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%pR0^° OFFICE OF INSPECTOR GENERAL
Operating efficiently and effectively
EPA Needs to Address
Internal Control
Deficiencies in the
Agencywide Quality System
Report No. 20-P-0200	June 22, 2020
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Agencywide
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Report Contributors:
Patrick Gilbride
Erin Barnes-Weaver
Alicia Buchanan
Jenny Drzewiecki
Fred Light
Abbreviations
CIO
Chief Information Officer
EPA
U.S. Environmental Protection Agency
EQMD
Enterprise Quality Management Division
GAO
U.S. Government Accountability Office
OEIP
Office of Enterprise Information Programs
OIG
Office of Inspector General
OMS
Office of Mission Support
ORD
Office of Research and Development
QSA
Quality System Assessment
Cover Image: A graphic representing the agencywide Quality System. (EPA OIG graphic)
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* *. U.S. Environmental Protection Agency	20-P-0200
§ mmj \ Office of Inspector General	June 22,2020
UsSi
At a Glance
Why We Did This Project
A November 2018 U.S.
Environmental Protection
Agency Office of Inspector
General scientific integrity
survey yielded hotline
complaints on potential internal
control issues with the EPA's
Quality System. We conducted
this audit to determine whether
the Office of Mission Support
has controls in place to carry
out its responsibility in
developing and coordinating
the mandatory agencywide
Quality System.
The Quality System provides
requirements for conducting
quality management activities
for all environmental data
collection performed by or for
the Agency. Its primary goal is
to ensure that environmental
data are of sufficient quantity
and quality to support intended
uses. Each EPA office
implements a quality system,
and Quality System staff is
responsible for its oversight,
policies, procedures, training,
and tracking.
This report addresses the
following:
•	Operating efficiently and
effectively.
This project addresses a key
EPA management challenge:
•	Improving data quality and
filling identified data gaps.
Address inquiries to our public
affairs office at (202) 566-2391 or
OIG WEBCOMMENTS@epa.gov.
List of OIG reports.
EPA Needs to Address Internal Control
Deficiencies in the Agencywide Quality System
After five years and
$1.3 million towards
the development of
an agencywide
tracking system, the
OMS does not know
the status of the
agencywide Quality
System.
What We Found
The OMS has not fully implemented internal controls for
the mandatory agencywide Quality System. We found
that the OMS has not reviewed policies, procedures,
and guidance within required time frames. For example,
reviews of two quality policies were 15 years overdue.
We also found that the OMS has not conducted required
annual reviews for five years. The OMS has also not
conducted regular assessments of program and regional
quality systems as more than half of the systems had
not had a review in the past six years. Also, the OMS has not assessed staff and
resource needs since 2008, and the OMS has not performed a programmatic risk
assessment. Additionally, the OMS has not developed a strategic plan,
implemented a tracking system, or provided agencywide training.
OMS leaders and staff identified four factors that led to control deficiencies:
(1)	Quality System leaders overtime have had varying priorities;
(2)	Quality System staff had a backlog of work; (3) Quality System leaders
determined that variations in the length, details, and format of annual reviews
made them difficult to analyze and compare; and (4) the Quality System lacked
resources for its work.
The EPA and the public rely upon the quality of the Agency's data, which helps
the Agency make reliable, cost-effective, and defensible decisions. Additionally,
the EPA uses its Quality System to manage the quality of its environmental data
generation, collection, and use. The Quality System covers activities such as
determining hazardous or toxic wastes in the environment and establishing
health risk levels, supporting enforcement monitoring efforts, and mapping
human health risk data. Poor data quality negatively impacts the EPA's
effectiveness in monitoring programs that directly impact public health and could
also subject the EPA to significant financial and legal risks.
OMS leaders agree that the Quality System needs improvement and are taking
steps to strengthen its internal control system. However, until the OMS fully
implements internal controls, it cannot know the status or health of the
agencywide Quality System.
Recommendations and Planned Agency Corrective Actions
We made 15 recommendations to the assistant administrator for Mission Support
to improve internal controls for the agencywide Quality System. The OMS agreed
with 13 recommendations, which are either completed or resolved with corrective
actions pending. The OMS disagreed with two recommendations which are
unresolved with resolution efforts in progress.

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UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, D.C. 20460
THE INSPECTOR GENERAL
June 22, 2020
MEMORANDUM
SUBJECT: EPA Needs to Address Internal Control Deficiencies in the Agencywide Quality System
Report No. 20-P-0200
This is our report on the subject audit conducted by the Office of Inspector General of the
U.S. Environmental Protection Agency. The project number for this audit was OA&E-FY19-0329. This
report contains findings that describe the problem the OIG has identified and corrective actions the OIG
recommends.
The Office of Enterprise Information Programs' Enterprise Quality Management Division, within the
Office of Mission Support, is primarily responsible for the subjects discussed in this report.
Action Required
While your office provided acceptable corrective actions and estimated milestone dates for most OIG
recommendations, which are resolved, this report also contains two unresolved recommendations. In
accordance with EPA Manual 2750, the resolution process for the two unresolved recommendations
begins immediately with the issuance of this report. We are requesting a meeting within 30 days between
the director of the Office of Enterprise Information Programs and the OIG's assistant inspector general
for Audit and Evaluation. We also request a written response to the final report within 60 days of this
memorandum. Your response will be posted on the OIG's website, along with our memorandum
commenting on your response. Your response should be provided as an Adobe PDF file that complies
with the accessibility requirements of Section 508 of the Rehabilitation Act of 1973, as amended. The
final response should not contain data that you do not want to be released to the public; if your response
contains such data, you should identify the data for redaction or removal along with corresponding
justification. If resolution is still not reached, the Office of Mission Support is required to complete and
submit a dispute resolution request to the chief financial officer.
We will post this report to our website at www.epa.gov/oig.
