, and its limited effect on the U S  retail price of cocaine  U S  State Department officials attribute Colombia's decline in coca cultivation after 2007 and prior to 2013 to the persistent aerial eradication of drug crops in tandem with manual eradication where viable  Between 2009 and 2013, Colombia aerially sprayed roughly 100,000 hectares annually  In 2013, however, eradication efforts declined  Colombia aerially eradicated roughly 47,000 hectares  It manually eradicated 22,120 hectares, short of the goal of 38,500 hectares  This reduction had a number of causes: the U S -supported spray program was suspended in October 2013 after two U S  contract pilots were shot down, rural protests in Colombia hindered manual and aerial eradication efforts, and security challenges limited manual eradicators working in border areas  In late 2013, Ecuador won an out-of-court settlement in a case filed in 2008 before the International Court of Justice in The Hague for the negative effects of spray drift over its border with Colombia  In negotiations with the FARC, the government and the FARC provisionally agreed in May 2014 that voluntary manual eradication would be prioritized over forced eradication  Aerial eradication remained a viable tool in the government's drug control strategy, according to the agreement, but would be permitted only if voluntary and manual eradication could not be conducted safely  In April 2015, the Santos administration determined that glyphosate, a broad-spectrum, nonselective herbicide used commercially, but in Colombia sprayed on coca plants to eradicate them, was "probably carcinogenic" to humans in a review published by a World Health Organization (WHO) affiliate  In October 2015, the government ended spraying operations and began to implement a new public health approach toward illicit drugs, one that proponents suggested would reduce human rights violations  On the supply side, Colombia's new drug policy gives significant attention to expanding alternative development and licit crop substitution while intensifying interdiction efforts  The State Department in its 2015 International Narcotics Control Strategy Report (INCSR), however, warned that illicit cultivation was expanding in areas long off-limits to aerial spraying, including national parks, a buffer zone with Ecuador where aerial eradication has been restricted, and in indigenous or protected Afro-Colombian territories  Colombian interdiction practices are deemed some of the most effective in the world  The Colombian government reported seizing more than 207 metric tons (mt) of cocaine base in 2014 and that seizure total doubled by 2017 with capture of 442 mt of cocaine  According to the U S  State Department's 2018 INCSR , Colombia also seized 197 mt of marijuana, 348 kilograms of heroin, and destroyed more than 3,400 cocaine base and hydrochloride labs  USAID funds and runs alternative development programs in Colombia to assist communities with transitioning from a dependency on illicit crops to licit employment and livelihoods  Alternative development was once focused narrowly on crop substitution and assistance with infrastructure and marketing  Since the Colombian government's shift to a consolidation strategy, USAID has supported "consolidation and livelihoods" programming in 40 of the 58 strategically located, conflict-affected municipalities targeted by the government's National Consolidation Plan  To facilitate economic development, USAID funds initiatives that assist farmers and others with shifting from coca growing to licit economic opportunities  These programs are designed to strengthen small farmer producer organizations, improve their productivity, and connect them to markets  Some observers maintain that poor and unsustainable outcomes from alternative development programs while the Colombian conflict was still under way resulted from ongoing insecurity and lack of timeliness or sequencing of program elements  The renewed commitment to alternative development and crop substitution in the 2016 peace accord with the FARC may be similarly challenged  Formal implementation of the peace accord on drug eradication and crop substitution began in late May 2017 with collective agreements committing communities to replace their coca crops with licit crops  In some regions, the program is extended to families who cultivate coca and also to producers of legal crops and landless harvesters  The Colombian government also committed to a combined approach of both voluntary and forced manual eradication  The government's goal set for 2017 was eradicating 100,000 hectares of coca, 50,000 through forced manual eradication and 50,000 through "crop substitution" accords reached with coca farming households who would voluntary eradicate  At the U S -Colombia High Level Dialogue held in Bogotá in March 2018, a renewed commitment to the enduring partnership between the United States and Colombia was announced  A major outcome was a U S -Colombia pledge to reduce illegal narcotics trafficking through expanded counternarcotics cooperation  The new goal set was to reduce Colombia's estimated cocaine production and coca cultivation to 50% of current levels by 2023  In addition, a memorandum of understanding was signed to combat the illegal gold mining that funds transnational criminal organizations  Although President Duque appears determined to pursue a more aggressive approach to drug policy, he has not clearly stated how his approach to counternarcotics will differ from that of his predecessor  The government may restart aerial eradication, a strategy that ended in 2015 due to the Colombian Health Ministry's