Veterans Affairs
Inadequate Controls over IT Equipment at Selected VA Locations Pose Continuing Risk of Theft, Loss, and Misappropriation Gao ID: GAO-07-505 July 16, 2007In July 2004, GAO reported that the six Department of Veterans Affairs (VA) medical centers it audited lacked a reliable property control database and had problems with implementation of VA inventory policies and procedures. Fewer than half the items GAO selected for testing could be located. Most of the missing items were information technology (IT ) equipment. Given recent thefts of laptops and data breaches, the requesters were concerned about the adequacy of physical inventory controls over VA IT equipment. GAO was asked to determine (1) the risk of theft, loss, or misappropriation of IT equipment at selected locations; (2) whether selected locations have adequate procedures in place to assure accountability and physical security of IT equipment in the excess property disposal process; and (3) what actions VA management has taken to address identified IT inventory control weaknesses. GAO statistically tested inventory controls at four case study locations.
A weak overall control environment for VA IT equipment at the four locations GAO audited poses a significant security vulnerability to the nation's veterans with regard to sensitive data maintained on this equipment. GAO's Standards for Internal Control in the Federal Government requires agencies to establish physical controls to safeguard vulnerable assets, such as IT equipment, which might be vulnerable to risk of loss, and federal records management law requires federal agencies to record essential transactions. However, GAO found that current VA property management policy does not provide guidance for creating records of inventory transactions as changes occur. GAO also found that policies requiring annual inventories of sensitive items, such as IT equipment; adequate physical security; and immediate reporting of lost and missing items have not been enforced. GAO's statistical tests of physical inventory controls at four VA locations identified a total of 123 missing IT equipment items, including 53 computers that could have stored sensitive data. The lack of user-level accountability and inaccurate records on status, location, and item descriptions make it difficult to determine the extent to which actual theft, loss, or misappropriation may have occurred without detection. GAO also found that the four VA locations reported over 2,400 missing IT equipment items, valued at about $6.4 million, identified during physical inventories performed during fiscal years 2005 and 2006. Missing items were often not reported for several months and, in some cases, several years. It is very difficult to investigate these losses because information on specific events and circumstances at the time of the losses is not known. GAO's limited tests of computer hard drives in the excess property disposal process found hard drives at two of the four case study locations that contained personal information, including veterans' names and Social Security numbers. GAO's tests did not find any remaining data after sanitization procedures were performed. However, weaknesses in physical security at IT storage locations and delays in completing the data sanitization process heighten the risk of data breach. Although VA management has taken some actions to improve controls over IT equipment, including strengthening policies and procedures, improving the overall control environment for sensitive IT equipment will require a renewed focus, oversight, and continued commitment throughout the organization.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-07-505, Veterans Affairs: Inadequate Controls over IT Equipment at Selected VA Locations Pose Continuing Risk of Theft, Loss, and Misappropriation
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
July 2007:
Veterans Affairs:
Inadequate Controls over IT Equipment at Selected VA Locations Pose
Continuing Risk of Theft, Loss, and Misappropriation:
GAO-07-505:
GAO Highlights:
Highlights of GAO-07-505, a report to congressional requesters
Why GAO Did This Study:
In July 2004, GAO reported that the six Department of Veterans Affairs
(VA) medical centers it audited lacked a reliable property control
database and had problems with implementation of VA inventory policies
and procedures. Fewer than half the items GAO selected for testing
could be located. Most of the missing items were information technology
(IT ) equipment. Given recent thefts of laptops and data breaches, the
requesters were concerned about the adequacy of physical inventory
controls over VA IT equipment. GAO was asked to determine (1) the risk
of theft, loss, or misappropriation of IT equipment at selected
locations; (2) whether selected locations have adequate procedures in
place to assure accountability and physical security of IT equipment in
the excess property disposal process; and (3) what actions VA
management has taken to address identified IT inventory control
weaknesses. GAO statistically tested inventory controls at four case
study locations.
What GAO Found:
A weak overall control environment for VA IT equipment at the four
locations GAO audited poses a significant security vulnerability to the
nation‘s veterans with regard to sensitive data maintained on this
equipment. GAO‘s Standards for Internal Control in the Federal
Government requires agencies to establish physical controls to
safeguard vulnerable assets, such as IT equipment, which might be
vulnerable to risk of loss, and federal records management law requires
federal agencies to record essential transactions. However, GAO found
that current VA property management policy does not provide guidance
for creating records of inventory transactions as changes occur. GAO
also found that policies requiring annual inventories of sensitive
items, such as IT equipment; adequate physical security; and immediate
reporting of lost and missing items have not been enforced. GAO‘s
statistical tests of physical inventory controls at four VA locations
identified a total of 123 missing IT equipment items, including 53
computers that could have stored sensitive data. The lack of user-level
accountability and inaccurate records on status, location, and item
descriptions make it difficult to determine the extent to which actual
theft, loss, or misappropriation may have occurred without detection.
The table below summarizes the results of GAO‘s statistical tests at
each location.
Table: Current IT Inventory Control Failures at Four Test Locations:
Control failures: Missing items;
Washington, D.C.: 28%;
Indianapolis: 6%;
San Diego: 10%;
VA HQ offices: 11%.
Control failures: Incorrect user organization;
Washington, D.C.: 80%;
Indianapolis: 69%;
San Diego: 70%;
VA HQ offices: 11%.
Control failures: Incorrect location;
Washington, D.C.: 57%;
Indianapolis: 23%;
San Diego: 53%;
VA HQ offices: 44%.
Control failures: Recordkeeping errors;
Washington, D.C.: 5%;
Indianapolis: 0%;
San Diego: 5%;
VA HQ offices: 3%.
Source: GAO analysis.
Note: Each of these estimates has a margin of error, based on a two-
sided, 95 percent confidence interval, of +/- 10 percent or less.
[End of table]
GAO also found that the four VA locations reported over 2,400 missing
IT equipment items, valued at about $6.4 million, identified during
physical inventories performed during fiscal years 2005 and 2006.
Missing items were often not reported for several months and, in some
cases, several years. It is very difficult to investigate these losses
because information on specific events and circumstances at the time of
the losses is not known. GAO‘s limited tests of computer hard drives in
the excess property disposal process found hard drives at two of the
four case study locations that contained personal information,
including veterans‘ names and Social Security numbers. GAO‘s tests did
not find any remaining data after sanitization procedures were
performed. However, weaknesses in physical security at IT storage
locations and delays in completing the data sanitization process
heighten the risk of data breach. Although VA management has taken some
actions to improve controls over IT equipment, including strengthening
policies and procedures, improving the overall control environment for
sensitive IT equipment will require a renewed focus, oversight, and
continued commitment throughout the organization.
What GAO Recommends:
GAO makes 12 recommendations to improve VA-wide policies and procedures
with respect to controls over IT equipment, including recordkeeping
requirements, physical inventories, user-level accountability, and
physical security. VA agreed with GAO‘s findings, noted significant
actions under way, and concurred on the 12 recommendations.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-505].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact McCoy Williams at (202)
512-9095 or williamsm1@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Inadequate IT Inventory Control and Accountability Pose Risk of Loss,
Theft, and Misappropriation:
Physical Security Weaknesses Increase Risk of Loss, Theft, and
Misappropriation of IT Equipment and Sensitive Data:
VA Actions to Improve IT Management and Controls Have Been Limited:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Objectives, Scope, and Methodology:
Appendix II: Comments from the Department of Veterans Affairs:
Appendix III: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Current IT Equipment Inventory Control Failure Rates at Four
Test Locations:
Table 2: Number of Missing IT Equipment Items at Four Test Locations,
Including Items That Could Have Stored Sensitive Information:
Table 3: Number of Missing IT Equipment Items by Headquarters Office
and Missing Items That Could Have Stored Sensitive Personal Data and
Information:
Table 4: Estimated Percentage of IT Inventory Control Failures Related
to Correct User and Location at the Four Test Locations:
Table 5: Estimated Percentage of Other IT Inventory Recordkeeping
Failures at Four Test Locations:
Table 6: Summary of Physical Inventories and Missing IT Equipment
Identified by the Four Current Case Study Locations as of February 28,
2007:
Table 7: Summary of Physical Inventories and Missing IT Equipment
Identified by Five Case Study Locations Previously Audited as of March
2, 2007:
Table 8: Population of VA IT Equipment at Locations Selected for
Testing:
Table 9: Number of Computer Hard Drives in the Property Disposal
Process Selected for Testing at Four Locations:
Figures:
Figure 1: VA's IT Property Management Process:
Figure 2: Photograph of Unsecured IT Equipment Storeroom in the VA
Headquarters Building:
Abbreviations:
AEMS/MERS: Automated Engineering Management System/Medical Equipment
Repair Service:
CFR: Code of Federal Regulations:
CIO: Chief Information Officer:
CMR: consolidated memorandum receipt:
DOD: Department of Defense:
EIL: equipment inventory listing:
FMFIA: Financial Managers' Financial Integrity Act of 1982:
HHS: Department of Health and Human Services:
HIPAA: Health Information Portability and Accountability Act of 1996:
IFCAPS: Integrated Funds Distribution Control Point Activity,
Accounting, and Procurement System:
IRM: information resource management:
IT: information technology:
MRI: magnetic resonance imaging:
NARA: National Archives and Records Administration:
NIST: National Institute of Standards and Technology:
USB: universal serial bus:
USC: United States Code:
VA: Department of Veterans Affairs:
VHA: Veterans Health Administration:
VISN: Veterans Integrated Service Network:
United States Government Accountability Office:
Washington, DC 20548:
July 16, 2007:
The Honorable Bob Filner:
Chairman:
The Honorable Steve Buyer:
Ranking Member:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable Harry E. Mitchell:
Chairman:
The Honorable Ginny Brown-Waite:
Ranking Member:
Subcommittee on Oversight and Investigations:
Committee on Veterans' Affairs:
House of Representatives:
In light of reported weaknesses in Department of Veterans Affairs (VA)
inventory controls and reported thefts of laptop computers and data
breaches, you were concerned about the adequacy of controls over VA
information technology (IT) equipment. In July 2004, we
reported[Footnote 1] that the six VA medical centers we audited lacked
a reliable property control database, which did not produce a complete
and accurate record of current inventory and compromised effective
management and security of agency assets. We found that key policies
and procedures established by VA to control personal property provided
facilities with substantial latitude in conducting physical
inventories[Footnote 2] and maintaining their property management
systems, which resulted in reduced property accountability. For
example, VA's Handbook 7127/3, Materiel Management Procedures[Footnote
3] allowed the person responsible for custody of VA property to attest
to the existence of that property rather than requiring independent
verification. Also, personnel at some locations interpreted a policy
that established a $5,000 threshold for property that must be
inventoried as a license to ignore VA requirements to account for
sensitive, lower cost items that are susceptible to theft or loss, such
as personal computers and peripheral equipment. Personnel at the VA
medical centers, which are part of the Veterans Health Administration
(VHA), located fewer than half of the 100 items we selected for testing
at each of five medical centers and 62 of 100 items at the sixth
medical center. Most of the items that could not be located were
computer equipment. Based on our work, we concluded in our July 2004
report that these weak practices, combined with lax implementation,
resulted in low levels of accountability and heightened risk of loss.
During 2006, VA employed nearly 235,000 employees and relied on an
undetermined number of contractors, volunteers, and students to support
its operations. VA provided these individuals a wide range of IT
equipment,[Footnote 4] including desktop and laptop computers, monitors
and printers, personal digital assistants, unit-level workstations,
local area networks, and medical equipment with memory and data
processing/communication capabilities. VA information resource
management (IRM) and property management personnel share responsibility
for management of IT equipment inventory.
This report responds to your request that we perform follow-up work to
determine (1) the risk of theft, loss, or misappropriation[Footnote 5]
of IT equipment at selected VA locations; (2) whether selected VA
locations have adequate procedures in place to assure physical security
and accountability over IT equipment in the excess property disposal
process;[Footnote 6] and (3) what actions VA management has taken to
address identified IT equipment inventory control weaknesses. In
assessing the risk of theft, loss, or misappropriation of IT equipment,
you also asked that we consider the results of physical inventories
performed by the four case study locations covered in this audit and
the six medical centers we previously audited.[Footnote 7]
To achieve our first two objectives, we used a case study approach,
selecting VA medical centers located in Washington, D.C., Indianapolis,
Indiana, and San Diego, California; associated clinics; and VA
headquarters organizations for our test work. To determine the risk of
theft, loss, or misappropriation of IT equipment at these locations, we
statistically tested IT equipment inventory to determine the
effectiveness of controls relied on for accurate recording of inventory
transactions, including existence (meaning IT equipment items listed in
inventory records exist and can be located), user-level accountability,
and inventory record accuracy. As requested, we also obtained and
analyzed the results of physical inventories performed by the case
study locations covered in our current and our previous audits. In
addition, our investigator assessed physical security of IT equipment
storerooms and procedures for reporting lost and missing items to VA
law enforcement officials at our four current case study locations. To
determine if the four case study locations had adequate procedures in
place for proper disposal of excess IT equipment, we assessed
procedures for security and accountability of excess IT equipment and
independently tested a limited selection of computer hard drives for
proper removal of data and compliance with VA property management
policies. We performed sufficient procedures to determine that
inventory data at the test locations were reliable for the purpose of
our audit.[Footnote 8] We conducted our audit and investigation from
September 2006 through March 2007. We performed our audit procedures in
accordance with generally accepted government auditing standards, and
we performed our investigative procedures in accordance with quality
standards for investigators as set forth by the President's Council on
Integrity and Efficiency. We obtained agency comments on a draft of
this report. A detailed discussion of our objectives, scope, and
methodology is included in appendix I.
