Preventing Drug Diversion: Disposal of Controlled Substances in Home Hospice Settings

Misuse of controlled substances continues to be a serious public health problem in the United States. Most commonly misused controlled substances include opioids (such as oxycodone), which are used to treat pain, and central nervous system depressants (such as diazepam), which are used to treat anxiety and sleep disorders. These types of drugs are commonly prescribed for patients in hospice care.

The SUPPORT Act included a provision for GAO to examine disposal of controlled substances in home hospice settings. This report describes selected home hospices' controlled substances disposal practices and the challenges they face in disposing of these substances.

GAO reviewed the SUPPORT Act and other related statutory and regulatory provisions. GAO also interviewed officials from the Centers for Medicare & Medicaid Services, the Drug Enforcement Administration, three national hospice trade associations, two national nurse trade associations, 11 state hospice associations, and seven hospices.

Hospice care helps patients who are terminally ill maintain their quality of life. Most patients get hospice care at home, which typically includes use of controlled substances, including opioids such as oxycodone, to provide pain relief. When hospice patients die at home, they often leave behind unused controlled substances, which can be diverted and misused by anyone with access to them. The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act), enacted in 2018, allows employees of qualified hospice programs to dispose of unused controlled substances by collecting and destroying the drugs in patients' homes. In addition, some states had laws allowing hospice employees to dispose of patients' unused controlled substances prior to 2018.

Three of the seven hospices GAO contacted operate in states without such laws. Officials from two of these hospices told us their hospices began disposing of patients' controlled substances in their homes following the enactment of the SUPPORT Act in 2018. However, one hospice had not begun disposing of these medications because the state department of health directed it not to do so until a state law granting disposal authority to hospices had been enacted. An official from that hospice said that it continued the practice of leaving the controlled substances in the home and educating family members about how to dispose of the drugs themselves.

Hospice officials we spoke to identified best practices for preventing diversion and disposing of controlled substances. Best practices include prescription drug counts performed by hospice employees to determine if controlled substances are being used properly, use of lock boxes to limit access to controlled substances in situations where diversion is suspected to be a risk, and having a witness for the disposal of unused controlled substances.

The officials also identified challenges their hospice employees have faced when disposing of controlled substances in patients' homes. Challenges include the cost of certain disposal methods, a lack of a witness to the disposal process, and inconsistencies between state laws and federal law concerning which hospice employees may dispose of controlled substances.

The Departments of Justice and Health and Human Services provided technical comments on a draft of this report, which GAO incorporated as appropriate.

Misuse of controlled substances continues to be a serious public health  problem in the United States. National survey data from the Substance  Abuse and Mental Health Services Administration show that in 2017, 53  percent of people 12 years of age and older in the United States who  misused prescription pain relievers in the past year, obtained the drugs  from friends and family. The most commonly misused controlled  substances include opioids (such as oxycodone), which are used to treat  pain, and central nervous system depressants (such as diazepam), which  are used to treat anxiety and sleep disorders. These types of drugs are  prescribed for a large proportion of patients in hospice care. Patients  select hospice care when they no longer want treatment for their terminal  illness, but rather choose a hospice team to provide symptom  management and control. In 2017, approximately 1.5 million Medicare  beneficiaries received hospice services, and 56 percent of those patients  received care in the patient’s home. Medicare is the largest payer for  hospice services.

When hospice patients die, any unused drugs left in the home create a  potential for diversion. One way to combat diversion of controlled  substances in home hospice settings is to ensure they are properly  disposed of when no longer needed by the patient. The Substance Use- Disorder Prevention that Promotes Opioid Recovery and Treatment for  Patients and Communities Act (SUPPORT Act), enacted in October 2018,  amended prior law to allow licensed medical and nursing employees of  qualified hospices to handle patients’ controlled substances for the  purpose of disposal as long as the disposal occurs onsite in accordance  with all applicable laws. The SUPPORT Act included a provision for GAO  to review the disposal of unused controlled substances in home hospice,  including federal oversight and the experiences of home hospices. In this  report, we describe selected hospices’ experiences disposing of and  preventing the diversion of controlled substances in home settings.

To describe what is known about the selected hospices’ experiences  disposing of and preventing the diversion of controlled substances in  home settings, we interviewed officials from 11 selected state hospice  associations and seven selected hospices. Of the 11 selected state  hospice associations, we interviewed officials from five operating in states  with laws on the disposal of controlled substances in home hospices and  six operating in states without such laws. The information obtained from  these interviews is not generalizable, but provided us with valuable  examples of hospices’ experiences with the disposal of controlled  substances. The 11 states were chosen for this review because they had  state hospice associations that were involved in disposal discussions with  national hospice associations or they had higher opioid-related death  rates than most states. The seven selected hospices whose officials we  interviewed were located in six of the 11 states. We interviewed officials  from four hospices in three of the selected states with disposal laws and  officials from three hospices in three of the selected states without  disposal laws. The hospices were chosen based on recommendations  from the national or state hospice associations with which we spoke. All  seven hospices are Medicare certified. We also spoke with officials from  the Centers for Medicare & Medicaid Services (CMS); the Drug  Enforcement Administration (DEA); the National Association for Home  Care and Hospice; the National Hospice and Palliative Care Organization;  the National Partnership for Hospice Innovation; the Hospice and  Palliative Nurses Association; and the Visiting Nurses Association of  America. We also reviewed the SUPPORT Act and other related statutory  and regulatory provisions.

We conducted this performance audit from April 2019 to April 2020 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Hospice care helps patients who are terminally ill—as well as the families  of those patients—maintain their quality of life. Hospice care focuses on  the comfort of patients (palliative care), not curing the illness. Patients are  eligible for hospice care under Medicare if they have a life expectancy of  six months or less. Most patients get hospice care at home, which  typically includes use of controlled substances, including opioids such as  oxycodone, to provide pain relief. According to CMS, hospice teams are  required to include a physician, nurse, social worker, and pastoral or  other counselor; and may also include hospice aides, trained volunteers,  and speech, physical, and occupational therapists. The patient selects a  primary caregiver when first admitted into home hospice, and this person  becomes a member of the home hospice team. The primary caregiver,  often a family member, provides most of the care for the patient in home  hospice, including most of the physical care for the patient, keeping  records of symptoms and other problems, and communicating with the  hospice team.