concerns over cancer-causing potential of the herbicide glyphosate, but no precise plans for restarting the program have been announced in the Duque Administration's first three months in office  Experimentation with delivering glyphosate by drones (rather than planes) began in June 2018 under the Santos Administration and is continuing under the Duque government  On October 1, 2018, President Duque authorized police to confiscate and destroy any quantity of drugs found on persons in possession of them, resulting in the seizure of more than 7 metric tons of drugs in less than two weeks  This enforcement measure may violate a 1994 Colombian Constitutional Court ruling, however, in which Colombians may carry small doses of drugs for personal use, including marijuana, hashish, and cocaine  Several court challenges have been filed that seek to nullify the Duque decree on constitutional grounds of protected personal use  Drug trafficking continues to trigger conflict over land in Colombia while affecting the most vulnerable groups, including Afro-Colombian, peasant, and indigenous populations  Some analysts warn that national and international pressure for drug eradication could also lead to increased human rights violations, including health consequences by reviving aerial spraying of drug crops and government actions to forcibly break up demonstrations by coca producers who resist eradication  Some analysts have advocated that investments to lower drug supply need to go beyond eradication, which has not been a lasting approach to reducing drug crop cultivation  For instance, the government could provide economic and education opportunities to at-risk youth to enhance their role in peace building and to prevent their recruitment into the drug trade and other illegal activity  Economic relations between Colombia and the United States have deepened  The U S -Colombia Free Trade Agreement (FTA) entered into force in May 2012  By 2020, it will phase out all tariffs and other barriers to bilateral trade between Colombia and the United States, its largest trade partner  Since the U S -Colombia FTA went into force, the stock of U S  investment in Colombia surpassed $7 billion in 2014 but dropped to $6 2 billion in 2016 (on a historical cost basis), concentrated mostly in mining and manufacturing  According to the U S  Department of Commerce, U S  exports to Colombia exceeded $26 8 billion in 2016 and Colombia was the 22 nd -largest market for U S  exports; however, U S  imports from Colombia declined between 2015 and 2016  Major U S  exports to Colombia include oil (noncrude oil products including gasoline), machinery, cereals, organic chemicals, and plastic  Because 65% of U S  imports from Colombia are crude oil imports, much of the decline in value was caused by the sharp fall in oil prices that began in 2014  Major U S  imports beside crude oil, include gold, coffee, cut flowers, and fruits  Congressional interest in Colombia now extends far beyond security and counternarcotics and has grown in the area of bilateral trade following implementation of the U S -Colombia FTA, (also known at the U S -Colombia Trade Promotion Agreement)  Colombia is a founding member of the Pacific Alliance, along with Chile, Mexico, and Peru, and has sought to deepen trade integration and cross-border investment with its partners in the alliance while reducing trade barriers  The Pacific Alliance aims to go further by creating a common stock market, allowing for the eventual free movement of businesses and persons, and serving as an export platform to the Asia-Pacific region  Colombia's leadership role in the Pacific Alliance and Colombia's accession to the Organization for Economic Cooperation and Development (OECD) in May 2018, following a review of the country's macroeconomic policies and changes, are major new developments  The accession to the OECD was approved by Colombia's lower house in October 2018 and the Senate in November 2018, but it remained under final review by Colombia's Constitutional Court in early February 2019  The Santos administration pushed to meet the criteria required for OECD membership because it maintained that such recognition signified Colombia's attainment of world-class development standards and policies  Colombia has made progress on trade issues such as copyright, pharmaceuticals, fuel and trucking regulations, and labor concerns (including subcontracting methods and progress on resolving cases of violence against union activists)  Congress remains interested in Colombia's future because the country has become one of the United States' closest allies  With 17 years of investment in Colombia's security and stability, some maintain that there has already been a strong return on U S  investment  Plan Colombia and its successor strategies broadened from counternarcotics to include humanitarian concerns, efforts to bolster democratic development and human rights protections, and trade and investment to spark growth  The record expansion of Colombia's coca crop and increasing cocaine exports to the United States, however, may significantly hinder the effort to consolidate peace in Colombia and could potentially increase corruption and extortion  A significant portion of the Colombian public remains skeptical of the peace process and the FARC's role in Colombia's democracy  Other Colombians maintain that support for peace programs in Colombia is important not only to benefit former FARC or other demobilized combatants but also to fulfill promises the government made in the peace accords to the country's 8 6 million victims of the five-decade conflict  As President Duque concluded his