Nuclear Security: CBP Needs to Take Action to Ensure Imported Radiological Material Is Properly Licensed

Thousands of shipments containing radiological material enter the United States each year through airports across the country. Radiological material is used in various medical and industrial applications, and possession requires a license from the Nuclear Regulatory Commission (NRC) or one of the 37 states to which NRC has relinquished licensing authority. Failure to verify the licenses could allow terrorists to acquire radiological material for a dirty bomb, which uses explosives to disperse the material.

GAO was asked to review CBP policies and procedures related to license verification. This report examines, among other things, (1) the extent to which CBP follows its policies and procedures, and (2) the effectiveness of these policies and procedures. GAO reviewed relevant policies and procedures, analyzed CBP data related to radiological material shipments and license verification, interviewed CBP and NRC officials, and selected four airports to visit based on expected traffic of radiological shipments.

U.S. Customs and Border Protection (CBP) agency officials at U.S. airports have not verified the legitimacy of all licenses for imported radiological materials as required by CBP's policy. The policy requires CBP officials, when alerted, to verify licenses by calling experts in a centralized CBP office. CBP officials at two of four airports GAO visited said they were calling as required. However, CBP officials at the other two airports did not verify many licenses from January 1, 2015, through September 30, 2016, and headquarters officials were unaware of non-compliance with CBP policy. Also, GAO found that during this time frame nationwide, CBP officials were alerted to verify licenses for a significant number of shipments of licensable radiological material for all U.S. airports, but they did not make all the required calls—leaving numerous shipments potentially unverified over this 21-month period. This situation occurred because CBP does not have a monitoring system to ensure that officials make license verification calls as required. Until CBP develops a monitoring system for license verification, it will not have reasonable assurance that it can identify activities inconsistent with its policy and take corrective action.

CBP procedures cannot effectively implement the agency's policy that its officials verify all radiological material shipments imported into the United States. The procedures are not effective for this policy in part because they rely on automated alerts that are based on some but not all relevant information that could indicate potentially dangerous radiological material. Consequently, CBP's current system and procedures cannot ensure that all such materials will be identified. Under federal internal control standards, agencies are to design control activities to achieve objectives and respond to risks. However, CBP does not have the information it needs to develop a robust system or revise its procedures because it has not conducted a comprehensive assessment of the information not included in its automated alert system. In particular, CBP has not assessed relevant information not currently included in the automated alert or how to create a more risk-based approach that distinguishes between higher- and lower-risk quantities of radiological materials. Without such an assessment, CBP may be unable to develop a system or procedures that best support its policy for verifying imported radiological materials.

This is a public version of a sensitive report GAO issued in September 2017. Information CBP deemed sensitive has been omitted.

GAO recommends that CBP develop a monitoring system to help ensure that CBP officials comply with the agency's license verification policy, conduct an assessment to determine relevant information that is not included in the automated alerts, and develop a system that allows it to identify shipments of greatest risk. CBP concurred with GAO's three recommendations and outlined actions to implement those recommendations.

Tens of thousands of shipments containing potentially dangerous  radiological material enter the United States each year through airports  spread across the country. Radiological material is commonly used in  thousands of locations throughout the United States and many other  countries for medical, industrial, and research purposes, such as treating  cancer, sterilizing food and medical instruments, and detecting flaws in  metal welds. In the hands of terrorists, radiological material could be used  to construct a “dirty bomb”—a type of radiological dispersal device that  uses conventional explosives to disperse radiological material. Depending  on the type, form, amount, and concentration of radiological material  used, a dirty bomb could expose nearby individuals to the material and  potentially increase their long-term risk of cancer. In addition, the  evacuation and cleanup after a dirty bomb explosion could result in  serious economic costs, as individuals with homes and businesses in the  vicinity may not be able to, or may choose not to, return for an extended  period until the investigation and remediation activities are complete.  Recent terrorist activity in the United States, Europe, and the Middle East  continues to remind us about the potential use of radiological material in a  malicious act, such as a dirty bomb, and the need to control radiological  material.

