Veterans Affairs: Inadequate Controls over IT Equipment at	 
Selected VA Locations Pose Continuing Risk of Theft, Loss, and	 
Misappropriation (16-JUL-07, GAO-07-505).			 
                                                                 
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. 	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-505 					        
    ACCNO:   A72709						        
  TITLE:     Veterans Affairs: Inadequate Controls over IT Equipment  
at Selected VA Locations Pose Continuing Risk of Theft, Loss, and
Misappropriation						 
     DATE:   07/16/2007 
  SUBJECT:   Accountability					 
	     Equipment inventories				 
	     Federal property management			 
	     Information technology				 
	     Internal controls					 
	     Inventory control					 
	     Inventory control systems				 
	     Physical security					 
	     Property and supply management			 
	     Property losses					 
	     Records management 				 
	     Risk assessment					 
	     Veterans hospitals 				 
	     Policies and procedures				 

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GAO-07-505

   

     * [1]Results in Brief
     * [2]Background

          * [3]Previously Reported Weaknesses in IT Inventory Controls
          * [4]VA's IT Property Management Process

               * [5]Request and Ordering of IT Equipment
               * [6]Recording of IT Equipment Acquisitions in Inventory
                 Records
               * [7]Issuance and Replacement of IT Equipment
               * [8]Physical Inventories of IT Equipment and Reports of
                 Survey
               * [9]Approval for Turn-in and Disposal
               * [10]Removal of Data from Hard Drives
               * [11]Final Disposition of IT Equipment

     * [12]Inadequate IT Inventory Control and Accountability Pose Risk

          * [13]Inventory Tests Identified Significant Numbers of Missing It

               * [14]Washington, D.C., Medical Center
               * [15]Indianapolis Medical Center
               * [16]San Diego Medical Center
               * [17]VA Headquarters Offices

          * [18]Pervasive Lack of User-Level Accountability for IT Equipment
          * [19]Errors in IT Equipment Inventory Status and Item Description
          * [20]Physical Inventories by Case Study Locations Identified Thou
          * [21]Physical Inventories Performed by Four Case Study Locations
          * [22]Physical Inventories by Five Locations Previously Audited Al

     * [23]Physical Security Weaknesses Increase Risk of Loss, Theft, a

          * [24]Weaknesses in Procedures for Controlling Excess Computer Har
          * [25]Physical Security Weaknesses at IT Storage Locations Pose Ri

     * [26]VA Actions to Improve IT Management and Controls Have Been L
     * [27]Conclusions
     * [28]Recommendations for Executive Action
     * [29]Agency Comments and Our Evaluation
     * [30]Appendix I: Objectives, Scope, and Methodology
     * [31]Appendix II: Comments from the Department of Veterans Affair
     * [32]Appendix III: GAO Contact and Staff Acknowledgments

          * [33]GAO Contact
          * [34]Acknowledgments

               * [35]Order by Mail or Phone

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

Contents

Letter 1

Results in Brief 4
Background 7
Inadequate IT Inventory Control and Accountability Pose Risk of Loss,
Theft, and Misappropriation 13
Physical Security Weaknesses Increase Risk of Loss, Theft, and
Misappropriation of IT Equipment and Sensitive Data 29
VA Actions to Improve IT Management and Controls Have Been Limited 34
Conclusions 35
Recommendations for Executive Action 36
Agency Comments and Our Evaluation 37
Appendix I Objectives, Scope, and Methodology 39
Appendix II Comments from the Department of Veterans Affairs 44
Appendix III GAO Contact and Staff Acknowledgments 53

Tables

Table 1: Current IT Equipment Inventory Control Failure Rates at Four Test
Locations 14
Table 2: Number of Missing IT Equipment Items at Four Test Locations,
Including Items That Could Have Stored Sensitive Information 15
Table 3: Number of Missing IT Equipment Items by Headquarters Office and
Missing Items That Could Have Stored Sensitive Personal Data and
Information 20
Table 4: Estimated Percentage of IT Inventory Control Failures Related to
Correct User and Location at the Four Test Locations 22
Table 5: Estimated Percentage of Other IT Inventory Recordkeeping Failures
at Four Test Locations 24
Table 6: Summary of Physical Inventories and Missing IT Equipment
Identified by the Four Current Case Study Locations as of February 28,
2007 27
Table 7: Summary of Physical Inventories and Missing IT Equipment
Identified by Five Case Study Locations Previously Audited as of March 2,
2007 29
Table 8: Population of VA IT Equipment at Locations Selected for Testing
40
Table 9: Number of Computer Hard Drives in the Property Disposal Process
Selected for Testing at Four Locations 42

Figures

Figure 1: VA's IT Property Management Process 8
Figure 2: Photograph of Unsecured IT Equipment Storeroom in the VA
Headquarters Building 33

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

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
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separately.