first 100 days in office, his government faced overlapping challenges: (1) an upsurge in illicit drug crops, which had set records in 2016 and 2017; (2) implementation of provisions of the peace accord negotiated by former president Santos but marred by slow implementation, attacks on land and human rights activists, and projected budgetary shortfalls; (3) renewed violent competition among criminal groups in rural areas, some of which reportedly are sheltering in Venezuela; and (4) Venezuela's humanitarian crisis, which resulted in a surge of migrants fleeing to or through Colombia  The annual level of foreign assistance provided by the U S  Congress for Colombia began to decline in FY2008 and then gradually increased in FY2017 and FY2018 to support peace and implementation of the FARC-government peace accord  Some Members of Congress may want to build on cooperation with Colombian partners to continue to train Central Americans and other third-country nationals in counternarcotics and security, including programs in citizen security, crime prevention and monitoring, military and police capacity building, and hostage negotiation and cybersecurity  Congress may continue to closely monitor Colombia's domestic security situation  It also may continue to oversee issues such as drug trafficking; Colombia's effort to combat other illegal armed groups such as Bacrim; the status of human rights protections; and the expansion of health, economic, environmental, energy, and educational cooperation  Congress may seek to foster Colombian leadership in the region to counter growing political instability in Venezuela  The U S  Congress has been interested in expanding investment and trade opportunities both bilaterally with Colombia and within regional groupings, such as the Pacific Alliance  Some analysts contend that U S -Colombian trade improvements rest on the strength of the overall relationship between Colombia and the United States  

ground_truth: The federal government owns roughly 640 million acres, heavily concentrated in 12 western states. Four agencies—the National Park Service (NPS), Fish and Wildlife Service (FWS), and Bureau of Land Management (BLM) in the Department of the Interior, and the U.S. Forest Service (FS) in the Department of Agriculture—administer about 95% of those lands. The extent to which each of these four federal agencies have authority to acquire and dispose of land varies considerably. The BLM has relatively broad authority for both acquisitions and disposals under the Federal Land Policy and Management Act of 1976 (FLPMA). The agency also has other authorities for disposing of land, including two laws that allow the agency to retain the proceeds for subsequent land acquisition, among other purposes, and a law that allows transfers to governmental units and other entities for public purposes. By contrast, the NPS has no general authority to acquire land to create new park units or to dispose of park lands. The FS authority to acquire lands is mostly limited to lands within or contiguous to the boundaries of a national forest. The agency has various authorities to dispose of land, but they are relatively constrained and infrequently used. The FWS has various authorities to acquire lands but no general authority to dispose of its lands. The agency frequently uses acquisition authority under the Migratory Bird Conservation Act of 1929 because of the availability of funding through the Migratory Bird Conservation Fund. The nature of the acquisition and disposal authorities of the four federal agencies also varies. In general, the acquisition authorities are designed to allow the four agencies to bring into federal ownership lands that many contend could benefit from federal management. Disposal authorities generally are designed to allow agencies to convey land that is no longer needed for a federal purpose or that might be chiefly valuable for another purpose. Some of the authorities specify particular circumstances where they can be used, such as the conveyance of FS land for educational purposes and the disposal of BLM land for recreation and public purposes. Congress often faces questions on the adequacy of existing acquisition and disposal authorities; the nature, extent, and location of their use; and the extent of federal land ownership overall. The current acquisition and disposal authorities form the backdrop for consideration of measures to establish, modify, or eliminate authorities, or to provide for the acquisition or disposal of particular lands. In some cases, Congress enacts bills to provide authority to acquire or dispose of particular parcels where no standing authority exists and, in other cases, to direct or facilitate land transactions. Congress also addresses acquisition and disposal policy in the context of debates on the role and goals of the federal government in owning and managing land generally, and it has considered broader measures to dispose of lands or to promote acquisition. Other issues for Congress pertain to the sources and levels of funds for land acquisition. The Land and Water Conservation Fund (LWCF) is the primary source of funding for land acquisition. Congress has considered diverse measures related to the LWCF, such as legislation to make LWCF funding permanent and bills to direct LWCF monies to additional, nonacquisition purposes. Additionally, the FWS has the Migratory Bird Conservation Fund, an account with mandatory spending authority supported by revenue from three sources. The BLM also has mandatory spending authorities that allow the proceeds from land sales to be used for land acquisition, among other purposes.