Results in Brief:
A weak overall control environment and pervasive weaknesses in
inventory control and accountability at the four locations we audited
put IT equipment at risk of theft, loss, and misappropriation and pose
a continuing security vulnerability to our nation's veterans with
regard to sensitive data maintained on this equipment. Our Standards
for Internal Control in the Federal Government[Footnote 9] requires
agencies to establish physical control to secure and safeguard
vulnerable assets, such as equipment that might be vulnerable to risk
of loss or unauthorized use. Further, federal records management law
and regulations require agencies to create and maintain records of
essential transactions, including property records, as part of an
effective internal control structure. However, we found that current VA
property management policy does not provide guidance for recording IT
equipment inventory transactions as events occur. We also found that
certain other VA policies have not been enforced, including policies
requiring (1) user-level accountability; (2) annual inventories of
sensitive items, including IT equipment; (3) adequate physical
security; and (4) immediate reporting of lost and missing items. Our
statistical tests of IT equipment inventory controls at our four VA
case study locations identified a total of 123 missing IT equipment
items, including 53 computers that could have stored sensitive data. We
estimate the percentage of inventory control failures related to these
missing items to be 6 percent at the Indianapolis medical center, 10
percent at the San Diego medical center, 28 percent at the Washington,
D.C., medical center, and 11 percent for VA headquarters
organizations.[Footnote 10] In addition, although VA property
management policy establishes guidelines for user-level accountability,
we found a pervasive lack of user-level accountability across the four
case study locations, and significant errors in recorded IT inventory
information concerning user organization and location. As a result, for
the four case study locations, we concluded that under the lax control
environment, essentially no one was accountable for IT equipment. The
lack of user-level accountability and inaccurate records on status,
location, and item descriptions make it difficult to determine the
extent to which actual theft, loss, or misappropriation may have
occurred without detection at the case study locations.
Our follow-up on the results of physical inventories performed by the
four case study locations included in our current audit and the five
other case study locations from our previous audit found that the case
study locations identified thousands of missing IT equipment items
valued at tens of millions of dollars. For example, the four case study
locations included in our current audit reported over 2,400 missing IT
equipment items, with a combined original acquisition value of about
$6.4 million. Information we obtained as of March 2, 2007, showed that
the five other locations we previously audited had identified over
8,600 missing IT equipment items with a combined original acquisition
value of over $13.2 million. One of the four case study locations in
our current audit and three of the five other case study locations
covered in our previous audit had not yet completed Reports of
Survey[Footnote 11] on losses identified in their physical inventories.
Because none of the nine case study locations consistently recorded
transactions as changes in IT equipment inventory status and location
occurred, it is not possible to determine the disposition of IT
equipment items that cannot be located. When attempts to locate missing
IT equipment items were unfruitful, the losses were administratively
reported for recordkeeping purposes, including the authorization to
write them off in the property records. According to VA Police and
security specialists,[Footnote 12] when losses are not immediately
identified and reported, it is very difficult to conduct an
investigation because information about the specific events and
circumstances of the losses is no longer available.
Our limited tests of computer hard drives in the excess property
disposal process at the four case study locations found no data on
those hard drives that were certified as sanitized.[Footnote 13]
However, at two of the four test locations, we found that hard drives
not yet subjected to data sanitization contained hundreds of names and
Social Security numbers. Further, file dates on the hard drives we
tested indicate that some of them had been in the disposal process for
several years without being sanitized, creating an unnecessary risk
that sensitive personal and medical information could be compromised.
Excessive delays in completing data sanitization processes and
noncompliance with VA physical security policy heighten the risk of
data breach related to sensitive personal information residing on hard
drives in the excess property disposal process. For example, we found
numerous unofficial IT equipment storage locations in VA headquarters
area office buildings that did not meet VA physical security
requirements. One IT storeroom at the VA headquarters building did not
have a door. At other VA headquarters buildings, we found IT equipment
stored in open areas, closets, and filing cabinets. These storage
locations did not meet VA physical security requirements for secure
walls, doors, locks, special keys, and intrusion detection alarms.
Since our July 2004 report, VA management has taken some actions and
has other actions under way to strengthen controls over IT equipment.
For example, on October 11, 2005, VA revised its Materiel Management
Procedures[Footnote 14] to emphasize that requirements for annual
inventories of sensitive items valued at under $5,000 include IT
equipment. On August 4, 2006, VA issued a new directive entitled
Information Security Program, which requires, in part, periodic
evaluations and testing of the effectiveness of all management,
operational, and technical controls and calls for procedures for
immediately reporting and responding to security incidents. In December
2006, VA's new Chief Information Officer (CIO) centralized functional
IT units across local VA organizations under the CIO organization.
Despite these improvements, the department has not yet established and
ensured consistent implementation of effective controls for
accountability of IT equipment inventory, and IT inventory
responsibilities shared by IRM and property management personnel are
not well-defined. Until these shortcomings are addressed, VA will
continue to face major challenges in safeguarding IT equipment and
sensitive personal data on this equipment from loss, theft, and
misappropriation.
This report contains 12 recommendations to VA to further improve the
overall control environment and strengthen key internal control
activities and to increase attention to protecting IT equipment used in
VA operations. In comments on a draft of this report, VA generally
agreed with our findings, noted significant actions under way, and
concurred on the 12 recommendations. VA also provided technical
comments. VA's comments, including its technical comments, are
discussed in the Agency Comments and Our Evaluation section of this
report. VA's written comments are reprinted in appendix II.
Background:
VA's mission is to serve America's veterans and their families and to
be their principal advocate in ensuring that they receive medical care,
benefits, and social support in recognition of their service to our
nation. VA, headquartered in Washington, D.C., is the second largest
federal department and has over 235,000 employees, including
physicians, nurses, counselors, statisticians, computer specialists,
architects, and attorneys. VA carries out its mission through three
major line organizations--VHA, Veterans Benefits Administration, and
National Cemetery Administration--and field facilities throughout the
United States. VA provides services and benefits through a nationwide
network of 156 hospitals, 877 outpatient clinics, 136 nursing homes, 43
residential rehabilitation treatment programs, 207 readjustment
counseling centers, 57 veterans' benefits regional offices, and 122
national cemeteries.
Previously Reported Weaknesses in IT Inventory Controls:
Our July 2004 report found significant property management weaknesses,
including weaknesses in controls over IT equipment items valued at
under $5,000 that are required to have inventory control. In that
report, we made several recommendations for improving property
management, including actions to (1) clarify existing policy regarding
sensitive items that are required to be accounted for in the property
control records, (2) provide a more comprehensive list of the type of
personal property assets that are considered sensitive for
accountability purposes, and (3) reinforce VA's requirement to attach
bar code labels to agency personal property.
VA's IT Property Management Process:
The Assistant Secretary for Information and Technology serves as the
CIO for the department and is the principal advisor to the Secretary on
matters relating to IT management in the department. Key functions in
VA's IT property management process are performed by IRM and property
management personnel. These functions include identifying requirements;
ordering, receiving, and installing IT equipment; performing periodic
inventories; and identifying, removing, and disposing of obsolete and
unneeded IT equipment. Figure 1 illustrates the IT property management
process. In general, this is the process we observed at the four VA
locations we audited.
Figure 1: VA's IT Property Management Process:
[See PDF for image]
Source: GAO.
[End of figure]
The steps in the IT property management process are key events, which
should be documented by an inventory transaction, financial
transaction, or both, as appropriate. Federal records management law,
as codified in Title 44 of the U.S. Code and implemented through
National Archives and Records Administration (NARA) guidance, requires
federal agencies to adequately document and maintain proper records of
essential transactions and have effective controls for creating,
maintaining, and using records of these transactions.[Footnote 15]
Request and Ordering of IT Equipment:
IRM personnel determine IT equipment requirements for a particular VA
medical center or headquarters office based on strategic planning,
medical center or office needs, specific requests, and budgetary
resources. IRM personnel then submit requests to the cognizant Veterans
Integrated Service Network (VISN),[Footnote 16] the CIO, and VA
headquarters in Washington, D.C., for approval. For VA medical centers,
the VISN generally purchases or leases IT equipment to realize
economies of scale, but individual medical centers also may place
incidental orders to meet their needs. In addition, headquarters
offices may place individual orders or use purchase cards to acquire IT
equipment. Medical equipment with IT capability is generally acquired
through procurement contracts. When contracting personnel create a
purchase order and submit it to the vendor, contracting personnel are
required to send a copy of the purchase order to the appropriate
property management personnel to notify them of a new order.
When the vendor delivers ordered IT equipment to the loading dock,
property management warehouse personnel inspect the boxes for visible
signs of damage, and after accepting delivery, store IT equipment until
they can transfer it to IRM personnel. Warehouse personnel confirm
receipt and acceptance in the Integrated Funds Distribution Control
Point Activity, Accounting, and Procurement System (IFCAPS), which then
notifies the Financial Management System so that payment can be made to
the vendor. Once the receipt is confirmed within IFCAPS, warehouse
personnel notify IRM personnel of the delivery and arrange a transfer
of the equipment to them. Upon transfer, an IRM official signs the
receipt document, signifying acceptance of custody for the IT
equipment.
Recording of IT Equipment Acquisitions in Inventory Records:
VA medical center property management personnel use information from
the purchase order, including item name, item description, model
number, manufacturer, vendor, and acquisition cost, to create property
record(s) in the Automated Equipment Management System/Medical
Equipment Repair Service (AEMS/MERS) for new IT equipment
acquisitions.[Footnote 17] AEMS/MERS is a general inventory management
system that is local to each VA medical center. Headquarters personnel
also use purchase order information to enter records of new IT
equipment in the Inte-GreatTM Property Manager system. Property
management personnel also identify the department responsible for the
IT equipment by recording an equipment inventory listing (EIL) code at
VA medical centers and a consolidated memorandum receipt (CMR) code at
headquarters. Once property records are created, property management
personnel generate a bar code label for each piece of IT equipment. IRM
personnel may prepare the equipment for issuance to specific users by
installing VA-specific software and configurations prior to
installation. In addition, VA medical center biomedical engineering
personnel may test medical equipment for electrical safety before
placing it in service.
Issuance and Replacement of IT Equipment:
IRM personnel or, in some cases, contractor personnel deliver new IT
equipment to the appropriate service or location for installation. IRM
or contractor personnel also remove and replace old IT equipment that
has been approved for replacement. At some VA facilities, a bar code
label is affixed to a door jam or other physical element of the
specific location in which the IT equipment has been installed to
document item locations in the property management system. Once the new
equipment is installed, IRM or contractor personnel transfer the
replaced equipment to an IRM storage room pending disposal.
Physical Inventories of IT Equipment and Reports of Survey:
VA policy[Footnote 18] mandates that each VA facility take physical
inventory of its accountable property using one of two methods. The
first method determines when the next inventory will be taken based on
the accuracy rate for each EIL or CMR during the previous inventory. If
an EIL or CMR was found to have an accuracy rate of 95 percent or
above, the VA facility may inventory that EIL or CMR in 12 months. If
the EIL or CMR has an accuracy rate of less than 95 percent, the VA
facility must inventory that EIL or CMR within 6 months. The second
method permits physical inventories to be performed on an exception
basis. Under this method, a VA facility uses property management system
data to identify the item bar codes that were scanned since the last
inventory. If items have been scanned since the last inventory, they
may be excluded from the current physical inventory.
When a VA facility determines that items listed in inventory cannot be
located, those items are listed on a Report of Survey and facility
personnel convene a Board of Survey. Reports of Survey are provided to
medical center VA Police or the Federal Protective Service officers at
VA headquarters, as appropriate. The Report of Survey documents the
circumstances of loss, damage, or destruction of government property.
VA policy[Footnote 19] mandates that a Board of Survey be appointed
when there is a possibility that a VA employee may be assessed
pecuniary liability or disciplinary action as a result of loss, damage,
or destruction of property and the value of the property involved is
$5,000 or more. The Board of Survey reviews the Report of Survey, which
identifies IT equipment that is unaccounted for and explains efforts
made to account for the missing items. An approved Report of Survey
provides necessary support for writing off lost and missing items. For
items on the Report of Survey, VA personnel are supposed to update the
use status in the property management system from "in-use" to "lost."
Updating the use status allows for the generation of an exception
report in case any of the items unaccounted for are subsequently
located.
Approval for Turn-in and Disposal:
An IRM technician originates the request for turn-in of old IT
equipment using VA Form 2237, "Request, Turn-In, and Receipt for
Property or Services," or users may submit an electronic form 2237.