FROM:
Sean W. O'Donnell
TO:
Donna J. Vizian, Principal Deputy Assistant Administrator
Office of Mission Support

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EPA Needs to Address Internal Control Deficiencies
in the Agencywide Quality System
20-P-0200
Table of C
Chapters
1	Introduction	 1
Purpose	 1
Background	 1
Responsible Office	 6
Scope and Methodology		6
2	Further Efforts Needed to Implement Controls		8
Control Environment		9
Risk Assessment		13
Control Activities		13
Information and Communication		15
Monitoring	 16
Conclusions	 18
Agency Response and OIG Assessment		19
Status of Recommendations and Potential Monetary Benefits		20
Appendices
A Agency Response to Draft Report	 21
B Distribution	 25

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Chapter 1
Introduction
Purpose
The U.S. Environmental Protection Agency Office of Inspector General
conducted a scientific integrity survey in late 2018, which yielded several hotline
complaints that indicated potential
internal control issues with the EPA's
Quality System overseen by the
Agency's Office of Mission Support.
The hotline complaints pertained to
leadership, organization, staffing, and
tracking of Quality System documents.
We conducted this audit to determine
whether the OMS has controls in place to carry out its responsibility in
developing and coordinating the mandatory agencywide Quality System.
Background
EPA's Agencywide Quality System
The EPA's agencywide Quality System
provides requirements for conducting
quality management activities for all
environmental data collected by or for
the Agency. According to the EPA's
"About EPA's Quality System"
webpage, the primary goal of the
Quality System is to "ensure that [the
Agency's] environmental data are of
sufficient quantity and quality to
support the data's intended use." The
Quality System provides the framework
for planning, implementing,
documenting, and assessing work
performed by the Agency, and for
carrying out required quality assurance
and quality control activities.
Examples of activities covered by the Quality System include:
•	Characterizing or evaluating ecological systems or human health.
•	Monitoring effluent discharges from operations.
Key Management Challenge
This audit addresses the following key
management challenge for the Agency, as
identified in OIG Report No. 19-N-0235,
FY 2019 EPA Management Challenges,
issued July 15, 2019:
• Improving data quality and filling
identified data qaps.
Environmental data are any measures or
information that describe environmental
processes, locations, or conditions;
ecological or health effects and
consequences; or the performance of
environmental technology.
For the EPA, environmental data include
both primary data (i.e., information collected
directly from measurements) and secondary
or existing data collected for other purposes
or obtained from other sources (e.g.,
literature, industry surveys, models,
databases, and information systems).
Source: EPA, Overview of the EPA Quality
System for Environmental Data and
Technology (November 2002).
20-P-0200
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•	Mapping environmental conditions or human health risk data.
•	Developing models to characterize environmental processes.
•	Establishing ambient air conditions.
According to the EPA, successful implementation of the Quality System leads to:
•	Scientific data integrity: The EPA will produce data of known and
documented quality based on sound scientific principles.
•	Reduced or justifiable resource expenditures: The EPA can reduce
resource expenditures if the information collected matches the EPA's
information needs. Through proper planning, the EPA will collect only the
correct type, amount, and quality data for its use.
•	Proper evaluation of internal and external activities: The EPA Quality
System provides documentation of activities and improved oversight for
evaluation purposes, which reduces the potential for waste and abuse.
•	Reliable and defensible decisions: It is easier to determine whether the
data can be used for a specific decision when the quality of data is known.
This reduces surprises and challenges to, among other things, regulations
and permits.
•	Burden reduction: As the EPA better defines the data needed for a specific
application, the burden on other organizations that are required to collect
or report data to the EPA may be reduced.
The agencywide Quality System covers all EPA offices, regions, and laboratories
that collect, evaluate, or use environmental data, or design, construct, or operate
environmental technology. The Quality System comprises more than 40
individual quality systems developed and implemented by the various EPA
regions, national program offices, and the Office of Research and Development.
Because of the diversity and dispersion of programs within the EPA, different
organizations within the Agency have individual quality systems that specifically
address their needs.
Figure 1 depicts the main components of the EPA Quality System.
20-P-0200
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Figure 1: Components of the EPA Quality System

Project Planning
£
Training
Methods and techniques to ensure
responsible personnel have the
skills and knowledge to complete
tasks in accordance with their
organizational quality system's
policies and procedures
Documented in Quality Assurance Project Plan
to develop data performance criteria, a plan to
satisfy criteria, and quality control activifes to
ensure criteria are satisfied

Organizational
Assessment
Quality System Assessments to
determine compfiance with
regulations and conformance to
policies and plans
Annual Reviews
& Planning
Quality Assurance Annual Report and Wortc
Plan submitted by each organization
Project
Ov j Implementation
Agencywide Quality System
£
Ensure EPA environmental data are
of sufficient quantity and quality to
support the data's intended use.
Documentation
Quality Management Plans describing
authorities, policies, procedures, and
training specificto the organization
Data collected and environmental
technology implemented according to
the Quality Assurance Project Plan
and standard operating procedures
Project
Assessment
Verify, validate, and analyze data
to determine if Quality Assurance
Project Plan performance criteria
and users' needs are met
I ~l Policies
Internal documents for EPA
organizations and Federal
Acquisition Regulations for non-
EPA organizations
Source; EPA OIG graphic based on Quality System documents.
Responsibility for the EPA's Quality System
The deputy assistant administrator for Environmental Information in the
OMS, who is also the chief information officer, serves as the senior quality
management official for the Agency and is responsible for assessing and
approving each EPA organization's quality system.
The OMS is responsible for developing, coordinating, and overseeing the
agencywide Quality System. The Environmental Quality Management
Division in the Office of Enterprise Information Programs has oversight
responsibility of the system. EQMD's Quality System staff conducts program
implementation and coordinates with program and regional offices. The
EQMD staff were developing the Quality Assurance Enterprise Management
System, an agencywide tracking system that the EPA planned to implement in
fiscal year 2020. As of November 2019, the EQMD had eight full-time
equivalent staff. Table 1 lists Quality System responsibilities for the EQMD.
20-P-0200
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Table 1: EQMD's responsibilities for the agencywide Quality System
Quality System policies
Develop and issue policies for agencywide use.
Quality Management Plan
Review and approve the EPA organization's plan.
Quality System
procedures and guidance
Develop and issue procedures and guidance for the
EPA and non-EPA organizations funded by the EPA.
Resources for Quality
System activities
Monitor and balance resource allocation across the
Agency and recommend improvements.
Quality System
Assessments
Periodically review each EPA organization, identify
agencywide problems, and mandate corrective
actions.
