You are given two reports by the government agency.  

Report 1:
Since 2001, the United States has made a commitment to building Afghanistan’s security and governance in order to prevent the country from once again becoming a sanctuary for terrorists. To achieve its security objectives, the United States currently has two missions in Afghanistan: a counterterrorism mission that it leads and the NATO-led Resolute Support train, advise, and assist mission, which it participates in with other coalition nations. The objective of Resolute Support, according to DOD reporting, is to establish self-sustaining Afghan security ministries and forces that work together to maintain security in Afghanistan. The United States is conducting these missions within a challenging security environment that has deteriorated since the January 2015 transition to Afghan-led security. The United Nations reported nearly 24,000 security incidents in Afghanistan in 2017—the most ever recorded—and, despite a slight decrease in the overall number of security incidents in early 2018, the United Nations noted significant security challenges, including a spike in high-casualty attacks in urban areas and coordinated attacks by the insurgency on ANDSF checkpoints. DOD provides both personnel and funding to support its efforts in Afghanistan. DOD documents indicate that the United States contributes more troops to Resolute Support than any other coalition nation. As of May 2018, the United States was contributing 54 percent of Resolute Support military personnel, according to DOD reporting. Of the approximately 14,000 U.S. military personnel in Afghanistan as of June 2018, about 8,500 were assigned to Resolute Support to train, advise, and assist the ANDSF, according to DOD reporting. For fiscal year 2018, Congress appropriated about $4.67 billion for the Afghanistan Security Forces Fund—the primary mechanism of U.S. financial support for manning, training, and equipping the ANDSF. Other international donors provided about $800 million, and the Afghan government committed to providing about $500 million, according to DOD reporting. Under Resolute Support and the International Security Assistance Force mission that preceded it, CSTC-A is the DOD organization responsible for (1) overseeing efforts to equip and train the ANA and ANP; (2) validating requirements, including equipment requirements; (3) validating existing supply levels; (4) submitting requests to DOD components to contract for procurement of materiel for the ANDSF; and (5) ensuring that the Afghan government appropriately uses and accounts for U.S. funds provided as direct contributions from the Afghanistan Security Forces Fund. OSD-P is responsible for developing policy on and conducting oversight of the bilateral security relationship with Afghanistan focused on efforts to develop the Afghan security ministries and their forces. In August 2017, we reported that the United States had spent almost $18 billion on equipment and transportation for the ANDSF from fiscal years 2005 through April 2017, representing the second-largest expenditure category from the Afghanistan Security Forces Fund. In that report, we identified six types of key equipment the United States funded for the ANDSF in fiscal years 2003 through 2016, including approximately: 600,000 weapons, such as rifles, machine guns, grenade launchers, shotguns, and pistols; 163,000 tactical and nontactical radios, such as handheld radios and 76,000 vehicles, such as Humvees, trucks, recovery vehicles, and mine resistant ambush protected vehicles; 30,000 equipment items for detecting and disposing of explosives, such as bomb disposal robots and mine detectors; 16,000 equipment items for intelligence, surveillance, and reconnaissance, such as unmanned surveillance drones and night vision devices; and 208 aircraft, such as helicopters, light attack aircraft, and cargo airplanes. The Ministry of Defense oversees the ANA, and the Ministry of the Interior oversees the ANP. According to DOD reporting, the authorized force level for the ANDSF, excluding civilians, as of June 2018 was 352,000: 227,374 for the Ministry of Defense and 124,626 for the Ministry of Interior. The ANA includes the ANA corps, Afghan Air Force, Special Mission Wing, ANA Special Operations Command, and Ktah Khas (counterterrorism forces). The ANP includes the Afghan Uniformed Police, Afghan Anti-Crime Police, Afghan Border Police, Public Security Police, Counter Narcotics Police of Afghanistan, and General Command of Police Special Units. The ANA Special Mission Wing, Ktah Khas, ANA Special Operations Command, and ANP General Command of Police Special Units are collectively referred to as the Afghan Special Security Forces. In this report, we refer to the Afghan Air Force and the Afghan Special Security Forces as specialized forces, and the other components of the ANDSF as conventional forces. According to DOD reporting, the combined authorized force level for the specialized forces as of June 2018 was approximately 34,500, or about 10 percent of the ANDSF’s total authorized force level of 352,000, compared with the conventional forces, which make up about 74 percent of the total authorized force level for the ANDSF. Figure 1 shows the ANDSF’s organization. U.S. and coalition advisors from Resolute Support focus on capacity building at the Ministry of Defense, Ministry of Interior, and ANDSF regional headquarters, according to DOD reporting. Ministerial advisors are located at Resolute Support headquarters in Kabul. At the ministerial level, advisors provide assistance to improve institutional capabilities, focusing on several functional areas. Table 1 summarizes the indicators of effectiveness that ministerial advisors are to use to measure ministerial progress in developing functioning systems that can effectively execute each of the functional areas. Regional Resolute Support advisors from seven advising centers located throughout Afghanistan provide support to nearby ANA corps and ANP zone headquarters personnel, according to DOD reporting. Some advisors are embedded with their ANDSF counterparts, providing a continuous coalition presence, while others provide less frequent support, based on proximity to and capability of their ANDSF counterparts. Regional advisors are to track ANDSF capability development by assessing the progress of the ANA corps and ANP zone headquarters based on five capability pillars (see table 2). DOD and other Resolute Support advisors are to document the results of these assessments each quarter in an ANDSF Assessment Report. According to DOD reporting, in addition to ministerial and regional advising, two tactical-level advisory commands provide continuous support for the ANDSF’s specialized forces: Train, Advise, and Assist Command–Air (TAAC-Air) advises the Afghan Air Force down to the unit level, and NATO Special Operations Component Command–Afghanistan (NSOCC-A) primarily provides tactical-level special operations advising for the Afghan Special Security Forces. TAAC-Air and NSOCC-A assess capabilities at the headquarters level based on the five capability pillars described above in table 2, and these assessments are included in the quarterly ANDSF Assessment Report. Figure 2 shows the levels of advising each Resolute Support advisory command type provides for the ANDSF conventional forces and specialized forces. Since Resolute Support began, the ANDSF have improved some capabilities related to the functional areas and capability pillars described above, but face several capability gaps that leave them reliant on coalition assistance, according to publicly available DOD reporting. DOD defines capability as the ability to execute a given task. A capability gap is the inability to execute a specified course of action, such as an ANDSF functional area or a capability pillar (see tables 1 and 2 above). According to DOD guidance, a gap may occur because forces lack a materiel or non-materiel capability, lack proficiency or sufficiency in a capability, or need to replace an existing capability solution to prevent a future gap from occurring. According to DOD reporting on the Afghan security ministries, ANA corps, and ANP zones, the ANDSF generally have improved in some capability areas since Resolute Support began, with some components performing better than others. For example, DOD has reported that the Afghan ministries have improved in operational planning, strategic communications, and coordination between the Ministry of Interior and Ministry of Defense at the national level. In general, the ANA is more capable than the ANP, according to DOD reporting. According to DOD officials and SIGAR reporting, this is due, in part, to the ANA having more coalition advisors and monitoring than the ANP. DOD officials also noted that the Ministry of Interior, which oversees the ANP, and Afghanistan’s justice system are both underdeveloped, hindering the effectiveness of the ANP. Corruption, understaffing, and training shortfalls have also contributed to the ANP’s underdevelopment, according to DOD and SIGAR reporting. The Afghan Special Security Forces are the most capable within the ANDSF and can conduct the majority of their operations independently without coalition enablers, according to DOD reporting. DOD and SIGAR reports have attributed the Afghan Special Security Forces’ relative proficiency to factors such as low attrition rates, longer training, and close partnership with coalition forces. The Afghan Air Force is becoming increasingly capable, and can independently plan for and perform some operational tasks, such as armed overwatch and aerial escort missions, according to DOD reporting. However, DOD has reported that the ANDSF generally continue to need support in several key areas. For example, as of December 2017, DOD reported several ministerial capability gaps, including force management; logistics; and analyzing and integrating intelligence, surveillance, and reconnaissance information. DOD also reported that, as of December 2017, the ANA and ANP continued to have capability gaps in several key areas, such as weapons and equipment sustainment and integrating fire from aerial and ground forces. The ANDSF rely on support from contractors and coalition forces to mitigate capability gaps in these key areas. For some capability areas, such as aircraft and vehicle maintenance and logistics, the ANDSF is not expected to be self- sufficient until at least 2023, according to DOD reporting. According to DOD officials and SIGAR reporting, coalition and contractor support helps mitigate ANDSF capability gaps in the immediate term but may make it challenging to assess the ANDSF’s