The Controlled Substances Act regulates the manufacture, distribution,  use, and disposal of controlled substances. In general, the Controlled  Substances Act was enacted to facilitate the use of controlled substances  for legitimate medical, scientific, research, and industrial purposes while  preventing them from being diverted for illegal uses. DEA is the primary  agency with responsibility for administering and enforcing the law, and  DEA provides oversight of all persons or entities required to register with  DEA. The Controlled Substances Act has been amended twice to clarify  federal requirements for patient disposal of controlled substances.

2010. The Secure and Responsible Drug Disposal Act of 2010  amended the Controlled Substances Act to allow a patient who has  lawfully obtained a controlled substance to deliver the controlled  substance to another person for the purpose of disposal, without  being registered with DEA. Any person lawfully entitled to dispose of  a deceased patient’s property may also deliver the patient’s controlled  substances to another person for the purpose of disposal. The person  receiving the controlled substances must be legally authorized to do  so and the disposal has to take place in accordance with DEA  regulations, which DEA issued in 2014. Among other things, the DEA  rulemaking clarified that home hospice personnel could not dispose of  a deceased patient’s controlled substances unless authorized to  dispose of the patient’s property by a state or local law. Instead, the  rulemaking encouraged home hospice personnel to assist patients  and their families in disposing of controlled substances in accordance  with the Controlled Substances Act, and partner with authorized  collectors to promote or jointly conduct mail-back programs.

2018. The SUPPORT Act amended the Controlled Substances Act to  allow employees of qualified hospices, whether or not registered with  DEA, to dispose of a patient’s unused controlled substances onsite  and in accordance with all applicable laws after the patient’s death or  the controlled substance expires. The employee must be a  physician, physician assistant, nurse, or other person who is: employed by a qualified hospice;  licensed to perform medical or nursing services by the jurisdiction  in which the patient is receiving hospice care; acting within the scope of their employment in accordance with  applicable state law; and  trained on the disposal of controlled substances by the qualified  hospice.

If the hospice patient no longer requires the controlled substances  because of a change in his or her care plan, only the patient’s DEA- registered physician may dispose of the patient’s unused controlled  substances. The authority to dispose of unused controlled substances  under the SUPPORT Act applies only to qualified hospices. Such  hospices must have written policies and procedures for assisting in the  disposal of controlled substances after the patient’s death, and must  document that they provided and discussed these policies and  procedures in an understandable manner with the patient and family. In  addition, the hospice must document the type of controlled substance,  dosage, route of administration, and quantity disposed, as well as the  time, date, and manner in which the disposal occurred. The SUPPORT  Act also allows the Attorney General to issue guidance to hospices  regarding the disposal of controlled substances in patients’ homes.

According to DEA officials, DEA’s oversight of the disposal of controlled  substances in home hospices is limited to instances of suspected or  actual diversion. This is because the SUPPORT Act allows employees of  qualified home hospices to dispose of unused controlled substances in  patients’ homes without registering with DEA.

CMS regulates Medicare-certified home hospices through the Hospice  Conditions of Participation, which are intended to protect the health and  safety of individuals under hospice care. Hospices must be in compliance  with the Hospice Conditions of Participation to participate in the Medicare  program. CMS oversees compliance with the Hospice Conditions of  Participation primarily through inspections, which are conducted by state  survey agencies contracted by CMS or CMS-approved national private  accrediting organizations. Among other things, the Hospice Conditions of  Participation require hospices to have written policies and procedures for  the management and disposal of controlled substances in the patient’s  home, discuss the hospice policies and procedures for managing the safe  use and disposal of controlled substances with the patient and family in a  manner that they understand, and document that the written policies and  procedures for managing controlled substances were provided and  discussed. CMS does not oversee the disposal process.

Selected Home Hospices’ Experiences, Best Practices, and Challenges in Disposing of Controlled Substances

Selected Home Hospices’ Experiences Disposing of Controlled Substances

According to a national hospice association official, each hospice had a  different approach to disposal prior to the DEA rulemaking in 2014. Some  hospices asked their employees to dispose of controlled substances to  prevent diversion and others did not. After the DEA rulemaking, some  states enacted laws granting authority to hospice employees to dispose of  patients’ unused controlled substances when the medications were no  longer needed, upon death of the patient, or both. Requirements under  states’ laws vary (see appendix I).

Hospices in some states without laws on the disposal of controlled  substances in home hospice began, or resumed, disposing controlled  substances in patients’ homes following the enactment of the SUPPORT  Act in 2018. Officials from six selected home hospices expressed  support for the authority to dispose of controlled substances granted by  the SUPPORT Act, and officials we interviewed from two hospices  operating in states without disposal laws told us their hospices had  resumed disposing of controlled substances in patients’ homes under the  authority granted by the SUPPORT Act. In contrast, an official from one  hospice told us that their hospice had not begun disposing of these  medications with the enactment of the SUPPORT Act because the state  department of health directed it not to do so until a state law granting  disposal authority to hospices had been enacted. For now, the hospice  has continued with its practice of educating patients’ family members on  how to dispose of controlled substances themselves.

Selected Home Hospices’ Policies and Best Practices for Disposing of Controlled Substances and Reducing the Risk of Diversion

Medicare-certified hospices, including the seven we selected for our  review, are required by CMS’s Hospice Conditions of Participation to  have written policies and procedures for the safe disposal of controlled  substances in a patient’s home. The policies and procedures may include  best practices, such as measures for assessing and mitigating the risk of  diversion in a patient’s home, and if and how the hospice will conduct  controlled substance disposal. According to officials we interviewed from  the selected hospices and state hospice associations, hospices utilize  various strategies or best practices to attempt to mitigate diversion risks,  including, but not limited to, the following:

Education on controlled substance use and disposal. Hospice  policies may include disposal education for patients and their  caregivers. Specifically, officials from five hospices and five state  hospice associations said that patient and family member education  on controlled substances and their disposal begins or should begin  upon the patient’s admission into hospice care or as soon as possible  thereafter. According to officials from three hospices, their staff may  use written agreements or acknowledgements that must be signed by  the patient or their caregiver. An official from one hospice association  told us the association made an agreement template available to their  hospice members that can be used to ensure patients understand  how to properly use prescribed controlled substances, agree to use  them properly, and will not give them to anyone else.