Quality Assurance Annual
Report and Work Plan
Compile information in a report to the OMS assistant
administrator and the EPA administrator.
Communication and
outreach
Perform outreach by hosting monthly conference
calls, participate in the annual National Quality
Assurance Conference, and represent the EPA on
quality practices and issues.
Training
Develop and issue training materials and provide
generic training on a limited basis.
Employee evaluation
(performance) standards
Develop and issue general standards policy.
Source: OIG analysis of Quality System policies, procedures, and guidance.
In addition to Quality System staff within the EQMD, quality assurance
managers in each program and regional office serve as the primary contacts
for their organization's quality system.
Oversight responsibility for the agencywide Quality System has switched
offices within the EPA. This function was in the ORD before the EPA
transferred it to the then-newly formed Office of Environmental Information
in 2000. It was renamed and reorganized under the OMS in 2018. All OMS
Quality System leadership changed in FY 2019, including a new CIO, OEIP
director and deputy, and EQMD director.
Policy and Program Requirements
Since 1979, the Agency required all EPA offices and all non-EPA
organizations performing work on behalf of the Agency through extramural
agreements, such as contractors, to participate in the Quality System. Each
EPA office is required to develop and implement a quality system that
complies with EPA Order CIO 2105.0 Policy and Program Requirements for
the Mandatory Agency-Wide Quality System, approved May 5, 2000. That
Order establishes the minimum requirements for quality systems that collect,
evaluate, and use environmental data by or for the EPA.
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The EPA's centralized Quality Staff develops management practices and
documents for use agencywide to enable effective planning, implementation,
documentation, and assessment of individual quality systems. This includes
developing and maintaining numerous policies, procedures, and guidance
documents, such as those found on the EPA's Quality System website. The EPA
Quality Manual for Environmental Programs, CIO 2105-P-01-0, dated May 5,
2000, makes all EPA quality-related requirements and guidance documents
valid for five years from the approval date, at which time the Agency must take
action to reaffirm the document's validity, revise it, or delete it from the
agencywide Quality System.
Federal and Agency Guidance on Internal Controls
The U.S. Government Accountability Office defines internal control as:
[A] process effected by an entity's oversight body, management,
and other personnel that provides reasonable assurance that the
objectives of an entity will be achieved. ... Internal control
comprises the plans, methods, policies, and procedures used to
fulfill the mission, strategic plan, goals, and objectives of the
entity.1
An internal control system is defined as:
[A] continuous built-in component of operations, effected by
people, that provides reasonable assurance, not absolute assurance,
that an entity's objectives will be achieved. ... Internal control is
not one event, but a series of actions that occur throughout an
entity's operations. ... Management is responsible for an effective
internal control system. As part of this responsibility, management
sets the entity's objectives, implements controls, and evaluates the
internal control system.2
Table 2 lists the five components and 17 principles of internal control. The GAO
notes that the "17 principles support the effective design, implementation, and
operation of the associated components and represent [the] requirements
necessary to establish an effective internal control system."
1	GAO, Standards for Internal Control in the Federal Government, GAO-14-704G, at 5 (September 2014).
2	Ibid, at 5-6.
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Table 2: Internal control components and principles
Components
Principles
Control
Environment
1.	Demonstrate commitment to integrity and ethical values.
2.	Exercise oversight responsibility.
3.	Establish structure, responsibility, and authority.
4.	Demonstrate commitment to competence.
5.	Enforce accountability.
6.	Define objective and risk tolerances.
7.	Identify, analyze, and respond to risks.
8.	Assess fraud risk.
9.	Identify, analyze, and respond to change.
10.	Design control activities.
11.	Design activities for information systems.
12.	Implement control activities.
13.	Use quality information.
14.	Communicate internally.
15.	Communicate externally.
16.	Perform monitoring activities.
17.	Remediate deficiency.	
Risk Assessment
Control Activities
Information and
Communication
Monitoring
Source: OIG summary of the GAO's Standards for Internal Control in the Federal Government,
GAO-14-704G, September 2014.
The Office of Management and Budget Circular A-123, Management's
Responsibility for Enterprise Risk Management and Internal Control, issued July
2016, defines obligations for risk management and internal control in federal
agencies. EPA Order 1000.24 CHG 2, Management's Responsibility for Internal
Control, approved July 18, 2008, requires all EPA organizations to establish and
maintain internal controls to achieve effective and efficient program operations,
including evaluating internal controls on an ongoing basis and taking prompt
actions to correct any vulnerabilities identified.
The OEIP's EQMD is primarily responsible for the subjects discussed in this
report.
We performed our work from September 2019 through April 2020. We conducted
this performance audit in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objective. We believe that the
evidence obtained provides a reasonable basis for our findings and conclusions
based on our audit objective.
We assessed internal controls necessary to satisfy the audit objective. In
particular, we assessed all internal control components and underlying principles
Responsible Office
Scope and Methodology
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as each was significant to the audit objective. Table 2 lists internal control
components and underlying principles significant to the audit objective.
To answer our objective, we reviewed the EPA's quality policies, procedures, and
guidance documents as well as other Agency materials including websites,
training courses, budget, and resources. We interviewed key OMS staff and
managers responsible for the Quality System, including the chief information
officer, OEIP director and deputy director, the current and former EQMD
director, and EQMD's Quality System staff. We also attended monthly quality
community calls and reviewed Quality Management Plans, QSAs, and the new
tracking system's test environment. We benchmarked where other federal
agencies organizationally place their quality systems.
In addition, to obtain feedback on the EPA's Quality System, we interviewed:
•	Hotline complainants and EPA quality contacts suggested by
complainants.
•	A random sample of ten national Quality System personnel, many of
whom serve as quality assurance managers for their organizations.
•	Four regional quality assurance managers.
We reviewed federal and Agency guidance on internal controls as well as OMS's
annual management integrity assurance letters for the past four years.
Additionally, we reviewed prior relevant reports issued by the OIG, including our
annual list of EPA management challenges which identified "data quality" as an
Agency challenge for nine years including fiscal years 2001-2007, 2018, and
2019. We also reviewed GAO's prior reports, as well as a 2014 program
evaluation of the EPA's Quality System conducted by an outside contractor.