Pending final approval of VA Form 2237, electronic notification is
given to property management and IRM personnel, who use this
documentation to ensure that they are removing and disposing of the
correct item(s). IRM or contractor personnel transfer the old IT
equipment to an IRM storage room for hard drive sanitization and
subsequent reuse or disposal. Medical equipment with IT capability is
generally traded in to the vendor for upgraded models after medical
center IRM personnel have documented that data sanitization procedures
were completed.
Federal agencies, such as VA, are required to protect sensitive data
stored on their IT equipment against the risk of data breaches and thus
the improper disclosure of personal identification information, such as
names and Social Security numbers. Such information is regulated by
privacy protections under the Privacy Act of 1974[Footnote 20] and,
when information concerns an individual's health, the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) and implementing
regulations.[Footnote 21]
Removal of Data from Hard Drives:
VA facilities have two options for removing data from hard drives of IT
equipment in the excess property disposal process. Under the first
option, the VA medical center removes the hard drives from the IT
equipment and ships them to a vendor for sanitization (data erasing).
The vendor physically destroys any hard drives it cannot successfully
erase. The vendor submits certification of hard drive sanitization or
destruction to IRM personnel and ships the sanitized hard drives back
to the VA facility for disposal. Under the second option, VA IRM
personnel perform the procedures to sanitize the hard drives using VA-
approved software, such as Data EraserTM. IRM personnel complete VA
Form 0751, "Information Technology Equipment Sanitization
Certification," to document the erasing of the hard drives. Hard drives
that Data EraserTM software cannot successfully sanitize are held at
the VA facility in IRM storage for physical destruction by another
contractor at various intervals throughout the year.
Final Disposition of IT Equipment:
After data have been removed from the hard drives, the hard drives can
be placed back into the IT equipment from which they were previously
removed so that the computers can be reused or shipped directly to a VA
IT equipment disposal vendor. For IT equipment that is not selected for
reuse within VA, IRM personnel will notify cognizant property
management personnel that the IT equipment is ready for final disposal
and property management personnel transfer the items to a warehouse. VA
facilities use different processes to handle the final disposal of IT
equipment. For example, property management personnel may contact
transportation personnel at the VA Central Office, who then contact a
shipper to take the IT equipment to a disposal vendor, or a disposal
vendor may pick up the IT equipment from the VA facility. Disposal
vendors, including Federal Prison Industries, Inc.,[Footnote 22]
determine what IT equipment is to be donated to schools. Generally,
within several days of the equipment being shipped to the disposal
vendor, property management personnel change the status field of the
equipment in the property management system from "in-use" to "turned-
in" and designate the property record as inactive.
Inadequate IT Inventory Control and Accountability Pose Risk of Loss,
Theft, and Misappropriation:
Our tests of IT equipment inventory controls at four case study
locations, including three VA medical centers and VA headquarters,
identified a weak overall control environment and a pervasive lack of
accountability for IT equipment items across the four locations we
tested. Our Standards for Internal Control in the Federal
Government[Footnote 23] states that a positive control environment
provides discipline and structure as well as the climate that
influences the quality of internal control. However, as summarized in
table 1, our statistical tests of key IT inventory controls at our four
case study locations found significant control failures related to (1)
missing IT equipment items in our existence tests, (2) inaccurate
information on user organization, (3) inaccurate information on user
location, and (4) other recordkeeping errors. None of the case study
locations had effective controls to safeguard IT assets from risk of
loss, theft, and misappropriation.
Table 1: Current IT Equipment Inventory Control Failure Rates at Four
Test Locations:
Control failures: Missing items in sample;
Washington, D.C., medical center: 28%;
Indianapolis medical center: 6%;
San Diego medical center: 10%;
VA headquarters: 11%.
Control failures: Incorrect user organization;
Washington, D.C., medical center: 80%;
Indianapolis medical center: 69%;
San Diego medical center: 70%;
VA headquarters: 11%.
Control failures: Incorrect user location;
Washington, D.C., medical center: 57%;
Indianapolis medical center: 23%;
San Diego medical center: 53%;
VA headquarters: 44%.
Control failures: Recordkeeping errors;
Washington, D.C., medical center: 5%;
Indianapolis medical center: 0%;
San Diego medical center: 5%;
VA headquarters: 3%.
Source: GAO analysis.
Notes: Each of these estimates has a margin of error, based on a two-
sided, 95 percent confidence interval, of +/-10 percent or less. The
details of our statistical testing are explained in app. I. Because the
four test locations did not record all IT equipment items in their
inventory records, our estimated failure rates relate to current
(recorded) inventory and not the population of all IT equipment at
those locations.
[End of table]
Moreover, our statistical tests identified a total of 123 lost and
missing IT equipment items across the four case locations, including 53
IT equipment items that could have stored sensitive personal
information. Personal information, such as names and Social Security
numbers, is regulated by privacy protections under the Privacy Act of
1974[Footnote 24] and information concerning an individual's health is
accorded additional protections from unauthorized release under HIPAA
and implementing regulations.[Footnote 25] Although VA property
management policy[Footnote 26] establishes guidelines for holding
employees and supervisors pecuniarily (financially) liable for loss,
damage, or destruction because of negligence and misuse of government
property, except for a few isolated instances, none of the case study
locations assigned user-level accountability. Instead, these locations
relied on information about user organization and user location, which
was often incorrect and incomplete. In addition, although our standards
for internal control require timely recording of transactions as part
of an effective internal control structure and safeguarding of
sensitive assets, we found that VA's property management
policy[Footnote 27] neither specified what transactions were to be
recorded for various changes in inventory status nor provided criteria
for timely recording. Further, IRM and IT Services personnel
responsible for installation, removal, and disposal of IT equipment did
not record or assure that transactions were recorded by property
management officials when these events occurred. Under this lax control
environment, missing IT equipment items were often not reported for
several months and, in some cases several years, until the problem was
identified during a physical inventory.
Inventory Tests Identified Significant Numbers of Missing Items:
As shown in table 2, our statistical tests of IT equipment existence at
the four case study locations identified a total of 123 missing IT
equipment items, including 53 items that could have stored sensitive
personal data and information. Although VA headquarters had the highest
number of missing items, none of the four test locations had effective
controls. Missing IT equipment items pose not only a financial risk but
also a security risk associated with sensitive personal data maintained
on computer hard drives.
Table 2: Number of Missing IT Equipment Items at Four Test Locations,
Including Items That Could Have Stored Sensitive Information:
Test results: Number of missing items in each sample;
Washington, D.C., medical center: 44;
Indianapolis medical center: 9;
San Diego medical Center: 17;
VA headquarters: 53.
Test results: Total missing items that could have stored sensitive
data;
Washington, D.C., medical center: 19;
Indianapolis medical center: 3;
San Diego medical Center: 8;
VA headquarters: 23.
Source: GAO analysis.
Note: After we completed our analysis, Washington, D.C., medical center
personnel provided documentation that one of the missing items--a new
computer monitor--had been located. This information is not reflected
in the table.
[End of table]
Because of the lack of user-level accountability and the failure to
consistently update inventory records for changes in inventory status
and user location, VA officials at our test locations could not
determine the user or type of data stored on the 53 missing IT
equipment items that could have stored sensitive personal information
and, therefore, the risk posed by the loss of these items. The details
of our test work at each location follow.
Washington, D.C., Medical Center:
Our physical inventory existence testing at the Washington, D.C.,
medical center identified an estimated 28 percent failure rate[Footnote
28] related to missing items in the recorded universe of 8,728 IT
equipment items. Our analysis determined that the primary cause of
these high control failure rates was a lack of coordination and
communication between medical center IRM and property management
personnel to assure that documentation on IT items in physical
inventory was updated in the property management system when changes
occurred. VA records management policy[Footnote 29] that implements
federal records management law and NARA guidance[Footnote 30] requires
the creation and maintenance of records of essential transactions, such
as creating a timely record of newly acquired IT equipment in the
property management system, and recording timely updates for changes in
the status of IT equipment, including transfers, turn-ins, and
replacement of equipment, and disposals.
The medical center's IT equipment inventory records included 550 older
IT equipment items that property management officials told us should
have been removed from active inventory. Because the inventory status
fields for these items were either blank or indicated the items were
"in use," we included these items in the universe of current inventory
for purposes of our statistical sample. Of the 44 missing IT equipment
items identified in our statistical tests at the Washington, D.C.,
medical center, 9 items related to the 550 older IT equipment items of
questionable status. Washington, D.C., medical center officials
asserted that because of their age, these items would likely have been
turned in for disposal. However, because the property system had not
been updated to reflect a turn-in or disposal and no hard copy
documentation had been retained, it was not possible to determine
whether any of the 44 missing IT equipment items, including 19 items
that could have stored sensitive personal information, had been sent to
disposal or if any of them were lost or stolen.
For other IT equipment items that could not be located during our
existence testing, IRM or property management officials were able to
provide documentation created and saved outside the property management
system that showed several of these items had been turned in for
disposal without recording the corresponding inventory transaction in
the property management system. In March 2006, the Washington, D.C.,
medical center initiated an automated process for electronic
notification and documentation of property turn-ins in the property
management system. If effectively implemented, the electronic process
should help resolve this problem going forward.
With regard to the use and type of data stored on the 19 computers that
our tests identified as missing, Washington D.C., medical center
officials could not tell us the users or the types of data that would
have been on these computers. This is because local medical center
property management procedures call for recording the local IRM
organization as the user for most IT equipment in the property
management system, rather than the actual custodian or user of the IT
equipment.
Indianapolis Medical Center:
The Indianapolis medical center had an estimated failure rate of 6
percent[Footnote 31] related to missing items in the recorded universe
of 7,614 IT equipment items. However, our test results do not allow us
to conclude that the center's controls over existence of IT equipment
inventory are effective. Our statistical tests identified 9 missing IT
equipment items, including 3 items that could have stored sensitive
personal and medical information. Of the 3 missing items that could
have stored sensitive information, medical center inventory records
showed that 2 of these items were medical devices assigned to the
radiology unit. Although medical center officials provided us with turn-
in documentation for one of these items--a magnetic resonance imaging
(MRI) machine that had just been disassembled and removed from service--
the documentation did not match the bar code (property identification
number) or the serial number for our sample item, indicating possible
recordkeeping errors. The user of the third item, a computer, was not
known.
In addition, our review of Indianapolis medical center purchase card
records determined that some IT equipment items that were not included
in property inventory records had been acquired with a government
purchase card. We found that VA purchase card policy[Footnote 32] does
not require cardholders to notify property management officials of the
receipt of property items acquired with a purchase card, including IT
equipment. As a result, there is no asset visibility[Footnote 33] or
accountability for these items. Further, there is no assurance that
sensitive personal data, medical data, or both that could be stored on
these items are properly safeguarded.
San Diego Medical Center:
We estimated an overall failure rate of 10 percent[Footnote 34] related
to missing items in the San Diego medical center's recorded universe of
11,604 IT equipment items. Our statistical tests at the San Diego
medical center identified 17 missing IT equipment items, including 8
items that could have stored sensitive personal data and information.
San Diego medical center officials could not tell us the user or type
of data that would have been stored on the missing computers. San Diego
medical center officials noted that some of the missing items were
older IT equipment that would no longer be in use. However, without
valid turn-in documentation, it is not possible to determine whether
these IT equipment items were disposed of without creating the
appropriate transaction record or if any of these items, including
items that could have stored sensitive personal and medical
information, were lost, stolen, or misappropriated without detection.
Our tests also determined that San Diego medical center officials were
not following VA policy for physical inventory control and
accountability of IT equipment. Consistent with a finding in our July
2004 report, we found that the San Diego medical center had not
included IT equipment items valued at less than $5,000 in annual
physical inventories. Although San Diego medical center property
management officials record IT equipment ordered through the formal
property acquisition process in inventory records at the time it is
acquired, absent an annual physical inventory, center officials have no
way of knowing whether these items are still in use or if any of these
items were lost, stolen, or misappropriated. VA property management
policy[Footnote 35] requires that sensitive items, including computer
equipment, be subjected to annual physical inventories. At the time of
our IT equipment inventory testing in January 2007, San Diego medical
center officials told us that consistent with requirements in VA
Handbook 7127/4, they were initiating a physical inventory of all IT
equipment items, including those items valued at less than $5,000.
In addition, our analysis of San Diego medical center purchase card
records identified several purchases of IT equipment that had not been
recorded in the medical center's inventory records. As a result, our
statistical tests did not include these items. Because the medical
center's IT Services and property management officials are not tracking
IT equipment items that were acquired with government purchase cards,
there is no accountability for these items. As a result, San Diego
medical center management does not know how many of these items have
not been recorded in the property inventory records or how many of
these items could contain sensitive personal information. If San Diego
medical center officials properly perform their fiscal year 2007
physical inventory, they should be able to locate and establish an
accountable record for IT equipment items acquired with purchase cards
that are being used within their facility. However, additional research
would be required to identify all IT equipment items that were acquired
with a purchase card and are being used at employees' homes or other
off-site locations.