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 reported1 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 inventories2 and maintaining their property management
systems, which resulted in reduced property accountability. For example,
VA's Handbook 7127/3, Materiel Management Procedures3 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.

1 GAO, VA Medical Centers: Internal Control over Selected Operating
Functions Needs Improvement, [36]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.

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,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 misappropriation5 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;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.7

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.

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.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.

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.

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 Government9 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.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.

9 GAO, Standards for Internal Control in the Federal Government,
[37]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.

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 Survey11 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,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.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.

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, S 8-301,
which requires performing three separate erasures for media sanitization.

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
Procedures14 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.

14 VA Handbook 7127/4 S 5302.3, "Inventory of Equipment in Use."

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

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.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),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.

15 44 U.S.C. SS 3101 and 3102, and implementing NARA regulations at 36
C.F.R. S 1222.38. This is consistent with the more general requirement for
agencies to establish internal controls under 31 U.S.C. S 3512 (c), (d),
commonly known as the Federal Managers' Financial Integrity Act of 1982
(FMFIA), and [38]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.

  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.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.

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.

  Physical Inventories of IT Equipment and Reports of Survey

VA policy18 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
policy19 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.

18 VA Handbook 7127/4, Materiel Management Procedures (Oct. 11, 2005).

19 VA Handbook 7125, Materiel Management General Procedures, pt. 5, S
5101-8.

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 197420 and, when information
concerns an individual's health, the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) and implementing regulations.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.,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.

20 Privacy Act of 1974, codified, as amended, at 5 U.S.C. S 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, S 264, 110 Stat. 1936,
2033-34 (Aug. 21, 1996), and implementing regulations at 45 C.F.R. pt.
164.

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 Government23 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.

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. S 9101 (3)(E), 18 U.S.C. SS
4121-4129.

23 [39]GAO/AIMD-00-21.3.1 .

Table 1: Current IT Equipment Inventory Control Failure Rates at Four Test
Locations

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.

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 197424 and
information concerning an individual's health is accorded additional
protections from unauthorized release under HIPAA and implementing
regulations.25 Although VA property management policy26 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 policy27 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.

24 Privacy Act of 1974, codified, as amended, at 5 U.S.C. S 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, S 5003 (Oct.
11, 2005).

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

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.

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.

27 VA Handbook 7127/3, Material Management Procedures, pt. 1 S 5002-2.3,
and VA Handbook 7127/4, Material Management Procedures, pt. 4, S 5302.3.

  Washington, D.C., Medical Center

Our physical inventory existence testing at the Washington, D.C., medical
center identified an estimated 28 percent failure rate28 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 policy29 that implements
federal records management law and NARA guidance30 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.

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, S 2 (Jan. 12,
1998).

30 44 U.S.C. SS 3101 and 3102, and implementing NARA regulations at 36
C.F.R. S 1222.38. This is consistent with the more general requirement for
agencies to establish internal controls under 31 U.S.C. S 3512 (c), (d),
commonly known as FMFIA, and [40]GAO/AIMD-00-21.3.1 .

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
percent31 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.

31 The two-sided, 95 percent confidence interval for this estimate is from
2 percent to 13 percent.

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 policy32 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 visibility33 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 percent34 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 policy35 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.

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.

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.

35 VA Handbook 7127/4, Materiel Management Procedures, pt. 1, S 5002.2 and
pt. 4, S 5302.3 (Oct. 11, 2005).

  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 rate36 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

Source: GAO analysis.

aAll other includes 17 additional VA headquarters organizations. The
missing item in this category related to the Human Resource Management
Office.

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.

36 The two-sided, 95 percent confidence interval for this estimate is from
8 percent to 15 percent.

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,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.

37 VA Handbook 7125, Materiel Management General Procedures, S 5003.

Table 4: Estimated Percentage of IT Inventory Control Failures Related to
Correct User and Location at the Four Test Locations

Source: GAO analysis.

Note: The percentages represent point estimates and the two-sided, 95
percent confidence interval.

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.38 Further, although VA headquarters
officials told us they use hand receipts39 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.

38 The margin of error, based on a two-sided, 95 percent confidence
interval is +/- 3 percent.

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.