20-P-0200
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Chapter 2
Further Efforts Needed to Implement Controls
The OMS has not fully implemented internal controls for the mandatory
agencywide Quality System. GAO's Standards for Internal Control in the
Federal Government describes management's responsibility for an effective
internal control system. As part of this responsibility, per GAO, management sets
the entity's objectives, implements controls, and evaluates the internal control
system using the five components of internal control. We identified issues that the
OMS as with all five components of the internal control system:
•	Control Environment: The OMS has not developed a strategic plan,
defined objectives, provided oversight via annual reporting, or adequately
assessed the workload for the Quality System staff.
•	Risk Assessment: Absent a strategic plan and objectives, the OMS has not
conducted a risk assessment to define risk tolerances or identify risks
requiring mitigation.
•	Control Activities: The OMS has not reviewed policies, procedures, and
guidance within required time frames. For example, reviews of two quality
policies were 15 years overdue. Additionally, the OMS has not provided
agencywide training in over two years.
•	Information and Communication: The EPA's Quality System website has
numerous outdated policies, procedures, and guidance documents, as well
as inaccuracies in its list of the EPA's national quality system personnel.
Additionally, half of 26 interviewees expressed concerns about the
adequacy of OMS's communication and outreach.
•	Monitoring: The OMS did not address three recommendations from a
November 2014 program evaluation. Additionally, the OMS has not
implemented a tracking system.
OMS leaders and staff identified four factors that led to control deficiencies:
(1)	Quality System leaders over time have had varying priorities;
(2)	Quality System staff had a backlog of work; (3) Quality System leaders
determined that variations in the length, details, and format of annual reviews
made them difficult to analyze and compare; and (4) the Quality System lacked
resources for its work.
The EPA and the public rely upon the quality of the Agency's data. For the
public, data quality directly impacts decision quality, and poor data quality can
mask risks to public health. Quality data helps the Agency make reliable, cost-
20-P-0200
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effective, and defensible decisions. Additionally, the EPA uses its Quality System
to manage the quality of its environmental data generation, collection, and use.
The Quality System covers activities such as determining hazardous or toxic
wastes in the environment and establishing health risk levels, supporting
enforcement monitoring efforts, and mapping human health risk data. Poor data
quality negatively impacts the EPA's effectiveness in overseeing programs that
directly impact public health and could also subject the EPA to significant
financial and legal risks.
OMS leaders agree that the Quality System needs improvement and are taking
steps to strengthen its internal control system. However, until the OMS fully
implements internal controls, it cannot know the status or health of the
agencywide Quality System.
Control Environment
Per GAO's federal internal control standards, the control environment is the
foundation for an internal control system and includes, among other things,
exercising oversight responsibilities and developing a strategic plan and
objectives as well as accompanying structure and staffing plans. In reviewing the
control environment for the Quality System, we found that the OMS has not
developed a strategic plan, defined objectives, provided oversight via annual
reporting, or adequately assessed the workload for the Quality System staff.
Interviewees noted that responsibility for the EPA's Quality System varies from
the Agency's past structure, and we found that placement varies from quality
systems at other federal agencies.
Absence of Strategic Plan, Objectives, and Required Reporting
The OMS has not developed a strategic plan
or defined objectives for the Quality System.
A strategic plan would help the EPA's
national Quality System personnel and other
stakeholders understand the goals, objectives,
and priorities for the Quality System, and
help the OMS evaluate performance against
those objectives. The lack of a strategic plan
and defined objectives resulted from varying
priorities of different Quality System leaders
over time. OMS leaders indicated that they
are working on strategic planning and setting
goals. As of June 2020, the OEIP had
finalized a mission statement and the EQMD
had developed draft strategic priorities.
OEIP Mission Statement:
To provide our partners and
customers innovative products and
services that improve the access,
management, and value of the EPA's
information in support of its mission to
protect human health and the
environment.
Draft EQMD Strategic Priorities:
•	Lead the Agency's quality
program.
•	Engage internal customers as
strategic partners.
•	Provide services and tools quickly
and cost effectively to states and
tribes.
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The OMS has not followed the requirements of EPA Order CIO 2105.0. For
example:
•	Required annual reviews, called Quality Assurance Annual Report and
Work Plans, have not occurred since fiscal year 2016, and OMS leaders
indicated that these reviews will not occur in fiscal year 2020.
•	Not all organizations have approved Quality Management Plans. These
plans document an organization's quality policy, describe its quality
system, and identify environmental programs to which the quality system
applies. In October 2019, the EQMD extended the expiration date of the
Quality Management Plans and provided a sequence for submitting new
plans to the OMS for review and approval.
•	Required periodic assessments, or QSAs, have not occurred. The
Agency's senior management official for Quality is required to perform
periodic management assessments of all EPA organizations. EPA
organizations are required to perform assessments of the effectiveness of
their quality system at least annually. The OMS has not completed
management assessments of most EPA organizations in more than six
years even though they should be completed on a three-year cycle. The
OMS uses these assessments to determine the effectiveness of each
organization's quality system and recommend corrective actions. OMS
leaders indicated that assessments will not resume until fiscal year 2021.
OMS leaders said they ceased requiring annual reports because the reports varied
in length, detail, and format, making them difficult to review, analyze, and
compare reported information. OMS leaders acknowledged issues with the
Quality System and stated they want to develop clear goals and objectives prior to
reinstituting required reporting. In December 2019, the EQMD had developed a
tactical priority to "eliminate overdue reports." OMS leaders noted that absent
required reporting, they do not know the
status or the health of program or
regional quality systems.
Decrease in Quality System Staff
Resulting in a Backlog of Work
Interviewees expressed concern about
the decrease in OMS Quality System
staff and the impact to workload (Figure
2). In 2000, there were 17 full-time
equivalent staff and, as of November
2019, there were eight, a decrease of
nearly 53 percent.
Figure 2: Quality System Staff
12 of 26
interviewees
expressed concerns
about the low
number of quality
system staff
Source: OIG data based on interviews.
(OIG image)
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OMS leaders said they did not realize that the Quality System had higher staff
levels in the past. Quality System staff described a significant backlog of work
due to lower staffing numbers. While the OMS noted that the Office of the Chief
Financial Officer leads the Agency's workload analysis, the OMS plans to
conduct its own staff assessment to help ensure that skills and competencies align
with Quality System tasks.