capabilities and gaps independent of such support. For example, vehicle and aircraft maintenance contractors are responsible for sustaining specific operational readiness rates for the equipment they service. While this helps ensure that ANDSF personnel have working equipment to accomplish their mission, thereby closing an immediate capability gap, it may mask the ANDSF’s underlying capabilities and potentially prolong reliance on such support, according to DOD officials and SIGAR reporting. DOD and the ANDSF have begun implementing plans and initiatives that aim to strengthen ANDSF capabilities. These include the following, among others: ANDSF Roadmap. In 2017, the Afghan government began implementing the ANDSF Roadmap—a series of developmental initiatives that seek to strengthen the ANDSF and increase security and governance in Afghanistan, according to DOD reporting. The Roadmap is structured to span 4 years, but DOD has reported that its full implementation will likely take longer than that. According to DOD reporting, the Roadmap aims to improve four key elements: (1) fighting capabilities; (2) leadership development; (3) unity of command and effort; and (4) counter-corruption efforts. Under the Roadmap’s initiative to increase the ANDSF’s fighting capabilities, DOD and the ANDSF have begun implementing plans to increase the size of the specialized forces. Specifically, DOD reports that the ANDSF plans to nearly double the size of the Afghan Special Security Forces by 2020 as an effort to bolster the ANDSF’s offensive reach and effectiveness. The Afghan Special Security Forces are to become the ANDSF’s primary offensive force, the conventional ANA forces are to focus on consolidating gains and holding key terrain and infrastructure, and the conventional ANP forces are to focus on community policing efforts. In addition, to provide additional aerial fire and airlift capabilities, the ANDSF began implementing an aviation modernization plan in 2017. The aim is to increase personnel strength and the size of the Afghan Air Force and Special Mission Wing fleets by 2023. Enhanced vehicle maintenance efforts. To help improve the ANDSF’s vehicle maintenance abilities, DOD awarded a National Maintenance Strategy Ground Vehicle Support contract, which, according to DOD officials, became fully operational in December 2017. The National Maintenance Strategy Ground Vehicle Support contract consolidated five separate vehicle maintenance and training contracts into a single contract and contains provisions for building the capacity of ANDSF and Afghan contractors to incrementally take control of vehicle maintenance over a 5-year period. Additional U.S. military personnel. As part of the South Asia strategy, the United States committed 3,500 additional military personnel to increase support to its missions in Afghanistan. According to DOD reporting, most of the additional personnel will support the Resolute Support mission, providing more advising and combat enabler support to the ANDSF. Additionally, in March 2018, the United States began deploying a Security Force Assistance Brigade—a new type of unit made up of U.S. Army personnel with expertise in training foreign militaries—to Afghanistan. The Security Force Assistance Brigade will advise conventional and specialized forces at and below the corps and zone levels and will accompany and support ANA conventional forces at the battalion level in ground operations as needed, according to DOD and SIGAR reporting. DOD collects some reliable information about the operation and maintenance abilities of ANDSF specialized forces, in part because advisors are embedded at the tactical level with the specialized forces, according to DOD officials. Specifically, U.S. and coalition forces advise specialized forces at the tactical level under Resolute Support because building ANDSF aviation and special operations abilities are considered particularly important, according to DOD reporting. DOD officials told us that since U.S. and coalition forces are embedded at the tactical level for specialized forces, they can monitor, assess, and report on tactical abilities, including the ability to operate and maintain equipment. Our analysis of information provided by DOD about the Afghan Air Force’s ability to operate and maintain MD-530 helicopters illustrates that DOD has some detailed information about specialized forces. TAAC-Air advisors help train Afghan pilots and maintainers and collect information on their tactical abilities. For example, TAAC-Air advisors track the percentage of maintenance performed by Afghan Air Force maintainers and aircraft operational readiness rates, according to DOD officials. According to DOD reporting and officials, as of December 2017, the Afghan Air Force could independently conduct MD-530 helicopter operations for short intervals without contractor support but relied on contractors to perform the majority of maintenance and sustainment activities. See appendix II for more information on the Afghan Air Force’s ability to operate and maintain MD-530 helicopters. U.S. and coalition forces perform high-level assessments of the ANDSF conventional forces’ capabilities at the corps and zone levels but do not assess their tactical abilities, such as the ability to operate and maintain equipment, according to DOD officials. For example, U.S. and coalition forces assess the ANA and ANP conventional forces in quarterly ANDSF Assessment Reports, but these reports are at the corps and zone headquarters levels, and are not meant to provide an evaluation of the entire ANDSF, according to DOD reporting. DOD officials stated that other U.S.- and coalition-produced reports and assessments, such as DOD’s semiannual Section 1225 reports to Congress, semiannual periodic mission reviews, and annual Afghanistan Plans of Record, provide some information on the ANDSF’s high-level capabilities. However, according to DOD officials, these reports do not routinely assess the conventional forces’ ability to operate and maintain equipment. According to DOD officials, DOD does not assess conventional forces’ tactical abilities because advisors have had little or no direct contact with conventional units below the corps and zone levels, and thus do not collect such information on conventional forces. Specifically, under Resolute Support, U.S. and coalition forces have not embedded with the conventional forces below the corps and zone levels except in limited circumstances. Since U.S. and coalition forces do not collect firsthand information on the conventional units’ tactical abilities, they rely on those units’ self-reporting for information on ANDSF abilities below the corps and zone levels, which, according to DOD officials, may be unreliable. ANDSF reporting is not verified by U.S. officials and can be unreliable in its consistency, comprehensiveness, and credibility, according to DOD officials and SIGAR. For example, the ANDSF produce a monthly tracker on vehicle availability, maintenance backlog, repair times, and personnel productivity, but DOD officials told us that the trackers are of questionable accuracy. Our analysis of information provided by DOD about the ANDSF’s ability to operate and maintain tactical and nontactical radios illustrates the limited amount of information DOD has on ANDSF conventional forces’ tactical abilities. Specifically, DOD officials could not say how well ANDSF personnel on the front lines operate radios in the field and had only limited information on the ANDSF’s ability to maintain radios. For example, the officials noted that the ANA conventional forces can perform some unit-level radio repairs but that complex ANA radio maintenance and all ANP radio maintenance is conducted by contractors. DOD officials at Resolute Support headquarters told us that they provide ministerial- level advising on how to manage ANDSF radio systems and do not provide tactical advising or inventory control for radios. See appendix III for more information on the ANDSF’s ability to operate and maintain radios. Our analysis of information provided by DOD about the ANDSF’s ability to operate and maintain Mobile Strike Force Vehicles (MSFV) highlights the limited amount of information DOD has on ANDSF conventional forces’ tactical abilities compared with specialized forces. DOD officials were able to provide operation and maintenance information for MSFVs that had transferred to the specialized forces as of January 2018 but were unable to provide operation and maintenance information for any other MSFVs. The ANDSF began transferring one of the ANDSF’s two MSFV brigades from the conventional to specialized forces in August 2017, according to DOD officials. As part of this transfer, NSOCC-A advisors—who provide tactical-level advising for the Afghan Special Security Forces—assumed oversight for the first brigade from Resolute Support headquarters advisors. DOD officials stated that the ANDSF’s ability to operate and maintain MSFVs in this brigade prior to the transfer was unknown, as neither Resolute Support headquarters nor the ANA had assessed this. The operation and maintenance abilities of the second brigade, which is still in the conventional forces, remains unknown. DOD officials at NSOCC-A were able to provide information such as inventory and mission capability rates for the MSFVs that had transferred, but only for the short period of time the vehicles had been under the control of the specialized forces. DOD officials told us that NSOCC-A plans to collect more information on the specialized forces’ ability to operate and maintain MSFVs as they are transferred. See appendix IV for more information on the ANDSF’s ability to operate and maintain MSFVs. In the absence of embedded advisors at the tactical level, DOD has not implemented alternative approaches to collect reliable information about the conventional forces’ ability to operate and maintain equipment. Federal internal control standards state that U.S. agencies should obtain and process reliable information to evaluate performance in achieving key objectives and assessing risks. DOD officials acknowledged that some of the plans described above that DOD and the ANDSF have begun implementing to address capability gaps may provide opportunities for DOD to collect more reliable information on the conventional forces’ ability to operate and maintain U.S.