Prescription drug counts. Officials from four hospices and two state  hospice associations told us that, in general, nurses conduct  prescription drug counts at every visit to check if the proper amounts  of medications remain. Officials from two of these hospices said that  drug counts should require the family’s acknowledgement or be  witnessed. Officials from three other state hospice associations  mentioned that their members use drug counts as well but did not  specify if this occurred at every visit. These counts can be used to  recognize possible drug misuse or diversion. If there is an indication  that diversion may be the cause of an incorrect count, hospices can  put additional drug diversion risk reduction practices in place.

Lockboxes. If diversion is suspected to be a risk or if there are  children present in the patient’s home, a hospice may choose to use a  lockbox to store the patient’s medications and limit access to only an  alert patient or their caregivers. Officials from five hospices and five  state hospice associations mentioned that their employees and  members use lockboxes for such purposes. One hospice official  explained that lockboxes may also be used as an accountability tool  so that those with access cannot accuse others of stealing if drugs are  unaccounted for.

Pharmacy cooperation. A hospice may choose to have the  pharmacy mail a prescribed controlled substance in smaller quantities  and with greater frequency. For example, an official from one of the  selected hospices explained that the pharmacy they use will deliver  medications as often as daily if needed to reduce the risk of controlled  substances being diverted. Similarly, an official from a state hospice  association explained that some pharmacy managers and benefits  managers note when a refill for a prescription is requested sooner  than it should have been and alert the hospice.

Witnessed disposal or assisted disposal. Pursuant to some state  disposal laws and according to officials from five hospices and four  state hospice associations, controlled substance disposal and  assisted disposal must or should be performed with a witness present.  The state disposal laws may specify who the witness must be. For  example, according to two state laws, a family member or a second  hospice employee may witness disposal.

In-home disposal products. Hospices may have varying  preferences for how they dispose of controlled substances; officials  from four of the selected hospices mentioned using in-home disposal  products, and two specifically explained they believed these to be the  safest disposal method, even though, according to the officials, it can  be costly. Officials from another hospice told us they receive their in- home disposal products through a grant program.

Documentation. Officials from four selected hospices told us their  employees document the completion of certain tasks, such as  diversion risk assessments, drug counts, drug disposal, and the  refusal of drug disposal. An official from one of these hospices told us  their staff perform and document a diversion risk assessment of the  patient’s home. While officials from four hospices told us their  employees perform drug counts, only one official specified that  employees from their hospice document the drug counts. Another  hospice official explained that disposal documentation includes the  name, dosage, form, and administration method of the medication.  One hospice official told us that if a patient’s family members refuse  disposal, they must sign a form stating they declined to allow the  nurse to dispose of the patient’s remaining drugs.

Selected Home Hospices’ Challenges with Disposing of Controlled Substances

Officials from selected hospices and state hospice associations in our  review described various challenges associated with disposing of  controlled substances in patients’ homes. The challenges described by  the selected hospices and state hospice associations include but are not  limited to the following:

Certain disposal methods may be too costly. An official from one  state hospice association said that most of its members do not use a  drug disposal process, which may include a mail-back program or in- home disposal product, because it is an extra expense, and an official  from one hospice said that after pricing an in-home disposal product,  their hospice decided it was cost prohibitive. One state hospice  association official explained that although most of its in-home  hospice members use an in-home disposal product, in instances  when the hospice employee is disposing of 40 to 50 vials, the  expense of this disposal method can be burdensome. The official told  us the product costs approximately $6 each and fits four to five vials  of pills in each.

Disposal can be time consuming. One hospice official said that  disposal can sometimes be a time-consuming and resource-intensive  activity. According to two state hospice association officials,  sometimes a patient’s family will ask the disposing hospice employee  to dispose of all of the patient’s unused prescription drugs that remain  in the home, not only controlled substances or drugs prescribed under  hospice care. Officials from two of our selected hospices and two  state hospice associations told us that it is not atypical for a hospice  patient to have bags or boxes full of unused medications, though the  officials did not describe this as a disposal challenge for hospices.

Lack of a witness. One hospice official told us that it is a challenge  when a witness is not available or is unwilling to participate in a drug  count or disposal. Another hospice official indicated that the patient’s  primary caregiver is not always the family member present at the time  of a drug count or disposal. This can create a challenge, as the  hospice employee must either wait for the patient’s primary caregiver  to arrive, or for that person to agree to witness a count, disposal, or  both.

Family members and caregivers sometimes refuse to dispose of  controlled substances. Officials from two hospices and three state  hospice associations indicated that a family’s refusal to dispose of a  patient’s remaining medications can be a challenge, though one  hospice official said it occurs infrequently. An official from another  hospice said that if a family initially refuses disposal, hospice staff  return after two weeks to complete the disposal process.

Inconsistencies between state laws and federal law. Hospices  must comply with applicable federal and state laws governing  controlled substances, and to the extent state law is inconsistent with  the Controlled Substances Act, hospices must follow federal law.  Hospice officials told us that inconsistencies between state laws and  federal law can cause challenges. For example, the SUPPORT Act  limits disposal to only physicians, physician assistants, nurses, or  other hospice employees who are licensed to provide medical or  nursing services. An official from one hospice stated that the hospice  used the help of social workers and volunteers to dispose of  controlled substances. Regulations in this state do not specify which  types of hospice employees are permitted to assist with disposal.  According to the official, social workers and volunteers helped dispose  of patients’ controlled substances when disposal occurred at a later  time, rather than immediately following a patient’s death. Since the  SUPPORT Act limits disposal to home hospice personnel with specific  qualifications, it is unclear whether hospices are able to allow social  workers and volunteers to help in that capacity.

As another example, under the SUPPORT Act, only a hospice  patient’s DEA-registered physician can dispose of the patient’s  controlled substances if the plan of care has been modified.  However, some state laws allow other types of hospice employees to  perform disposal in this circumstance. Officials from two hospices in  these states indicated it will be a challenge for disposal to be limited to  physicians when a patient’s plan of care is modified. Similarly, officials  from two other selected hospices in states without disposal laws also  stated that this would be a challenge. For example, one hospice  official explained that their hospice does not have many physicians,  and it would be unlikely for a physician to be able to visit a patient’s  home solely to handle disposal.

We provided a draft of this report to the Departments of Justice and  Health and Human Services for review. The Departments of Justice and  Health and Human Services provided technical comments, which we  incorporated as appropriate.

We are sending copies of this report to the appropriate congressional  committees, the Attorney General of Justice, the Secretary of Health and  Human Services, and other interested parties. In addition, the report will  be available at no charge on GAO’s website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or at CosgroveJ@gao.gov. Contact points for our  Office of Congressional Relations and Office of Public Affairs can be  found on the last page of this report. Other major contributors to this  report are listed in appendix II.