Office Responsible for the Quality System Varies from the EPA's
Past Structure and from Other Federal Agencies
Per GAO's control standards, management should establish the organizational
structure necessary to enable it to plan, execute, control, and assess the
organization in achieving its objectives. As described in Chapter 1, the EPA
placed oversight responsibility for the agencywide Quality System in the ORD
until 2000 when the EPA transferred it to the Office of Environmental
Information, and then to the OMS in 2018. From 2000 onward, the Quality
System reported to the assistant administrator for Environmental Information. As
shown on Figure 3, the EPA moved the Quality System lower organizationally to
the divisional level in the EQMD by 2018.
Figure 3: Changes overtime in organizational placement of the EPA Quality
System and number of Quality System staff
Administrator
Level
G
Assistant
Administrator
Level
tJ
Office
Level

Divisional
Level
2000
2018
Source: OIG graphic based on analysis of Quality System organization and staffing.
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While we did not find evidence of clear negative impacts from moving the
Quality System to the divisional level, interviewees described the agencywide
program as less influential and said that internal processes take longer.
Additionally, almost half of the interviewees stated that the OMS is not the
appropriate office for the agencywide Quality System (Figure 4). In addition to
the Quality System, other OMS functions include information technology,
contracts and grants management, and human capital. The OMS also houses the
CIO. Interviewees expressed concerns that the more immediate needs related to
information technology tended to take
precedence over the Quality System.
We found that nine out of the 14 agencies
we benchmarked housed their quality
programs and systems separately from
information technology. Four interviewees,
including some within the EQMD,
recommended connecting the Quality
System with other components like
scientific integrity and peer review, which
are under the ORD. OMS and ORD leaders
have discussed whether the Quality System
should return to the ORD and have agreed
to postpone the decision to allow the
ORD's reorganization, initiated in
September 2019, more time to mature. The
chief information officer said that the OMS and the ORD discussions include
assessing structurally where the Quality System would best fit. OMS leaders
added that they will continue to work to improve the Quality System while it
remains OMS's responsibility.
Control Environment Recommendations
We recommend that the assistant administrator for Mission Support:
1.	Develop and implement a strategic plan and objectives for the agencywide
Quality System.
2.	Develop and implement a standard operating procedure to conduct annual
reviews of program and regional quality systems.
3.	Determine the skillsets needed to fulfill responsibilities for developing and
coordinating the agencywide Quality System.
4.	Work with the Office of the Chief Financial Officer to conduct a workload
analysis for the agencywide Quality System.
Figure 4: Organizational placement
12 of 26
interviewees
expressed concerns
about
Quality System
placement
in the OMS
Source: OIG data based on interviews.
(OIG image)
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Risk Assessment
Per GAO's federal internal control standards, internal control should provide an
assessment of the risks that the agency faces from both internal and external
sources. Once risks have been identified, they should be analyzed for their
possible effect. After setting program objectives, risk assessment requires
agencies to identify vulnerabilities that could impede the efficient and effective
achievement of those objectives. Management should then formulate an approach
for risk management and put controls in place to mitigate those risks, including
during times of change.
The OMS has not developed a strategic plan or objectives for the agency wide
Quality System, nor has the OMS conducted a risk assessment. OMS leaders said
that they did not need to conduct a formal risk analysis to recognize problems
with the Quality System. They further stated that they want to address other issues
first, such as policy updates and training, before conducting an in-depth risk
analysis. Until the OMS develops a strategic plan and objectives, it cannot define
risk tolerances or identify risks that require mitigation. However, we agree with
the OMS on the immediate need to address risks related to policy updates and
training.
Risk Assessment Recommendation
We recommend the assistant administrator for Mission Support:
5. Conduct and document an internal control risk assessment on the
agencywide Quality System based on the Office of Mission Support's
strategic plan for the Quality System.
Control Activities
Per GAO's federal internal control standards, control activities are the actions
management takes to achieve objectives and respond to risks, such as
implementing policies and procedures. Control activities include reviewing actual
performance to planned or expected results, such as through annual reporting and
managing human capital through training and other tools. We found that the OMS
did not review quality policies, procedures, and guidance within the required
five-year approval time frame or reaffirm the validity of some policies. We also
found that the OMS did not provide agencywide training.
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Outdated and Unclear Policies, Procedures, and Guidance
Per the EPA Quality Manual for Environmental Programs, all EPA quality-related
requirements and guidance documents are valid for a period of five years from the
approval date, at which time the OMS must take action to reaffirm the document's
validity, revise it, or delete it. The OMS has not reviewed most of its quality
policies, procedures, or guidance within
the required five-year approval time frame
(Figure 5). For example, the OMS began
reviewing EPA Order CIO 2105.0 15
years after its review date. We found that
25 out of 26 Quality System documents
on the EPA quality website are overdue
for review. We also found the validity of
the EPA's Quality Policy, CIO 2106.0,
approved on October 20, 2008, unclear
because the OMS has neither
implemented nor rescinded it.
Interviewees expressed concerns about the
adequacy of Quality System documents.
Outdated or unclear policies lead to
confusion among national Quality System
personnel and inconsistent program
implementation across the Agency.
OMS leaders agreed that, over the years, core Quality System aspects like policy
updates were not completed as they were not a focus of the leaders at the time.
According to one OEIP senior leader, the lack of updated policies has weakened
the entire Quality System, which is essential to the EPA's mission. OEIP's
director added that, anytime a program is not running well, or is perceived to not
run well, it exposes the Agency to vulnerability. As of December 2019, the
EQMD had developed a tactical priority to update quality directives and guidance
to improve the Quality System.
Absence of Agencywide National Training
EPA Order CIO 2105.0 requires the OMS to provide training for all levels of
management and staff so that they understand quality management
responsibilities and requirements at every stage of project implementation.
Furthermore, EPA Order CIO 2105.0 requires sufficient resources to assure
performance of an adequate level of quality assurance and quality control
activities. The OMS has not provided agencywide training in over two years.