The Department of Homeland Security’s U.S. Customs and Border  Protection (CBP) and the Nuclear Regulatory Commission (NRC) work to  ensure that only licensed radiological material enters the United States.  NRC authorizes the possession of radiological materials through licenses,  which can be issued by NRC or one of 37 Agreement States with  licensing authority. CBP monitors ports of entry to help ensure that only  properly licensed shipments of radiological material are permitted to enter  the United States. CBP is also part of the global nuclear detection  architecture—a framework that includes numerous other federal agencies  that work domestically and internationally to detect, analyze, and report  on radiological materials that are out of regulatory control. Within this  framework, CBP deploys technology at and between ports of entry— which include border crossings, seaports, and airports—that can detect  the presence of radiological material hidden in cargo or vehicles. In  addition, CBP personnel take steps to ensure that radiological material  imported into the United States is properly licensed.

We have previously reported on vulnerabilities in CBP and NRC policies  and procedures to prevent unauthorized individuals from obtaining  radiological material. In March 2006, we were able to transport unlicensed  radiological material across the U.S. border using a fake license. In  response to that report, CBP developed a policy to verify the legitimacy of  licenses. In June 2008, we reported that many CBP field staff were not  aware of, or properly using CBP systems to verify licenses. We  recommended, among other things, that CBP communicate verification  guidance to ports of entry. CBP concurred with the recommendation. In  response, CBP sent a memorandum to all ports of entry requiring that  they incorporate new guidance into their operating procedures and  ensure that the guidance be a part of their on-the-job training. In 2016, we  again reviewed the rigor of NRC’s radiological materials licensing  program. For that review, we obtained a genuine license to possess  radiological material by establishing fictitious companies, and we later  altered that license in order to procure additional quantities of radiological  material. Using both the genuine and altered licenses, we secured  commitments from radiological material distributors to sell us a dangerous  quantity of radiological material considered attractive for use in a dirty  bomb. In response to that report, NRC is considering making  enhancements to its pre-licensing process. In 2016, we also found that  CBP faces limitations in the air cargo radiological screening  environment. In 2017, we found weaknesses in NRC’s and the  Department of Transportation’s processes for ensuring compliance with  ground transportation security requirements for dangerous radiological  shipments. That report recommended, among other things, that NRC  should collect information on the number of shipments and mode of  transport for shipments of radiological material. NRC disagreed with the  recommendation.

You asked us to review how CBP ensures that only properly licensed  radiological material is imported into the United States. Specifically, this  report (1) describes CBP’s policies and procedures for ensuring that  imported radiological material is properly licensed, (2) examines the  extent to which CBP follows its policies and procedures, and (3)  evaluates the effectiveness of these policies and procedures. This report  is a public version of a sensitive report that we issued in September  2017. CBP deemed some of the information in our September report to  be sensitive, which must be protected from public disclosure. Therefore,  this report omits sensitive information about the extent of CBP’s  verification of licenses and its procedures for doing so. Although the  information provided in this report is more limited, the report addresses  the same objectives as the sensitive report and uses the same  methodology, which we have described in less detail to omit references to  sensitive information.

To describe CBP’s policies and procedures for ensuring that imported  radiological material is properly licensed, we reviewed regulations,  policies, and procedures related to the verification of licenses for imports  of radiological material into the United States. We also interviewed  agency officials at CBP and NRC to obtain their views on the policies and  procedures related to license verifications.

To examine the extent to which CBP is following these policies and  procedures, we conducted telephone and in-person interviews with CBP  officials in headquarters, experts at CBP’s Laboratories and Scientific  Services Directorate—Teleforensic Center, and officials and private- sector company personnel at airports where radiological material is  frequently imported into the United States. We selected four airports to  visit based on a high or low frequency of contacts made with the  Teleforensic Center to verify licenses and on expected traffic of  radiological materials shipments for a 21-month time frame from January  1, 2015, through September 30, 2016. We received data in October 2016  that included calls made from January 2015 through the last full month  prior to the data request (September 2016). We believe this 21-month  time frame provided a sufficient amount of time to examine trends within  the program. The information we obtained at airports is not generalizable  to all airports but provides examples of how airports are following CBP  policies and procedures. Finally, we gathered data from CBP on the  number of shipments of radiological material at ports of entry and  compared it with data on the number of calls to the Teleforensic Center to  verify licenses. We discussed the reliability of these data with  knowledgeable CBP officials and questioned them about the system’s  controls to verify the accuracy and completeness of the data. We also  analyzed these data for missing information and obvious outliers. We  found the data sufficiently reliable for our reporting purposes.

