Background In 1990, GAO began a program to report on government operations that  we identified as “high risk.” Since then, generally coinciding with the start  of each new Congress, we have reported on the status of progress  addressing previously identified high-risk areas and have updated the  High-Risk List to add new high-risk areas. Our most recent high-risk  update in February 2017 identified 34 high-risk areas. Overall, our high-risk program has served to identify and help resolve  serious weaknesses in areas that involve substantial resources and  provide critical services to the public. Since the program began, the  federal government has taken high-risk problems seriously and has made  long-needed progress toward correcting them. In a number of cases,  progress has been sufficient for us to remove the high-risk designation. To determine which federal government programs and functions should  be designated high risk, we use our guidance document, Determining  Performance and Accountability Challenges and High Risks. In making  this determination, we consider whether the program or function is of  national significance or is key to the performance and accountability of  the federal government, among other things. Our experience has shown that the key elements needed to make  progress in high-risk areas are top-level attention by the administration  and agency leaders grounded in the five criteria for removal from the  High-Risk List, as well as any needed congressional action. The five  criteria for removal that we identified in November 2000 are listed in table  1 below. In each of our high-risk updates, we have assessed agencies’ progress to  address the five criteria for removing a high-risk area from the list using  the following definitions: Met. Actions have been taken that meet the criterion. There are no  significant actions that need to be taken to further address this  criterion. Partially Met. Some, but not all, actions necessary to meet the  criterion have been taken. Not Met. Few, if any, actions towards meeting the criterion have been  taken. Figure 1, which is based on a general example, shows a visual  representation of varying degrees of progress in each of the five criteria  for a high-risk area. We use this system to assess and track the progress  of all agencies with areas on our High Risk list. When we rate Interior and  HHS’s progress on Improving Federal Management of Programs that  Serve Tribes and Their Members for the first time in our 2019 High Risk  report, we will provide similar information. Status of GAO’s  Recommendations on  Indian Education As we have previously reported, the Office of the Assistant Secretary- Indian Affairs (Indian Affairs), through BIE, is responsible for providing  quality education opportunities to Indian students and oversees 185  elementary and secondary schools that serve approximately 41,000  students on or near Indian reservations in 23 states, often in rural areas  and small towns. About two-thirds of BIE schools are operated by tribes,  primarily through federal grants, and about one-third are operated directly  by BIE. BIE’s Indian education programs originate from the federal  government’s trust responsibility to Indian tribes. It is the policy of the  United States to fulfill this trust responsibility for educating Indian children  by working with tribes to ensure that education programs are of the  highest quality and, in accordance with this policy, Interior is responsible  for providing children a safe and healthy environment in which to learn. All BIE schools—both tribally- and BIE-operated—receive almost all of  their operational funding from federal sources—namely, Interior and the  Department of Education (Education)—totaling about $1.2 billion in 2016.  Indian Affairs considers many BIE schools to be in poor condition. BIE is primarily responsible for its schools’ educational functions, while  their administrative functions—such as safety, facilities, and property  management—are divided mainly between two other Indian Affairs’  offices: BIA and the Office of the Deputy Assistant Secretary of  Management. As discussed below, we have made 23 recommendations to Interior on  Indian education—including recommendations cited in GAO’s 2017 High  Risk report and included in two late May reports. Interior generally agreed  with our recommendations. However, none have been fully implemented. Indian Affairs’  Management and  Accountability for BIE  Schools In our 2017 High Risk report, we cited 3 recommendations from a 2013  report on management challenges facing Indian Affairs, with which  Interior agreed, and these recommendations remain unimplemented as of  late August 2017. These recommendations were based on our findings  of Indian Affairs’ poor management and lack of accountability for BIE  schools. In particular, we found that BIE did not have procedures in place  specifying who should be involved in making key decisions, resulting in  inaccurate guidance provided to some BIE schools about the appropriate  academic assessments required by federal law. We also found that Indian  Affairs had not developed a strategic plan with specific goals and  measures for itself or BIE or conducted workforce analysis to ensure it  has the right people in place with the right skills to effectively meet the  needs of BIE schools. Further, we found that fragmented administrative  services for BIE schools and a lack of clear roles for BIE and Indian  Affairs’ Office of the Deputy Assistant Secretary for Management  contributed to delays in BIE schools acquiring needed materials, such as  textbooks. As a result, we recommended that Indian Affairs develop  decision-making procedures and a strategic plan for BIE and revise its  workforce plan, among other areas. Of the 3 unimplemented recommendations we made to Interior on Indian  Affairs’ management and accountability for BIE schools, agency officials  reported that they have taken several actions to address them, including  drafting written procedures for BIE decision-making; starting to develop a  strategic plan for BIE; and conducting workforce planning. Indian Affairs’  actions to implement our recommendations to develop decision-making  procedures and a strategic plan for BIE had not been completed as of late  August. Indian Affairs officials told us they believed they had fully  implemented our recommendation on strategic workforce planning.  