-purchased equipment. For example, the National Maintenance Strategy Ground Vehicle Support contract requires that contractors regularly report the total work orders received, work in progress, and completed maintenance work performed by ANDSF personnel as well as vehicle availability rates, which may be more reliable than the ANDSF’s monthly report on vehicle availability. In addition, the Security Force Assistance Brigade may be able to collect and report on the tactical abilities of units they advise and accompany on missions since they are being deployed at or below the corps and zone levels. However, as of June 2018, DOD officials had not decided which, if any, of these options to pursue. Without reliable information on the equipment operation and maintenance abilities of ANDSF conventional forces, which represent nearly 75 percent of the ANDSF, DOD may be unable to fully evaluate the success of its train, advise, assist, and equip efforts in Afghanistan. The United States invested nearly $84 billion in Afghan security in the 17- year period spanning fiscal years 2002 through 2018, but DOD continues to face challenges to developing a self-sustaining ANDSF. While DOD has reported the ANDSF have improved in several capability areas, they continue to face critical capability gaps, impeding their ability to maintain security and stability in Afghanistan independent of U.S. and coalition forces. Moreover, DOD lacks reliable information about the degree to which conventional forces—which make up about three-quarters of the ANDSF—are able to operate and maintain U.S.-purchased equipment. This limits DOD’s ability to fully evaluate the success of its train, advise, assist, and equip efforts in Afghanistan. The Secretary of Defense should develop and, as appropriate, implement options for collecting reliable information on the ANDSF conventional forces’ ability to operate and maintain U.S.-purchased equipment. (Recommendation 1) We provided a draft of this report to DOD and State for comment. DOD declined to provide written comments specifically on this public version of the report, but DOD’s comments on the sensitive version of this report are reprinted in appendix V. The sensitive version of this report included two recommendations, which DOD cited in its comments on the draft of the sensitive report. One of those recommendations related to information that DOD deemed to be sensitive and that must be protected from public disclosure. Therefore, we have omitted that recommendation from DOD’s comment letter in appendix V. This omission did not have a material effect on the substance of DOD’s comments. In its comments, DOD concurred with the recommendation we made in this version of the report and stated it will take steps to implement it. DOD also provided technical comments, which we incorporated as appropriate. The Department of State had no comments. We are sending copies of this report to the appropriate congressional committees, the Secretary of Defense, and the Secretary of State. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff has any questions about this report please contact me at (202) 512-7114 or farbj@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix VI. House Report 114-537 associated with the National Defense Authorization Act for Fiscal Year 2017 included a provision for us to review the Afghan National Defense and Security Forces’ (ANDSF) capability and capacity to operate and sustain U.S.-purchased weapon systems and equipment. This report is a public version of a sensitive report that we issued on September 20, 2018. Our September report included three objectives, including one on the extent to which DOD considers ANDSF input and meets their needs when identifying equipment requirements. DOD deemed the information related to that objective to be sensitive, which must be protected from public disclosure. Consequently, we removed that objective and a related recommendation from this public report. This version includes information on the other two objectives: (1) what has been reported about ANDSF capabilities and capability gaps and (2) the extent to which DOD has information about the ANDSF’s ability to operate and maintain U.S.-purchased equipment. Although the information provided in this report is more limited, the report uses the same methodology for the two objectives as the sensitive report. To identify what has been reported about ANDSF capabilities and capability gaps, we reviewed North Atlantic Treaty Organization (NATO) and DOD documents and reports, such as DOD’s semiannual Section 1225 reports to Congress, produced after the start of the NATO-led Resolute Support mission on January 1, 2015. To determine what steps DOD and NATO have taken to try to address gaps, we reviewed reports the Center for Naval Analyses produced for DOD, as well as DOD and NATO documents and reports produced after January 1, 2015, and reports from GAO, the Special Inspector General for Afghanistan Reconstruction (SIGAR), and the DOD Inspector General. We also interviewed Center for Naval Analyses representatives and DOD officials in the United States and Afghanistan, including DOD officials at the Combined Security Transition Command–Afghanistan (CSTC-A) and in the Office of the Undersecretary of Defense for Policy (OSD-P) who helped create the DOD reporting we reviewed. To determine the extent to which DOD has information about the ANDSF’s ability to operate and maintain U.S.-purchased equipment, we reviewed DOD documents and reports and interviewed DOD officials in the United States and Afghanistan, including DOD officials who advise the ANDSF. We also reviewed federal internal control standards to determine what responsibilities agencies have specifically related to information collection. To provide illustrative examples of information DOD has about the ANDSF’s ability to operate and maintain U.S.- purchased equipment and what that information indicates about the ANDSF’s abilities and challenges, we interviewed and analyzed written responses from DOD officials, including DOD officials who provide procurement and lifecycle management for some ANDSF aircraft and vehicles, about three equipment types—MD-530 helicopters, Mobile Strike Force Vehicles (MSFV), and radios. We selected these three equipment types from a list that we developed, for an August 2017 report, of key ANDSF equipment the United States purchased from fiscal years 2003 through 2016. We made our selections after reviewing DOD documentation and interviewing DOD officials regarding a number of considerations, such as (1) how critical the equipment is to the ANDSF’s ability to achieve its mission; (2) which ANDSF component uses the equipment (i.e., Afghan National Police, Afghan National Army, or both); (3) whether DOD intends to continue procuring the equipment for the ANDSF; and (4) whether the equipment had been in use at least 5 years. We collected detailed information about the ANDSF’s ability to operate and maintain MD-530 helicopters, MSFVs, and radios, as well as other key statistics DOD provided about the equipment, such as inventory, average lifespan, average cost, role, and training. This information was based mainly on DOD responses collected from January 2018 to February 2018 as well as DOD documents and reports produced after January 1, 2015. The total amount of MD-530s and radios authorized for procurement was based on DOD data that we collected for our August 2017 report on key ANDSF equipment the United States purchased in fiscal years 2003 through 2016, which we supplemented with additional data DOD provided on U.S.-purchased equipment from October 1, 2016, through December, 31, 2017. The performance audit upon which this report is based was conducted from August 2016 to September 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. We subsequently worked with DOD from September 2018 to October 2018 to prepare this public version of the original sensitive report for public release. This public version was also prepared in accordance with those standards. Manufacturer: MD Helicopters, Inc. U.S. Program Management Office: U.S. Army, Non-Standard Rotary Wing Aircraft Project Management Office Program Advising: Train Advise Assist Command–Air (TAAC-Air) The United States originally procured 6 unarmed MD-530s for the AAF for rotary wing training in 2011. In 2014, the United States purchased 12 armed MD-530s and began retrofitting the 5 remaining trainer helicopters with armament for operational missions to address a close air attack gap. MD- 530s were chosen to fill the gap over other aircraft, in part because they could be delivered relatively quickly as the AAF awaited A-29 light attack aircraft that were experiencing procurement delays, according to Department of Defense (DOD) officials. The United States procured additional MD-530s in 2015, 2016, and 2017 because of the aircraft’s positive impact on the battlefield, according to DOD officials (see fig. 3). Key Statistics Variants: All can be armed with .50-cal machine gun pods and/or 2.75 inch rocket pods. Total Authorized for Procurement: 60 as of December 31, 2017 Inventory: 25 as of January 2018 (30 are scheduled for delivery; attrition of 5 due to crashes and enemy fire) Average Lifespan: Absent mishaps, and with good maintenance, there is no defined lifespan limit for MD-530s, according to DOD officials. National Army and Afghan National Police, depending on the mission, in all but one region of Afghanistan, which is supported by other aircraft. MD-530s are typically tasked two at a time for missions, according to DOD officials. An MD-530 crew consists of a pilot and co-pilot, according to DOD. Average cost: $6.3 million per aircraft, including all electronic devices, weapons management systems, and weapons (excluding ordnance), according to DOD officials. o Division of labor is based on the individual crew members' capabilities, with one pilot handling navigation and communication while the other identifies targets and operates the weapon systems. Army pilot advisors at Kandahar Air Field, according to DOD officials. o MD-530 pilot training takes about 3 years (see fig. 4). 1. The GAO report number cited in DOD’s letter refers to a draft of the sensitive version of this report, which we issued on September 20, 2018. Prior to issuing that version, we changed its report number to GAO-18- 662SU to reflect its sensitive nature. That version of this report included two recommendations. The second recommendation has been omitted from DOD’s letter in this public version because it was related to information that DOD deemed to be sensitive. In addition to the contact named above, Joyee Dasgupta (Assistant Director), Kara Marshall, Katherine Forsyth, and Bridgette Savino made key contributions to this report. The team also benefitted from the expert advice and assistance of David Dayton, Neil Doherty, Justin Fisher, Ashley Alley, Cary Russell, Marie Mak, James Reynolds, Sally Williamson, Ji Byun, and J. Kristopher Keener.