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



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

Report 1: The federal government owns roughly 640 million acres, more than a quarter of the land in the United States  These lands are heavily concentrated in 12 western states (including Alaska), where t he federal government owns roughly half of the overall land area  Four federal agencies—the National Park Service (NPS), Fish and Wildlife Service (FWS), and Bureau of Land Management (BLM), all in the Department of the Interior (DOI), and the U S  Forest Service (FS) in the Department of Agriculture—administer about 95% of those lands  No single law provides authority for these four agencies to acquire and/or disposal of lands  Rather, Congress provided various acquisition and disposal authorities through laws enacted over more than a century  This report describes the primary authorities of the four agencies  The extent to which each of the agencies has authority to acquire and dispose of land, and the nature of the authorities, varies considerably  Some of the agencies have relatively broad authority to acquire and/or dispose of land  Most notably, the BLM has relatively broad authority for both acquisitions and disposals  By contrast, the NPS has no general authority to acquire land to create new park units or to dispose of park lands  The extent of the acquisition and disposal authorities for the FS and the FWS are not nearly as broad as the BLM's but not nearly as restrictive as the NPS's  The FS authority to acquire lands is mostly limited to lands within or contiguous to the boundaries of a national forest  The agency has various authorities to dispose of land, but they are relatively constrained and infrequently used  The FWS has various authorities to acquire lands but no general authority to dispose of its lands  The acquisition authorities differ as to the circumstances in which they apply, and the disposal authorities likewise differ as to their purposes  Thus, where a specific acquisition or disposal by an agency is contemplated, the particular authority at issue should be consulted  In general, the acquisition authorities are designed to allow federal agencies to acquire lands that could be viewed as benefitting from federal management  Among other circumstances, acquisition might be authorized to bring inholdings or lands adjacent to federal lands into federal ownership to improve or simplify management of federal lands  Acquisitions also might be authorized to conserve species, protect natural and cultural resources, and increase opportunities for recreation  The disposal authorities generally are designed to allow federal agencies to dispose of land that is no longer required for a federal purpose, might be inefficient to manage, or might be chiefly valuable for another purpose  For instance, disposal might be authorized to allow lands to be used for agriculture, community development, mineral extraction, or educational purposes  Agencies also acquire and dispose of federal land in exchanges  Exchanges are not discussed separately in this report, as often the authorities to acquire and dispose of lands also apply to land exchange  However, there are provisions of law particularly applicable to exchanges  The exchange authorities for the NPS and the FWS are relatively narrow  The Federal Land Policy and Management Act of 1976 (FLPMA; 43 U S C  §§1701-1781) provides broader exchange authority and is the main authority governing exchanges by the BLM and the FS  Congress often faces questions on the adequacy of existing acquisition and disposal authorities; the nature, extent, and location of their use; the extent of federal land ownership overall; and the sources and levels of land acquisition funds, among other issues  The suitability of the acquisition and disposal authorities, and the extent and circumstances of their use by the agencies, forms the backdrop for congressional consideration of measures to establish, modify, or eliminate the use of authorities  With regard to the establishment of new authorities, for instance, some 115 th Congress proposals would authorize states to exchange land grant parcels for federal lands  Other measures would authorize the BLM and FS to convey small tracts to adjacent landowners and to govern the use of proceeds from these conveyances  Proposals to modify authorities include measures in the 115 th Congress to reauthorize and amend BLM authority to sell or exchange land under the Federal Land Transaction Facilitation Act (FLTFA; 43 U S C  §§2301 et seq ), as well as bills to amend the Small Tracts Act (16 U S C  §521e) regarding the type and value of FS lands that can be disposed of and the use of related proceeds  Among the provisions to eliminate the use of authorities are those to prevent the disposal of federal land under the General Mining Law of 1872, which have been contained in annual Interior appropriations laws since FY1995  In addition, Congress frequently considers legislation authorizing and governing the acquisition or disposal of specific parcels  For example, Title XXX of P L  113-291 contained various provisions to authorize the acquisition and/or disposal of land  Congress may consider such legislation to provide an agency with acquisition or disposal authority in a particular instance because it is lacking  In other cases, Congress directs a particular acquisition or disposal to facilitate the action  For instance, the legislation may seek to direct an acquisition based on Congress's assessment of public needs and priorities  It may expedite the process for acquiring a parcel of land, such as by limiting the assessments and evaluations that ordinarily would be required under law  The legislation also might authorize actions not ordinarily permitted, such as the conveyance of land at reduced or no cost rather than at fair market value  Congress also addresses acquisition and disposal policy in the context of deliberations on the role and goals of the federal government in owning and managing land generally  The extent to which the federal government should own land remains controversial  Many westerners contend that there is excessive federal influence over their