However, in reviewing their supporting documentation, we determined  that their actions did not address our recommendation to ensure that the  staff who are responsible for providing administrative support to BIE  schools have the requisite skills and knowledge and are placed in the  appropriate offices. For a full description of the agency’s actions and our  evaluation of these actions, see recommendations in table 2 in appendix  I. Oversight of BIE School  Spending We made 4 recommendations in a 2014 report on BIE’s oversight of  school spending, none of which have been implemented. These  recommendations were based on our findings of key weaknesses in  Indian Affairs’ oversight of BIE school spending. In particular, we found  that BIE lacked sufficient staff with expertise to oversee school  expenditures, and as a result, these staff told us they lacked the  knowledge and skills to understand the audits they needed to review. We  also found that some staff did not have access to some of these audits. In  addition, we found that BIE lacked written procedures and a risk-based  approach to overseeing school spending—both integral to federal internal  control standards—which resulted in schools’ misuse of federal funds. For  example, external auditors identified $13.8 million in unallowable  spending at 24 schools. Auditors also found that one school lost about  $1.7 million in federal funds that were improperly transferred to off-shore  accounts. As a result, we recommended that Indian Affairs take several  actions to address these oversight weaknesses, including developing  written procedures and a risk-based approach to monitor school spending  and a process to share relevant information, such as audit reports, with all  BIE staff responsible for overseeing BIE school spending, among other  areas. Of the 4 unimplemented recommendations we made to Interior on the  oversight of BIE school spending, agency officials reported taking several  actions, including providing their auditors with needed access to schools’  audit reports. Officials also said they would put in place written  procedures and a risk-based approach to improve the financial monitoring  of BIE schools. As of late August 2017, officials had not provided us with  documentation of any steps they have taken to improve oversight of  school spending. For a full description of the agency’s actions and our  evaluation of these actions, see recommendations in table 2 in appendix  I. Safety and Health at  Indian School Facilities We made 4 recommendations in a 2016 report on the safety and health of  BIE school facilities, none of which have been implemented. These  recommendations were based on our findings that Indian Affairs was not  annually inspecting all BIE schools, as required by Indian Affairs’ policy.  We also found that the agency did not have a plan to monitor safety  inspections across its regions to ensure that inspection practices were  consistent and supported the collection of complete and accurate  inspection information. Further, we found the agency had not taken steps  to assist BIE schools to build their capacity to address identified safety  deficiencies. Some school officials we spoke to reported lacking staff with  the knowledge and skills necessary to understand and address safety  issues. Further, at one school we visited, we found seven boilers that  failed inspection because of multiple high-risk safety deficiencies,  including elevated levels of carbon monoxide and a natural gas leak. Four  of the boilers were located in a student dormitory, and three were located  in classroom buildings. All but one of the boilers were about 50 years old.  Although the poor condition of the boilers posed an imminent danger to  the safety of students and staff, most of them were not repaired until  about 8 months after failing their inspection, prolonging safety risks to  students and staff. As a result of these findings, we recommended that  Indian Affairs take several actions, including developing a plan to build  BIE schools’ capacity to address safety hazards identified by BIA  inspectors, among other areas. Of the 4 unimplemented recommendations we made to Interior on  ensuring safety and health at BIE schools, Indian Affairs completed safety  inspections at all BIE schools in 2016, among other actions. However,  based on our review of the agency’s actions, we determined that several  steps remain for these recommendations to be fully implemented. For  example, as of late August 2017 the agency had not provided us with  documentation that it has developed a plan for monitoring safety  inspections across its regions to ensure that inspection practices are  consistent. Further, Indian Affairs did not provide documentation that it  had taken any actions to develop a plan to build BIE schools’ capacity to  address safety and health problems identified with their facilities. For a full  description of the agency’s actions and our evaluation of these actions,  see recommendations in table 2 in appendix I. We also made 6 recommendations in a May 2017 report on oversight and  accountability for BIE school safety inspections, none of which have been  implemented. These recommendations were based on our findings of  key weaknesses in Indian Affairs’ oversight of school safety inspections.  In particular, we found that Interior and Indian Affairs had not taken  actions to address identified weaknesses in BIA’s safety program, despite  internal evaluations since 2011 that consistently found it to be failing. For  example, no Indian Affairs office routinely monitored the quality or  timeliness of inspection reports, and BIA employees were not held  accountable for late reports despite a new employee performance  standard on timely report submission. We found that 28 of 50 inspection  reports we reviewed were incomplete, inaccurate, or unclear, including  reports in which inspectors did not include all school facilities or  incorrectly gave schools a year to fix broken fire alarms instead of the  required 24 hours. We concluded that unless steps are taken to address  safety program weaknesses, the safety and health of BIE students and  staff may be at risk. As a result, we recommended that Indian Affairs take  steps to address weaknesses in BIA’s safety program, including  establishing processes to monitor the quality and timeliness of BIE school  inspection reports, among other areas. Of these 6 