 

 Report 2:
CAPTA, originally enacted in 1974, provides formula grants to states to improve child protective service systems. ACF administers the CAPTA state grant program and provides guidance and oversight to states. In fiscal year 2017, Congress provided about $25 million for the program. As part of the CAPTA state grant program, states are required to submit to the Secretary of HHS plans outlining how they intend to use CAPTA funds to improve their child protective service systems, among other things. State plans remain in effect for the duration of states’ participation in the grant program; if modifications are needed, these must be submitted. In addition to state plans, states are required to submit to HHS an annual data report providing information on agency decisions made in response to referrals of child abuse and neglect, as well as preventive services provided to families, among other things. CAPTA requires state governors to provide a series of assurances in their state plans. Since 2003, governors have had to provide an assurance that states have in effect and are enforcing a state law or program that includes policies and procedures to address the needs of infants affected by prenatal substance abuse or displaying withdrawal symptoms at birth. Under states’ policies and procedures, health care providers are required to notify CPS of such infants. Governors must also assure that a plan of safe care is developed for these infants. Although CAPTA does not define “plans of safe care,” for the purposes of this report we define them as plans to ensure the safety and well-being of infants who are born substance-affected. The Comprehensive Addiction and Recovery Act of 2016 (CARA) amended certain provisions of CAPTA that relate to substance-affected infants (see table 1). In addition to provisions related to substance-affected infants, CAPTA also requires governors to provide an assurance to the Secretary of HHS that they have provisions or procedures for certain individuals to report known and suspected instances of child abuse and neglect, which are generally referred to as mandated reporter laws. All states have statutes identifying persons who are required to report suspected child maltreatment to an appropriate agency, such as child protective services, a law enforcement agency, or a state’s toll-free child abuse reporting hotline, according to a 2016 HHS report. Mandatory reporters often include social workers; teachers, principals, and other school personnel; physicians, nurses, and other health care workers; and counselors, therapists, and other mental health professionals. The circumstances under which a mandatory reporter must make a report vary from state to state, according to HHS. Typically, a report must be made when the reporter, in his or her official capacity, suspects or has reason to believe that a child has been abused or neglected. State laws require mandatory reporters to report the facts and circumstances that led them to suspect that a child has been abused or neglected; they do not have the burden of providing proof that abuse or neglect has occurred. CPS, a division within state and local social services, is generally the agency that conducts an initial assessment or investigation of reports of child abuse and neglect. It also offers services to families and children where maltreatment has occurred or is likely to occur. Typically, when CPS agencies receive a notification about suspected child abuse, including a substance-affected infant, social workers review the referral to determine if it should be accepted for investigation. During an investigation, social workers determine, among other things, the nature, extent, and cause of abuse or neglect, and identify the person responsible for the maltreatment. An investigation may include the following: a visit to the hospital and/or infant’s home; observation of the infant; risk and safety assessments; evaluation of the home environment; background checks, including criminal record checks of adults that reside with the family; as well as mental health evaluations. If social workers determine that there is enough evidence to suggest that an infant is at risk for harm or neglect, or that abuse or neglect occurred, the case is substantiated. Once a case is substantiated, CPS develops a case plan with the family outlining objectives and tasks for the family. Among other things, CPS may refer the family to services in the community, such as early intervention services, parenting classes, and substance abuse treatment. Generally, CPS attempts to strengthen the family and alleviate the problems which led to maltreatment. If the case is not substantiated, but there is genuine concern about the child’s situation and the family may benefit from services in the community, the case may be closed and/or the family may be referred for voluntary services (see figure 1). Prenatal maternal opioid use has increased considerably in recent years. This increase has contributed to a significant rise in the rate of NAS. According to a recent study, the rate of NAS has increased from 1.2 per 1,000 hospital births in 2000 to 5.8 per 1,000 hospital births in 2012, reaching a total of 21,732 infants diagnosed with NAS. NAS occurs with considerable variability. According to a recent HHS report, various studies indicate that anywhere from 55 to 94 percent of infants exposed to opioids in-utero exhibit some degree of symptoms. Typically, infants with NAS develop symptoms within 72 hours of birth, but may develop symptoms within the first 2 weeks of life, including after hospital discharge. For the purpose of this report, infants exposed to opioids ingested by mothers in utero are considered substance-exposed, and those born negatively affected by exposure or experiencing withdrawal symptoms are considered substance-affected. According to experts, NAS is considered an expected and treatable result of women’s prenatal opioid use. Opioid exposure during pregnancy may occur for the following reasons: Women receiving pain medication with a prescription under the care of a physician. Medications can include fentanyl and oxycodone. Women under the care of a physician and undergoing treatment for an opioid use disorder with medications, such as methadone or buprenorphine. This type of treatment is generally referred to as medication-assisted treatment (MAT). Women misusing opioid pain medications with or without a prescription (such as using without a prescription, using a different dosage than prescribed, or continuing to use a drug when no longer needed for pain). Women using or abusing illicit opioid, such as heroin. In response to our survey, 42 states reported that state policies and procedures require health care providers to notify CPS about substance- affected infants. Some states reported that they explicitly require health care providers to notify CPS of substance-affected infants. For example, Wisconsin reported that under its state law if tests indicate that infants have controlled substances or controlled substance analogs in their bodily fluids, the health care provider shall report the occurrence of that condition to CPS. Others reported that the requirement is met by their states’ mandated reporter law—whereby people in certain positions, including health care providers, are required to notify CPS about substance-affected infants, similar to the manner in which other mandatory reporters, like school teachers, day care personnel, and social workers are required to report other instances of child abuse and neglect. For example, Kentucky statute requires that “any person who knows or has reasonable cause to believe that a child is dependent, neglected, or abused shall immediately” make a report to the police or CPS. The statutory definition for an abused or neglected child in Kentucky includes situations where a child’s health or welfare is harmed or threatened with harm because of parental incapacity due to alcohol and other drug abuse. Of the 42 states that require health care providers to notify CPS of substance-affected infants, 21 reported that notification is required for infants affected by both illegal and legal use of opioids. For example, in Massachusetts health care providers are required to notify CPS orally and, in writing within 48 hours, about substance-affected infants physically dependent on drugs, even if the drugs were legally obtained and the mother is under the care of a prescribing medical professional. Sixteen of the 42 states reported that health care providers are required to notify CPS of infants affected only by the illegal use of opioids, and five of the 42 states reported that they did not know if health care providers were required to notify CPS of infants affected by the illegal and legal use of opioids. The other eight states reported that although they did not have policies and procedures that require health care providers to notify CPS about substance-affected infants, they have laws or policies that encourage notification. Specifically, in written responses to our survey: Two states reported that under their state mandated reporter laws health care providers are encouraged, but not required, to notify CPS about substance-affected infants. Four states reported that they are working to amend their states’ policies and procedures to require that health care providers refer substance-affected infants to CPS. Another state reported that it encourages the notification from health care providers, but has not sought legislation to require health care providers to report substance-affected infants to CPS because of concerns that any laws that criminalize prenatal substance use would further deter substance-using pregnant women from seeking prenatal care. The state’s law requires all hospital personnel who suspect abuse and neglect or observe conditions that are likely to result in abuse or neglect to notify CPS. One state reported that all persons, including health care providers, are required to report child abuse and neglect, but reporting depends on whether a hospital’s policy indicates substance abuse is child abuse or neglect. Further, the state CPS director reported collaboration with the health care community on reporting substance exposed infants to its child abuse hotline. Although one state reported in our survey that it does not require or encourage health care providers to notify CPS about substance-affected infants, in an interview, state officials explained that its policy requires that health care providers notify CPS if, through an assessment, they conclude that infants are at risk for abuse and neglect. Under the state’s law, health care providers in each county are required to assess the needs of mothers and substance-affected infants using a protocol established by county health departments, CPS agencies, and hospitals. State officials told us that under the state’s law, the birth of a substance- affected infant is not in and of itself a sufficient basis for reporting child abuse or neglect. In addition to having policies and procedures regarding the reporting of substance-affected infants, in written responses to our survey some states reported providing training and guidance to support the efforts of health care providers to notify CPS about these infants. Three states reported that they offer mandatory reporter training to inform health care providers that they are obligated to notify CPS about substance-affected infants. Another state reported that its Department of Human Services developed a guide for mandated reporters that discusses what needs to be