San Diego medical center IT Services personnel told us that they
created and maintained informal "cuff records" outside the property
management system to document installation and removal of IT equipment
because property management officials did not permit them to have
access to the property management system. In addition, IT Services
personnel did not provide information from their informal cuff records
to property management officials so that they could update the formal
records maintained in property management system. As a result, the
formal IT equipment inventory records saved in the property management
system remained out-of-date, while more accurate records were
maintained as separate IT Services files outside the formal system and
were not available for management decision making. Further, San Diego
IT Services personnel were not provided handheld scanners so that they
could electronically update inventory records when they installed or
removed IT equipment. The San Diego medical center IT Services'
informal cuff records create internal control weaknesses because they
do not provide reasonable assurance of furnishing information the
agency needs to conduct current business.
VA Headquarters Offices:
We statistically tested a random sample of VA headquarters IT equipment
items, which included IT equipment for each headquarters office. Based
on our sample, we estimate an 11 percent failure rate[Footnote 36]
related to missing items in the VA headquarters recorded universe of
25,353 IT equipment items. In addition, our tests of VA headquarters IT
inventory identified 53 missing IT equipment items, including 23
computers that could have stored sensitive personal information. VA
headquarters officials could not tell us the use or type of information
that would have been stored on the missing computers. Table 3
identifies missing IT equipment items in our stratified sample by VA
headquarters office.
Table 3: Number of Missing IT Equipment Items by Headquarters Office
and Missing Items That Could Have Stored Sensitive Personal Data and
Information:
Test location: Acquisition and Materiel;
Number of missing IT items in stratified sample: 0 of 10;
Missing items with data storage capability: 0.
Test location: General Counsel;
Number of missing IT items in stratified sample: 2 of 10;
Missing items with data storage capability: 0 of 2.
Test location: Information and Technology;
Number of missing IT items in stratified sample: 9 of 94;
Missing items with data storage capability: 6 of 9.
Test location: Policy and Planning;
Number of missing IT items in stratified sample: 0 of 10;
Missing items with data storage capability: 0.
Test location: Veterans Health Administration;
Number of missing IT items in stratified sample: 17 of 95;
Missing items with data storage capability: 7 of 17.
Test location: Veterans Benefits Administration;
Number of missing IT items in stratified sample: 24 of 93;
Missing items with data storage capability: 10 of 24.
Test location: All other[A];
Number of missing IT items in stratified sample: 1 of 32;
Missing items with data storage capability: 0 of 1.
Source: GAO analysis.
[A] All other includes 17 additional VA headquarters organizations. The
missing item in this category related to the Human Resource Management
Office.
[End of table]
We found that VA headquarters property records were incomplete and out-
of-date, particularly with regard to users and locations. VA
headquarters officials told us that IT coordinators had access to the
headquarters property system for purposes of updating records for their
units. However, we found that the IT coordinators maintained informal
spreadsheets, or cuff records, to track IT equipment assigned to their
units instead of updating IT equipment records in the formal VA
headquarters property system. As stated previously, the use of informal
cuff records creates an internal control weakness because management
does not have visibility over this information for decision making
purposes.
VA headquarters officials also told us that various headquarters
offices acquire IT equipment using government purchase cards and that
these items are not identified and recorded in inventory unless they
are observed coming through the mail room or they are identified during
physical inventories. As previously discussed, VA purchase card policy
does not require purchase card holders to notify property management
officials at the time they receive IT equipment and other property
acquired with government purchase cards.
Pervasive Lack of User-Level Accountability for IT Equipment at Case
Study Locations:
VA management has not enforced VA property management policy and has
generally left implementation decisions up to local organizations,
creating a nonstandard, high-risk environment. Although VA property
management policy establishes guidelines for user-level
accountability,[Footnote 37] the three medical centers we tested
assigned accountability for most IT equipment to their IRM or IT
Services organizations, and VA headquarters organizations tracked IT
equipment items through their IT inventory coordinators. However,
because these IT personnel and IT coordinators did not have possession
(physical custody) of all IT equipment under their purview, they were
not held accountable for IT equipment determined to be missing during
physical inventories. This weak overall control environment at the four
case study locations resulted in a pervasive lack of user-level
accountability for IT equipment.
Absent user-level accountability, accurate information on the using
organization and location of IT equipment is key to maintaining asset
visibility and control over IT equipment items. The high failure rates
in our tests for correct user organization and location of IT
equipment, shown in table 4, underscore the lack of user-level
accountability at the four case study locations. The lack of
accountability has in turn resulted in a lax attitude about controlling
IT equipment. As a result, for the four case study locations, we
concluded that under the current lax control environment, essentially
no one was accountable for IT equipment.
Table 4: Estimated Percentage of IT Inventory Control Failures Related
to Correct User and Location at the Four Test Locations:
Test location: Washington, DC, medical center;
Incorrect user organization: 80%; (72% to 87%);
Incorrect user location: 57%; (49% to 64%).
Test location: Indianapolis, IN, medical center;
Incorrect user organization: 69%; (60% to 78%);
Incorrect user location: 23%; (15% to 33%).
Test location: San Diego, CA, medical center;
Incorrect user organization: 70%; (61% to 78%);
Incorrect user location: 53%; (43% to 63%).
Test location: VA headquarters organizations;
Incorrect user organization: 11%; (8% to 15%);
Incorrect user location: 44%; (37% to 51%).
Source: GAO analysis.
Note: The percentages represent point estimates and the two-sided, 95
percent confidence interval.
[End of table]
Our statistical tests found numerous instances where inventory records
were not updated when equipment was transferred to another VA unit,
moved to another location, or removed from a facility. We also found
that critical inventory system data fields, such as user and location,
were often blank. Completion of these data fields would have created
records of essential transactions for IT inventory events. Because
property management system inventory records were incomplete and out-
of-date, it is not possible to determine the timing or events
associated with lost IT equipment as a basis for holding individual
employees accountable.
In addition to failures in our tests for accurate user organization and
location, we found that the inventory system data field for identifying
IT coordinators at headquarters units was often blank or incorrect. The
IT coordinator role, which is unique to VA headquarters offices, is
intended to provide an additional level of control for tracking and
managing assignment of IT equipment within each headquarters
organizational unit. Our tests for accurate and complete information on
headquarters IT coordinators found 85 errors out of a sample of 344
records tested. We estimated the failure rate for the IT coordinator
records at VA headquarters units to be 47 percent.[Footnote 38]
Further, although VA headquarters officials told us they use hand
receipts[Footnote 39] for user-level accountability of mobile IT
equipment that can be removed from VA offices for use by employees who
are on travel or are working at home, we found this procedure was not
used consistently. For example, we requested hand receipts for 15
mobile IT equipment items in our statistical sample that were being
used by VA headquarters employees. These items either could be or were
taken off-site. We received 9 hand receipts--1 that had expired, 6 that
were dated after the date of our request, and 2 that were valid.
Officials at the three medical centers we tested were able to provide
hand receipts for IT equipment that was being used by their employees
at home.
Officials at all four case study locations expressed concerns that it
would be difficult and burdensome to implement user-level
accountability for IT equipment, particularly in the case of shared
workstations used by multiple employees. However, Washington, D.C.,
medical center officials initiated actions to establish user-level
accountability for individual employees and unit heads who have shared
workstations. In March 2007, Washington, D.C., medical center officials
implemented a policy for user-level accountability and began training
their employees on the new requirements. The new policy requires
employees to sign personal custody receipts for IT equipment assigned
to them, and it requires supervisors to be responsible for IT equipment
that is shared among staff in their sections. The policy states that
users of IT equipment will be held accountable for acts deemed
inappropriate or negligent and that employees are personally and
financially responsible for loss, theft, damage, or destruction of
government property caused by negligence. VA headquarters officials
told us that they are considering approaches for implementing a VA-wide
policy for user-level accountability of IT equipment.
Errors in IT Equipment Inventory Status and Item Description
Information:
As shown in table 5, we also found some problems with the accuracy of
IT equipment inventory records, including inaccurate information on
status (e.g., in use, turned-in, disposal), serial numbers, model
numbers, and item descriptions. The estimated overall error rates for
these tests were lower than the error rates for the other control
attributes we tested, and the Indianapolis medical center had no
errors.
Table 5: Estimated Percentage of Other IT Inventory Recordkeeping
Failures at Four Test Locations:
Test location: Washington, D.C., medical center;
Inventory status information: 1%; (0% to 4%);
Serial number: 6%; (2% to 11%);
Item description: 0%; (0% to 5%);
Total failures: 5%; (2% to 10%).
Test location: Indianapolis medical center;
Inventory status information: 0%; (0% to 2%);
Serial number: 0%; (0% to 4%);
Item description: 0%; (0% to 2%);
Total failures: 0%; (0% to 4%).
Test location: San Diego medical center;
Inventory status information: 2%; (0% to 7%);
Serial number: 1%; (0% to 6%);
Item description: 2%; (0% to 8%);
Total failures: 5%; (2% to 12%).
Test location: VA headquarters organizations;
Inventory status information: 0%; (0% to 2%);
Serial number: 2%; (1% to 7%);
Item description: 1%; (0% to 2%);
Total failures: 3%; (1% to 6%).
Source: GAO analysis.
Note: The percentages represent point estimates and the two-sided, 95
percent confidence interval.
[End of table]
The errors we identified affect management decision making and create
waste and inefficiency in operations. For example, inaccurate
information on the status of IT equipment inventory items impairs
management's ability to determine what items are available or in use.
Errors in item descriptions impair management decision making on the
number and types of available items and timing for replacement of these
items, and serial number errors impair accountability. Further,
inaccurate inventory information on the IT equipment item status, as
well as the location errors discussed above, caused significant waste
and inefficiency during physical inventories. Many of these errors
should have been detected and corrected during annual physical
inventories.
Physical Inventories by Case Study Locations Identified Thousands of
Missing IT Equipment Items Valued at Millions of Dollars:
To assess the effect of the lax control environment for IT equipment,
we asked VA officials at the case study locations covered in both our
current and previous audits to provide us with information on the
results of their physical inventories performed after issuance of
recommendations in our July 2004 report, including Reports of
Survey[Footnote 40] information on identified losses of IT equipment.
VA policy[Footnote 41] requires that when property items are determined
to be lost or missing, they are to be listed in a Report of Survey and
an investigation is to be conducted into the circumstances of the loss
before these items are written off in the property records. As of
February 28, 2007, the four case study locations covered in our current
audit reported over 2,400 missing IT equipment items with a combined
original acquisition value of about $6.4 million as a result of
inventories they performed during fiscal years 2005 and 2006. Based on
information obtained through March 2, 2007, the five case study
locations we previously audited had identified over 8,600 missing IT
equipment items with a combined original acquisition value of over
$13.2 million. Because inventory records were not consistently updated
as changes in user organization or location occurred and none of the
locations we audited required accountability at the user level, it is
not possible to determine whether the missing IT equipment items
represent recordkeeping errors or the loss, theft, or misappropriation
of IT equipment. Further, missing IT equipment items were often not
reported for several months and, in some cases several years, because
most of the nine case study locations had not consistently performed
required annual physical inventories or completed Reports of Survey
promptly. Although physical inventories should be performed over a
finite period, at most of the nine case study locations these
inventories were not completed for several months or even several years
while officials performed extensive searches in an attempt to locate
missing items before preparing Reports of Survey to write them off.
According to VA Police and security specialists,[Footnote 42] it is
very difficult to conduct an investigation at this point because the
details of the incidents cannot be determined. As law enforcement
officers, VA Police are trained in investigative techniques that could
potentially track and recover lost and missing items if promptly
reported. Further, because VA Police are responsible for facility
security, consistent reporting of lost and missing IT equipment to the
Chief of Police at each VA medical center or federal law enforcement
officers responsible for building security at VA headquarters locations
could identify patterns of vulnerability that could be addressed
through upgraded security plans.
Physical Inventories Performed by Four Case Study Locations Identify
Significant Numbers of Missing IT Equipment Items:
The timing and scope of the physical inventories performed by the four
case study locations in our current audit varied. For example, the
Indianapolis medical center had been performing annual physical
inventories in accordance with VA policy for several years. As a
result, IT equipment inventory records were more accurate and physical
inventories identified fewer missing items than most locations tested.
The Washington, D.C., medical center performed a wall-to-wall physical
inventory in response to our July 2004 report, which found that
previously performed physical inventories of IT equipment were
ineffective. In this case, inventory results reflected several years of
activity involving IT inventory records that had not been updated and
lost and missing IT equipment items that had not previously been
identified and reported. Although the San Diego medical center had
performed periodic physical inventories, it had not followed VA policy
for including sensitive items, such as IT equipment valued at less than
$5,000. As a result, the San Diego medical center's Reports of Survey
are not a good indicator of the extent of lost and missing IT equipment
at this location. The fiscal year 2006 VA headquarters physical
inventory identified IT equipment items that may have been lost or
missing for several years without detection or final resolution. For
example, VA headquarters officials told us that during renovations of
headquarters offices 10 years ago, IT equipment was relocated to office
space designated as storerooms. When this space had to be vacated for
renovation, the IT equipment had to be relocated, and many items were
sent to disposal. According to VA headquarters officials,
accountability for individual IT equipment items was not maintained
during the renovation or disposal process. This weak overall control
environment presents an opportunity for theft, loss, or
misappropriation to occur without detection.