unimplemented recommendations we made to Interior to  improve its oversight of school safety inspections, Indian Affairs reported  taking several actions. In particular, Indian Affairs reported that its safety  office had established a procedure to monitor the timeliness of inspection  report submissions to schools, and that BIA is currently developing a  corrective action plan to address findings and recommendations from a  2016 Interior review of BIA’s safety program. However, as of late August  2017, Indian Affairs had not provided us with any documentation on these  two actions. For a full description of the agency’s actions and our  evaluation of these actions, see recommendations in table 2 in appendix  I. Indian Affairs’ Oversight of  School Construction  Projects We made 6 recommendations in a May 2017 report on school  construction projects, none of which have been implemented. These  recommendations were based on our findings of key weaknesses in  Indian Affairs’ oversight of school construction projects. In particular, we  found that Indian Affairs did not have a comprehensive capital asset plan  to guide the allocation of funding for school construction projects. We  concluded that until Indian Affairs develops such a plan, it risks using  federal funds inefficiently and not prioritizing funds to schools with the  most pressing needs. Additionally, we found that Indian Affairs has not  consistently used accountability measures or conducted sufficient  oversight to ensure that BIE school construction projects are completed  on time, within budget, and meet schools’ needs. For instance, Indian  Affairs has not always used accountability measures, such as warranties,  to have builders replace defective parts or repair poor workmanship, and  project managers do not always understand how to use accountability  measures because Indian Affairs had not provided them guidance. We  concluded that until Indian Affairs develops and implements guidance to  ensure accountability throughout the school construction process and  improves its oversight of construction projects, it will have little assurance  they are completed satisfactorily and meet the needs of students and  staff. As a result, we recommended that Indian Affairs take several  actions, including developing a comprehensive capital asset plan and  guidance on the effective use of accountability measures for managing  BIE school construction projects, among other areas. Of these 6 unimplemented recommendations that we made to Interior to  improve its oversight of BIE school construction projects, Indian Affairs  reported taking several actions. For example, Indian Affairs reported that  to support the effective use of accountability measures, it established new  oversight mechanisms, hired staff with expertise in construction  contracting, and administered training for contracting staff. As of late  August 2017, however, Indian Affairs had not provided us any  documentation of these steps, so we cannot verify that the actions were  responsive to our recommendations. Further, Indian Affairs did not report  taking any actions to develop guidance on the effective use of  accountability measures, which our recommendation specifies. Indian  Affairs also reported that it is currently in the process of establishing a  new work group to focus on asset management and will continue working  to develop a capital asset management plan. Finally, the agency reported  it was planning to take several other actions to address our  recommendations. For a full description of the agency’s actions and our  evaluation of these actions, see recommendations in table 2 in appendix  I. Status of GAO’s  Recommendations on  Indian Energy As we have previously reported, some tribes and their members hold  abundant energy resources and have decided to develop these resources  to meet the needs of their community, in part because energy  development provides opportunities to improve poor living conditions,  decrease high levels of poverty, and fund public services for tribal  members. While tribes and their members determine how to use their  energy resources, if the resources are held in trust or restricted status,  BIA—through its 12 regional offices, 85 agency offices, and other  supporting offices—generally must review and approve leases, permits,  and other documents required for the development of these resources. In the past 2 years, we have reported that BIA has mismanaged Indian  energy resources held in trust, thereby limiting opportunities for tribes and  their members to use those resources to create economic benefits and  improve the well-being of their communities. Specifically, we issued 3  reports that identified concerns associated with BIA management of  energy resources and categorized those concerns into the following four  areas: (1) BIA’s data and technology; (2) oversight of BIA activities; (3)  collaboration and communication; and (4) BIA’s workforce planning. As discussed below, we made 14 recommendations to BIA to help  address BIA management weaknesses that were cited in our 2017 High  Risk report. BIA generally agreed with these recommendations. However,  none have been fully implemented. BIA’s Data and Technology We made 2 recommendations related to data and technology for which  BIA has taken some actions and made some progress to implement.  However, neither of these recommendations has been fully  implemented. We made these recommendations based on our June  2015 findings that BIA did not have the necessary geographic information  systems (GIS) mapping data and that BIA’s federal cadastral surveys  cannot be found or are outdated. According to Interior guidance, GIS  mapping technology allows managers to easily identify resources  available for lease and where leases are in effect. However, we found  that BIA did not have the necessary GIS mapping data for identifying who  owns and uses resources, such as existing leases. We also found that  BIA could not verify who owned some Indian resources or identify where  leases were in effect in a timely manner because, in part, federal  cadastral surveys could not be found or were outdated. In addition, we  found the extent of this deficiency was unknown because BIA did not  maintain an inventory of Indian cadastral survey needs, as called for in  Interior guidance. Of the 2 unimplemented recommendations to help ensure that BIA can  verify ownership in a