reported and where to make reports. Also, one state reported that it sent a formal letter to its state hospital association about how to report substance-affected infants to CPS. This state also sent a memo to its CPS county directors instructing them to contact their local health care providers on the importance of reporting substance-affected infants to CPS and the process for doing so. In addition, during our Massachusetts site visit, officials shared with us a memo that was sent to mandated reporters, community partners, and other stakeholders that offered guidance on when to file a report about substance-exposed infants. Further, local CPS staff at one Massachusetts field office told us that upon request they provide mandated reporter training to health care providers. Despite these policies, procedures, and guidance, in written responses to our survey, a few states reported concerns about requiring health care providers to notify CPS about substance-affected infants and the definition of substance-affected. All of the hospitals that we visited have policies consistent with their state’s law that require that health care providers, primarily hospital social workers, to notify CPS about substance-affected infants. However, one state reported that some medical personnel have been reluctant to report some infants that are positive for illegal and legal substances due to fears of mothers being arrested. Another state reported that stakeholders are concerned that having to notify CPS about substance-affected infants will have a chilling effect on the willingness of pregnant women who use substances to be honest with providers and seek the help and support they need and deserve. According to one state, there is often an inherent resistance to contacting CPS in these cases as health care providers tend to view child welfare involvement as punitive rather than a potential resource for the family. In addition, three states reported in written responses to our survey challenges understanding how to define terms, such as substance- affected, under CAPTA. For example, the Pennsylvania CPS director expressed concerns during our site visit, suggesting that CAPTA raises many unanswered questions, such as (1) if “affected by substances” means at-risk of being or physically affected by substances, (2) what policies relating to substance-affected infants should look like and include, and (3) whether “affected by substances” should include women who are under the care of health care or treatment providers and taking their medications as prescribed. A Kentucky public health official told us that a drug test, or whether the infant is affected by legal or illegal substances, should not be the sole factor in determining CPS’ involvement with a family. Rather, a holistic view of the family, whether the substance prohibits the mother’s ability to care for her child, and any risk factors present that places the infant at risk should also be considered. According to officials, an infant that is exposed to substances, but has not been affected by the substance, can still be at risk for child abuse and neglect. In response to our survey, 46 states reported that they have policies and procedures for deciding which notifications about substance-affected infants are accepted for investigation. Seventeen of those states reported that all notifications of substance-affected infants are accepted for investigation, regardless of the circumstances. The remaining 29 states reported that they apply specific criteria to determine if children who present as substance-affected are accepted for investigation by CPS. Several states reported in written responses to our survey that they base their criteria for accepting notifications on the infant’s safety. For these states, drug exposure does not by itself indicate that an infant’s safety is at risk. For example, one state explained that in determining a child’s safety risk, staff evaluate a number of factors including the history of the family; the family’s presentation at the birthing hospital (appearance of chaotic behavior, suspected intoxication of adults, lack of appropriate concern or bonding with the infant); the presentation of the infant’s physical condition; the results of any testing of parent or child (blood, urine, etc.); discrepancies identified in the parent’s representation of their substance use or substance use treatment; and any other concerns noted by the reporting source. Other states reported that their criteria for accepting notifications for investigation are based on the degree or type of drug exposure in question. For example, one state reported that its policy directs CPS agencies to accept notifications for investigation when a parent has used illegal substances or non-medical use of prescribed medication during the last trimester of pregnancy. Another state reported that it will accept notifications for investigation if the infant is born with a positive toxicology or is experiencing drug withdrawal, or if the mother tests positive for substances. A few states reported using both risk to the safety of infants as well as degree or type of drug as their criteria for accepting notifications. For example, one state reported that it considers factors, such as the type of drug, the parent’s ability to care for the child, addiction history, and the parent’s readiness and preparation to care for the infant. In follow-up correspondences with states that reported that they do not have policies and procedures to decide whether to accept for investigation notices about substance-affected infants, one state reported that decisions are made on a case-by-case basis. A few states reported that after receiving notifications about substance- affected infants, CPS agencies may decide to opt out of investigating some families, referred to as “screening out” families. For example, in Massachusetts, CPS can “screen out” referrals of mothers if the only substance affecting the infants was used by the mothers as prescribed by their physician. In these instances, when CPS in Massachusetts is notified by the hospital about an infant, the screener gathers information from the caller and consults with a supervisor to determine whether the referral should be accepted for investigation or screened out. If the mother is on methadone, for example, but is involved with services and is in a treatment plan, CPS verifies with medical or other qualified providers that the mother used the drug as part of substance abuse or medical treatment as authorized. Additionally, CPS confirms that there are no other concerns of child abuse and/or neglect. If CPS officials in Massachusetts are unable to collect all the information that they need to screen out families, for example when a mother does not sign a release allowing CPS officials to speak with her health care providers, notifications about substance-affected infants are accepted for investigation. In response to our survey, 49 states reported that their CPS agency has policies to develop a plan to ensure the safety and well-being of substance-affected infants who meet the state’s criteria for investigation. Two states reported that CPS staff are not required to develop such a plan, even if a notification is accepted for an investigation or an assessment. For purposes of this report, we are defining a plan of safe care as a plan to ensure the safety and well-being of the infant. States’ approaches to identifying children and families who will receive a plan of safe care generally fall into two categories: 38 states reported that CPS is required to develop a plan of safe care for all notifications of substance-affected infants that are accepted for investigation, including those that are not substantiated. 11 states reported that CPS staff are required to develop a plan of safe care only in those instances where an investigation substantiates the notification or uncovers an unmet need or present or emerging danger. For example, local Pennsylvania CPS officials told us that they only develop plans when there is a safety threat or other concern about the infant. Most states reported that after a notification of a substance-affected infant is accepted for investigation, CPS always conducts a needs assessment for the infant and caregivers. For example, one local CPS office that we visited told us that social workers assess risk to and safety of infants, their function (development, age appropriate behavior, etc.), and environment. In addition, workers assess the caregiver’s ability to parent and employment status, as well as housing. The assessments conducted as part of the investigation inform the development of plans of safe care, as well as decisions about the removal of infants from the home. Among the 49 states that reported that plans of safe care are developed for all or some substance-affected infants, 47 reported that these plans either always or sometimes address infants’ safety needs. Plans also address other needs, such as infants’ immediate medical and longer-term developmental needs, as well as caregiver’s substance use treatment needs. See figure 2 for the number of states whose plans of safe care address various issues facing the infant and parent. In written responses to our survey and during our site visits, officials reported that plans of safe care and referrals for services included in the plans are individualized based on the infant and family’s needs. For example, Massachusetts state CPS officials told us that plans of safe care are developed for each family based on the information that staff collect from the safety, risk, and family assessments, as well as information collected from individuals who may have knowledge that would inform the family assessments, such as medical and treatment providers, and family members. Kentucky state CPS officials told us that the local organizations and service providers that they collaborate with to develop the plan of safe care also vary based on the family’s needs. For example, Kentucky will only collaborate with substance use treatment providers to develop the plan of safe care when families have substance use disorders. Similarly, during our site visits, officials from two states told us that the decision to place an infant in foster care is based on the individualized needs of the infant and caregiver. For example, Massachusetts state officials told us that their decision to remove a baby from the home depends on a myriad of factors and is determined on a case-by-case basis. Officials explained that if a mother is discharged from the hospital and begins using drugs again and does not have adequate supports in place to care for her baby, CPS may decide to place the infant in foster care. However, if a mother has existing support systems in place to mitigate safety risks, CPS may decide to keep the baby in the home. In our survey, all 51 states reported that their agencies either always or sometimes refer parents or caregivers to substance use treatment programs, and most states reported that they always or sometimes refer parents or caregivers to parenting classes or programs (49), and other supportive services (49). CPS officials in each of the three states that we visited told us that their plans of safe care include referrals to address not only the immediate needs of the infants, but also the needs of the parent or caregiver. For example, officials from a local Kentucky CPS agency told us that staff refer mothers of substance-exposed infants to a program called Sobriety Treatment and Recovery Team (START). START is comprised of a social worker