Appendix I: Summary of Five States’ Controlled Substances Disposal Laws for Hospices

To describe what is known about selected hospices’ experiences  disposing of and preventing the diversion of controlled substances in  home settings, we selected five states with laws on the disposal of  controlled substances in home hospices and six states without such  laws. The five states with disposal laws were chosen for this review  because they had state hospice associations that were involved in  disposal discussions with a national hospice association or they had  higher opioid-related death rates than most states. The summaries in  Table 1 below reflect our reviews of the five states’ laws.

Appendix II: GAO Contact and Staff Acknowledgments

In addition to the contact name above, Martin T. Gahart (Assistant  Director), Deborah J. Miller (Analyst in Charge), Samuel G. Amrhein,  Kaitlin M. Farquharson, and Christina C. Murphy made key contributions  to this report.

When hospice patients die at home, they often leave behind commonly misused controlled substances, such as oxycodone. A 2018 law allows employees of qualified hospice programs to collect and destroy these drugs. This report describes selected home hospices’ disposal practices and the challenges they face.

Hospice representatives identified best practices such as having a disposal witness and using lock boxes to limit drug access. Challenges include the cost of certain disposal methods, a lack of required disposal witnesses, and inconsistencies between state and federal laws over which hospice employees may dispose of controlled substances.


Army Corps of Engineers: Process for Selecting Section 219 Projects for Funding Could Be Strengthened

Under Section 219 of the 1992 Water Resources Development Act, as amended, Congress authorized the Corps to provide assistance for the design and construction of environmental infrastructure projects, known as Section 219 projects. Such projects include the development of water transmission lines. Congress typically provides a lump sum appropriation for the Corps' construction account, out of which Section 219 and other environmental infrastructure projects are funded.

GAO was asked to review projects carried out under the Section 219 program. This report examines (1) the number and type of Section 219 projects and expenditures from fiscal years 2013 through 2017, and (2) how the Corps prioritizes funding for Section 219 projects. GAO reviewed relevant federal laws and agency guidance; analyzed agency data for fiscal years 2013 through 2017, the most recent time period for which data were available; and interviewed agency officials at headquarters, three divisions, and three districts–selected based on geographic distribution and the amount of Section 219 project expenditures.

From fiscal years 2013 through 2017, the most recent available data, the U.S. Army Corps of Engineers (Corps) spent approximately $81 million on 29 Section 219 projects to develop drinking water, wastewater, and stormwater infrastructure. For example, through the St. Croix Falls, Wisconsin Section 219 project, the Corps assisted with improvements to a wastewater treatment plant. Of the 29 projects, the Corps spent over half of the funding during this period on four projects: (1) Calumet Region, Indiana; (2) Desoto County, Mississippi; (3) Jackson County, Mississippi; and (4) Lakes Marion and Moultrie, South Carolina.

The Corps generally follows its standard budget prioritization process—which involves districts, divisions, and headquarters ranking each project and headquarters making final funding decisions—to prioritize Section 219 funding. However, the Corps has not developed criteria to guide this process. GAO found the Corps varies in the factors it uses to rank Section 219 projects. For example, one district considers whether a project can be completed within the fiscal year, while another considers the level of congressional support and dollar value of the project. Headquarters officials said the agency views Section 219 projects as outside its core mission areas and therefore has not developed written criteria. Congressional direction has indicated that the Corps is to consider characteristics—such as projects with the greater economic impact—in prioritizing Section 219 project funding. While aware of this direction, Corps officials said they do not consider it when ranking projects. Federal standards for internal control states that agencies should use quality information to achieve their objectives. By establishing written criteria, the Corps would have greater assurance that its Section 219 project selections align with a clear set of priorities, such as those identified by recent congressional direction.

GAO recommends that the Corps develop written criteria for ranking Section 219 projects for funding, taking into account a clear set of priorities, such as those identified by recent congressional direction. The agency concurred with the recommendation.

The U.S. Army Corps of Engineers (Corps), within the Department of  Defense, is one of the world’s largest public engineering, design, and  construction management agencies. Through its Civil Works program, the  Corps plans, designs, constructs, operates, and maintains water resource  projects under three core mission areas: restoration, protection, and  management of aquatic ecosystems; flood risk management; and support  of commercial navigation. The Corps also carries out other activities. For  example, the Corps provides design and construction assistance for  environmental infrastructure projects. These projects focus on a variety of  purposes, such as drinking water treatment and distribution and  wastewater treatment.

Among the environmental infrastructure projects for which the Corps  provides assistance are those authorized by Section 219 of the Water  Resources Development Act (WRDA) of 1992, as amended, known as  the Section 219 program. Under the Section 219 program, the Corps  manages private contractors that construct, among other things, drinking  water, wastewater, and stormwater infrastructure, for nonfederal  sponsors, such as cities, counties, and regional authorities. Section 219  projects may consist of a number of subprojects. For example, a Section  219 project might involve the construction of water transmission lines for  several different counties, which the Corps would manage as several  subprojects.

Since fiscal year 2012, Congress has generally provided a lump sum  appropriation for the Corps’ construction account, out of which  environmental infrastructure projects, including Section 219 projects, are  funded. The Corps finalizes its funding allocation decisions in an annual  work plan to Congress, which delineates the Civil Works projects that are  planned for the year. We have previously reported on aspects of the  Corps’ Section 219 budget process. Specifically, in December 2009, we  found that the Corps did not have criteria for funding Section 219 projects  along the U.S.-Mexico border and recommended that the Corps develop  eligibility criteria and a standard process to review and select projects for  funding so that those with the greatest need receive assistance.

You asked us to review projects carried out under Section 219 of the  1992 WRDA. This report (1) describes the number and type of Section  219 projects and expenditures from fiscal years 2013 through 2017, and  (2) examines how the Corps prioritizes funding for Section 219 projects.