lives and economies and that the federal government should divest itself of many lands  Many others support the policy of retaining lands in federal ownership on behalf of the public and sometimes advocate adding more lands to enhance protection  Recent Congresses considered diverse bills pertaining to the extent of federal land ownership  Among others, 115 th Congress measures would authorize or direct the Secretary of the Interior and the Secretary of Agriculture to offer to sell a certain percentage of land in each of several fiscal years  Other bills provide that where a land management agency acquires land, an equal number of acres is to be offered for sale  Another set of issues pertains to the sources and levels of funds for land acquisition  The principal financing mechanism for federal land acquisition is discretionary appropriations under the Land and Water Conservation Fund (LWCF)  Provisions of the Land and Water Conservation Fund Act of 1965 (LWCF Act; 54 U S C  §§200301 et seq ) had provided for $900 million in specified revenues to be deposited in the LWCF annually  These provisions expired September 30, 2018  Each year, Congress determines the level of appropriations from the LWCF for federal land acquisition  Total appropriations for land acquisition and the amount provided to each of the federal land management agencies have varied substantially since the program's origin in 1965  In the 115 th Congress, some measures propose permanent reauthorization of the LWCF and/or mandatory appropriations at the authorized level  Advocates of such bills typically seek stable, predictable funding to promote a strong federal role in acquiring and managing sensitive resources  Other measures would direct a portion of funding to particular purposes, such as acquisitions in areas with restricted access for fishing, hunting, and other types of recreation  Still other proposals would allow LWCF to be used for a broader array of purposes, including nonacquisition purposes, due to concerns about the extent of federal land ownership and the availability of funding for other federal activities  Additional sources of funding are available for some agencies or under certain authorities  For instance, the FWS has a mandatory source of funds for land acquisition through the Migratory Bird Conservation Fund, as discussed below  As another example, the BLM also has mandatory spending authorities that allow the agency to keep the proceeds of land sales and use these proceeds for subsequent acquisitions and other purposes  These authorities are discussed below  The application of mandatory spending authorities, including the uses of the proceeds, has been the subject of congressional debate  As noted above, various laws authorizing and governing specific land acquisitions have been enacted  In addition, the four federal land management agencies have different standing authorities for acquiring lands  In general, all four agencies are authorized to accept land as gifts and bequests  In addition, each generally is authorized to use eminent domain —taking private property, through condemnation, for public use—while compensating the landowner  However, this practice is controversial, and it is rarely used by the land management agencies  The primary land acquisition authorities are described below for each of the four federal land management agencies  In general, the agencies are presented in the order of the breadth of their authorities, with the NPS (the narrowest authorities) first and the BLM (the broadest authorities) last  The NPS does not have standing authority to acquire lands for new or existing units of the National Park System, except in limited circumstances  Rather, most units have been created by Congress, and the law creating a park unit typically includes specific authority for the NPS to acquire nonfederal inholdings within the identified boundaries of that park  The Secretary of the Interior is authorized to make certain boundary adjustments of park units for "proper preservation, protection, interpretation, or management" and to acquire the nonfederal lands within the adjusted boundary, under specified provisions and conditions (54 U S C  §100506(c))  Some of these conditions have been interpreted to apply particularly to boundary adjustments requiring land purchases, as opposed to those in which added lands are acquired by donation, transfer, or exchange  The President has authority to create national monuments on federal lands under the Antiquities Act of 1906 (54 U S C  §§320301 et seq )  In total, 158 monuments have been created by presidential proclamation  Most are managed by the NPS, but some are managed by the BLM and other agencies  Under law, the Secretary of the Interior and the NPS have responsibilities related to the potential acquisition of lands for the National Park System  Among other requirements, the Secretary is directed "to investigate, study, and continually monitor the welfare of" areas that could potentially be added to the system and to report to Congress on possible additions (54 U S C  §100507)  Furthermore, the general management plan for each unit is to include potential changes to the boundaries of the unit and the reasons for such changes (54 U S C  §100502)  The Secretary also is to conduct a "systematic and comprehensive review of certain aspects of the National Park System" and to submit a related report to Congress at least every three years (54 U S C  §100505(a)) that includes a list of all authorized but unacquired lands within the boundaries of park units and a priority listing of these unacquired parcels (54 U S C  §100505(c))  The Secretary of Agriculture has various authorities to acquire lands for the National Forest System (NFS)  The NFS consists of 284 units covering 232 4 million acres of federal and nonfederal land, including national forests, national grasslands, purchase units, land utilization projects, and other areas  Today, only an act of Congress can create new NFS units, but the Secretary may acquire lands within or contiguous to the proclaimed exterior boundaries of an NFS unit  The NFS contains substantial acreage of nonfederal lands within the proclaimed boundaries of the system, particularly