and a peer support mentor who has at least 3 years of sobriety, previous involvement with CPS, and was successfully able to regain or keep custody of her own children. According to officials, the START program has been able to provide participants with quick access to substance use disorder treatment. Officials from a Massachusetts local CPS agency told us that one of the services that they provide to parents of substance-affected infants is a parent aide who can help monitor how the parent is caring for the infant, such as administering the infant’s medications appropriately and ensuring the parent is not abusing the infant’s drugs. In addition, a parent aide can provide emotional support and help parents adjust after the infant is discharged from the hospital. Kentucky officials noted the effect that a healthy caregiver has on the outcome of the infant and emphasized that a baby cannot be healthy if the mother is not. Kentucky CPS officials said that they have found that the earlier caregivers enter treatment, the better the outcomes are for mothers and babies. According to Kentucky officials, parents who participate in the START program are less likely to have their child placed in foster care. Officials from the states that we visited told us that developing and monitoring plans of safe care under CAPTA’s new requirements for infants affected by their mother’s legal use of prescribed medications, as well as plans for these infants’ caregivers, present challenges. Specifically, officials reported concerns about increased caseloads, particularly if they are required to provide plans and services for infants at low risk of abuse or neglect, the content of plans, and confidentiality restrictions. Thirty-one of 50 states reported on our survey that staffing or resource limitations was very or extremely challenging, and CPS officials across the 3 states we visited said that the opioid epidemic has directly contributed to increased caseloads. According to a local Kentucky CPS office, the number of babies that met criteria for being accepted for investigation has increased about 55 percent from 2011 to 2016, while the number of staff has remained the same. Similarly, hospitals reported being impacted by this challenge. For example, staff at four hospitals we visited told us that they have delayed discharging infants from the hospital because CPS social workers did not identify caregivers to whom infants may be released or make plans for infants in a timely manner. In addition, staff from three hospitals told us that some CPS workers are difficult to contact and not especially responsive to their questions. One hospital social worker told us that she is concerned that the changes to CAPTA that require notifying CPS of all substance-affected newborns will inundate the agencies with cases. Officials from two of the three states we visited anticipated that providing services to infants affected by the legal use of prescribed medications, but not likely to be at risk for child abuse and neglect, will result in an increase in the number of families referred to CPS. This, in turn, will require a plan of safe care and further strain limited resources. Twenty- five states reported in our survey that the plan they develop for substance-affected infants is the same as for other children in CPS care, suggesting that states devote the same level of resources to these infants as other cases. The states we visited interpret CAPTA to require that plans of safe care be developed for all substance-affected infants who are referred to CPS, including those who may not meet usual criteria to be accepted for an investigation. Some state officials we interviewed questioned whether the new CAPTA requirements would allow for the best use of limited resources. For example, one senior state CPS official questioned whether it would be a good use of resources to develop plans of safe care for mothers in substance use disorder treatment or mothers using opioid medications due to chronic pain. A local CPS official we interviewed stated that drug exposure, in and of itself, is not necessarily a safety risk, and CPS should not intervene with families who are not at risk for child abuse or neglect. Instead, hospitals or treatment providers should intervene and refer families who do not meet criteria for CPS involvement, but could benefit from additional supports, to voluntary services. Kentucky public health officials told us that the period after a woman gives birth is a critical time for families as mothers may be stressed, sleep-deprived, exhausted, and may have other children in the home. This period may be especially challenging for mothers with substance use disorders, if adequate supports are not in place. According to officials women are typically covered for substance use treatment during pregnancy; however, this coverage ends roughly 60 days after the baby is born. In written responses to our survey, some states reported that they would rely on other agencies to develop plans of safe care. Similarly, in order to manage limited CPS resources, officials from two of the three states that we visited said they are considering having hospitals or other agencies assume responsibility for developing plans of safe care when there is no evidence of abuse or neglect and there appears to be minimal risk to the safety and well-being of the infant. Kentucky officials told us that they envision that CPS will be responsible for developing a plan of safe care for notifications that are accepted for investigation, while hospitals, or another agency, will be responsible for developing plans of safe care for referrals that are screened out by CPS. According to CPS state officials, the plan of safe care for the infant and the family can be part of the discharge plan prior to the family leaving the hospital. However, officials reported that obtaining cooperation from other agencies may be difficult. Some state officials reported being concerned that other agencies may not feel obligated to develop these plans, in part, because CAPTA provides funding to child welfare, and other agencies may therefore believe that child welfare should be responsible for developing the plan of safe care. CPS officials we interviewed in two of our site visit states, as well as one state we followed up with, told us that they were unsure of whether their current plans will meet new CAPTA requirements because CAPTA does not define a plan of safe care. For example, Massachusetts officials said that their plans include everything that a family might need to ensure the safety of the child, including resources to ensure stabilization and reunification of a family, but they are not sure whether the plans meet new CAPTA requirements, in part because they are not familiar with the term “plan of safe care.” An official in another state was also unsure about whether his state’s “safety plans” would meet CAPTA requirements. According to the official, safety plans may include a treatment plan for mothers, and referral services, such as early intervention for the child. In practice, plans of safe care generally address gaps that place an infant at risk for harm or neglect. However, state officials we interviewed reported being unsure about what a plan of safe care should look like for families where these gaps do not exist. Also, in a written response to our survey, one state expressed uncertainty about CPS’ role if required to work with infants who do not typically receive CPS services. For example, a Pennsylvania official said that it is unclear what types of interventions child welfare should conduct with families of infants exposed to legal substances, such as medications prescribed by doctors, when the caregivers are taking their medications correctly. Similarly, officials also questioned whether a plan would be necessary, and what the plan would entail, for caregivers who are already addressing their substance use disorder and taking steps to ensure their infant’s safety. Officials from a local Kentucky CPS office described a case in which a mother was participating in medication-assisted treatment, had attended counseling three times per week throughout her pregnancy, and was continuing treatment in the postpartum period. Through CPS’ investigation, the agency found that the case was not substantiated, in part, because there were no additional services that CPS could connect her with that she was not already receiving. Officials across the three states we visited also said that state and federal drug and alcohol confidentiality restrictions may challenge their ability to monitor plans of safe care. To monitor plans of safe care, CPS staff may need access to confidential information in order to know how caregivers are progressing in treatment, particularly now that these plans must address the substance use disorder needs of the caregiver. However, federal law restricts the disclosure and use of alcohol and drug patient records maintained in connection with the performance of any federal- assisted alcohol and drug abuse program. Generally, confidential information may be disclosed in accordance with the prior written consent of the patient. State and local CPS staff we interviewed said that strict confidentiality requirements make it challenging for drug and alcohol treatment providers to share information about mothers and infants. A CPS state director from Pennsylvania said that treatment providers are often reluctant to provide CPS case workers with information or updates on a mother’s treatment, which prevents child welfare workers from fully understanding how mothers are progressing with their treatment and the extent to which those in treatment are adhering to prescribed directions as outlined by treatment providers. In addition, one official from a state we visited said state statutes regarding sharing of drug and alcohol treatment information may be more restrictive than the federal statute. Some states have developed ways to obtain confidential information about mothers in substance use disorder treatment. For example, officials from one local CPS office told us that in instances when they have to develop a long-term plan of safe care for families, they have mothers sign a release of information form in order to obtain updates about her treatment adherence from the medication- assisted treatment provider. Similarly, a local Massachusetts CPS office told us that typically staff obtain releases from mothers so that they can verify whether mothers are actively participating in their treatment and that there are no records of relapse. In HHS’ role to assist states in the delivery of child welfare services, two agencies—ACF and the Substance Abuse and Mental Health Services Administration (SAMHSA)—provided technical assistance to states through the National Center on Substance Abuse and Child Welfare (NCSACW). In addition, in ACF’s role to administer and monitor states’ implementation of CAPTA, the agency has provided some guidance to states on the provisions pertaining to substance-affected infants and has begun its monitoring responsibilities. ACF and SAMHSA, which leads public health efforts to reduce the impact of substance abuse and mental illness, established the NCSACW in 2002. The NCSACW provides technical assistance to states, and has issued publications and hosted forums to help states develop policies and procedures around issues affecting substance-affected infants. The technical assistance has focused on a broad range of issues, including collaboration among service providers, and plans of safe care. With respect to