timely manner and identify resources available for  development, BIA has taken several actions. Regarding GIS data, BIA  officials told us that the agency has integrated and deployed data viewing  and map creation capabilities into its database for recording and  maintaining historical and current data on ownership and leasing of Indian  land and mineral resources—the Trust Asset and Accounting  Management System (TAAMS)—on August 31, 2017. We will work with  BIA to obtain the documentation needed to determine if the deployed GIS  capability has the functionality for us to consider this recommendation as  fully implemented. Regarding cadastral surveys, according to a BIA  official, the agency requested that each of its 12 regions review and  identify historic survey requests from a data system that has not been  fully maintained or consistently used since 2011 to determine if the  requests are still valid. BIA officials told us the next step is to create a  new database that will track cadastral survey needs and a reporting  mechanism for each BIA region to use when making new survey  requests. According to BIA officials, the agency anticipates the new  database and reporting mechanism will be deployed by September 30,  2017. For a full description of the agency’s actions and our evaluation of  these actions, see table 3 in appendix II. BIA’s Oversight of Its  Review Process for  Energy Development We made 5 recommendations to BIA related to its review process for  energy development, none of which have been fully implemented. In June  2015 and June 2016, we found that BIA did not have a documented  process or the data needed to track its review and response times  throughout the development process, including the approval of leases,  rights-of-way (ROW) agreements, and communitization agreements  (CA). The ability to track and monitor the review of permits and  applications is a best practice to improve the federal review process. Of the 5 unimplemented recommendations we made to help ensure that  BIA fulfills its responsibilities concerning the review and approval of  documents related to energy development in an efficient and transparent manner, BIA has taken some actions and identified other actions it plans  to take. For example, on May 17, 2017, the Acting Assistant Secretary-  Indian Affairs testified before this committee that a group of BIA subject  matter experts have been working to modify TAAMS, incorporating the  key identifiers and data fields needed to track and monitor review and  response times for oil and gas leases and agreements. The Acting  Assistant Secretary also stated that BIA is in the process of evaluating  and reviewing the current realty tracking system and TAAMS to improve  efficiencies and timeliness in processing workloads. BIA identified actions  to track and monitor review and response times for oil and gas leases and  agreements; however, BIA did not indicate whether it intends to track and  monitor its review of other energy-related documents, such as ROW  agreements, that must be approved before tribes can develop resources. In another example, on May 17, 2017, the Acting Assistant Secretary-  Indian Affairs testified before this committee that a National Policy  Memorandum has been developed that establishes time frames for  review and approval of Indian CAs. The Acting Assistant Secretary also  stated that such time frames will also be incorporated into the BIA Fluid  Mineral Estate Procedural Handbook and the Onshore Energy and  Mineral Lease Management Interagency Standard Operating Procedures.  However, in our review of the National Policy Memorandum we did not  find that it establishes time frames for review and approval of Indian CAs.  In response to our request for clarification, a BIA official told us the  agency is in the process of drafting suggested time frames. For a full  description of the agency’s actions and our evaluation of these actions,  see table 3 in appendix II. BIA’s Collaboration and  Communication We made 5 recommendations related to collaboration and communication  in our June 2015 and November 2016 reports. BIA has taken some  actions, but the actions are generally limited in scope and none of these  recommendations have been fully implemented. We found in our  November 2016 report that BIA has taken steps to form an Indian Energy  Service Center that is intended to, among other things, help expedite the  permitting process associated with Indian energy development.  However, we found several weaknesses in BIA’s collaboration processes  and structure. For example, in November 2016, we reported that BIA did  not coordinate with other key regulatory agencies that can have a role in  the development of Indian energy resources, including Interior’s Fish and  Wildlife Service (FWS), the Army Corps of Engineers (Corps), and the  Environmental Protection Agency (EPA). As a result, the Service Center  was neither established as the central point for collaborating with all  federal regulatory partners generally involved in energy development, nor  did it serve as a single point of contact for permitting requirements. In addition, BIA did not include the Department of Energy (DOE) in a  participatory, advisory, or oversight role in the development of the Service  Center. Further, although Interior’s Office of Indian Energy and  Economic Development (IEED) developed the initial concept and  proposal for the Service Center and has special expertise regarding the  development of Indian energy resources, BIA did not include IEED in the  memorandum of understanding (MOU) establishing the Service Center.  BIA also did not document the rationale for key management decisions or  the alternatives considered in forming the Service Center—a leading  practice for effective organizational change. In addition, several tribal  leaders and tribal organizations made suggestions that were not currently  reflected in BIA’s Service Center. Without documentation on alternatives  considered, it was unclear whether these requests were appropriately  considered. Of the 5 unimplemented recommendations to help improve efficiencies in  the federal regulatory process, BIA reported that it has taken some  actions. For example: According to a BIA official, the agency has initiated discussions with  FWS, EPA, and the Corps in an effort to establish formal agreements.  