in the east, where national forests were established after extensive settlement  NFS units in the Eastern and Southern Regions average about 46% nonfederal land within their boundaries, while Western Region NFS units average about 10%  The FS has very limited regulatory authority over the uses of the 39 5 million acres of nonfederal land within the NFS  The FS's primary land acquisition authority is the Weeks Act of 1911 (16 U S C  §515), which was used to acquire many of the lands that became the eastern national forests  The Weeks Act authority continues to be the agency's primary authority to acquire lands; however, acquisitions are now limited to lands within (or adjacent to) established NFS unit boundaries  The Weeks Act also authorizes the Secretary to modify the NFS unit boundary as needed to encompass new acquisitions  Other laws authorize the FS to acquire lands for the national forests, typically in specific areas or for specific purposes  For example, Section 205 of the Federal Land Policy and Management Act (FLPMA; P L  94-579 ) authorizes the acquisition of access corridors—including easements—to national forests across nonfederal lands (43 U S C  §1715(a))  Another example is the Act of August 3, 1956 (7 U S C  §428(a)), which authorizes the FS to acquire lands without any geographical limitations but does require a provision be made in a specific appropriation or other law  Another law authorizes proceeds from certain land sales or exchanges to be used for acquisitions, including for administrative sites and enhancement of recreational access  However, the acquisitions are limited to the state in which FS previously conveyed NFS land under specific disposal authorities, as discussed later in this report  Several other acquisition authorities apply to specific national forests, such as the Act of June 11, 1940, which authorizes the purchase of lands within the Angeles National Forest in California  In addition, the Secretary of Agriculture and the secretary of a military department that has lands within or adjacent to proclaimed NFS land may interchange lands, without reimbursement or transfer of funds  Many of the acquisition authorities also allow the FS to accept donations of land as specified  Within the NFS, the Secretary of Agriculture also is authorized to acquire privately owned lands within or adjacent to designated wilderness areas (16 U S C  §1134(c)), Wild and Scenic River corridors (16 U S C  §1277), and certain segments of designated National Trails (16 U S C  §1244), as specified by the law creating the trail  Lands may be added to the National Wildlife Refuge System (NWRS) in a number of ways, including through congressional and administrative actions and donations  A principal FWS land acquisition authority is the Migratory Bird Conservation Act of 1929 (MBCA; 16 U S C  §§715 et seq )  This act authorizes the Secretary of the Interior to recommend areas "necessary for the conservation of migratory birds" to the Migratory Bird Conservation Commission, after consulting with the relevant governor (or state agency) and appropriate local government officials (16 U S C  §715a and §715c)  In addition, the state in which the purchase is located must have consented to the acquisition by law (16 U S C  §715f and §715k-5)  The Secretary may then purchase or rent areas or interests therein approved by the commission and acquire by gift or devise any area or interest therein (16 U S C  §715d)  The MBCA authority is used frequently because of the availability of funding through the Migratory Bird Conservation Fund (MBCF, 16 U S C  §718d)  The MBCF is supported by multiple sources of funding, including three major sources: the sale of hunting and conservation stamps (commonly known as duck stamps); import duties on arms and ammunition; and a portion of certain refuge entrance fees  MBCF funds are permanently appropriated to the extent of receipts and, after paying certain administrative costs, may be used for the "location, ascertainment, and acquisition of suitable areas for migratory bird refuges    " (16 U S C  §718d(b))  The predictability of funding and permanent authority for use makes the MBCF, and thus the MBCA, particularly important for FWS land acquisition and unique among the four agencies  Other laws provide general authority to expand the NWRS, including the Fish and Wildlife Coordination Act of 1934 (16 U S C  §§661-667a), the Fish and Wildlife Act of 1956 (16 U S C  §§742a et seq ), and the Endangered Species Act of 1973 (16 U S C  §§1531-1544)  The National Wildlife Refuge System Administration Act of 1966 (16 U S C  §§668dd-668ee) authorizes the Secretary of the Interior to acquire land or interests therein through donated funds or exchange (16 U S C  §668dd(b))  Further, FLPMA authorizes the Secretary of the Interior to withdraw lands from the public domain for creating or adding to refuges (which would be an interagency transfer), although withdrawals exceeding 5,000 acres are subject to congressional approval (43 U S C  §1714(c))  In contrast to NPS and FS land acquisition, where the lands generally must be within the boundaries of established units, the FWS can acquire new lands to create a new refuge or to expand an existing one under the general FWS authorities cited above, as well as under certain other laws  Some national wildlife refuge (NWR) units have been created by specific acts of Congress, such as Protection Island NWR (WA) and Bayou Sauvage Urban NWR (LA) (16 U S C  §668dd note)  Units also can be created by executive order; for example, the Midway Atoll NWR was created by President Clinton in Executive Order 13022  The BLM has broad, general authority to acquire lands, principally under Section 205 of FLPMA  Specifically, the Secretary of the Interior is authorized to acquire, by purchase, exchange, donation, or use of eminent domain, lands or interests therein (43 U S C  §1715(a))  The BLM acquires land or interests in land, including inholdings, for a variety of reasons  These include to protect natural and cultural resources, to increase opportunities for public access and recreation, and to improve management of lands  As noted above, various laws directing the disposal of particular