collaboration, NCSACW has issued several studies that identify opportunities for strengthening interagency efforts to prevent, intervene, identify, and treat prenatal substance exposure. The NCSACW collaboration guides encourage states to involve CPS agencies with medical providers in an interagency collaborative setting, thereby facilitating the process for CPS agencies to be notified of substance- affected infants. Regarding plans of safe care, NCSACW has provided technical assistance and best practices to states around development of these plans. For example, in one state it has facilitated discussion groups to help the state develop a model plan. From calendar year 2011 to 2016, NCSACW processed approximately 600 requests from state CPS agencies for short-term technical assistance related to improving care for substance-affected infants and their families. This short-term technical assistance included activities such as responding to telephone inquiries, mailing information, identifying needed resources, and making referrals. The NCSACW has also provided in- depth assistance to 16 states to strengthen collaboration and linkages across child welfare, addiction treatment, medical communities, early care and education systems, and family courts to improve outcomes for substance-affected infants and their families. Through this in-depth assistance, NCSACW identified areas for improvement in states, including a lack of clarity regarding compliance with CAPTA requirements (such as identification, notification, and developing plans of safe care) and the need for state models to comply with CAPTA requirements to develop plans of safe care. In one state, the project overview report indicated that a next step for the in-depth technical assistance is to continue development of the plan of safe care model and ensure practices and protocols are in place across systems to meet CAPTA requirements. The report indicated that this will include ongoing work with hospitals to ensure consistent identification of infants with prenatal exposure and notifications to CPS. Although18 states reported in our survey that technical assistance from the NCSACW was very or extremely helpful, 11 reported that it was moderately helpful, 7 reported that it was slightly helpful, and 1 reported that it was not at all helpful. Eleven states reported that they were not familiar with this assistance. Since July 2016, when the most recent amendments to CAPTA were enacted, ACF has issued one information memorandum and two program instructions to states about provisions relating to substance-affected infants. According to an ACF official, information memoranda share information with states, while program instructions provide interpretations of the law and inform states of actions they must take. ACF issued an August 2016 information memorandum informing states of the 2016 amendments to CAPTA. The August 2016 information memorandum also provided states with best practices, drawing on an NCSACW guide on collaboration for developing multi-systemic approaches to assist child welfare, medical, substance use disorder treatment, and other systems to support families affected by opioid use disorders. In January 2017, ACF issued a program instruction which provided guidance to states on implementing the 2016 amendments to CAPTA made by CARA and informed states of the flexibilities that they have under the law. Particularly, the guidance noted that: “CAPTA does not define ‘substance abuse’ or ‘withdrawal symptoms resulting from prenatal drug exposure.’ We recognize that by deleting the term ‘illegal’ as applied to substance abuse affecting infants, the amendment potentially expands the population of infants and families subject to the provision [that states have policies and procedures in place to address their needs]. States have flexibility to define the phrase, ‘infants born and identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure,’ so long as the state’s policies and procedures address the needs of infants born affected by both legal (e.g., prescribed drugs) and illegal substance abuse.” “While CAPTA does not specifically define a ‘plan of safe care,’ CARA amended the CAPTA state plan requirement . . . to require that a plan of safe care address the health and substance use disorder treatment needs of the infant and affected family or caregiver.” “CAPTA does not specify which agency or entity must develop the plan of safe care; therefore the state may determine which agency will develop the plans. We understand that in most instances the state already has identified the responsible agency in its procedures. When the state reviews and modifies its policies and procedures to incorporate the new safe care plan requirements in CARA, the state may wish to revisit its procedures regarding which agency develops the plan of safe care, including any role for agencies collaborating with CPS in caring for the infant and family.” In addition, in April 2017, ACF issued a program instruction on reporting requirements, including changes in those requirements brought about by the 2016 amendments to CAPTA. ACF conducted limited monitoring of states prior to the amendments passed in 2016. According to ACF officials, if presented with evidence of potential deficiencies, the agency would attempt to learn more about the state’s activities. In one instance, ACF reviewed South Carolina’s policies and found them to not be in compliance with the notification and safe care plan requirements of CAPTA. It directed the state to develop a program improvement plan to bring it into full compliance, which South Carolina submitted in April 2016. In a recent progress report (February–April 2017), South Carolina reported that it was focused on updating statutes, developing policies and procedures, training child protective service workers, and building relations with health care providers. In response to the 2016 amendments to CAPTA that added the requirement for HHS to monitor state policies and procedures to address the needs of substance-affected infants, ACF officials told us that staff in regional offices will review states’ annual reports, submitted in June 2017. In its program instruction describing the reporting requirements, ACF asked each state to submit a new Governor’s Assurance, as well as a narrative explaining what they have done in response to the amendments. Specifically, ACF asked states to provide information on any changes that were made in state laws, policies, or procedures related to identifying and referring infants affected by substance abuse to CPS as a result of prenatal drug exposure. It also requested updates on states’ policies and procedures regarding the development of plans of safe care; a description of how states have developed systems to monitor plans of safe care; and a description of any outreach or coordination efforts the states have taken to implement the amendments, among other things. According to ACF officials, as of October 1, 2017, some states have provided information and a Governor’s Assurance demonstrating compliance with the amended provisions and some states have been placed on Program Improvement Plans, but the agency does not yet have information on the status of all states. An ACF official explained that, in their annual reports, some states either acknowledged that they are trying to get legislation enacted to bring them into compliance with the law and it has failed, or that they are not in compliance, for example, because they were limiting their policies to those infants affected only by illegal substances. In addition, in May 2017, ACF issued a technical bulletin informing states of the new data collection requirements that resulted from the 2016 amendments to CAPTA. ACF stated that it intends to collect data required by the amendments to CAPTA through the National Child Abuse and Neglect Data System, beginning with states’ submission of fiscal year 2018 data. This system is maintained by ACF and contains data from states about children who have been abused or neglected. ACF issued a Federal Register notice about the proposed data elements and requested comments on the accuracy and quality of the proposed data collection, among other things; the comment period closed in July 2017. In the Federal Register notice, ACF notes that the 2016 amendments to CAPTA require it to collect information from state CPS agencies on the number of notifications from health care providers that are accepted for investigation or screened out. Further, of those infants screened in, ACF is required to collect data on the number of safe care plans developed for substance- affected infants as well as the number of infants for whom a referral was made for appropriate services, including services for the affected family or caregiver. In the Federal Register notice, ACF proposed to collect this information using a combination of existing and new data from states. Thirty-two states reported in our survey that they already collect data on the incidence of substance-affected and/or substance-exposed infants; 15 of those 32 states also collect data on the incidence of NAS. Further, 18 states reported that they collect data on the number of notifications health care providers make to CPS. Of those states, 8 reported that they collect specific data on notifications related to infants diagnosed with NAS. Most states reported in our survey that additional guidance and assistance would be extremely or very helpful (see figure 3). For example, 38 states reported that additional guidance on requirements for health care providers to notify CPS of substance-affected infants would be extremely or very helpful. Similarly, 37 states reported that additional guidance on developing, implementing, and monitoring plans to ensure the safety and well-being of substance-affected infants would be extremely or very helpful. In written responses to our survey, states suggested ideas for additional guidance, training, and technical assistance to help them address the needs of substance-affected infants. States’ suggestions ranged from assisting in the development of substance abuse training curriculum for staff to video conferences with other states to share information about implementing CAPTA. A few states suggested that the guidance ACF has provided to date is not clear and reported grappling with the meaning of terms such as “affected” and “legal vs. illegal” substances, and two states requested “concrete guidance” and “specificity.” A few other states suggested that it would be helpful to obtain additional information about meeting the requirements of plans of safe care within the constraints of state and federal confidentiality laws, technical assistance on what plans of safe care look like, and a format for a plan of safe care. ACF officials told us that states have flexibility with implementing the law and the agency does not anticipate issuing additional written guidance on the amendments to CAPTA made by CARA. ACF officials explained, in October 2017, that they were finalizing their review of the plans that states were required to submit. These plans are expected to include details on how the states are addressing the CAPTA requirements. While ACF could not provide the number, officials reported that some of the state plans submitted to date did not meet the requirements and those states have been asked to develop program improvement plans. They expect states to work with the ACF regional offices, which will provide or facilitate technical assistance to states on their implementation of the provisions, as needed. In