To address these objectives, we reviewed relevant laws, including  Section 219 of the 1992 WRDA, as amended. For background purposes,  we obtained and summarized data from the Corps of Engineers Financial  Management System (CEFMS) on the total number of authorized projects  since 1992; the total amount of authorized dollars and expenditures on  those projects; and the number of deauthorized projects, including the  date of deauthorization. We interviewed Corps headquarters officials  responsible for Section 219 budget development. In addition, we  interviewed officials from a nongeneralizable sample of three Corps  districts (Charleston, Chicago, and Los Angeles) and three divisions  (South Atlantic, Great Lakes and Ohio River, and South Pacific) who  oversee Section 219 projects. We selected these districts and divisions  based on geographic distribution and the amount of Section 219 project  expenditures. From August to October 2018, we visited the Chicago and  Los Angeles district offices and four Section 219 projects, and interviewed  nonfederal sponsors responsible for the four projects. We reviewed  documents, such as fact sheets, from district officials and nonfederal  sponsors on each of the Section 219 projects included in the site visits.  We also conducted telephone interviews with officials from the Charleston  District and South Atlantic Division, as well as a nonfederal sponsor  responsible for a project within their jurisdictions. Because this was a  nongeneralizable sample, our findings cannot be generalized to all Corps  districts and divisions but provide illustrative examples of Section 219  program operations.

To describe the number and type of Section 219 projects and  expenditures from fiscal years 2013 through 2017, we analyzed and  summarized data from CEFMS on the total number of active and  completed projects for this period and the total amount expended on the  projects. We selected fiscal years 2013 through 2017 because it was the  most recent period for which data were available. We summarized data  on Section 219 projects, such as the division and district responsible for  managing the project, location, description, year of authorization, and  phase of the project. To assess the reliability of the Corps’ data, we  reviewed program documentation on system controls, interviewed officials  responsible for data quality, and reviewed the Corps’ data to identify any  potential missing fields, duplicate entries, or other anomalies. As a result  of our assessment, the Corps updated its data set for fiscal years 2013  through 2017, including removing some duplicate projects. We concluded  that the updated Corps data on Section 219 projects were sufficiently  reliable for the purposes of our review. We also reviewed fact sheets and  other Corps documents on Section 219 projects.

To examine how the Corps prioritizes funding for Section 219 projects, we  reviewed Corps guidance, including the Corps’ policy guidance for budget  development (budget guidance) from fiscal years 2013 through 2017.  We also reviewed appropriations acts for the period, including  congressional direction that accompanies these acts on how the Corps is  to prioritize funding for environmental infrastructure projects. We  examined the Corps’ annual work plans for the period, which contain the  final list of Section 219 projects that the Corps allocated funding to in  each fiscal year. In addition, we examined a list of Section 219 projects  that were not selected to receive funding in fiscal year 2018 (the most  recent budget cycle), along with the Corps’ rationale for the funding  decisions. We discussed the Corps’ procedures for prioritizing Section  219 funding with headquarters, division, and district officials. We  compared the Corps’ budget guidance with relevant portions of the  Standards for Internal Control in the Federal Government, such as using  quality information to achieve objectives, to determine if the budget  guidance aligned with the standards.

We conducted this performance audit from March 2018 to June 2019 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Headquartered in Washington, D.C., the Corps has eight divisions  established generally according to watershed boundaries and 38 districts  that carry out its Civil Works program. Corps headquarters primarily  develops policies and provides agency oversight. The Assistant Secretary  of the Army for Civil Works, appointed by the President, sets the strategic direction for the agency and has principal responsibility for the overall  supervision of functions relating to the Civil Works program. The Chief of  Engineers—a military officer—oversees the Corps’ civil works and military  missions. The eight divisions—Great Lakes and Ohio River, Mississippi  Valley, North Atlantic, Northwestern, Pacific Ocean, South Atlantic, South  Pacific, and Southwestern—coordinate Civil Works projects in the districts  within their respective divisions. Corps districts are responsible for  planning, engineering, constructing, and managing Civil Works projects.

Section 219 Program Overview and Funding Process

Congress established the Section 219 program in the 1992 WRDA, which  authorized the Corps to provide planning and design assistance to  nonfederal sponsors in carrying out 18 environmental infrastructure  projects, located in certain specified locations around the United States.  For example, the 1992 WRDA authorized the Corps to provide assistance  for a combined sewer overflow treatment facility for the city of Atlanta,  Georgia. In subsequent acts, Congress authorized the Corps to provide  construction assistance for Section 219 projects, in addition to planning  and design, and significantly expanded the number of authorized projects.  From 1992 through 2007, Congress authorized a total of 310 Section 219  projects, with the most recent and largest number of project  authorizations occurring in 2007 (see table 1).

For Section 219 projects, Congress specifies the geographic location  (e.g., city, county), amount of authorized dollars, and purpose or scope of  the project (e.g., development of drainage facilities to alleviate flooding  problems). In general, Section 219 projects fall into one or more of the  following types of projects:

Drinking water treatment and distribution. Projects that build water  treatment plants, water storage tanks, and water distribution lines.

Wastewater treatment. Projects that build sewage treatment plants,  wastewater collection systems, and facilities that purify treated  wastewater for irrigation and other purposes.

Stormwater management. Projects that help improve the  management of storm sewers, eliminate or control sewer overflows,  and address flooding.

According to Corps data, of the 310 originally authorized Section 219  projects, 58 have been deauthorized and were no longer active, as of  November 2018. The Corps is required by the 1986 WRDA, as amended,  to annually identify all authorized projects that have not received  obligations in the preceding 5 full fiscal years and submit that list to  Congress. If funds are not obligated for planning, design, or construction  of a project on that list during the next fiscal year, the project is  deauthorized. The Secretary of the Army publishes a list of deauthorized  projects in the Federal Register. Based on this process, the Corps  considered deauthorizing 197 additional Section 219 projects in its fiscal  year 2017 report to Congress. However, the 2018 WRDA provided that  the projects identified for deauthorization in the Corps’ fiscal year 2017  report were generally not to be deauthorized unless they met certain  additional requirements.

The Corps allocates funding for Section 219 projects and other  environmental infrastructure programs from the construction account.  That account generally receives no-year appropriations through the  Energy and Water Development Appropriations Act—meaning the  appropriation remains available for obligation for an indefinite period of  time. Prior to fiscal year 2012, the conference reports accompanying the  annual Energy and Water Development Appropriations Acts generally  listed individual Section 219 projects and specific allocations of funding  for each project. However, since fiscal year 2012, Congress has not  provided allocation direction for individual projects, but instead generally  has designated an amount in reports and joint explanatory statements for  environmental infrastructure overall, ranging from about $30 million to $55  million annually. According to Corps data, from fiscal years 1992 through  2017, the Corps expended over $440 million on Section 219 projects.