To evaluate the effectiveness of CBP’s policies and procedures for  ensuring that imported radiological material is properly licensed, we  identified relevant internal control standards and compared them to CBP’s  system of internal controls procedures for verifying licenses for  radiological material imported into the United States. We also spoke to  CBP officials about the data systems and automated rule they have in  place to notify CBP officials that a shipment requires license verification.  In discussions with the officials, we discussed the history of the data systems and which information indicating a shipment contains licensable  radiological material is included in the automated rule. We also obtained  data from January 1, 2015, through September 30, 2016, on licensable  radiological material imports. The 21-month time frame for these data  matched the data we received showing calls to the Teleforensic Center to  verify licenses, and it provided a consistent time frame for comparison.  These data included the port of entry, company receiving the shipment,  and mode of transport (i.e. air, ground, or sea), among other things. We  analyzed these data to determine how many shipments with radiological  material were not checked to verify that their license was legitimate. We  discussed the reliability of these data with knowledgeable CBP and NRC  officials, and we found the data sufficiently reliable for counting the  number of shipments of radiological material.

We conducted this performance audit from September 2016 to January  2018 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.

Radiological material is used throughout the world for medical and  industrial purposes. Possession of this material within the United States  requires a license from NRC or from one of the 37 Agreement States to  which NRC has relinquished regulatory responsibility. NRC and  Agreement States issue two types of licenses authorizing the possession  and use of radiological materials: specific licenses and general licenses.  Specific licenses are issued for devices that typically contain larger  quantities of radiological material, such as medical equipment used to  treat cancer, cameras used for industrial radiography, and moisture and  density gauges used in construction. Devices approved for use under a  general license, by contrast, such as luminous exit signs, normally  contain relatively small quantities of radiological material. Such devices  are designed with inherent safety features, are widely available  commercially, and do not require NRC or Agreement State approval to  possess. Not all radiological material requires an NRC license for  possession. For example, there is naturally occurring radioactive material  in ceramics, fertilizers, and granite tile that does not require a license.  This report focuses on radiological material that requires specific licenses  for possession and use.

Beyond requiring specific licenses for possession of radiological material,  NRC may also require a general or specific license to import such  material. Generally, NRC will issue an import license when the recipient  of the material is authorized to receive and possess the material being  imported.

When issuing licenses for the possession of radiological material, NRC  and Agreement States take steps to ensure companies are legitimate.  Specifically, NRC and Agreement State officials are to conduct pre- licensing visits with all unknown applicants, using detailed screening  criteria. According to NRC, the purpose of the site visit is to have a face- to-face meeting with the applicant to determine whether there is a basis  for confidence that the applicant will use the radiological materials sought  as represented in the application when the applicant receives the license.  NRC has established a 14-point checklist to guide pre-licensing site visits  and has developed a list of questions and activities related to each  applicant’s business operations, facility, radiation safety operations, and  personnel qualifications, to scrutinize the applicant and provide a basis for  confidence that the applicant will use the radiological material as specified  in the license.

In 2003, the International Atomic Energy Agency published a system— which NRC adopted in 2004—that ranks quantities of individual  radionuclides into one of five categories on the basis of their potential to  harm human health. Under this system, a given radionuclide is  considered dangerous when gathered in sufficient quantity and in close  enough proximity to people to cause direct human health effects. A  category 1 quantity, if not safely managed or securely protected, is likely  to cause permanent injury to a person who handles or is otherwise in  contact with it for more than a few minutes. Being close to this amount of  unshielded material for a period of a few minutes to an hour will probably be fatal. A category 2 quantity, if not safely managed or securely  protected, can cause permanent injury to a person who handles or is  otherwise in contact with it for a short time (minutes to hours). Being close  to this amount of unshielded radioactive material for a period of hours to  days can be fatal. A category 3 quantity, if not safely managed or  securely protected, can cause permanent injury to a person who handles  or is otherwise in contact with it for some hours. Being close to this  amount of unshielded radioactive material for a period of days to weeks  can be fatal. Category 4 and 5 quantities are unlikely to cause permanent  injury.