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.

Table 5: Estimated Percentage of Other IT Inventory Recordkeeping Failures
at Four Test Locations

Source: GAO analysis.

Note: The percentages represent point estimates and the two-sided, 95
percent confidence interval.

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 Survey40 information on identified
losses of IT equipment. VA policy41 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.

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, S 5101
and S 5101-21.

According to VA Police and security specialists,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.

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.

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

Source: GAO analysis.

aThe San Diego medical center IT Services personnel inventoried only items
valued at $5,000 or more.

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 locations43 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.

43 The Washington, D.C., medical center was covered in both audits.

Table 7: Summary of Physical Inventories and Missing IT Equipment
Identified by Five Case Study Locations Previously Audited as of March 2,
2007

Source: GAO analysis.

aThe Houston medical center inventoried only items valued at $5,000 or
more.

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.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 197445 and personal medical information accorded additional
protections under HIPAA46 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.

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, S 8-301, which
requires performing three separate erasures for media sanitization.

45 Privacy Act of 1974, codified, as amended, at 5 U.S.C. S 552a.

46 Pub. L. No. 104-191, S 264, 110 Stat. 1936, 2033-34 (Aug. 21, 1996),
and implementing regulations at 45 C.F.R. pt. 164.

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

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 policy47 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 policy48 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.

47 VA Handbook 7127/4, Materiel Management Procedures (Oct. 11, 2005).

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.

48 Universal Serial Bus (USB) Flash Drive User Guide 2.0 (Mar. 9, 2007).

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.

           o 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.
           o 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.
           o 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.
           o 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.
           o 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.
           o 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.
           o 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.
           o 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.

           o 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.
           o Establish a process for reviewing Reports of Survey for lost,
           missing, and stolen IT equipment items to identify systemic
           weaknesses for appropriate corrective action.
           o 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.
           o 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 [41][email protected] , 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.

           McCoy Williams
			  Director
			  Financial Management and Assurance
			  
			  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.

           o 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.
           o Results of physical inventories of IT equipment performed by
           case study locations covered in this audit and our previous audit.
           o An assessment of the adequacy of VA's physical security and
           accountability procedures for IT equipment in the property
           disposal process.
           o 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 Government1 and
           our Internal Control Management and Evaluation Tool.2 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.
			  
1 GAO, Standards for Internal Control in the Federal Government,
[48]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.

2 GAO, Internal Control Management and Evaluation Tool, [49]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.

           Table 8: Population of VA IT Equipment at Locations Selected for
           Testing

           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.

           aIncludes 4,127 leased IT equipment items.

           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

           Source: GAO analysis.

           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.
			  
			  Appendix II: Comments from the Department of Veterans Affairs

           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.
			  
			  Appendix III: GAO Contact and Staff Acknowledgments
			  
			  GAO Contact

           McCoy Williams, (202) 512-9095 or [email protected]
			  
			  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.
			  
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For more information, contact McCoy Williams at (202) 512-9095 or
[email protected].

Highlights of [51]GAO-07-505 , a report to congressional requesters

July 2007

VETERANS AFFAIRS

Inadequate Controls over IT Equipment at Selected VA Locations Pose
Continuing Risk of Theft, Loss, and Misappropriation

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.

[52]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.

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.

Current IT Inventory Control Failures at Four Test Locations

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.

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.

References

Visible links
  36. http://www.gao.gov/cgi-bin/getrpt?GAO-04-755
  37. http://www.gao.gov/cgi-bin/getrpt?GAO/AIMD-00-21.3.1
  38. http://www.gao.gov/cgi-bin/getrpt?GAO/AIMD-00-21
  39. http://www.gao.gov/cgi-bin/getrpt?GAO/AIMD-00-21.3.1
  40. http://www.gao.gov/cgi-bin/getrpt?GAO/AIMD-00-21.3.1
  41. mailto:[email protected]
  42. http://www.gao.gov/
  43. http://www.gao.gov/
  44. http://www.gao.gov/fraudnet/fraudnet.htm
  45. mailto:[email protected]
  46. mailto:[email protected]
  47. mailto:[email protected]
  48. http://www.gao.gov/cgi-bin/getrpt?GAO/AIMD-00-21
  49. http://www.gao.gov/cgi-bin/getrpt?GAO-01-1008G
  50. http://www.gao.gov/cgi-bin/getrpt?GAO-07-505
  51. http://www.gao.gov/cgi-bin/getrpt?GAO-07-505
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