Process for Managing Section 219 Projects

Similar to other Civil Works projects, the Corps generally becomes  involved in Section 219 projects when a nonfederal sponsor contacts the  Corps for assistance on an authorized project. Corps districts gather  additional information on the project from the nonfederal sponsor and  determine if it is ready to be initiated. Once the Corps receives an  appropriation from Congress, the agency decides whether to allocate  funding to the project. If the project is selected to receive funding, it enters  the preconstruction engineering and design phase. The purpose of this  phase is to complete any additional planning studies and all of the  detailed technical studies and designs—such as environmental impact  studies—needed to begin construction. During this phase, the Corps also  completes an environmental assessment of the proposed project.

To initiate construction, the Corps and the nonfederal sponsor sign a  project partnership agreement that specifies how the parties will  collaborate, their respective roles and responsibilities, and the terms and conditions under which they will execute their responsibilities. The project  partnership agreement typically requires the sponsor to provide without cost to the U.S. government all lands, easements,  rights-of-way, relocations, and disposal areas necessary for the  construction and subsequent maintenance of the project; maintain and operate the project after completion without cost to the provide cash or work-in-kind contributions to make the sponsor’s total  contribution equal to 25 percent if the value of the sponsor’s land  contribution does not equal or exceed 25 percent of the project cost.

The Corps manages the construction phase, contracting out construction  work to private engineering and construction contractors. Throughout the  construction phase, the Corps oversees the contractors’ work, performing  routine inspections to ensure it meets the Corps’ design and engineering  specifications. During construction, the Corps, the nonfederal sponsor,  and the private contractor typically appoint representatives to a project  coordination team that meets regularly until the period of construction  ends. Upon notification by the District Engineer that construction is  complete, the nonfederal sponsor is responsible for operations and  maintenance. Figure 1 shows the major steps in managing a Section  219 project.

From Fiscal Years 2013 through 2017, the Corps Spent About $81 Million on 29 Section 219 Projects to Develop Drinking Water, Wastewater, and Stormwater Infrastructure

The Corps expended about $81 million on 29 Section 219 projects from  fiscal years 2013 through 2017, which included various types of projects  such as drinking water treatment and distribution, wastewater treatment,  and stormwater management. Examples of these projects include the  following:

Drinking Water Treatment and Distribution. The Corps manages a  Section 219 project that includes the development of water  desalination infrastructure in various sections of the South Perris  community, located east of Los Angeles, California. In general, the  South Perris area relies on a mixture of groundwater and water  imported from different sources, including the Colorado River.  According to the Corps’ environmental assessment, various factors,  such as drought, caused the community to supplement its drinking  water supply through increased use of groundwater; however, the  groundwater in the area historically contained high salt content. Since  the project’s authorization in fiscal year 2001 through fiscal year 2017,  the Corps has helped construct groundwater wells and pipelines,  which connect to drinking water treatment facilities that reduce the  amount of salt in the water (see fig. 2). According to the nonfederal  sponsor for the South Perris project, the overall project has provided  benefits such as creating a local potable water source to meet  anticipated population growth and reducing the community’s  dependence on imported water.

Wastewater Treatment. The Corps manages a Section 219 project  that includes the rehabilitation of sewer lines within the metropolitan  area of St. Louis, Missouri. The city’s wastewater system dates back  to the 1800s and lacks the capacity to handle large flows. From the  project’s authorization in fiscal year 1999 through fiscal year 2017, the  Corps has assisted the community, among other things, in sewer  rehabilitation of deep tunnels. According to documentation from the  Corps’ St. Louis District, the rehabilitation of sewers is important in  protecting the health and safety of the public, given the risk of  untreated sewage being discharged into the environment.

Stormwater Management. The Corps manages a Section 219  project that involves the development of stormwater infrastructure,  among other things, across a five-county region (Calumet region) in  northern Indiana. For example, flooding is a widespread problem in  the region and it has affected commercial corridors, including within  Gary, Indiana. From the project’s authorization in fiscal year 1999  through fiscal year 2017, the Corps has been assisting the region with  measures to alleviate flooding, such as constructing stormwater  storage areas under the street (see fig. 2). According to a nonfederal  sponsor we interviewed, the Corps’ efforts in the Calumet region have  offered benefits to local communities by, among other things,  improving storm drainage in an area that experienced flooding during  heavy rainfall.

The 29 Section 219 projects with expenditures from fiscal years 2013  through 2017 were located in different parts of the country and managed  by six Corps divisions, although the majority of the projects were under  the South Pacific Division (10 of the 29 projects) and Great Lakes and  Ohio River Division (eight of the 29 projects). The five states with the  largest number of projects during this period were

California, with nine Section 219 projects;

Virginia, with three Section 219 projects; and

Michigan, Pennsylvania, and Mississippi, each with two Section 219  projects.

These projects varied in terms of the geographic area covered, such as a  city, county, or region (e.g., multiple counties). Based on the project  descriptions we reviewed, 10 of the projects focused on the  environmental infrastructure needs of cities, nine focused on counties and  10 on regions. Projects that cover a broad geographic area, such as  those at the county or regional level, generally consist of different types of  subprojects. For example, the Cook County, Illinois Section 219 project  included several subprojects, such as the construction of water mains and  sewer improvements in different areas across the county.

Most of the Section 219 projects (24 of the 29 projects) were authorized  in 2000 or earlier and were ongoing as of November 2018. Only one of  the 29 projects was completed; the project in St. Croix Falls, Wisconsin,  was completed in fiscal year 2014. For the St. Croix Falls project, the  Corps assisted with improvements to a wastewater treatment plant, such  as installing equipment to screen out large solids that otherwise would be  released into the St. Croix River. Of the 28 remaining projects that were  ongoing, as of November 2018, 17 were in the construction phase, and  11 were in the preconstruction engineering and design phase. Table 2  summarizes information on the 29 projects with expenditures from fiscal  years 2013 through 2017 by division and district. See appendix I for  additional information on each project, including a detailed description  and the total amount of expenditures from fiscal years 2013 through  2017.

As previously noted, the Corps spent about $81 million on these 29  Section 219 projects from fiscal years 2013 through 2017. During that  period, expenditures by fiscal year ranged from about $11 million to $22  million. Divisions with the largest percentage of overall expenditures from  fiscal years 2013 through 2017 were the South Atlantic Division (36  percent) and Mississippi Valley Division (25 percent). The divisions with  the smallest percentage of overall expenditures during the period were  the North Atlantic Division (less than 1 percent) and Southwestern  Division (4 percent). Table 3 summarizes overall expenditures from fiscal  years 2013 through 2017 by division and fiscal year.