As of February 28, 2007, based on inventories they performed during
fiscal years 2005 and 2006, the four case study locations covered in
our current audit reported over 2,400 missing IT equipment items with a
combined original acquisition value of about $6.4 million. Table 6
provides information on the results of physical inventories performed
by our four current case study locations.
Table 6: Summary of Physical Inventories and Missing IT Equipment
Identified by the Four Current Case Study Locations as of February 28,
2007:
Test location: Washington, D.C., medical center;
Fiscal years of inventory: 2005 thru 2006;
Dates of Reports of Survey: Mar. 2006 thru Oct. 2006;
Number of missing items identified: 1,133;
Original acquisition value of missing items: $1,758,096.
Test location: Indianapolis medical center;
Fiscal years of inventory: 2005; 2006;
Dates of Reports of Survey: Dec. 2004; Oct. 2006;
Number of missing items identified: 6; 112;
Original acquisition value of missing items: $23,206; $79,230.
Test location: San Diego medical center[A];
Fiscal years of inventory: 2005; 2006;
Dates of Reports of Survey: Dec. 2004; Ongoing;
Number of missing items identified: 42; 15;
Original acquisition value of missing items: $135,344; $24,418.
Test location: VA headquarters offices;
Fiscal years of inventory: 2006 and ongoing;
Dates of Reports of Survey: Not yet finalized;
Number of missing items identified: 1,162;
Original acquisition value of missing items: $4,385,444.
Source: GAO analysis.
[A] The San Diego medical center IT Services personnel inventoried only
items valued at $5,000 or more.
[End of table]
In response to our test work, in January 2007, the Washington, D.C.,
medical center prepared an additional Report of Survey to write off 699
older IT equipment items valued at $794,835 that had not been located
or removed from current inventory. The VA headquarters physical
inventory had initially identified about 2,700 missing IT equipment
items, and officials told us that their research has resolved over half
of the discrepancies. VA headquarters officials told us that they have
not yet prepared a Report of Survey because they believe some of their
missing IT equipment items may still be located.
Physical Inventories by Five Locations Previously Audited Also Identify
Significant Numbers of Missing IT Equipment Items:
We also followed up with the five other case study locations[Footnote
43] that we previously audited to determine the results of physical
inventories performed in response to recommendations in our July 2004
report. As of the end of our fieldwork in February 2007, the Tampa,
Florida, medical center had not yet completed its physical inventory.
In addition, the Houston, Texas, medical center's fiscal year 2005
physical inventory procedures continued to exclude IT equipment valued
under $5,000 because the center had followed inaccurate guidance from
its VISN.
Our standards for internal control require federal agencies to have
policies and procedures for ensuring that the findings of audits and
other reviews are promptly resolved. In accordance with these
standards, managers are to (1) promptly evaluate findings from audits
and other reviews, including those showing deficiencies and
recommendations; (2) determine proper actions in response to findings
and recommendations; and (3) complete, within established time frames,
all actions that correct or otherwise resolve the matters brought to
management's attention. The failure to ensure that VA organizations
take appropriate, timely action to address audit findings and
recommendations indicates a significant control environment weakness
with regard to a "tone at the top" and does not set an example that
supports performance-based management and establishes controls that
serve as the first line of defense in safeguarding assets and
preventing and detecting errors.
Based on information obtained through March 2, 2007, the five case
study locations we previously audited had identified over 8,600 missing
IT equipment items with a combined original acquisition value of over
$13.2 million. As noted in table 7, of the three medical centers that
completed their physical inventories, the Los Angeles, California,
medical center reported over 8,400 missing IT equipment items valued at
over $12.4 million.
Table 7: Summary of Physical Inventories and Missing IT Equipment
Identified by Five Case Study Locations Previously Audited as of March
2, 2007:
Medical center test location: Atlanta, GA;
Fiscal year of inventory: Ongoing since 2005;
Dates of Reports of Survey: Not yet prepared;
Number of missing items: 195;
Original acquisition value of missing items: $254,666.
Medical center test location: Houston, TX[A];
Fiscal year of inventory: 2005;
Dates of Reports of Survey: Mar. 2005;
Number of missing items: 3;
Original acquisition value of missing items: $79,703.
Medical center test location: Los Angeles, CA;
Fiscal year of inventory: 2006;
Dates of Reports of Survey: Not yet prepared;
Number of missing items: 8,402;
Original acquisition value of missing items: $12,424,860.
Medical center test location: San Francisco, CA;
Fiscal year of inventory: 2005;
Dates of Reports of Survey: Oct. 2004 thru Dec. 2005;
Number of missing items: 68;
Original acquisition value of missing items: $463,373.
Medical center test location: Tampa, FL;
Fiscal year of inventory: Ongoing since Jan. 2006;
Dates of Reports of Survey: Not yet prepared;
Number of missing items: Unknown;
Original acquisition value of missing items: Unknown.
Source: GAO analysis.
[A] The Houston medical center inventoried only items valued at $5,000
or more.
[End of table]
We found that Houston medical center property management policy did not
include IT equipment within its definition of sensitive items requiring
annual physical inventories. As a result, the Houston medical center
inventoried items valued at $5,000 or more and reported 3 missing IT
equipment items valued at $79,703. Houston medical center officials
told us that they are now complying with VA policy to include all IT
equipment in their current annual physical inventory effort. The
Atlanta medical center identified 195 missing IT equipment items valued
at $254,666, and the San Francisco medical center reported a total of
68 missing IT equipment items valued at $463,373. Three of the five
medical centers--in Atlanta, Los Angeles, and Tampa--had not yet
prepared Reports of Survey on the missing items identified in their
physical inventories.
Physical Security Weaknesses Increase Risk of Loss, Theft, and
Misappropriation of IT Equipment and Sensitive Data:
Our investigator's inspection of physical security at officially
designated IT warehouses and storerooms that held new and used IT
equipment found that most of these storage facilities met the
requirements in VA Handbook 0730/1, Security and Law Enforcement.
However, not all of the formally designated storage locations had
required motion detection alarm systems and special door locks. In
response to our findings, physical security specialists at the four
case study locations told us that they had recommended that the needed
mechanisms be installed. We also found numerous instances of IT
equipment storage areas at VA headquarters offices that had not been
formally designated as IT storerooms, and these informal IT storage
areas did not meet VA physical security requirements. In addition,
although VA requires that hard drives of IT equipment and medical
equipment be sanitized prior to disposal to prevent unauthorized
release of sensitive personal and medical information, we found
weaknesses in the disposal process that pose a risk of data
breach.[Footnote 44] For example, our tests of computer hard drives in
the excess property disposal process found that hard drives at two of
the four case study locations that had not yet been sanitized contained
hundreds of names and Social Security numbers. We also found that some
of the hard drives had been in the disposal process for several years
without being sanitized, creating an unnecessary risk that sensitive
personal information protected under the Privacy Act of 1974[Footnote
45] and personal medical information accorded additional protections
under HIPAA[Footnote 46] could be compromised. Weaknesses in physical
security heighten the risk of data breach related to sensitive personal
information residing on hard drives in the property disposal process
that have not yet been sanitized.
Weaknesses in Procedures for Controlling Excess Computer Hard Drives:
As previously discussed, VA requires that hard drives of excess
computers be sanitized prior to reuse or disposal because they can
store sensitive personal and medical information used in VA programs
and activities, which could be compromised or used for unauthorized
purposes. For example, our limited tests of excess computer hard drives
in the disposal process that had not yet been sanitized found 419
unique names and Social Security numbers on three of the six Board of
Veterans Appeals hard drives and one record on one of two VHA hard
drives we tested. Our tests of five San Diego medical center hard
drives that had not yet been sanitized found that one hard drive held
at least 20 detailed patient medical histories, including 5 histories
that contained Social Security numbers. Our limited tests of hard
drives that were identified as having been subjected to internal or
contractor data sanitization procedures did not find data remaining on
these hard drives.
However, our limited tests identified some problems that could pose a
risk of data breach with regard to sensitive personal and medical
information on hard drives in the disposal process that had not yet
been sanitized. For example, our IT security specialist found that five
hard drives stored in a bin labeled by the San Diego medical center as
holding hard drives that had not been erased had in fact been
sanitized. The lack of proper segregation and tracking of hard drives
in the sanitization process poses a risk that some hard drives could
make it through this process and be selected for reuse without having
been sanitized. Further, based on the file dates on some of the
computer hard drives that had not yet been sanitized at the San Diego
and Indianapolis medical centers, our IT security specialist noted
excessive delays--up to 6 years--in performing data sanitization once
the computer systems had been identified for removal from use and
disposal. Excessive delays in completing hard drive sanitization and
disposal procedures pose an unnecessary risk when sensitive personal
and medical information that is no longer needed is not removed from
excess computer hard drives in a timely manner.
Physical Security Weaknesses at IT Storage Locations Pose Risk of Data
Breach:
VA Handbook 0730/1, Security and Law Enforcement, prescribes physical
security requirements for storage of new and used IT equipment.
Specifically, the Handbook requires warehouse-type storerooms to have
walls to ceiling height with either masonry or gypsum wall board
reaching to the underside of the slab (floor) above. IRM storerooms are
required to have overhead barricades that prevent "up and over" access
from adjacent rooms. Warehouse, IRM, and medical equipment storerooms
are all required to have motion intrusion detection alarm systems that
detect entry and broadcast an alarm of sufficient volume to cause an
illegal entrant to abandon a burglary attempt. Intrusion detection
alarms for storerooms outside facility grounds, such as outpatient
clinics, are required to be connected remotely to a commercial security
alarm monitoring firm, local police department, or security office
charged with building security. Finally, IRM storerooms also are
required to have special key control, meaning room door lock keys and
day lock combinations that are not master keyed for use by others.
Most of the designated IT equipment storage facilities at the four case
study locations met VA IT physical security requirements in VA Handbook
0730/1; however, we identified some deficiencies. For example, our
investigator found that the Washington, D.C., and San Diego medical
center IRM equipment storerooms lacked motion intrusion detection alarm
systems and the Washington, D.C., medical center IRM storeroom did not
meet door locking requirements. Based on our investigator's findings,
physical security specialists at the San Diego and Washington, D.C.,
medical centers told us they have recommended that required intrusion
detectors be installed in their IRM storerooms. In addition, the
Washington, D.C., medical center reduced the number of keys to its IRM
storerooms and changed storeroom locks to meet established
requirements. Designated IT equipment storage facilities at the
Indianapolis medical center met VA physical security requirements.
Despite the established physical security requirements, we found
numerous informal, undesignated IT equipment storage locations that did
not meet VA physical security requirements. For example, our
investigator observed an IT workroom at the Indianapolis medical center
where new IT equipment was placed on the floor. This room lacked a
motion detection alarm system and the type of locking system prescribed
in VA policy. Indianapolis VA Police told our investigator that such a
level of security was not required for this room under VA policy,
because it was not designated as a storeroom. In addition, at the VA
headquarters building, our investigator found that the physical
security specialist was unaware of the existence of IT equipment in
some storerooms. Thus, these storerooms had not been subjected to
required physical security inspections. VA Police and physical security
specialists at our test locations agreed with our investigator's
assessment that the physical security of these IT storerooms was
inadequate.
During our statistical tests, we observed one IT equipment storeroom in
the VA headquarters building IT Support Services area that had a
separate wall, but no door. As shown in figure 2, the wall opening into
the storeroom had yellow tape labeled "CAUTION" above the doorway. The
store room was within an IT work area that had dropped ceilings that
could provide "up and over" access from adjacent rooms, such as the
employee store, and no alarm or intrusion detector. This storeroom did
not meet VA's physical security requirements for motion intrusion
detection and alarms and secure doors, locks, and special access keys.
Figure 2: Photograph of Unsecured IT Equipment Storeroom in the VA
Headquarters Building:
[See PDF for image]
Source: GAO.
[End of figure]
In another headquarters building, which housed VA's Office of General
Counsel, we observed excess IT equipment, including computers with hard
drives that had been awaiting turn-in and disposal for several months.
This IT equipment was stacked in the corners of a large work area that
had multiple doors and open access to numerous individuals, including
vendors, contractors, employees, and others. Because our limited tests
found sensitive personal data and information on hard drives that had
not yet been sanitized, the failure to provide adequate security leaves
this information vulnerable to data breach. Further, because software
that can be used to image, or copy, this information is readily
available, it is important to provide adequate security for these
items. For example, imaging software, such as "Foremost," which was one
of the imaging software products used by our IT security specialist,
can be downloaded at no cost from the Internet and used to copy
information from one hard drive to another in a few minutes. Thus, it
is possible for a data breach to occur without theft of the IT
equipment on which the data reside.