BIA has a target of December 31, 2017, to establish these  agreements. However, in its current structure, the Service Center is  not serving as a lead agency or single point of contact to coordinate  and navigate the regulatory process. Without additional information, it  is unclear if the formal agreements alone will allow the Service Center  to serve this role. We will continue to work with BIA officials to  understand how the formal agreements with other regulatory agencies  will help to transform the Service Center into a central point of contact  for Indian energy development. According to a BIA official, the agency developed and is currently  reviewing an addendum to expand an existing MOU between DOE  and IEED to include the Service Center. However, the existing MOU  between DOE and IEED does not identify the role for these agencies  as related to the Service Center. As such, the addendum, as currently  described to us by a BIA official, will not fully implement our  recommendation. On May 17, 2017, the Acting Assistant Secretary- Indian Affairs  testified before this committee that Interior considers this  recommendation implemented because (1) the development of the  Service Center was the result of a concept paper produced by a multi- agency team and (2) a multi-agency team held a tribal listening  session, received written comments, and conducted conference calls  in an effort to gather input from relevant stakeholders. We do not  agree that these actions meet the intent of the recommendation. BIA’s  actions have not resulted in documentation on the alternatives  considered, whether tribal input and requests were considered, and  the rationale for not incorporating key suggestions. In addition, in 2005, Congress provided an option for tribes to enter into a  tribal energy resource agreement (TERA) with the Secretary of the  Interior that allows the tribe, at its discretion, to enter into leases,  business agreements, and rights-of-way agreements for energy resource  development on tribal lands without review and approval by the  Secretary. However, in a June 2015 report, we found that uncertainties  about Interior’s regulations for implementing this option have contributed  to deter tribes from pursuing agreements. We recommended that  Interior provide clarifying guidance. On May 17, 2017, the Acting  Assistant Secretary- Indian Affairs testified before this committee that  Interior is working to provide additional energy development-specific  guidance on provisions of TERA regulations that tribes have identified to  the department as unclear. As part of this effort, the Acting Assistant  Secretary reported that IEED continues to perform training and technical  assistance on the TERA regulations, and plans to issue guidance on  those provisions of TERA that have been identified as unclear. As of  September 6, 2017, Interior has not issued additional guidance and  several Interior officials told us it is unlikely any new guidance will clarify  “inherently federal functions”—one provision of Interior’s regulations tribes  have identified as unclear. For a full description of the agency’s actions  and our evaluation of these actions, see table 3 in appendix II. BIA’s Workforce Planning We made 2 recommendations on workforce planning to BIA in November  2016, neither of which has been fully implemented. In our November  2016 report we found BIA had high vacancy rates at some agency offices  and that the agency had not conducted key workforce planning activities  consistent with Office of Personnel Management standards and leading  practices identified in our prior work. Of the 2 unimplemented recommendations to help ensure that it has a  workforce with the right skills, appropriately aligned to meet the agency’s  goals and tribal priorities, BIA has reported several actions it plans to  take. On May 17, 2017, the Acting Assistant Secretary- Indian Affairs  testified before this committee that BIA is in the process of identifying and  implementing a workforce plan regarding positions associated with the  development of Indian energy and minerals. Specifically, the Acting  Assistant Secretary stated that the Service Center will collect data directly  from BIA, Bureau of Land Management (BLM), the Office of Natural  Resources Revenue (ONRR), and the Office of Special Trustee (OST)  employees in an effort to identify workload and necessary technical  competencies. Then, the Service Center will work with partner bureaus to  assess skills and competencies needed for energy and mineral workforce  standards. BIA’s target for completion of the activities is the end of 2017.  BIA stated it is taking steps to identify workload and technical  competencies, but without additional information, it is unclear if these  actions will identify potential gaps in its workforce or result in the  establishment of a documented process for assessing BIA’s workforce  composition at agency offices. For a full description of the agency’s  actions and our evaluation of these actions, see table 3 in appendix II. Status of GAO’s  Recommendations on  Indian Health Care As we have previously reported, the Indian Health Service (IHS), an  agency within the Department of Health and Human Services (HHS), is  charged with providing health care to approximately 2.2 million Indians.  IHS oversees its health care facilities through a decentralized system of  area offices, which are led by area directors and located in 12 geographic  areas. In fiscal year 2016, IHS allocated about $1.9 billion for health  services provided by federally and tribally operated hospitals, health  centers, and health stations. Federally operated facilities—including 26  hospitals, 56 health centers, and 32 health stations—provide mostly  primary and emergency care, in addition to some ancillary or specialty  services. When services are not available at federally operated or tribally operated  facilities, IHS may, in some cases, pay for services provided through  external providers through its Purchased/Referred Care (PRC) program— previously referred to as the Contract Health Services program. The PRC  program is funded through annual appropriations and must operate within  the limits of available appropriated funds. To be eligible for PRC services,  recipients must generally meet several criteria, including being a member  or descendant of a federally recognized tribe or having close social and  economic ties with the tribe, and living within a designated PRC area.  