Of the 29 projects with expenditures from fiscal years 2013 through 2017,  15 projects expended less than $1 million each, representing a total of  $2.3 million. The majority of these projects (10 of the 15 projects) were in  the preconstruction engineering and design phase. For example, as part  of the Cambria, California, project, the Corps expended about $244,000  on preconstruction engineering and design activities, such as evaluating  the environmental impacts of constructing a seawater desalination facility.  In addition, for the Cumberland County, Tennessee, project, the Corps  expended about $261,000 on planning and design for water supply  projects.

In comparison, 14 of the 29 projects expended more than $1 million each  over the same time period, representing a total of $78.2 million. In  particular, the Corps spent over half of the funding during this time period  on four projects: Calumet Region in Indiana; DeSoto County, Mississippi;  Jackson County, Mississippi; and Lakes Marion and Moultrie in South  Carolina (see fig. 3). These projects generally consisted of multiple  subprojects and covered a wide geographic area. For example, the  Calumet Region project has involved over 25 subprojects since its  authorization in fiscal year 1999 through August 2018. Through these  subprojects, the Corps has managed various activities, including  replacing drinking water lines, improving wastewater treatment plants,  and installing stormwater infrastructure in a number of cities across  Indiana. Additionally, the Lakes Marion and Moultrie project in South  Carolina has included a range of subprojects, such as construction of a  water treatment plant, construction of a water tower, and installation of  water transmission lines across six counties.

The Corps Generally Follows Its Standard Budget Prioritization Process for Section 219 Projects but Does Not Use Written Criteria to Rank Projects for Funding

The Corps generally follows its standard budget process for prioritizing  funding for the Section 219 program. This process involves ranking  Section 219 projects for funding by all three levels of the Corps’  organization—districts, divisions, and headquarters.

District officials identify Section 219 projects, including subprojects,  and other environmental infrastructure projects for potential funding;  enter a numerical ranking for each project in the Civil Works  Integrated Funding Database; and submit the information to the  division through the database.

Division officials receive the rankings from each of the multiple  districts in the division. Division officials then re-rank the Section 219  and other environmental infrastructure projects from all of their  districts against one another. Division officials enter the numerical  ranking for all projects across all their districts into the Civil Works  Integrated Funding Database and submit the information to  headquarters through the database.

Headquarters officials receive the rankings from each division. They  re-rank the projects from all divisions against each other to generate  the final nationwide rankings. Based on the final rankings, not all  Section 219 and other environmental infrastructure projects that the  divisions submitted will receive funding. Headquarters officials then  determine a funding amount for each Section 219 project selected to  receive funding and publish these decisions in the agency’s annual  work plan. After headquarters publishes the annual work plan,  headquarters officials begin to allocate funding to Section 219  projects.

However, the Corps does not have written criteria to guide the ranking of  Section 219 projects, in contrast to other types of projects. Specifically, in  our December 2018 report, we found that the Corps uses written criteria—such as the rate of economic return, populations at risk, and  economic impact—to prioritize funding for core mission areas, such as  flood risk management and navigation projects. While Corps budget  guidance indicates the criteria each core mission area should use in the  ranking process, it does not specify criteria for Section 219 or other  environmental infrastructure projects. In the absence of written criteria,  Corps officials use their discretion on how to rank Section 219 projects for  funding, according to Corps headquarters officials.

When ranking Section 219 projects for funding, officials in each of the  districts we interviewed generally consider whether Section 219 projects  can be completed within the fiscal year. However, we found that the  districts vary in terms of whether other factors are considered and what  those factors are. Specifically,

One district considers the level of congressional support and the  potential public health impacts of the project.

Another district considers the level of congressional support and the  dollar value of the project.

A third district only considers whether the project can be completed  within the fiscal year.

At the division level, officials we interviewed stated that they consider,  among other things, the level of congressional support for the projects;  however, to a large extent they rely on the rankings provided by their  respective districts. Headquarters officials said that they primarily focus  on ensuring that projects are geographically dispersed across the  divisions when assigning final rankings for Section 219 projects.

In recent years, congressional direction has indicated that the Corps,  when allocating funding, is to consider giving priority for environmental  infrastructure projects that have certain characteristics. For example, the  Joint Explanatory Statement accompanying the Consolidated  Appropriations Act in 2017 directed the Corps to consider characteristics  such as projects: with the greater economic impact;  in rural communities;  in communities with significant shoreline and instances of runoff;  in or that benefit counties or parishes with high poverty rates; and  in financially distressed municipalities.

Corps headquarters, division, and district officials we interviewed said that  while they are generally aware of this congressional direction, they do not  use it to guide the Section 219 ranking process. According to a division  official, written criteria would be helpful for ranking projects across  multiple districts and would clarify procedures for new staff. Officials we  interviewed in the three districts said, in general, written criteria would  clarify the ranking process. For example, one Corps district official stated  that written criteria would provide standardization to the ranking process,  ensuring that each district is focused on the highest priorities of the  agency.

According to Corps headquarters officials, although they see value in  having written criteria to prioritize Section 219 funding, they have not  developed such criteria because the agency considers Section 219  projects to be outside the agency’s core mission areas, such as flood  control. According to a 2008 Corps report to Congress, “Funds provided  to the Corps for wastewater treatment and municipal and industrial water  supply projects necessarily reduce the amount of funds that instead could  be used for the primary mission areas of the Corps. Thus, provision of  Civil Works funding for these environmental infrastructure programs  negatively affects the Corps’ ability to meet critical mission needs…such  as restoring nationally significant ecosystems.” Headquarters officials  confirmed that this report accurately reflects the agency’s current position.  Corps officials also stated that developing written criteria has not been a  priority because Section 219 projects represent a small percentage of the  agency’s overall Civil Works budget.

Federal standards for internal control states that agencies should use  quality information to achieve their objectives by identifying information  requirements. The federal standards also call for agencies to design  control activities to achieve objectives and respond to risks, such as by  clearly documenting internal control in management directives,  administrative policies, or operating manuals. By establishing written  criteria, the Corps would have greater assurance that its project  selections align with a clear set of priorities, such as the characteristics  identified in recent congressional direction for the agency to consider  when selecting Section 219 projects for funding.