addition to the review of state plans, ACF officials explained that regional officials may learn about states’ needs for technical assistance through meetings or informational exchanges. Finally, the NCSACW is expected to review and prepare a summary of CAPTA state plans, current state statutes and policies and procedures relating to amended CAPTA requirements. In addition, according to ACF, NCSACW will continue to offer technical assistance on the development and implementation of plans of safe care to states. Technical assistance may include responding to requests for information, disseminating written materials and resources, and conducting webinars/conference calls. Further, ACF reported that some states will receive more in-depth technical assistance, albeit in some instances on a time-limited basis. Undertaking these actions can enhance states’ understanding of CAPTA requirements and better address known challenges such as the ones described in this report. However, more specific guidance from HHS on the issues which states have expressed confusion can assist them in better understanding CAPTA requirements and providing more effective protections and services for the children and families most in need. The opioid epidemic has generated a significant increase in the number of substance-affected infants born and diagnosed with NAS. These vulnerable infants may be at risk for child abuse and neglect if adequate supports and services are not available to ensure their safety. CAPTA requires states to have policies and procedures to address the needs of these infants and their families, including mothers with a substance use disorder. However, states have experienced challenges implementing new CAPTA requirements. Many states reported in our survey that they are not completely adhering to the law. This is reflected in ACF’s review of state plans, some of which are resulting in program improvement plans. States cite challenges that stem, in part, from ACF’s lack of specificity in providing guidance on implementing CAPTA requirements. Specifically, states report that ACF has not provided clear guidance about which substance-affected infants health care providers are required to notify CPS about, as well what a plan of safe care is and for whom it should be developed. Given the challenges that states reported facing in implementing the provisions, a majority reported wanting more help from ACF, such as trainings and teleconferences with other states, to help overcome their challenges. Additional guidance and assistance from HHS would help states better understand what they need to do to develop policies and procedures that meet the needs of children and families affected by substance use. The Secretary of HHS should direct ACF to provide additional guidance and technical assistance to states to address known challenges and enhance their understanding of CAPTA requirements, including the requirements for health care providers to notify CPS of substance- affected infants and the development of a plan of safe care for these infants. We provided a draft of this report to HHS for review and comment. HHS’s comments are reproduced in appendix I. HHS also provided technical comments, which we incorporated into our report where appropriate. HHS did not concur with our recommendation. HHS stated that: in January 2017, ACF clarified in guidance several of the issues raised in the report, including the population of infants and families covered by the provision and the state flexibility inherent in determining which infants are “affected by” substance abuse, and the terminology used in the federal law of what a “plan of safe care” is; ACF believes it is necessary to allow states the flexibility to meet the requirements in the context of their state CPS program; several of the challenges that the GAO notes are not specific to CAPTA compliance with the safe care plan and notification requirements; and it does see the value in continuing to provide technical assistance to states to address known challenges and to enhance their understanding of CAPTA requirements. With respect to HHS’ January 2017 guidance, state officials reported in our survey and during site visits that they found some terms unclear and were uncertain about what is required of them. In written responses to our survey, states reported challenges understanding how to define substance-affected under CAPTA. In addition, as we note in our report, the guidance about plans of safe care described the following: “While CAPTA does not specifically define a ‘plan of safe care,’ CARA amended the CAPTA state plan requirement . . . to require that a plan of safe care address the health and substance use disorder treatment needs of the infant and affected family or caregiver.” States reported in our survey and in follow-up discussions that this lack of specificity remained an ongoing challenge for them. For example, as we discuss in our report, one state that we followed up with in August 2017 was still unsure about whether its safety plans would meet CAPTA requirements for plans of safe care. In addition, as of October 2017, HHS confirmed that some state plans did not meet CAPTA requirements and that the states were asked to develop program improvement plans. Accordingly, a key ongoing challenge was not addressed by the January guidance. Regarding allowing states flexibility to meet CAPTA requirements, we acknowledge in our report that HHS said that states have flexibility. However, in our survey and site visits, states indicated that they would find it helpful for HHS to provide them with greater specificity around terms, including the degree of flexibility they are allowed. States added that this would include parameters within which they can develop policies and procedures that meet CAPTA requirements. We continue to believe that additional guidance addressing these concerns would benefit states and could be provided without imposing additional mandates. Concerning HHS’ third point that some of the issues raised in the report are not specific to CAPTA, the states we visited interpret CAPTA to require that plans of safe care be developed for all substance-affected infants who are referred to CPS. During our discussions with states and in responses to our survey, state officials did not delineate which federal requirement impacted their approach to serving children and families. As stated in our conclusion, vulnerable infants may be at risk for child abuse and neglect if adequate supports and services are not available to ensure their safety. Lastly, HHS indicated that it will continue to provide technical assistance to states and fund demonstration sites to establish or enhance collaboration across community agencies and courts. Although continuing to provide technical assistance to states should be beneficial, our findings demonstrate that additional guidance is also needed. For example, 38 states reported that additional guidance on requirements for health care providers to notify CPS of substance-affected infants would be extremely or very helpful. Similarly, 37 states reported that additional guidance on developing, implementing, and monitoring plans to ensure the safety and well-being of substance-affected infants would be extremely or very helpful. Overall, given the results of our review, we continue to believe our recommendation is warranted. Effective implementation of our recommendation should help states better implement protections for children. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to the appropriate congressional committees and the Secretary of Health and Human Services. In addition, the report is 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) 512-7215 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. GAO staff who made key contributions to this report are listed in appendix II. Kathryn A. Larin, (202) 512-7215 or larink@gao.gov. In addition to the contact above, Sara Schibanoff Kelly (Assistant Director), Ramona L. Burton (Analyst-in-Charge), Kay E. Brown, Hannah Dodd, Ada Nwadugbo, and Srinidhi Vijaykumar made key contributions to this report. Also contributing to this report were Sandra L. Baxter, James Bennett, Gina Hoover, Jessica Orr, Rhiannon Patterson, Jean McSween, and James Rebbe.

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

Answer: Developing independently capable ANDSF is a key component of U.S. and coalition efforts to create sustainable security and stability in Afghanistan under the North Atlantic Treaty Organization (NATO)-led Resolute Support mission. The United States is the largest contributor of funding and personnel to Resolute Support, providing and maintaining ANDSF equipment, along with training, advising, and assistance to help the ANDSF effectively use and sustain the equipment in the future. House Report 114-537 included a provision for GAO to review the ANDSF's capability and capacity to operate and sustain U.S.-purchased weapon systems and equipment. This report addresses (1) what has been reported about ANDSF capabilities and capability gaps and (2) the extent to which DOD has information about the ANDSF's ability to operate and maintain U.S.-purchased equipment. To conduct this work, GAO analyzed DOD and NATO reports and documents, examined three critical equipment types, and interviewed DOD officials in the United States and Afghanistan. This is a public version of a sensitive report issued in September 2018. Information that DOD deemed sensitive has been omitted. Since the Resolute Support mission began in 2015, the Afghan National Defense and Security Forces (ANDSF) have improved some fundamental capabilities, such as high-level operational planning, but continue to rely on U.S. and coalition support to fill several key capability gaps, according to Department of Defense (DOD) reporting. DOD has initiatives to address some ANDSF capability gaps, such as a country-wide vehicle maintenance and training effort, but DOD reports it does not expect the ANDSF to develop and sustain independent capabilities in some areas, such as logistics, for several years. While DOD has firsthand information on the abilities of the Afghan Air Force and Special Security Forces to operate and maintain U.S.-purchased equipment, it has little reliable information on the equipment proficiency of conventional ANDSF units. U.S. and coalition advisors are embedded at the tactical level for the Air Force and Special Security Forces, enabling DOD to directly assess those forces' abilities. However, the advisors have little direct contact with conventional ANDSF units on the front lines. As a result, DOD relies on those units' self-assessments of tactical abilities, which, according to DOD officials, can be unreliable. GAO's analysis of three critical equipment types illustrated the varying degrees of DOD's information (see figure above). For example, DOD provided detailed information about the Air Force's ability to operate and maintain MD-530 helicopters and the Special Security Forces' ability to operate and maintain Mobile Strike Force Vehicles; however, DOD had limited information about how conventional forces operate and maintain radios and Mobile Strike Force Vehicles. DOD's lack of reliable information on conventional forces' equipment operations and maintenance abilities adds to the uncertainty and risk in assessing the progress of DOD efforts in Afghanistan. GAO recommends that DOD develop options for collecting reliable information on conventional ANDSF units' ability to operate and maintain U.S.-purchased equipment. DOD concurred with this recommendation.