Figure 5: Overdue reviews
25 of 26
^policies, procedures/
and guidance are
outside of the five-
year review and
approval date
Source: OIG data based on EPA
documents. (OIG image)
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OMS leaders attributed this to a lack of
resources and a training approach that did
not have leadership buy-in. Interviewees
told us that they would like more training,
particularly for new staff as well as for
grant recipients (Figure 6). Interviewees
added that, without needed training,
Quality System staff may inconsistently
review project-specific plans that require
approval, and interviewees said that old
training and outdated documents on the
EPA website led to confusion. OMS
leaders said they are developing five
training modules: Overview, Quality
Assurance Manager/Management, Project
Manager, Senior Executive, and Quality
Assurance Field Activities.
Control Activities Recommendations
We recommend the assistant administrator for Mission Support:
6.	Develop and implement a plan and timeline to review and act on all
outdated quality policies, procedures, and guidance documents.
7.	Develop and deploy agencywide training modules.
8.	Develop and require training for new Quality System personnel.
Information and Communication
Per GAO's federal internal control standards, for an agency to execute and control
its operations, it must have relevant and reliable information. An agency should
record and communicate information to management and other stakeholders in a
form and within a time frame that enables the agency to carry out its operational
responsibilities. We found that the Quality System website had numerous
outdated policies, procedures, and guidance documents, including the EPA's
Quality Policy, CIO 2106.0, which has not been implemented or rescinded.
Furthermore, we found inaccuracies in the EPA's list of national Quality System
personnel. As noted previously, reductions in the number of Quality System staff,
down by 53 percent over the past 20 years, has resulted in a workload backlog,
including website updates and timely reviews of policies, procedures, and
guidance. Inaccuracies on the Quality System website lead to confusion on
applicable policies and current national contacts, thus diminishing the website's
value. In February 2020, the EQMD indicated that it began updating the estimated
Figure 6: Training concerns
interviewees
expressed concerns
about
training
Source: OIG data based on interviews.
(OIG image)
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400 pages under the Quality System domain, including updating all organization
names and Quality System contacts.
Additionally, although the EQMD conducts a monthly informational
teleconference for the EPA's quality community, half of the interviewees
expressed concerns about the adequacy of OMS's communication and outreach.
Interviewees indicated that in-depth discussions on the Quality System cannot
occur during the monthly calls because of the large number of varied participants,
which may lead some personnel to not participate at all. As of December 2019,
the EQMD had a tactical priority to strengthen communications with internal
quality partners.
Information and Communication Recommendations
We recommend the assistant administrator for Mission Support:
9.	Update the EPA Quality System website to reflect the current status of all
policies, procedures, and guidance, as well as Quality System contacts.
10.	Query national Quality System personnel on the value and frequency of
Quality System communication methods and revise methods as needed,
depending on the input received.
Monitoring
Per GAO's federal internal control standards, monitoring the internal control
system is an essential and dynamic process that continually adapts to meet the
risks and changes an entity faces. Internal control monitoring should assess the
quality of performance over time and promptly resolve findings of audits and
other reviews. Additionally, management should build monitoring activities, such
as automated tools, into an entity's operations and evaluate results. We found that
the OMS did not address three of the six recommendations from a 2014 EPA-
contracted program evaluation conducted by an outside contractor. We also found
that the OMS has not yet implemented an agencywide tracking system to monitor
Quality System activities and evaluate results. Additionally, the OMS has not
finalized core metrics or reporting requirements for the new tracking system.
Prior Recommendations Not Addressed
An outside contractor conducted a program evaluation of the EPA's Quality
System and issued a report in November 2014, titled, Evaluating the Effectiveness
of the EPA Quality System. The report made six recommendations; however, the
OMS did not complete actions on the following three recommendations:
• "Work with program partners to define [OMS's] role and clarify Quality
System guidance.
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•	"Develop a comprehensive staffing plan to address vacancies and skills
gaps in the Quality System.
•	"Rebrand the EPA's Quality System to increase support from project
personnel and senior managers."
OMS leaders said that while they have started some work on the first
recommendation to define OMS's role and clarify guidance, they have not
produced any updated Quality System guidance in several years. As noted, OMS
leaders said they plan to work on a staff skillset assessment and increase support
for the Quality System. Per GAO's federal internal control standards, corrective
actions from audits and other reviews complement control activities to achieve
objectives.
Absence of Agencywide Tracking System
Since 2015, the OMS has invested $1.3 million in developing an agencywide
quality tracking system. The OMS said that the tracking system should simplify
and modernize the quality assurance annual reporting process by tracking EPA
organizations' quality information and providing a holistic picture of the current
state of quality in the Agency. In addition to tracking organizations' quality
information, the OMS said that the system should facilitate knowledge exchange
through sharing templates, standard operating procedures, and best practices. In
order to realize the benefits of efficiency and cost reduction, the OMS said that its
new tracking system would have replaced approximately 80 systems used across
the Agency. However, some EPA organizations plan to maintain their existing
individual tracking systems until they have assurance that the new system will
meet organizational needs. Two programs indicated that they would each invest
about $100,000 annually to maintain their systems.
Although the OMS has developed a measure that tracks the review and approval
time of state and tribal Quality Assurance Project Plans, it has not finalized core
program metrics or reporting requirements for the new tracking system. OMS
leaders said they wanted new metrics developed that had senior leadership buy-in
and wanted to ensure that the metrics could measure program requirements, such
as Quality Management Plans and QSAs. Developing new metrics and data
migration from existing systems delayed the rollout and implementation of the
new agencywide tracking system.
Without an agencywide tracking system, the OMS could not readily provide us
with a list of required and completed QSAs. Without QSAs, the OMS cannot
monitor deficiencies or determine needed corrective actions. Absent these
monitoring activities, the OMS cannot assess the quality of performance over time
and promptly resolve issues. Furthermore, if multiple tracking systems continue to
exist, the OMS will not realize the benefits of efficiency and cost reduction.
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In March 2020, the OMS formed a team to review the planned tracking system
and other quality assurance system capabilities and make recommendations to the
CIO. In May 2020, after we issued our draft report, the OMS team met with the
CIO to discuss the path forward on developing a reporting tool for tracking annual
reporting. The CIO decided to disinvest in the agencywide tracking system and to
leave in place the approximately 80 tracking tools used across the Agency. The
CIO agreed with the OMS team that requirements for annual reporting need to
occur and be reflected in quality documents prior to developing any
enterprisewide system.