Since the inception of the Section 219 program in 1992, the Corps has  spent over $440 million on water infrastructure projects across its  divisions and districts. However, the Corps has not developed written  criteria for ranking Section 219 projects for funding as it has for other Civil  Works programs within the agency’s core mission areas. Consequently,  officials at the district, division, and headquarters levels are using their  discretion regarding which factors to consider in ranking Section 219  projects for funding. Further, Congress has provided direction to the  Corps on which characteristics to consider in prioritizing Section 219  funding; however, Corps officials stated that they do not use it to guide  their ranking of Section 219 projects. By establishing written criteria, the  Corps would have greater assurance that its project selections align with  a clear set of priorities, such as the characteristics identified in recent  congressional direction for the agency to consider when selecting Section  219 projects for funding.

The Secretary of the Army should direct the Chief of Engineers and  Commanding General of the U.S. Army Corps of Engineers to develop  written criteria for ranking Section 219 projects for funding, taking into  account a clear set of priorities, such as those identified by recent  congressional direction.

We provided a draft of this report to the Department of Defense for review  and comment. In its written comments, reprinted in appendix II, the  department concurred with our recommendation and described the  actions they plan to take. Specifically, the Corps will develop and  document a more rigorous set of priorities in line with those identified by  recent Congressional direction. The department also provided technical  comments, which we incorporated as appropriate.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Defense, the Chief of Engineers and  Commanding General of the U.S. Army Corps of Engineers, and other  interested parties. In addition, the report is available at no charge on the  GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-3841 or fennella@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made key contributions to this report  are listed in appendix III.

Appendix I: Description of U.S. Army Corps of Engineers Section 219 Projects and Expenditures from Fiscal Years 2013 through 2017

Appendix I: Description of U.S. Army Corps of  Engineers Section 219 Projects and  Expenditures from Fiscal Years 2013 through  2017 Project description as authorized by statute  Water-related environmental infrastructure, Allegheny County,  Pennsylvania.

A combined sewer overflow treatment facility for the city of Atlanta, Georgia  and watershed restoration and development in the regional Atlanta  watershed including Big Creek and Rock Creek.

Water-related infrastructure for the parishes of East Baton Rouge,  Ascension, and Livingston, Louisiana.

Water-related infrastructure projects in the counties of Benton, Jasper,  Lake, Newton, and Porter, Indiana.

Desalination infrastructure, Cambria, California.

Water and wastewater infrastructure for the Contra Costa Water District,  California.

Water-related infrastructure and resource protection and development,  Cook County, Illinois.

Water supply projects in Cumberland County, Tennessee.

Desert Hot Springs, California  Resource protection and wastewater infrastructure, Desert Hot Springs,  California.

Wastewater treatment project in the county of DeSoto, Mississippi.

Water supply and wastewater infrastructure projects in the counties of  Accomack, Northampton, Lee, Norton, Wise, Scott, Russell, Dickenson,  Buchanan, and Tazewell, Virginia.

Water-related infrastructure and resource protection, including stormwater  management, and development, El Paso County, Texas.

Wastewater infrastructure assistance to reduce or eliminate sewer  overflows, Genesee County, Michigan.

Industrial water reuse project for the Harbor/South Bay area, California.

Water infrastructure, Inglewood, California.

Provision of an alternative water supply for Jackson County, Mississippi.

Wastewater treatment and water supply treatment and distribution projects  in the counties of Berkeley, Calhoun, Clarendon, Colleton, Dorchester, and  Orangeburg, South Carolina.

A project to provide water facilities for the Fox Field Industrial Corridor,  Lancaster, California.

Alleviation of combined sewer overflows for Lynchburg, Virginia, in  accordance with combined sewer overflow control plans adopted by, and  currently being implemented by, the non-Federal sponsor.

Water-related infrastructure in the counties of Lackawanna, Lycoming,  Susquehanna, Wyoming, Pike, Wayne, Sullivan, Bradford, and Monroe,  Pennsylvania, including assistance for the Montoursville Regional Sewer  Authority, Lycoming County, Pennsylvania.

Project description as authorized by statute  Water and wastewater infrastructure in Hancock, Ohio, Marshall, Wetzel,  Tyler, Pleasants, Wood, Doddridge, Monongalia, Marion, Harrison, Taylor,  Barbour, Preston, Tucker, Mineral, Grant, Gilmer, Brooke, and Ritchie  Counties, West Virginia.

A project to eliminate or control combined sewer overflows in the cities of  Berkley, Ferndale, Madison Heights, Royal Oak, Birmingham, Hazel Park,  Oak Park, Southfield, Clawson, Huntington Woods, Pleasant Ridge, and  Troy, and the village of Beverly Hills, and the Charter Township of Royal  Oak, Michigan.

Recycled water transmission infrastructure, Eastern Municipal Water  District, Perris, California.

Alleviation of combined sewer overflows for Richmond, Virginia, in  accordance with combined sewer overflow control plans adopted by, and  currently being implemented by, the non-federal sponsor.

San Ramon Valley, California  A project for recycled water for San Ramon Valley, California.

Water supply desalination infrastructure, South Perris, California.

Wastewater infrastructure, St. Croix Falls, Wisconsin.

Projects to eliminate or control combined sewer overflows in the city of St.  Louis and St. Louis County, Missouri.

Appendix II: Comments from the Department of Defense

Appendix III: GAO Contact and Staff Acknowledgments

Anne-Marie Fennell, (202) 512-3841 or fennella@gao.gov.

In addition to the contact named above, Vondalee R. Hunt (Assistant  Director), Anthony C. Fernandez (Analyst-In-Charge), Patricia Moye,  Gloria Ross, and Sheryl Stein made significant contributions to this report.  Important contributions were also made by Patricia Donahue, Tim  Guinane, Susan Murphy, Sara Sullivan, Kiki Theodoropoulos, and Walter  Vance.

The Army Corps of Engineers builds water-related environmental infrastructure—such as wastewater treatment plants—for cities, counties, and regions. These infrastructure projects are known as "Section 219" projects after their authorizing law.

The Corps spent about $81 million on 29 of these projects in fiscal years 2013-2017.

While the Corps uses written criteria to prioritize funding for other projects, it doesn't do so for these. The Corps also doesn't consider congressional guidance, by, for example, prioritizing projects with greater economic impact.

We recommended the Corps develop written criteria to rank these projects for funding.