We also found that VA headquarters IT coordinators used storerooms and
closets with office-type door locks to store IT equipment that was not
currently in use. Other headquarters organizations stored laptops that
were in the "loaner pool" for use by employees on travel or at home in
locked filing cabinets in open areas. In addition, during our test
work, we observed that very few IT equipment items had been secured by
locked cables. Physical security of IT equipment is of particular
concern at the VA medical centers because these centers provide open
access to visitors, students, contractors, and others. The lack of
secure storage leaves this IT equipment and any sensitive personal
information stored on this equipment vulnerable to theft, loss,
misappropriation, and data breach.
VA Actions to Improve IT Management and Controls Have Been Limited:
Although VA has strengthened existing property management
policy[Footnote 47] in response to recommendations in our July 2004
report, issued several new policies to establish guidance and controls
for IT security, and reorganized and centralized the IT function within
the department under the CIO, these actions have not yet been fully
implemented. For example, the CIO has no formal responsibility for
medical equipment that stores or processes patient data. VA
headquarters CIO officials agree that this is an area of vulnerability
that needs to be addressed. In addition, the new CIO organization
structure does not address roles or necessary coordination between IRM
and property management personnel with regard to inventory control of
sensitive IT equipment items. The Assistant Secretary for Information
and Technology, who serves as the CIO, told us that his staff is aware
of this problem and the new CIO organization structure includes a unit
that will have responsibility for IT equipment asset management once it
becomes operational. However, this unit has not yet been funded or
staffed.
Regarding new policies, on October 11, 2005, VA revised its Handbook on
materiel management procedures to emphasize that annual inventory
requirements for sensitive items valued at under $5,000 include IT
equipment, and specifically lists these items as including desktop and
laptop computers, CD drives, printers, monitors, and handheld portable
telecommunication devices. However, as noted in this report, VA has not
ensured that sensitive IT equipment items valued at less than $5,000
have been subjected to annual physical inventories. In addition, on
March 9, 2007, at the time we began briefing VA management on the
results of our audit, VA's Office of Information and Technology issued
a policy[Footnote 48] that includes assignment of user-level
accountability for certain IT equipment, including external drives,
desktop and laptop computers, and mobile phones that can be taken
offsite for individual use. However, this policy had not yet been
coordinated with property management officials who will be responsible
for implementing the policy.
On August 4, 2006, VA issued a new directive entitled Information
Security Program, which requires, in part, periodic evaluations and
testing of the effectiveness of all management, operational, and
technical controls and calls for procedures for immediately reporting
and responding to security incidents. A thorough understanding of the
IT inventory control process and required internal controls within this
process will be key to effective testing and oversight. Managers were
not always aware of the inherent problems in their IT inventory
processes discussed in this report, including the lack of required
controls. Because the directive does not provide specific information
on how these procedures will be carried out, the CIO is developing
supplementary user guides. Effective implementation will be key to the
success of VA IT policy and organizational changes.
Conclusions:
Poor accountability and a weak control environment have left the four
VA case study organizations vulnerable to continuing theft, loss, and
misappropriation of IT equipment and sensitive personal data. To
provide a framework for accountability and security of IT equipment,
the Secretary of Veterans Affairs needs to establish clear,
sufficiently detailed mandatory policies rather than leaving the
details of how policies will be implemented to the discretion of local
VA organizations. Keys to safeguarding IT equipment are effective
internal controls for the creation and maintenance of essential
transaction records; a disciplined framework for specific, individual
user-level accountability, whereby employees are held accountable for
property assigned to them, including appropriate disciplinary action;
and maintaining adequate physical security over IT equipment items.
Although VA management has taken some actions to improve inventory
controls, strengthening the overall control environment and
establishing and implementing specific IT equipment controls will
require a renewed focus, oversight, and continuing commitment
throughout the organization.
Recommendations for Executive Action:
We recommend that the Secretary of Veterans Affairs require that the
medical centers and VA headquarters offices we tested and other VA
organizations, as appropriate, take the following 12 actions to improve
accountability of IT equipment inventory and reduce the risk of
disclosure of sensitive personal data, medical data, or both.
To help minimize the risk of loss, theft, and misappropriation of
government IT equipment used in VA operations, we recommend that the
Secretary take the following eight departmentwide actions.
* Revise VA property management policy and procedures to include
detailed requirements for what transactions must be recorded to
document inventory events and to clearly establish individual
responsibility for recording all essential transactions in the property
management process.
* Revise VA purchase card policy to require purchase card holders to
notify property management officials of IT equipment and other property
items acquired with government purchase cards at the time the items are
received so that they can be recorded in property management systems.
* Establish procedures to require specific, individual user-level
accountability for IT equipment. In implementing this recommendation,
consideration should be given to making the unit head, or a designee,
accountable for shared IT equipment.
* Enforce user-level accountability and IT coordinator responsibility
by taking appropriate disciplinary action, including holding employees
financially liable, as appropriate, for lost or missing IT equipment.
* Establish specific time frames for finalizing a Report of Survey once
an inventory has been completed so that research on missing items is
completed expeditiously and does not continue indefinitely without
meeting formal reporting requirements.
* Establish a mechanism to monitor adherence by the San Diego and
Houston medical centers and other VA organizations, as appropriate, to
VA policy for performing annual inventories of sensitive items under
$5,000, including IT equipment.
* Require that IRM and IT Services personnel at the various medical
centers be given access to the central property database and be
furnished with hand scanners so they can electronically update the
property control records, as appropriate, during installation, repair,
replacement, and relocation or disposal of IT equipment.
* Require physical security personnel to perform inspections of
buildings and storage facilities to identify informal and undesignated
IT storage locations so that security assessments are performed and
corrective actions are implemented, where appropriate.
To assure inventory accuracy and prompt resolution of inventory
discrepancies and improve security of IT equipment and any sensitive
data stored on that equipment, we recommend that the Secretary require
the CIO to take the following four actions.
* Establish a formal policy requiring a review of the results of annual
inventories to ensure that IT equipment inventory records are properly
updated and no blank fields remain.
* Establish a process for reviewing Reports of Survey for lost,
missing, and stolen IT equipment items to identify systemic weaknesses
for appropriate corrective action.
* Establish and implement a policy requiring IRM personnel and IT
coordinators to inform physical security officers of the site of all IT
equipment storage locations so that these store rooms can be subjected
to required inspections.
* Establish and implement a policy for reviewing the results of
physical security inspections of IT equipment storerooms and ensure
that needed corrective actions are completed.
Agency Comments and Our Evaluation:
In written comments dated June 22, 2007, on a draft of this report, VA
generally agreed with our findings, noted significant actions under
way, and concurred on the 12 recommendations. For example, with regard
to establishing detailed requirements for what transactions must be
recorded to document inventory events, VA stated that it is performing
a comprehensive update of department policies and procedures and plans
to provide additional training and equipment audits, as necessary. With
regard to establishing user-level accountability, VA stated that it is
developing a policy that will require (1) unit heads or their designees
to sign for all IT equipment issued to their service/unit and (2) hand
receipts for IT equipment at the user-level.
VA also provided technical comments regarding the information in tables
6 and 7. Specifically, VA stated that our data did not specify whether
the estimated value provided for missing IT equipment was based on a
depreciated loss value or a replacement value. Consistent with VA's
reporting requirements for its Reports of Survey on lost personal
property items, which include IT equipment, we used the original
acquisition value for our estimates. Accordingly, we revised the column
headings in the tables to note that the reported dollar value of
missing items relates to the original acquisition value. Further, VA
stated that some of the missing equipment included in our estimate may,
in fact, have been properly disposed of but the proper documentation
was not available. As stated in our report, proper documentation of key
equipment events, such as transfer, turn-in, and disposal, must be
documented by an inventory transaction, financial transaction, or both,
as appropriate. Because the property system had not been updated to
reflect a transfer, turn-in, or disposal and no hard copy documentation
had been retained, it is not possible to determine whether any of the
missing IT equipment items had been properly sent to disposal, and VA
has no assurance that they were not lost or stolen.
As agreed with your offices, unless you announce its contents earlier,
we will not distribute this report until 30 days from its date. At that
time, we will send copies to interested congressional committees; the
Secretary of Veterans Affairs; the Veterans Affairs Chief Information
Officer; the Acting Secretary of Health, Veterans Health
Administration; and the Director of the Office of Management and
Budget. We will make copies available to others upon request. In
addition, this report will be available at no charge on the GAO Web
site at http://www.gao.gov.
Please contact me at (202) 512-9095 or williamsm1@gao.gov, if you or
your staff have any questions concerning this report. Contact points
for our Offices of Congressional Relations and Public Affairs may be
found on the last page of this report. Major contributors to this
report are acknowledged in appendix III.
Signed by:
McCoy Williams:
Director:
Financial Management and Assurance:
[End of section]
Appendix I: Objectives, Scope, and Methodology:
Pursuant to a request from the Chairman and Ranking Minority Member of
the House Committee on Veterans' Affairs, we audited the Department of
Veterans Affairs (VA) information technology (IT) equipment inventory
controls. Our audit covered the following.
* An assessment of the risk of loss, theft, and misappropriation of VA
IT equipment items based on statistical tests of VA IT equipment
inventory at selected case study locations and our investigator's
evaluations of physical security and VA law enforcement investigations
of incidents of loss or theft.
* Results of physical inventories of IT equipment performed by case
study locations covered in this audit and our previous audit.
* An assessment of the adequacy of VA's physical security and
accountability procedures for IT equipment in the property disposal
process.
* Management actions taken or under way to address previously
identified IT equipment inventory control weaknesses.
We used as our criteria applicable law and VA policy, as well as our
Standards for Internal Control in the Federal Government[Footnote 49]
and our Internal Control Management and Evaluation Tool.[Footnote 50]
To assess the control environment at our test locations, we obtained an
understanding of the processes and controls over IT equipment from
acquisition to issuance and periodic inventories and disposal. We
performed walk-throughs of these processes at all four test locations.
We reviewed applicable program guidance provided by the test locations
and interviewed officials about their IT inventory processes and
controls.
In selecting our case study locations, we chose one location--the
Washington, D.C., VA medical center--that had the most significant
problems identified in our July 2004 report and two other
geographically dispersed VA medical centers. We also tested inventory
at VA headquarters as a means of assessing the overall control
environment, or "tone at the top." Table 8 shows the VA locations
selected for IT equipment inventory control testing and the number and
reported value of IT equipment items at each location.
Table 8: Population of VA IT Equipment at Locations Selected for
Testing:
VA location: Washington, D.C., medical center;
Sample size and number of VA IT equipment items: 168 of 8,728[A];
Value of VA IT equipment inventory: $33,065,322.
VA location: Indianapolis, IN medical center;
Sample size and number of VA IT equipment items: 144 of 7,614;
Value of VA IT equipment inventory: 29,101,577.
VA location: San Diego, CA medical center;
Sample size and number of VA IT equipment items: 148 of 11,604;
Value of VA IT equipment inventory: 48,077,071.
VA location: VA headquarters;
Sample size and number of VA IT equipment items: 344 of 25,353;
Value of VA IT equipment inventory: 31,301,951.
Source: GAO analysis of VA facility IT equipment inventory.
Note: The data represent current inventory at the time we pulled our
samples. The reported value is the original acquisition cost.
[A] Includes 4,127 leased IT equipment items.
[End of table]
To follow up on actions taken in response to recommendations in our
July 2004 report for improving physical inventories, we obtained and
reviewed information on physical inventory results at the four case
study locations as well as the five other case study locations
previously audited.
We performed appropriate data reliability procedures, including an
assessment of each VA test location's procedures for assuring data
reliability, and tests to assure that IT equipment inventory was
sufficiently complete for the purposes of our work. Our procedures and
test work identified a limitation related to IT equipment inventory
completeness at our four test locations. IT equipment inventories at
the Indianapolis and San Diego medical centers and VA headquarters
organizations did not include all IT equipment acquired with purchase
cards or purchased directly from local vendors. Also, the Washington,
D.C., medical center inventory did not include one inventory category
consisting of 149 older computer monitors and workstations. This data
limitation prevented us from projecting our test results to the
population of IT equipment inventory at each of our four test
locations. However, we determined that these data were sufficiently
reliable for us to project our test results to the population of
current, recorded IT equipment inventory at each of the four locations.
From the universe of current, recorded IT equipment inventory at the
time of our tests, we selected stratified random probability samples of
IT equipment, including medical equipment with data storage capability,
at each of the three medical center locations. For the 23 VA
headquarters organizations, we stratified our sample by 6 major offices
and used a seventh stratum for the remaining 17 organizations. With
these statistically valid samples, each item in the population for the
four case study locations had a nonzero probability of being included,
and that probability could be computed for any item. Each sample item
for a test location was subsequently weighted in our analysis to
account statistically for all items in the population for that
location, including those that were not selected.
We performed tests on statistical samples of IT equipment inventory
transactions at each of the four case study locations to assess whether
the system of internal controls over physical IT equipment inventory
was effective (i.e., provided reasonable assurance of the reliability
of inventory information and accountability of the individual items).
For each IT equipment item in our statistical sample, we assessed
whether (1) the item existed (meaning that the item recorded in the
inventory records could be located), (2) inventory records and
processes provided adequate accountability, and (3) identifying
information (property number, serial number, model number, and
location) was accurate. We explain the results of our existence tests
in terms of control failures related to missing items and recordkeeping
errors. The results of our statistical samples are specific to each of
the four test locations and cannot be projected to the population of VA
IT transactions as a whole. We present the results of our statistical
samples for each population as (1) our projection of the estimated
error overall and for each control attribute as point estimates and (2)
the two-sided, 95 percent confidence intervals for the failure rates.