In addition to categorizing radionuclides on the basis of their potential to  harm human health, NRC has identified 16 radionuclides that are  sufficiently attractive for use in a dirty bomb or for other malicious  purposes. These 16 radionuclides of concern, shown in table 1, warrant  enhanced security and protection measures—such as cameras, alarms,  and other physical security measures—under NRC regulations.

Radiological material is imported into the United States by both express  consignment couriers arriving by air and air cargo carriers. Express  consignment couriers, such as FedEx, move cargo for the public under  express commercial services and provide door-to-door delivery. Air cargo  carriers transport radiological material in cargo containers on commercial  airlines. We have previously reported on the disparity in portal monitor  deployment between the express consignment and air cargo  environments. There are dozens of portal monitors in U.S. airports  servicing express couriers, but few servicing air cargo carriers.  According to CBP officials, handheld monitors are used to scan  radioactive material at airports where portal monitors are not available.

The CBP mission includes the border enforcement of the customs,  immigration, and agriculture laws and regulations of the United States  and enforcement on behalf of numerous federal agencies. The mission  includes enforcement of the laws relating to the importation and  exportation of merchandise into and out of the United States. In addition,  the agency’s mission includes denying entry to terrorists and their  weapons and criminals and their contraband. CBP’s Office of Field  Operations is responsible for passenger and cargo processing activities  related to border security, trade, immigration, and agricultural inspection  at the nation’s air, sea, and land ports of entry. Prior to importing goods  into the United States, information is submitted to CBP declaring the  contents of shipments. This information includes, among other things, a  description of goods, the name of the recipient, the port of entry, and a  tariff code that classifies goods.

CBP uses various data systems to track shipments into the United States  and identify shipments for license verification. According to CBP, the  Automated Commercial Environment is the primary system for processing  shipments entering the United States, and it enables the government to  make determinations about whether to admit goods into the country. The  data stored in the Automated Commercial Environment are also used to  ensure proper duty is collected for imported goods. CBP officials also  view Automated Commercial Environment data in CBP’s Automated  Targeting System, which is a decision support tool that analyzes  shipment data to assess risk and identify potential violations. The  Automated Targeting System includes automated alerts, which notify  CBP officials when they need to take additional actions before shipments  can be released. Information about NRC and Agreement State licenses  for radiological material is included in NRC’s Web-Based Licensing  System, which includes information about NRC and Agreement State  licenses for category 1 and 2 quantities of radiological material. In  addition, the Web-Based Licensing System includes up-to-date  information on all NRC and six Agreement States’ specific licenses,  including licenses that authorize possession of radiological material below  the category 2 threshold. However, licenses for quantities of material  below the category 2 threshold issued by 31 Agreement States are not  kept in the system. The CBP data systems used to identify shipments for  license verification are listed in table 2.

CBP’s Policies and Procedures Require License Verification for Imported Radiological Material

CBP has implemented a policy and procedures requiring CBP officials at  airports to contact experts within a centralized CBP office to verify  licenses for radiological material being shipped into the United States.  Specifically, CBP issued its “Radiation Detection Standard Operating  Procedures Directive” policy in March 2014, outlining when CBP officials  at ports of entry are required to contact internal experts at CBP’s  Teleforensic Center who possess the technical expertise to verify that  NRC and Agreement State licenses for radiological materials are  legitimate. The function of the Teleforensic Center is to provide field  CBP officials with assistance in resolving scientific and technological  questions, including detection, isolation, and control of potential threats  that may result from the presence of chemical, biological, radiological, or  nuclear materials. The Teleforensic Center is staffed with scientists with  expertise in a range of scientific disciplines, including chemistry, biology,  explosives, radiological science, and nuclear science. The Teleforensic  Center has established a hotline to receive requests for license  verification, among other things, and the experts are available 24 hours a  day, 7 days a week.