Although funding available for the PRC program has recently increased,  we have reported that the program is unable to pay for all eligible  services, and that these gaps in services sometimes delay diagnoses and  treatments, which can exacerbate the severity of a patient’s condition and  necessitate more intensive treatment. As discussed below, we made 13 recommendations to IHS that were  unimplemented when we issued our 2017 High Risk report, with which  HHS generally agreed. One has been fully implemented. Estimating PRC Program  Needs In our February 2017 High Risk report, we cited 2 recommendations from  a 2011 report on the accuracy of data used for estimating PRC needs,  with which HHS agreed.  These recommendations remain  unimplemented as of late August 2017. We based these  recommendations on our finding that IHS’s estimates of the extent to  which unmet needs exist in the PRC program were not reliable because  of deficiencies in the agency’s oversight of the collection of data on  deferred and denied PRC program services. As a result, we made several  recommendations for IHS to develop more accurate data for making  these estimates and improving agency oversight. Of the 2 recommendations not yet fully implemented that we made to IHS  on estimating PRC program needs, HHS officials reported that updated  policy and procedural guidance will be issued to all IHS sites by  September 30, 2017. We will evaluate the policy and procedural guidance  when it is issued. For a full description of the agency’s actions and our  evaluation for these unimplemented recommendations, see table 4 in  appendix III. Ensuring Equitable  Allocation of PRC  Program Funds We made 3 recommendations to IHS to help make its allocation of PRC  program funds more equitable, none of which have been implemented.  We also raised a matter for Congress to consider requiring IHS to  develop and use a new PRC funding allocation methodology. These  recommendations and matter for Congress to consider were based on  our findings of wide variations in PRC funding across the 12 IHS areas,  that these variations were largely maintained by IHS’s long-standing use  of its base funding methodology, that variation in PRC funding was  sometimes not related to the availability of IHS-funded hospitals, that  IHS’s estimate of PRC service users was imprecise, and that IHS allowed  area offices to distribute program increase funds to local PRC programs  using different criteria than the PRC allocation formula without informing  IHS. As a result, we suggested that Congress consider requiring IHS to develop and use a new method to allocate all PRC program funds to  account for variations across areas, and recommended that IHS use  actual counts of PRC users and variations in levels of available hospital  services in allocation formulas, and develop written policies and  procedures to require area offices to notify IHS when changes are made  to the allocations of funds to PRC programs. In response to our matter for Congress to consider, a bill that would have  addressed this matter was introduced in the House and reported out of  committee in 2016, but the bill did not become law. In response to our  recommendations, HHS officials told us that a tribal/federal workgroup is  currently discussing the PRC fund allocation issues. In July 2017, we  requested additional information about the workgroup and any discussion  that has occurred or decisions that have been made about PRC funding  allocation since we made the recommendation 5 years ago, but as of late  August 2017, we have not received any information. As the workgroup  continues to discuss the PRC fund allocation issues, we will evaluate any  decisions that are made to determine if they address this  recommendation. For a full description of the agency’s actions and our  evaluation for these recommendations, see table 4 in appendix III. Revising IHS Payment  Rates for Nonhospital  Services We made 1 recommendation to IHS in a 2013 report on IHS payment  rates for nonhospital services through the PRC program, which has not  been fully implemented, as well as a matter for Congress to consider.  The recommendation and matter for Congress to consider were based on  our finding that IHS primarily paid nonhospital providers, including  physicians, at their billed charges, despite an IHS policy—in place since  1986—that stated that area offices should attempt to negotiate with  providers at rates that are no higher than Medicare rates. As a result, we  suggested that Congress consider imposing a cap on payments for  physician and other nonhospital services made through IHS’s PRC  program that is consistent with the rates paid by other federal agencies.  We also recommended that IHS monitor PRC program patient access to  physician and other nonhospital care in order to assess how any new  payment rates may benefit or impede the availability of care. In response to our recommendation, HHS officials told us that the agency  has developed an online PRC rates provider tracking tool that enables  PRC programs to document providers that refuse to contract for their  most favored customer rate or accept the Medicare-like rate. We have  requested documentation of this provider tracking tool, but as of late  August 2017, we have not yet received information sufficient to consider  the recommendation implemented. For a full description of the agency’s  actions and our evaluation for these recommendations, see table 4 in  appendix III. Ensuring Successful  Outreach to Increase  Enrollment in Expanded  Coverage Options In our February 2017 High Risk report, we cited 1 recommendation from a  2013 report on the eligibility and enrollment of American Indians in  expanded health care programs, with which HHS neither agreed nor  disagreed. This recommendation remains unimplemented as of late  August 2017. We reported that the expansion of Medicaid and new  coverage options under the Patient Protection and Affordable Care Act  (PPACA) may allow many American Indians to obtain additional health  care benefits for which they were not previously eligible, resulting in IHS  facilities receiving increased reimbursements from third-party payers and  an increased workload for IHS facility staff responsible for processing  these payments. We also found that IHS did not have an effective plan  in place to ensure that a sufficient number of facility staff were prepared  to assist with enrollment and to process increased third-party payments.  