Our investigator supported our tests of IT physical inventory controls
by assessing physical security and reporting of missing items for
purposes of law enforcement investigations. As part of our assessment,
our investigator interviewed VA Police at the three medical centers and
federal agency law enforcement officers at VA headquarters about
reports and investigations of lost, stolen, and missing IT equipment.
Our investigator also met with physical security specialists at each of
the test locations to discuss the results of physical security
inspections and the status of VA actions on identified weaknesses.
To determine if the four test locations had adequate procedures for
control and removal of data from hard drives of IT equipment in the
property disposal process, our IT security specialist selected a
limited number of computer hard drives for testing. We attempted to
test a total of 10 hard drives in each category--drives with data and
drives that had been sanitized--at each of the four test locations.
Because some hard drives we selected were damaged or computer systems
pulled for hard drive testing did not contain hard drives, the number
of hard drives actually tested was less than the number we selected for
testing. At the San Diego medical center, 5 hard drives selected for
testing that were labeled as unerased had in fact been sanitized, and
we included these hard drives in our sanitization testing. Table 9
shows the numbers of hard drives tested at the four locations we
audited.
Table 9: Number of Computer Hard Drives in the Property Disposal
Process Selected for Testing at Four Locations:
Medical centers.
Test location: Washington, D.C;
Drives with data: 4;
Sanitized drives: 4;
Total: 8.
Test location: Indianapolis;
Drives with data: 5;
Sanitized drives: 6;
Total: 11.
Test location: San Diego;
Drives with data: 10;
Sanitized drives: 15;
Total: 25.
VA headquarters offices.
Test location: Veterans Health Administration;
Drives with data: 2;
Sanitized drives: 1;
Total: 3.
Test location: Board of Veterans Appeals;
Drives with data: 6;
Sanitized drives: 8;
Total: 14.
Test location: Office of Cyber Information Security;
Drives with data: 3;
Sanitized drives: 1;
Total: 4.
Test location: VA headquarters, subtotal;
Drives with data: 11;
Sanitized drives: 10;
Total: 21.
Source: GAO analysis.
[End of table]
In performing these tests, our specialist used SMARTTM and Foremost
software. SMARTTM is a software utility that has been designed and
optimized to support forensic data practitioners and information
security personnel in pursuit of their respective duties and goals.
SMARTTM is currently used by federal, state, and local law enforcement;
U.S. military and intelligence organizations; accounting firms; and
forensic data examiners. Foremost is a program used to recover files
based on their headers, footers, and internal data structures.
Foremost, originally developed by the United States Air Force Office of
Special Investigations and the Center for Information Systems Security
Studies and Research, is now available to the general public. In
addition, our investigator performed physical security inspections and
assessed accountability over computer hard drives in the disposal
process.
To identify management actions taken in response to previously
identified control weaknesses, we interviewed VA officials at our test
locations, walked through the IT inventory processes to observe
controls as implemented, and met with VA's Chief Information Officer
(CIO). We also obtained and reviewed copies of new and revised VA
policies and procedures.
We briefed VA managers at our test locations and VA headquarters,
including VA medical center directors, VA headquarters information
resource management and property management officials, and VA's CIO on
the details of our audit, including our findings and their
implications. On April 9, 2007, we requested comments on a draft of
this report. We received comments on June 22, 2007, and have summarized
those comments in the Agency Comments and Our Evaluation section of
this report. We conducted our audit work from September 2006 through
March 2007 in accordance with generally accepted government auditing
standards, and we performed our investigative work in accordance with
standards prescribed by the President's Council on Integrity and
Efficiency.
[End of section]
Appendix II: Comments from the Department of Veterans Affairs:
The Deputy Secretary Of Veterans Affairs:
Washington:
June 22, 2007:
Mr. McCoy Williams:
Director:
Information Management Issues:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 205413:
Dear Mr. Williams:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report: Veterans Affairs:
Inadequate Controls over IT Equipment at Selected VA Locations Pose
Continuing Risk of Theft; Loss, and Misappropriation (GAO-07-505) and
generally agrees with its findings. VA supports GAO's conclusion that
improving the overall control environment for sensitive information
technology (IT) equipment requires renewed focus, oversight, and
continued commitment throughout the organization.
The Department has already taken significant actions, including the
recent transformation of VA's IT program to a single authority under
the Chief Information Officer. This will enable the Department to
centralize and standardize IT equipment accountability policies and
procedures, and replicate identified IT inventory best practices across
VA.
Accomplishing this task will require a concerted effort by many
different offices within the Department. VA will analyze why VA medical
center employees were found to have used their own systems to track IT
equipment assigned to their units instead of updating records through
VA's existing formal control system. Accordingly, the Department will
convene a formal work group to include representatives from at least
the Office of Information and Technology, Office of Acquisition and
Materiel Management, the Office of Security and Law Enforcement, the
Veterans Health Administration, and the Office of Human Resources and
Administration to ensure development of a comprehensive strategy to
address all of GAO's recommendations.
Additionally, during the past 9 months VA Central Office (VACO) has
revised and implemented procedures to improve the reconciliation
process of future annual VACO inventories. These procedures include
refresher training for all Equipment Inventory Listing (EIL) Officials,
incorporating property accountability and responsibility in New
Employee Orientation, and strengthening controls over the employee
clearance process to ensure greater property accountability as
individuals depart VACO.
The Department is finalizing new policy directives that will require
senior IT officials at the facility level to maintain an inventory of
all IT equipment. The VA Office of Acquisition and Materiel Management
provides current policy regarding the use and protection of VA-owned IT
equipment. Department officials will reinforce those policies across
all business lines.
I appreciate your efforts to illuminate continuing weaknesses that
undermine VA's efforts to protect the sensitive personal information
the Department needs to provide services to our Nation's veterans. The
enclosure discusses each of GAO's recommendations in detail. It also
suggests some technical clarification for the report's overall
accuracy.
Sincerely yours,
Signed by:
Gordon H. Mansfield:
Enclosure:
Department of Veterans Affairs (VA) comments to:
Government Accountability Office (GAO) draft report Veterans Affairs:
Inadequate Controls over IT Equipment at Selected VA Locations Pose
Continuing Risk of Theft, Loss, and Misappropriation (GAO-07-505):
To help minimize the risk of loss, theft, and misappropriation of
government IT equipment used in VA operations, GAO recommends that the
Secretary of Veterans Affairs take the following departmentwide
actions.
* Revise VA property management policy and procedures to include
detailed requirements for what transactions must be recorded to
document inventory events and to clearly establish individual
responsibility for recording all essential transactions in the property
management process.
Concur-VA is performing a comprehensive update of Department policies
and procedures on equipment management, and we will include detailed
requirements as appropriate.
To improve awareness of and compliance with existing policies and
procedures, the Veterans Health Administration (VHA) recently issued 11
standard operating procedures with detailed guidance to supplement VA
policy and procedures on equipment management.
In addition, VA's Office of Acquisition and Materiel Management (OA&MM)
is working with VHA, the Veterans Benefits Administration, the National
Cemetery Administration and the Office of Information and Technology
(OI&T) to identify specific ways to improve compliance with VA's
policies and procedures on equipment management. Topics under review
include:
* launch of a nationwide training program on equipment accountability;
* review of logistical organizational structures;
* implementation of a logistics certification program; and:
* issuance of a memorandum to facility directors emphasizing the
importance of equipment management and recommended actions to
strengthen local programs.
Finally, OA&MM is collaborating with VHA's Office of Business Oversight
to include additional areas of audit for equipment management. This
will also include a review of audit findings to determine where
policies and procedures need enhancement.
* Revise VA purchase card policy to require purchase card holders to
notify property management officials of IT equipment and other property
items acquired with a government purchase card at the time the items
are received so that they can be recorded in property management
systems.
Concur - The Office of Finance will revise VA purchase card policy to
require purchase card holders to notify property management officials
of IT equipment and other property items acquired with a government
purchase card at the time the items are received so that they can be
recorded in property management systems. Target completion date is July
2007.
On page 7, under "Requests and Ordering of IT Equipment," the sentence
that begins on line 7 is no longer applicable. Headquarters offices may
no longer place individual orders or use purchase cards to acquire IT
equipment per recent guidance from the Chief Information Officer (CIO).
* Establish procedures to require specific, individual user-level
accountability for IT equipment In implementing this recommendation,
consideration should be given to making the unit head, or a designee,
accountable for shared IT equipment:
Concur - The Office of Information and Technology is developing an
operations policy that requires the senior IT official at a facility to
maintain an inventory of all IT equipment and to have the business/
service unit head or designee sign for all IT equipment issued to their
service/unit. Also, the policy will require issuing of hand receipts
for IT equipment at the user-level.
* Enforce user-level accountability and IT coordinator responsibility
by taking appropriate disciplinary action, including holding employees
financially liable, as appropriate, for lost or missing IT equipment:
Concur-For VA Central Office (VACO), O/A's Property Management Division
is responsible for processing Report of Surveys from Central Office
organizations for lost or damaged VA property. The Property Management
Division will expeditiously assign the Report of Survey to a Survey
Board to determine if the employee(s) should be held financially liable
or if disciplinary actions should be taken as a result of the loss,
damage, or destruction of the property.
When the Survey Board recommends that an employee should be held
financially liable, a copy of the Report of Survey, complete findings
and recommendations will be sent directly to the employee, instructing
them to submit a written concurrence or objections to the findings
within 10 working days to the approving official. An employee's failure
to submit a written reply to the approving official within 10 working
days will be submitted as acceptance of financial liability. Employees
have the right to have an adverse survey finding reviewed by higher
authority if requested within 10 working days after receiving
notification of findings. The decision of the higher approving
authority will be final. VA supervisors are responsible for ensuring
that their employees are held accountable for VA property assigned to
them in performance of their job. Supervisors are also responsible for
any property not directly assigned to an individual employee in their
area.
OIA's Property Management Division is also implementing new VACO
procedures to increase supervisory awareness and accountability for
property lost, damaged, or destroyed by employees under their
supervision, when supported by findings and recommendations from the
Survey Board. This procedure includes the issuance of a memorandum from
the approving official and Report of Survey findings, to the employee's
supervisor with a courtesy copy to the second-line supervisor and
Employee Relations, Central Office Human Resources Service,
recommending that the supervisor take corrective action, including
disciplinary action as appropriate, against the employee. Employee
Relations, Central Office Human Resources Service, will follow up with
the employee's immediate and second-line supervisors to ensure
appropriate action is taken within 45 calendar days.
* Establish specific timeframes for finalizing a Report of Survey once
an Inventory has been completed so that research on missing items is
completed in an expeditious manner and does not continue indefinitely
without meeting formal reporting requirements.
Concur-OI&T is developing an operations policy that will include the
requirement that a Report of Surrey will be completed within 15 working
days following completion of annual inventory. In VACO, after an annual
Equipment Inventory is conducted, the Not Found Property Report must be
reconciled within 15 days of receiving the report. (in the past, the
Office of Administration [OA) has honored organizational requests to
extend this timeframe for equipment believed misplaced rather than
stolen.) Equipment that cannot be reconciled must immediately be
reported on a Report of Survey to the Property Management Division.
Property Management Division will immediately conduct an investigation
on the missing equipment by forming a Board of Survey. Recent
memorandums to the various VACO department heads addressed these
procedures. Details were also provided to Equipment Inventory List
(EIL) Officials in VACO.
* Establish a mechanism to monitor San Diego, California, and Houston,
Texas, medical center and other VA organization adherence as
appropriate, to VA policy for performing annual Inventories of
sensitive items under $5,000, including IT equipment.
Concur-The Veterans Health Administration's (VHA) Prosthetics and
Clinical Logistics Office (P&CLO) is monitoring all VA medical centers
to ensure adherence to policy requiring an annual inventory of all
items. To facilitate this effort, all facilities are required to report
their Electronic Inventory List compliance on a quarterly basis to the
Deputy Under Secretary for Health for Operations and Management
(DUSHOM). This monitoring includes sensitive items under $5,000. P&CLO
will disseminate further direction to the field on sensitive items
through annual training, reminders at the materiel management
conference calls, and e-mails.
* Require that IRM and IT Services personnel at the various medical
centers be given access to the central property database and be
furnished with hand scanners so they can electronically update the
property control records, as appropriate, during installation, repair,
replacement, and relocation or disposal of IT equipment:
Concur-VA's current asset management system (AEMS/MERS) allows for IRM
and IT Services to be given restricted access to the AEMS/MERS system
in order to record/update inventory records to reflect status and
location. Hand scanners can be purchased locally as needed.