Monitoring Recommendations
We recommend the assistant administrator for Mission Support:
11.	Address the three unimplemented recommendations from the 2014
program evaluation by the outside contractor to work with program
partners to define the role of the Office of Mission Support and clarify
Quality System guidance, develop a comprehensive staffing plan to
address vacancies and skill gaps in the Quality System, and rebrand the
EPA's Quality System to increase support from project personnel and
senior managers.
12.	Develop and implement a means to track Quality System Assessments.
13.	Complete Quality System Assessments for organizations that are outside
of the required three-year assessment time frame.
14.	Complete development and rollout of an agencywide tracking system that
includes finalized core metrics.
15.	Coordinate with program and regional offices to eliminate redundant or
duplicative tracking systems.
Conclusions
The OMS had not implemented needed internal control components intended to
provide reasonable assurance that the OMS can carry out its responsibility in
developing and coordinating the mandatory agencywide Quality System. OMS's
leaders have recognized that they could improve controls and have initiated
actions to strengthen the agency's Quality System. These improvements, along
with our recommendations, will help the OMS achieve the primary goal of the
Quality System: To ensure that the EPA's environmental data are of sufficient
quantity and quality to support the data's intended use.
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Agency Response and OIG Assessment
The OMS concurred with Recommendations 1-8 and 10-13 and provided
estimated corrective action dates, and those recommendations are resolved with
corrective actions pending. The OMS completed Recommendation 9 and we
corresponded with the OMS to verify website updates and corrections.
Recommendations 14 and 15 are unresolved with resolution efforts in progress. In
its response to Recommendation 14, the OMS said that "the CIO determined that
a single enterprise approach does not meet the unique tracking and programmatic
needs of the Regions, National Programs and the Office of Research and
Development." We note that the CIO made this determination despite the OMS's
five-year and $1.3 million investment in developing the agencywide tracking
system. We continue to believe that the OMS needs a monitoring approach that
meets the goals of the planned agencywide tracking system, which includes
simplifying annual reporting, providing a holistic picture on the state of quality in
the Agency, and exchanging knowledge through shared procedures and practices.
Absent an enterprisewide monitoring or tracking system, it is unclear how the
OMS will achieve these goals. Moreover, the CIO's decision to leave the tracking
systems in place in program and regional offices means the Agency continues to
have redundant and duplicative systems, a risk which Recommendation 15 is
designed to address.
The Agency's full response to the draft report is in Appendix A.
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Status of Recommendations and
Potential Monetary Benefits
RECOMMENDATIONS
Rec.
No.
Page
No.
Subject
Status1
Action Official
1	12 Develop and implement a strategic plan and objectives for the
agencywide Quality System.
2	12 Develop and implement a standard operating procedure to
conduct annual reviews of program and regional quality systems.
3	12 Determine the skillsets needed to fulfill responsibilities for
developing and coordinating the agencywide Quality System.
4	12 Work with the Office of the Chief Financial Officer to conduct a
workload analysis for the agencywide Quality System.
5	13 Conduct and document an internal control risk assessment on the
agencywide Quality System based on the Office of Mission
Support's strategic plan for the Quality System.
6	15 Develop and implement a plan and timeline to review and act on
all outdated quality policies, procedures, and guidance
documents.
7	15 Develop and deploy agencywide training modules.
8	15 Develop and require training for new Quality System personnel.
9	16 Update the EPA Quality System website to reflect the current
status of all policies, procedures, and guidance, as well as Quality
System contacts.
10	16 Query national Quality System personnel on the value and
frequency of Quality System communication methods and revise
methods as needed, depending on the input received.
11	18 Address the three unimplemented recommendations from the
2014 program evaluation by the outside contractor to work with
program partners to define the role of the Office of Mission
Support and clarify Quality System guidance, develop a
comprehensive staffing plan to address vacancies and skill gaps
in the Quality System, and rebrand the EPA's Quality System to
increase support from project personnel and senior managers.
12	18 Develop and implement a means to track Quality System
Assessments.
13	18 Complete Quality System Assessments for organizations that are
outside of the required three-year assessment time frame.
14	18 Complete development and rollout of an agencywide tracking
system that includes finalized core metrics.
15	18 Coordinate with program and regional offices to eliminate
redundant or duplicative tracking systems.
Planned
Completion
Date
Potential
Monetary
Benefits
(in $000s)
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
Assistant Administrator for
Mission Support
12/31/21
6/30/22
12/31/21
12/31/21
12/31/21
6/30/22
6/30/22
1/15/21
5/14/20
12/31/20
12/31/21
12/31/21
6/30/25
1C = Corrective action completed.
R = Recommendation resolved with corrective action pending.
U = Recommendation unresolved with resolution efforts in progress.
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Appendix A
Agency Response to Draft Report
UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, D.C. 20460
OFFICE OF MISSION SUPPORT
MEMORANDUM
SUBJECT: Response to Office of Inspector General Draft Report No. OA&E-FY 19-0329 "EPA
Needs to Address Internal Control Deficiencies in the Agencywide Quality Systemdated
April 13,2020
FROM: Vaughn Noga, Chief Information Officer VAUGHN NOGA 13^2020.05.14 07:29:19
Thank you for the opportunity to respond to the subject audit report. The following summarizes
the agency's overall position. For those report recommendations with which the agency agrees,
we have provided high-level intended corrective actions with completion dates. For the report
recommendation that the agency does not agree, we have explained our position.
AGENCY'S OVERALL POSITION
The Office of Mission Support (OMS) supports thirteen (13) of the report recommendations and
disagrees with two. Successful resolution for several of the corrective actions is dependent upon
the resolution of other corrective actions. OMS' Enterprise Quality Management Division
(OMS/EQMD) depends on the cooperation of the entire agency's Quality Assurance Community
to successfully resolve the proposed corrective actions. The agency's Quality System is instituted
all across the agency with OMS/EQMD providing oversight, guidance and training. It is
important to recognize that different agency programs and regions approach quality differently.
Therefore, we want to avoid instituting a one-size-fits-all approach to Quality at EPA because it
will not be successful.
AGENCY'S RESPONSE TO REPORT RECOMMENDATIONS
The chart below provides corrective actions and target completion dates for each of the report
recommendations that the agency agrees with.