lands sometimes have been enacted  In addition, the four federal land management agencies have different standing authorities for disposing of lands  The specific disposal authorities are discussed below for each of the four agencies in the order of their apparent breadth, with the NPS (the narrowest authorities) first and the BLM (the broadest authorities) last  The NPS does not have general authority to dispose of National Park System lands  Units and lands of the Park System that were established by acts of Congress can be disposed of only by acts of Congress  Preservation of park units is a management goal and provisions of law limit the power of the Secretary of the Interior to dispose of land in changing park boundaries  Although the Secretary can, under specified conditions, make boundary changes that concurrently add and remove land within the boundary, minor boundary revisions solely to remove NPS acreage can be made only by Congress  Also, the Secretary can acquire by exchange lands that are adjacent to a boundary revision, but the Secretary cannot dispose of NPS land to do so (54 U S C  §100506(c))  Presidents have modified the boundaries of national monuments established by previous presidential proclamations, in some cases reducing the size of the monument  However, no president has terminated a monument established by proclamation  The FWS does not have general authority to dispose of its lands  With certain exceptions, wildlife refuge lands administered by the FWS can be disposed only by an act of Congress (16 U S C  §§668dd(a)(5) and (6))  For refuge lands reserved from the public domain, FLPMA prohibits the Secretary of the Interior from modifying or revoking any withdrawal which added lands to the NWRS (43 U S C  §1714(j))  For acquired lands, disposal is allowed only if: (1) the disposal is part of an authorized land exchange (16 U S C  §§668dd(a)(6) and (b)(3)); or (2) the Secretary determines the lands are no longer needed and the Migratory Bird Conservation Commission approves the disposal (16 U S C  §668dd(a)(5))  In the latter case, the disposal must recover the acquisition cost or be at the fair market value (whichever is higher), and the receipts must be deposited in the Migratory Bird Conservation Fund  The Secretary of Agriculture has numerous authorities to convey lands within proclaimed NFS boundaries out of federal ownership—through sale or exchange—although previous, broader authorities have been modified or revoked  Many of the authorities put constraints on land disposal, such as applying only to a specific geographical area or to the disposal of particular administrative properties or facilities  Many of the authorities are used in conjunction with FLPMA and other federal law and as such may place requirements on the sale or exchange of land  This includes obtaining at least fair market value for the sale of federal lands; requiring that nonfederal land exchanged for federal land be in the same state; and requiring exchanged lands to be of equal value, although value may be partially equalized with a cash payment (43 U S C  §1716)  The General Exchange Act of 1922 (16 U S C  §485) authorizes the exchange of NFS land or timber that was reserved from the public domain if the Secretary determines it will be in the public interest  The nonfederal land must be within the same state and within the exterior boundary of a national forest, and it must be chiefly valuable for national forest purposes, among other provisions  The Weeks Act of 1911 allows for similar exchanges for acquired NFS lands (16 U S C  §516)  The 1983 Small Tracts Act authorizes the Secretary to dispose of NFS land by sale or exchange, generally up to certain specified acreage limits  The disposal may be To improve management efficiencies where NFS lands are interspersed with nonfederal mineral rights owners, or if the Secretary determines the parcels to be inaccessible, physically isolated from other federal land, or to have lost national forest character (40 acres maximum); To relieve encroachments including due to erroneous surveys, or encroachments by a permanent habitable improvement if there is no evidence that the encroachment was intentional or due to negligence (10 acres maximum); To dispose of unneeded federal rights-of-way substantially surrounded by nonfederal lands (no specified acreage limitation); and If the parcel is used as a cemetery, landfill, or sewage plant pursuant to a special use authorization for the use and occupancy of NFS land (no specified acreage limitation) (16 U S C  §521e)  The conveyance must be determined to be in the public interest and the tracts may not be valued at more than $500,000  The land can be disposed of for cash, lands, interests in land (such as an easement), or any combination thereof for at least the value of the land being sold or exchanged (16 U S C  §521d) plus "all reasonable costs of administration, survey, and appraisal incidental to such conveyance" (16 U S C  §521f)  In some cases, the proceeds may be used for specified land acquisition purposes  The 1958 Townsites Act authorizes the Secretary to transfer up to 640 acres of NFS land adjacent to communities in Alaska or the 11 western states for townsites, if the "indigenous community objectives     outweigh the public objectives and values which would be served by maintaining such tract in Federal ownership" (16 U S C  §478a)  Public notice of the application for such transfer is required, and upon a "satisfactory showing of need," the Secretary may offer the land to a local governmental entity at "not less than the fair market value " The Education Land Grant Act, also known as the Sisk Act (16 U S C  §479a), authorizes the Secretary to transfer up to 80 acres of NFS land for a nominal cost upon written application of a public school district  It provides for reversion of the title to the federal government if the lands are not used for the educational purposes for which they were acquired  There are a few other specific authorities that allow for the disposal of NFS lands  For example, the 1911 Weeks Act authorizes the disposal of NFS lands that are "chiefly valuable for agriculture" but were acquired inadvertently or otherwise, if agricultural