CBP’s 2014 policy requires CBP personnel to verify the legitimacy of  NRC and Agreement State licenses for all commercial imports of  industrial and medical radionuclides that require a license from NRC or  one of the 37 Agreement States. To implement this policy, CBP has  established procedures for private-sector entities and CBP. These  procedures, which apply equally to all quantities and types of licensable  radiological material, can be broken down into three parts: submission of  paperwork, identification of material, and verification of the license by  experts in the Teleforensic Center, as outlined in figure 1.

Once the shipment information is entered into the Automated Commercial  Environment, CBP data systems identify which shipments of radiological  material require license verification. Specifically, CBP’s Automated  Targeting System uses certain information to identify shipments requiring  license verification. Details about this information are omitted from this  report because they were deemed to be sensitive by CBP. Once  shipments are flagged as containing licensable radiological material, an  alert is sent to CBP officials at the airport informing them that the material  requires a license from NRC or an Agreement State. The alert outlines  the steps the officials need to take to verify that the license is legitimate.  Among other things, the alert explicitly states the phone number for  contacting the Teleforensic Center and includes instructions for handling  the material. According to CBP procedures, CBP officials are not allowed  to release the shipment until they receive approval from the Teleforensic  Center.

Officials at the Teleforensic Center primarily use NRC’s Web-Based  Licensing database to verify the legitimacy of licenses granted by NRC.  However, as we’ve previously reported, licenses for some radiological  material that are granted by Agreement States are not kept in that  database, requiring the center’s experts to also call specific points of  contacts at Agreement States to verify these licenses. CBP officials told  us that Agreement State offices typically are not open 24 hours a day, 7  days a week, occasionally requiring CBP to hold shipments until an  official can be reached. In addition to consulting the Web-Based  Licensing database and contacting Agreement State officials to verify  licenses, experts at the Teleforensic Center can also request additional  information from CBP officials at the airports. After the experts verify that  a license is legitimate, they give approval to the CBP officials at the  airport to release the shipment. CBP officials at the airport then document  the release. CBP officials at the four airports we visited and experts at the  Teleforensic Center told us that it typically takes 30 to 90 minutes to verify  a license, but it can take longer if the experts have to consult with an  Agreement State. If a license cannot be verified, the shipment is returned  to the sender or, in the case of an illegal shipment, seized and referred to  proper law enforcement officials, as outlined in the policy.

CBP Has Not Verified All Licenses as Required by Its Policy and Procedures

CBP has not verified all licenses for radiological materials as required in  its policy and procedures. During the 21-month period we reviewed, CBP  personnel at airports across the country did not verify the legitimacy of a  significant number of shipments CBP considered as containing potentially  dangerous radiological material. CBP officials at two of the four airports  we visited may not have verified the legitimacy of licenses for many of the  shipments of radiological material imported during the 21-month period,  which was not consistent with CBP policy. After we brought this issue to  CBP’s attention, it issued additional guidance. However, this guidance  was not clear and caused confusion at the two airports we visited where  actions continued to be taken that were not consistent with CBP policy.

CBP Is Not Consistently Implementing Its Procedures, Potentially Leaving Many Shipments of Radiological Material Unverified

CBP officials did not verify the legitimacy of licenses for many of the  shipments of radiological material imported from January 1, 2015, to  September 30, 2016. We found that during this time frame, CBP officials  stationed at airports nationwide did not make the required calls to verify  licenses for a significant number of shipments of radiological material  identified by CBP as requiring license verification—leaving many licenses  unverified over this 21-month period. These shipments came through  airports across the United States and, according to CBP officials we  interviewed, arrived by both express courier and air cargo companies.

At two of the four airports we visited, we observed that CBP officials were  taking actions that were consistent with CBP policy. Specifically, we noted  the following:

At one airport, officials responsible for reviewing shipments of  imported radiological material told us that they call the Teleforensic  Center whenever they receive an alert from CBP’s data system,  consistent with CBP policy. In addition, the officials said that they  send any requested information to the Teleforensic Center and wait  for approval from the center before releasing shipments.

At another airport, officials responsible for reviewing shipments of  imported radiological material told us that they also call the  Teleforensic Center whenever they receive an alert and only release  shipments upon receiving approval.