Digitally signed by VAUGHN
TO:
Patrick Gilbride,
Director, Environmental Research Programs
Office of Inspector General
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Agreements
No.
Recommendation
High-level
Corrective Action(s)
Target
Completion Date
1
Develop and implement a strategic
plan and objectives for the
agencywide Quality System.
Develop and implement a strategic
plan and objectives for the agency-
wide Quality System.
December 31,
2021
2
Develop and implement a standard
operating procedure to conduct
annual reviews of program and
regional quality systems.
Develop and implement a standard
operating procedure to conduct
annual reviews of program and
regional quality systems.
June 30, 2022
3
Determine the skill sets needed to
fulfill responsibilities for
developing and coordinating the
agencywide Quality System.
Determine the skill sets needed to
fulfill responsibilities for developing
and coordinating the agencywide
Quality System.
December 31,
2021
4
Work with the Office of the Chief
Financial Officer to conduct a
workload analysis for the
agencywide Quality System.
Work with the Office of the Chief
Financial Officer to conduct a
workload analysis for the
agencywide Quality System.
December 31,
2021
5
Conduct and document an internal
control risk assessment on the
agencywide Quality System based
on the Office of Mission Support's
strategic plan for the Quality
System.
Conduct and document an internal
control risk assessment on the
agencywide Quality System based
on the Office of Mission Support's
strategic plan for the Quality
System.
December 31,
2021
6
Develop and implement a plan and
timeline to review and act on all
outdated quality policies,
procedures, and guidance
documents.
Develop and implement a plan and
timeline to review and act on all
outdated quality policies,
procedures, and guidance
documents.
June 30, 2022
7
Develop and deploy agencywide
training modules.
Develop and deploy agencywide
training modules.
June 30, 2022
8
Develop and require training for
new Quality System personnel.
OMS is finalizing a Quality Program
course and will deploy this in
FedTalent before the end of the
calendar year.
January 15, 2021
9
Update the EPA Quality System
website to reflect the current status
of all policies, procedures, and
guidance as well as Quality System
contacts.
Update the EPA Quality System
website to reflect the current status
of all policies, procedures, and
guidance as well as Quality System
contacts each quarter.
Complete
10
Query national Quality System
personnel on the value and
frequency of Quality System
communication methods and revise
Query national Quality System
personnel on the value and
frequency of Quality System
communication methods and revise
December 31,
2020
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No.
Recommendation
High-level
Corrective Action(s)
Target
Completion Date

methods as needed, depending on
the input received.
methods as needed, depending on
the input received.

11
Address the three unimplemented
recommendations from the 2014
program evaluation by Industrial
Economics to work with program
partners to define the role of the
Office of Mission Support and
clarify Quality System guidance,
develop a comprehensive staffing
plan to address vacancies and skill
gaps in the Quality System, and
rebrand the EPA's Quality System
to increase support from project
personnel and senior managers.
Address the three unimplemented
recommendations from the 2014
program evaluation by Industrial
Economics to work with program
partners to define the role of the
Office of Mission Support and
clarify Quality System guidance,
develop a comprehensive staffing
plan to address vacancies and skill
gaps in the Quality System, and
rebrand the EPA's Quality System
to increase support from project
personnel and senior managers.
December 31,
2021
12
Develop and implement a means to
track Quality System Assessments.
Develop and implement a means to
track Quality System Assessments.
December 31,
2021
13
Complete Quality System
Assessments for organizations that
are outside of the required three-
year assessment time frame.
Complete Quality System
Assessments for organizations that
are outside of the required three-year
assessment time frame on a rolling
basis driven by the submission of
new Quality Management Plans
(QMPs) from each RPIO.
June 30, 2025
Disagreement
The chart below notes the report recommendations that the agency does not agreement along
with detailed explanations.
No.
Recommendation
Agency Response
Proposed Alternative
14
Complete
development and
rollout of the
agency wide
tracking system
that includes
finalized core
metrics.
In response to an April 17,
2020, EQMD and Quality
Community report to the CIO,
he decided that QA annual
reporting requirements need to
be determined and approved
by management in an updated
Agency Quality Policy and
Procedure. Also, the CIO
determined that a single
enterprise approach does not
meet the unique tracking and
programmatic needs of the
N/A
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No.
Recommendation
Agency Response
Proposed Alternative


Regions, National Programs
and the Office of Research and
Development.

15
Coordinate with
program and
regional offices to
eliminate
redundant or
duplicative
tracking systems.
EPA already has a robust
process to address redundant
and duplicative tracking
systems at the enterprise level.
The CIO's October 1,2019
policy, "Improving the
Management of Small and
Non-Investments", establishes
Mission Investments and uses
financial IT data and data from
EPA's READ system to
streamline systems.
EPA will not create a
redundant policy on reducing
and eliminating redundant
applications just for tracking
systems. The agency will
continue managing this process
through the enterprise
approach.
N/A
CONTACT INFORMATION
If you have any questions regarding this response, please contact Mitchell Hauser, OMS's audit
follow-up coordinator on (202) 564-7636.
cc: Erin Collard
Dan Coogan
Jan Jablonski
Monisha Harris
Marilyn Armstrong
Mitchell Hauser
Jeffrey Wells
Katherine Chalfant
Erin Barnes-Weaver
Alicia Buchanan
Jenny Drzewiecki
Fred Light
Annette Morant
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Appendix B
Distribution
The Administrator
Assistant Deputy Administrator
Associate Deputy Administrator
Chief of Staff
Deputy Chief of Staff/Operations
Agency Follow-Up Official (the CFO)
Agency Follow-Up Coordinator
General Counsel
Associate Administrator for Congressional and Intergovernmental Relations
Associate Administrator for Public Affairs
Assistant Administrator for Mission Support
Principal Deputy Assistant Administrator for Mission Support
Associate Deputy Assistant Administrator for Mission Support
Deputy Assistant Administrator for Environmental Information and Chief Information Officer
Director, Office of Continuous Improvement, Office of the Administrator
Director, Office of Enterprise Information Programs, Office of Mission Support
Audit Follow-Up Coordinator, Office of the Administrator
Audit Follow-Up Coordinator, Office of Mission Support
Audit Follow-Up Coordinator, Office of Enterprise Information Program, Office of Mission
Support
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