As a result, we recommended that IHS realign its resources and  personnel to increase its capacity to assist with increased enrollment and  third-party billing. IHS has not reported taking any new action to implement the remaining  recommendation. In response to our request for an update, IHS again  provided a copy of a planning template it developed for facility Chief  Executive Officers (CEO) that encourages them to assess the need for  staffing changes in light of new and expanded coverage options available  under PPACA. IHS previously explained, during the course of our review,  that its planning template is a document that facility CEOs have been  directed to use. We agree that developing a template to aid facilities in  their planning for PPACA implementation is a good step. However,  considering the large, system-wide growth in eligibility for new and  expanded coverage options described in our report, we expect to see a  system-wide response. Under its current approach, preparing for  increased eligibility is dependent on the discretion of facility CEOs. IHS  has not provided any evidence that this approach has resulted in the  realignment of personnel needed to address an increased need for  application assistance and third party billing. For a full description of the  agency’s actions and our evaluation for these recommendations, see  table 4 in appendix III. Improving IHS’s PRC  Program We made 2 recommendations in a 2013 report on opportunities for IHS to  improve the PRC program, neither of which has been fully implemented.  Our recommendations were based on our finding that determining  eligibility for PRC funding—including the need to ascertain each time a  referral is received whether the patient met residency requirements and  the service met medical priorities—is inherently complex. As a result, we  recommended that IHS take steps to improve the PRC program, including  separately tracking IHS referrals and self-referrals, and revising its  practices to allow available funds to be used to pay for PRC program  staff. HHS agreed with our recommendation to separately track IHS referrals  and self-referrals, but not to revise its practices to allow available funds to  be used to pay for PRC program staff. HHS agreed to our  recommendation to proactively develop potential options to streamline  program eligibility requirements. IHS has not yet fully implemented these  recommendations. HHS officials told us that IHS is developing 2 new  measures that will track and measure PRC authorized referrals and self- referrals to time of payment for each type of referral. We will review the  proposed changes when they are available. For a full description of the  agency’s actions and our evaluation for these recommendations, see  table 4 in appendix III. Improving IHS Oversight  of Patient Wait Times We made 2 recommendations in a 2016 report on IHS oversight of patient  wait times, one of which was implemented in August 2017. These  recommendations were based on our finding that IHS had not set any  agency-wide standards for patient wait times at IHS federally operated  facilities. We found that, while individual facilities had taken steps to help  improve patient wait times, IHS had not monitored the timeliness of  patient care on an agency-wide scale. As a result, we recommended that  IHS 1) develop specific agency-wide standards for patient wait times, and  2) monitor patient wait times in its federally operated facilities and ensure  corrective actions are taken when standards are not met. In response to our first recommendation, IHS developed specific  standards for patient wait times and published them to the IHS Indian  Health Manual website in August 2017. As a result of this action, we  consider this recommendation to be fully implemented. In response to our  second recommendation, in early September 2017 HHS officials told us  that data collection tools for monitoring are under development. We will  review IHS’s monitoring of facility performance, as well as any corrective  actions, when these steps have been completed. For a full description of  the agency’s actions on the unimplemented recommendation and our  evaluation, see table 4 in appendix III. Improving IHS Oversight  of Quality of Care We made 2 recommendations in a 2017 report on IHS’s oversight of  quality of care in its federally operated facilities, neither of which has been  fully implemented. These recommendations were based on our finding  that IHS’s oversight of the quality of care provided in its federally operated  facilities has been limited and inconsistent, due in part to a lack of  agency-wide quality of care standards. We found that these  inconsistencies were exacerbated by significant turnover in area  leadership and that the agency had not defined contingency or  succession plans for the replacement of key personnel, including area  directors. As a result, we recommended that IHS develop agency-wide  standards for quality of care, systematically monitor facility performance  in meeting these standards, enhance its adverse event reporting system,  and develop contingency and succession plans for the replacement of  key personnel. HHS agreed with our recommendations, and officials reported that the  development of agency-wide measures, goals, and benchmarks are  nearing completion. According to HHS, it is also developing a system- wide dashboard of performance accountability metrics for use at the  enterprise, area, and facility levels. HHS officials told us that the  enhancements to their adverse event reporting system are delayed  because key personnel on the project became unavailable due to  deployment. Finally, HHS officials told us that all IHS headquarters offices  and area offices established a succession plan that identified staff and  development needs to prepare for future leadership opportunities. We  requested documentation of these succession plans, but as of late August  2017, we have not received any. For a full description of the agency’s  actions and our evaluation for these recommendations, see table 4 in  appendix III. In conclusion, although Interior and HHS have taken some actions to  address our recommendations related to federal programs serving Indian  tribes, 49 recommendations discussed in this testimony have not yet  been fully implemented. We plan to continue monitoring the agencies’  