Nevertheless, VHA's P&CLO is working with the DUSHOM to disseminate a
memorandum to all VA medical centers directing them to give access to
AEMS/MERS for all applicable information resource management and IT
staff involved in IT asset management. P&CLO and DUSOHOM will provide
direction in the memorandum to ensure open communication between IT
staff and logistics staff in coordination of either procuring bar code
scanners or making available existing bar code scanners at the medical
centers. The memorandum will specify follow-up through regular
conference calls and e-mails as required. Lastly, P&CLO is working with
OI&T to establish better communication in defining roles and
responsibilities of front line staff in updating the equipment records
as appropriate.
* Require physical security personnel to perform inspections of
buildings and storage facilities to identify informal and undesignated
IT storage locations so that security assessments are performed and
corrective actions are implemented, where appropriate.
Concur - The current version of the Security and Law Enforcement policy
(073011) is referenced in this report. This version has undergone a
large-scale revision and is in the Department concurrence process.
There is a new requirement to the revised policy that each VA facility
establish a Security Management Committee (SMC). One of the tasks of
the SMC is to develop a local strategic security plan (SSP). The SSP is
intended as a framework for identifying a facility's security needs and
resolutions.
We also wish to note that specific physical security requirements for
IT resources and spaces have been updated. In addition, IT spaces are
now required to be protected with physical access control systems
(PACS). In previous versions, this was an optional item.
To assure inventory accuracy and prompt resolution of inventory
discrepancies and improve security of IT equipment and any sensitive
data stored on that equipment, GAO recommends that the Secretary
require the CIO to take the following four actions:
* Establish a formal policy requiring a review of the results of annual
inventories to ensure that IT equipment inventory records are properly
updated and no blank fields remain.
Concur -OI&T is developing a policy that requires the senior IT
official at a facility to maintain an inventory of all IT equipment and
to have the business/service unit head or designee sign for all IT
equipment issued to their service/unit. The policy will require issuing
of hand receipts for IT equipment at the user-level. The senior IT
official at a facility will be required to complete an annual survey
that ensures IT equipment inventory records are complete and up-to-
date.
* Establish a process for reviewing Reports of Survey for lost,
missing, and stolen IT equipment items to identify systemic weaknesses
for appropriate corrective action.
Concur-OI&T is developing a policy that will include the requirement
that a report of survey will be completed within 15 working days
following completion of annual inventory. The policy will also require
an analysis of the reports to identify any weakness trends.
* Establish and implement a policy requiring IRM Personnel and IT
coordinators to Inform Physical Security Officers of the location of
all IT equipment storage locations so that these store rooms can be
subjected to required inspections.
Concur - OI&T is developing a policy that will require the senior IT
official at every facility to provide IT equipment storage locations to
facility security personnel to perform regular inspections.
* Establish and implement a policy for reviewing the results of
physical security inspections of IT equipment store rooms and ensure
that needed corrective actions are completed.
Concur- OI&T is developing a policy that will require senior IT
Officials at every site to complete corrective actions addressed from
all physical security inspections of IT equipment store rooms.
Technical comments:
Pages 4 and 20, and Tables 6 and 7, portray IT equipment that cannot be
accounted for as having a combined potential financial loss in the
millions of dollars. However, the report does not specify whether this
cost estimate is provided as a depreciated loss value or a replacement
value. Distinguishing between the two is very important as it directly
impacts the loss estimate value. For instance, if IT equipment was
purchased in previous years, it depreciates at a significant determined
rate. On the other hand, if GAO used replacement costs to estimate the
loss value, it needs to further clarify which year values it used (i.e.
2002 values, 2005 values, or current 2007 values). In addition, the
tally of unaccounted-for equipment that GAO used for its estimate of
loss value was surmised as a result of this audit. However, VA could,
in fact, have properly disposed of some of the "missing" equipment, but
the proper documentation of the disposal is just not available. If this
is the case, then it should not be subject to having a replacement cost
associated with it.
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
McCoy Williams, (202) 512-9095 or williamsm1@gao.gov:
Acknowledgments:
In addition to the contact named above, Gayle L. Fischer, Assistant
Director; Andrew O'Connell, Assistant Director and Supervisory Special
Agent; Abe Dymond, Assistant General Counsel; Monica Perez Anatalio;
James D. Ashley; Francine DelVecchio; Lauren S. Fassler; Dennis Fauber;
Jason Kelly; Steven M. Koons; Christopher D. Morehouse; Chris J.
Rodriguez; Special Agent Ramon J. Rodriguez; Lori B. Tanaka; and
Danietta S. Williams made key contributions to this report.
Technical expertise was provided by Keith A. Rhodes, Chief
Technologist, and Harold Lewis, Assistant Director, Information
Technology Security, Applied Research and Methods.
FOOTNOTES
[1] GAO, VA Medical Centers: Internal Control over Selected Operating
Functions Needs Improvement, GAO-04-755 (Washington, D.C.: July 21,
2004).
[2] Physical inventory is the process of reconciling personal property
records with the property actually on hand.
[3] Department of Veterans Affairs, VA Handbook 7127/3, Materiel
Management Procedures.
[4] For the purpose of this audit, we defined IT equipment as any
equipment capable of processing or storing data, regardless of how VA
classifies it. Therefore, medical devices that would typically not be
classified as IT equipment, but may capture, process, or store patient
data, were considered IT equipment for this audit.
[5] As used in this report, theft and misappropriation both refer to
the unlawful taking or stealing of personal property, with
misappropriation occurring when the wrongdoer is an employee or other
authorized user.
[6] As used in this report, the term excess property refers to property
that a federal agency leases or owns that is not required to meet
either the agency's needs or any other federal agency's needs.
[7] The Washington, D.C., medical center was also covered in our 2004
report.
[8] The universe of IT equipment items for the four test locations did
not include the population of all IT equipment at those locations.
Therefore, we can project our test results to the universe of current,
recorded IT equipment inventory at each location, but not the
population of all IT equipment. Our tests were specific to each of the
case study locations and cannot be projected to VA IT equipment
inventory as a whole.
[9] GAO, Standards for Internal Control in the Federal Government, GAO/
AIMD-00-21.3.1 (Washington, D.C.: November 1999).
[10] Each of these estimates has a margin of error, based on a two-
sided, 95 percent confidence interval, of +/-7 percent or less.
[11] The Report of Survey system is the method used by VA to obtain an
explanation of the circumstances surrounding loss, damage, or
destruction of government property other than through normal wear and
tear.
[12] VA medical centers and other facilities have a VA Police Service,
which provides law enforcement and physical security services,
including security inspections and criminal investigations. The VA
headquarters building does not have a police service. VA headquarters
law enforcement duties are the responsibility of the Federal Protective
Service.
[13] VA IRM personnel and contractors follow National Institute of
Standards and Technology (NIST) Special Publication 800-88 guidelines
as well as more stringent Department of Defense (DOD) policy in DOD
5220.22-M, National Industrial Security Program Operating Manual, ch.
8, § 8-301, which requires performing three separate erasures for media
sanitization.
[14] VA Handbook 7127/4 § 5302.3, "Inventory of Equipment in Use."
[15] 44 U.S.C. §§ 3101 and 3102, and implementing NARA regulations at
36 C.F.R. § 1222.38. This is consistent with the more general
requirement for agencies to establish internal controls under 31 U.S.C.
§ 3512 (c), (d), commonly known as the Federal Managers' Financial
Integrity Act of 1982 (FMFIA), and GAO/AIMD-00-21.3.1.
[16] VHA has 21 VISNs that oversee medical center activities within
their area, which may cover one or more states.
[17] VA Handbook 7127, Materiel Management Procedures (Sept. 19, 1995),
required that all sensitive items, including those valued under $5,000,
be inventoried regardless of cost. According to VA Handbook 7127/1
(Oct. 21, 1997), records of property costing $5,000 or greater will be
maintained in AMES/MERS. In addition to assets valued over $5,000, VA
Handbook 7124/4 (Oct. 11, 2005) added a further explanation that
sensitive items include handheld and portable telecommunication
devices, printers, data storage equipment (e.g., desktop and laptop
computers), video imaging equipment, cell phones, radios, motor
vehicles, and firearms and ammunition.
[18] VA Handbook 7127/4, Materiel Management Procedures (Oct. 11,
2005).
[19] VA Handbook 7125, Materiel Management General Procedures, pt. 5, §
5101-8.
[20] Privacy Act of 1974, codified, as amended, at 5 U.S.C. § 552a.
[21] HIPAA required the Secretary of Health and Human Services (HHS) to
submit to Congress detailed recommendations on standards related to the
privacy of individually identifiable health information, including an
individual's rights with respect to such information, procedures for an
individual to exercise those rights, and the authorized uses and
disclosures of such information by others, such as health care
providers and insurers. The HHS Secretary has prescribed such standards
in the HIPAA Medical Privacy Rule. See Pub. L. No. 104-191, § 264, 110
Stat. 1936, 2033-34 (Aug. 21, 1996), and implementing regulations at 45
C.F.R. pt. 164.
[22] Federal Prison Industries, Inc. (also known as UNICOR) is a wholly
owned U.S. government corporation, which operates factories and employs
inmates in federal prisons. See 31 U.S.C. § 9101 (3)(E), 18 U.S.C. §§
4121-4129.
[23] GAO/AIMD-00-21.3.1.
[24] Privacy Act of 1974, codified, as amended, at 5 U.S.C. § 552a.
[25] The HHS Secretary has prescribed standards for safeguarding
medical information in the HIPAA Medical Privacy Rule. See 45 C.F.R.
pt. 164.
[26] VA Handbook 7125, Materiel Management General Procedures, § 5003
(Oct. 11, 2005).
[27] VA Handbook 7127/3, Material Management Procedures, pt. 1 § 5002-
2.3, and VA Handbook 7127/4, Material Management Procedures, pt. 4, §
5302.3.
[28] The two-sided, 95 percent confidence interval for this estimate is
from 21 percent to 35 percent.
[29] VA Directive 6300, Records and Information Management, § 2 (Jan.
12, 1998).
[30] 44 U.S.C. §§ 3101 and 3102, and implementing NARA regulations at
36 C.F.R. § 1222.38. This is consistent with the more general
requirement for agencies to establish internal controls under 31 U.S.C.
§ 3512 (c), (d), commonly known as FMFIA, and GAO/AIMD-00-21.3.1.
[31] The two-sided, 95 percent confidence interval for this estimate is
from 2 percent to 13 percent.
[32] VA Handbook 1730/1, Use and Management of the Government Purchase
Card Program (June 17, 2005).
[33] Asset visibility refers to accurate and timely information on the
location, movement, status, and identifying information for property
and equipment assets.
[34] The two-sided, 95 percent confidence interval for this estimate is
from 5 percent to 17 percent.
[35] VA Handbook 7127/4, Materiel Management Procedures, pt. 1, §
5002.2 and pt. 4, § 5302.3 (Oct. 11, 2005).
[36] The two-sided, 95 percent confidence interval for this estimate is
from 8 percent to 15 percent.
[37] VA Handbook 7125, Materiel Management General Procedures, § 5003.
[38] The margin of error, based on a two-sided, 95 percent confidence
interval is +/-3 percent.
[39] A hand receipt is a document used to assign individual custody of
a government-furnished equipment item. At VA headquarters a hand
receipt includes the description and bar code number of the item, and
it is signed by the employee responsible for the equipment and an
authorizing official.
[40] The Report of Survey System is the method used by VA to obtain an
explanation of the circumstances surrounding loss, damage, or
destruction of government property other than through normal wear and
tear.
[41] VA Handbook 7125, Materiel Management General Procedures, pt. 5, §
5101 and § 5101-21.
[42] VA medical centers and other facilities have a VA Police Service,
which provides law enforcement and physical security services,
including security inspections and criminal investigations. The VA
headquarters building does not have a police service. VA headquarters
law enforcement duties are the responsibility of the Federal Protective
Service.
[43] The Washington, D.C., medical center was covered in both audits.
[44] VA IRM personnel and contractors follow NIST Special Publication
800-88 guidelines as well as more stringent DOD policy in DOD 5220.22-
M, National Industrial Security Program Operating Manual, ch. 8, § 8-
301, which requires performing three separate erasures for media
sanitization.
[45] Privacy Act of 1974, codified, as amended, at 5 U.S.C. § 552a.
[46] Pub. L. No. 104-191, § 264, 110 Stat. 1936, 2033-34 (Aug. 21,
1996), and implementing regulations at 45 C.F.R. pt. 164.
[47] VA Handbook 7127/4, Materiel Management Procedures (Oct. 11,
2005).
[48] Universal Serial Bus (USB) Flash Drive User Guide 2.0 (Mar. 9,
2007).
[49] GAO, Standards for Internal Control in the Federal Government,
GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999). This document was
prepared to fulfill our statutory requirement under 31 U.S.C. 3512 (c),
(d), commonly known as the Federal Managers' Financial Integrity Act of
1982, to issue standards that provide the overall framework for
establishing and maintaining internal control.
[50] GAO, Internal Control Management and Evaluation Tool, GAO-01-1008G
(Washington, D.C.: August 2001). This document was prepared to assist
agencies in maintaining or implementing effective internal control and,
when needed, to help determine what, where, and how improvements can be
implemented. Although this tool is not required to be used, it is
intended to provide a systematic, organized, and structured approach to
assessing the internal control structure.
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