use will not injure the forests or streamflows and the lands are not needed for public purposes  The lands can be sold as homesteads in parcels of up to 80 acres (16 U S C  §519)  The Bankhead-Jones Farm Tenant Act of 1937 (7 U S C  §§1010-1012) also authorizes the disposal of lands acquired under its authority, although the FS has adopted regulations stating that the Bankhead-Jones lands comprising the national grasslands will be held permanently (36 C F R  §213 1(b))  The BLM can dispose of land under several authorities  They include (1) exchanges and sales under FLPMA, (2) sales or exchanges under the FLTFA, (3) transfers to other governmental units or nonprofit entities for public purposes, (4) patents under the General Mining Law of 1872, and (5) geographically limited sale authorities  With regard to exchanges under FLPMA, the exchanges must serve the public interest, and the federal and nonfederal lands in the exchange must be located in the same state and be of equal value (with cash equalization payments possible), among other requirements (43 U S C  §1716)  With regard to sales under FLPMA, the BLM is authorized to sell certain tracts of public land that are identified through the land-use planning process  Such tracts must meet specific criteria (43 U S C  §1713(a)): (1) such tract because of its location or other characteristics is difficult and uneconomic to manage as part of the public lands, and is not suitable for management by another Federal department or agency; or (2) such tract was acquired for a specific purpose and the tract is no longer required for that or any other Federal purpose; or (3) disposal of such tract will serve important public objectives, including but not limited to, expansion of communities and economic development, which cannot be achieved prudently or feasibly on land other than public land and which outweigh other public objectives and values, including, but not limited to, recreation and scenic values, which would be served by maintaining such tract in Federal ownership  The size of the tracts for sale is determined by "the land use capabilities and development requirements " Proposals to sell tracts of more than 2,500 acres first must be submitted to Congress and can be disapproved by Congress  Lands may not be sold at less than their fair market value  They generally must be sold through competitive bidding, although modified competition and noncompetitive sales are allowed  FLTFA provides for the sale or exchange of BLM lands identified for disposal under BLM land- use plans  The law create s a separate Treasury account for most of the proceeds (96%) from the sale or exchange, and it provide s for the use of those funds by the Secretary of the Interior and the Secretary of Agriculture  The Secretaries may acquire nonfederal lands, specifically inholdings , lands adjacent to federal lands that contain exceptional resources , and areas adjacent to inaccessible lands that are open to recreation  Up to 20% of the funds in the account may be used for administrative costs, and at least 80% of the funds for acquisition are to be in the state in which the funds are generated   The Recreation and Public Purposes Act (43 U S C  §869) authorizes the Secretary, upon application by a qualified applicant, to dispose of any public lands to a State, Territory, county, municipality, or other State, Territorial, or Federal instrumentality or political subdivision for any public purposes, or to a nonprofit corporation or nonprofit association for any recreational or any public purpose consistent with its articles of incorporation or other creating authority  The lands can be sold or leased, and the act specifies conditions, qualifications, and acreage limitations for transfer  The price of the land depends on the type of entity that will receive it, for instance, whether a state government or a nonprofit organization  The price also depends on the intended use of the land, with some sales and leases made at no cost  Although the BLM can dispose of lands through patents under the General Mining Law of 1872, since FY1995 a series of annual moratoria on issuing mineral patents has been enacted into law  These moratoria, contained in the annual Interior appropriations laws, have effectively prevented this means of federal land disposal  Specifically, the Mining Law allows access to and development of hardrock minerals on federal lands that have not been withdrawn from entry  With evidence of valuable minerals and sufficient developmental effort, the Mining Law allows mining claims to be patented, with full title (of surface and mineral rights) transferred to the claimant upon payment of the appropriate fee  Nonmineral lands used for associated milling or other processing operations can also be patented (30 U S C  §42)  Patented lands may be used for purposes other than mineral development  The BLM also has geographically limited land sale authorities  The program with the largest revenue stream has been the Southern Nevada Public Land Management Act of 1998, which allows the Secretary of the Interior to sell or exchange certain lands around Las Vegas  The BLM and the local government unit jointly decide on the lands to be offered for sale or exchange  In general, 85% of the proceeds are deposited into a special account, and are available to the Secretary of the Interior for land acquisition in Nevada and other purposes in the state, such as certain capital improvements and development of parks, trails, and natural areas  The other 15% of the proceeds are for state or local purposes, specifically the State of Nevada General Education Fund (5%) and the Southern Nevada Water Authority (10%)  Other provisions of law similarly provide for BLM land sales in particular areas (mostly in Nevada), with specific allocations of the proceeds  Further, the BLM continues to dispose of land in Alaska as required by law, such as through transfers to the state of Alaska and to Alaska native corporations  A total of about 150 million acres in Alaska will be transferred from federal to state and private ownership  


Report 2:  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 

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.