efforts to address these unimplemented recommendations. In order for the Federal Management of Programs that Serve Tribes and  Their Members to be removed from our High-Risk List, Interior and HHS  need to show improvement on the five key elements described earlier:  leadership commitment, capacity, action plan, monitoring, and  demonstrated progress. These five criteria form a road map for agencies’  efforts to improve and ultimately address high-risk issues. We look forward to continuing our work with this committee in overseeing  Interior and IHS to ensure that they are operating programs for tribes in  the most effective and efficient manner, consistent with the federal  government’s trust responsibilities, and working toward improving  services for tribes and their members. Chairman Hoeven, Vice Chairman Udall, and Members of the Committee,  this completes my prepared statement. My colleagues and I would be  pleased to respond to any questions that you may have. GAO Contacts and  Staff  Acknowledgments If you or your staff have any questions about education issues in this  testimony or the related reports, please contact Melissa Emrey-Arras at  (617) 788-0534 or emreyarrasm@gao.gov. For questions about energy  resource development, please contact Frank Rusco at (202) 512-3841 or  ruscof@gao.gov. For questions about health care, please contact  Kathleen King at (202) 512-7114 or kingk@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found  on the last page of this statement. Key contributors to this statement  include Elizabeth Sirois (Assistant Director), Edward Bodine (Analyst-in- Charge), James Bennett, Richard Burkard, Kelly DeMots, Christine Kehr,  Liam O’Laughlin, William Reinsberg, James Rebbe, Jay Spaan, Ann  Tynan, and Emily Wilson. Appendix I: Status of Unimplemented  Recommendations to the Department of the  Interior on Indian Education Appendix II: Status of Unimplemented  Recommendations to the Department of the  Interior on Indian Energy Appendix III: Status of Unimplemented  Recommendations to the DHHS on the  Indian Health Service Appendix III: Status of Unimplemented  Recommendations to the DHHS on the Indian  Health Service This is a work of the U.S. government and is not subject to copyright protection in the  United States. The published product may be reproduced and distributed in its entirety  without further permission from GAO. However, because this work may contain  copyrighted images or other material, permission from the copyright holder may be  necessary if you wish to reproduce this material separately.
GAO's High-Risk Series identifies federal program areas needing attention from Congress and the executive branch. GAO added federal management of programs that serve Indian tribes and their members to its February 2017 biennial update of high-risk areas in response to serious problems with management and oversight by Interior and HHS. This testimony identifies GAO's recommendations to Interior and HHS from prior GAO reports on the federal management and oversight of Indian education, energy resources, and health care that remain unimplemented. It also examines agencies' recent actions to address the recommendations and the extent to which these actions address GAO's recommendations. To conduct this work, GAO reviewed and analyzed agency documentation on actions taken to implement the recommendations and conducted interviews with agency officials. As discussed in the 2017 High Risk report, GAO has identified numerous weaknesses in how the Department of the Interior (Interior) and the Department of Health and Human Services (HHS) manage programs serving Indian tribes. Specifically, these weaknesses were related to Interior's Bureau of Indian Education (BIE) and Bureau of Indian Affairs (BIA)—under the Office of the Assistant Secretary-Indian Affairs (Indian Affairs)—in overseeing education services and managing Indian energy resources, and HHS's Indian Health Service (IHS) in administering health care services. GAO cited nearly 40 recommendations in its 2017 High Risk report that were not implemented, and has since made an additional 12 recommendations in two new reports on BIE school safety and construction published in late May of this year. Interior and HHS have taken some steps to address these recommendations but only one has been fully implemented. Education. GAO has found serious weaknesses in Indian Affairs' oversight of Indian education. For example, in 2016, GAO found that the agency's lack of oversight of BIE school safety contributed to deteriorating facilities and equipment in school facilities. At one school, GAO found seven boilers that failed inspection because of safety hazards, such as elevated levels of carbon monoxide and a natural gas leak. In 2017, GAO found key weaknesses in the way Indian Affairs oversees personnel responsible for inspecting BIE school facilities for safety and manages BIE school construction projects. Of GAO's 23 recommendations on Indian education—including recommendations cited in GAO's 2017 High Risk report and in two late May reports—none have been fully implemented. Energy resource management. In three prior reports on Indian energy, GAO found that BIA inefficiently managed Indian energy resources and the development process, thereby limiting opportunities for tribes and their members to use those resources to create economic benefits and improve the well-being of their communities. GAO categorized concerns associated with BIA management of energy resources and the development process into four broad areas, including oversight of BIA activities, collaboration, and BIA workforce planning. GAO made 14 recommendations to BIA to address its management weaknesses, which were cited in the 2017 High Risk report. However, none have been fully implemented. Health care. GAO has found that IHS provides inadequate oversight of its federally operated health care facilities and of its Purchased/Referred Care program. For example, in 2016 and 2017, GAO found that IHS provided limited and inconsistent oversight of the timeliness and quality of care provided in its facilities and that inconsistencies in quality oversight were exacerbated by significant turnover in area leadership. GAO also found that IHS did not equitably allocate funds to meet the health care needs of Indians. Of GAO's 13 recommendations on Indian health care cited in GAO's 2017 High Risk report, one has been fully implemented.