However, at the remaining two airports we visited, officials responsible for  reviewing shipments of imported radiological material took actions that  were not consistent with CBP policy to verify the legitimacy of radiological  shipments entering the country. As a result, officials at these airports had  not verified hundreds of licenses as required under CBP’s policy because  the officials misunderstood what they were required to do. In discussions  with these officials, some described taking actions that were not  consistent with the license verification requirements. Details about the  extent of verification are omitted from this report because the information  was deemed to be sensitive by CBP.

At one airport, CBP officials told us they typically verify licenses on- site without calling the Teleforensic Center. This airport had more than  100 shipments of licensable radiological material during the 21-month  period for which CBP provided data, but officials only made a few  calls to the Teleforensic Center to verify licenses during this time,  leaving many shipments of material unverified. Instead of calling the  Teleforensic Center as required, the CBP officials said that they  reviewed the shipment paperwork and looked for anomalies. CBP  officials said that they undertake this paperwork review regardless of  the risk of the radiological material in the shipment. For example, they  said they would use this approach to verify licenses for category 1  materials, which NRC and the International Atomic Energy Agency  classify as likely to cause permanent injury to a person who comes  into contact with them. The officials told us that they call the  Teleforensic Center only when there is something wrong with the  shipment. Officials at CBP headquarters told us that this procedure  does not comply with their verification policy and would not be  effective.

At the second airport, CBP officials we interviewed told us that license  verification was conducted by private-sector express couriers  overseas, negating the need for officials at the port of entry to call the  Teleforensic Center. The CBP officials at the airport believed that a  Memorandum of Understanding (MOU) between CBP and private  companies delegates responsibility to express couriers to scan  material with radiation detection equipment. These CBP airport  officials said that express couriers also verify licenses as part of this  process. However, the MOU between CBP and express couriers does  not address the verification of licenses for radiological shipments.  CBP headquarters officials we interviewed told us that the airport’s  practice does not comply with the agency’s verification policy and  confirmed that the Teleforensic Center is the only entity that can verify  licenses. The headquarters officials also reiterated to us that license  verification is not conducted by overseas private-sector companies.  Officials we interviewed from an express courier that ships  radiological material also told us that they do not verify licenses. This  airport made few calls to the Teleforensic Center to verify licenses  during the 21-month period, according to the data provided to us by  CBP.

CBP Issued Additional Guidance, but This Guidance Did Not Initially Improve Compliance

In February 2017, we briefed CBP headquarters officials on our findings  from the site visits to the four airports. We included in our briefing a  summary of findings from our site visits and information on the number of  calls made by CBP officials to verify licenses. At this meeting, CBP  headquarters officials indicated that they would look into why calls were  not made. Subsequently, in March 2017, in response to this briefing, CBP  headquarters issued additional guidance to remind all field officials of  CBP’s license verification policy. The guidance states that CBP officials  must contact the Teleforensic Center to verify the license for all  shipments of licensable radiological material. In addition, the guidance  states that shipments may not be released from the airport until experts at  the Teleforensic Center have completed verification of the license. The  guidance was issued in the form of a “muster”—a type of memorandum  addressed to all CBP field offices to emphasize CBP policy. Once such a  memorandum is issued, CBP relies on local officials to interpret and pass  along this information to those working directly with the shipments.  According to CBP officials, the guidance was communicated to managers  and then the managers communicated this information to front-line staff  through weekly meetings and informal discussions.

However, the muster was not successful in correcting previous  misconceptions at the two airports we visited where officials’ actions were  not consistent with CBP policy and the muster did not fully resolve their  noncompliance with CBP policy. In part this was because, according to  officials, they found the muster confusing. In April and May 2017, several  weeks after CBP issued the muster, we contacted officials at the four  airports we previously visited. Based on interviews with CBP officials at  the two airports where actions were not consistent with CBP policy before  the muster, we determined that they were continuing to take actions that  were not consistent with CBP policy after they received the muster. For  example, CBP officials at one of the two airports said they were  continuing to conduct license verification without the assistance of the  Teleforensic Center. Officials at this airport told us that they believed their  actions were consistent with the policy, even though they had not altered  their actions in response to the muster. Similarly, at the other airport  where actions were not consistent with the CBP policy before the muster,  officials told us again that license verification can be conducted overseas  by express couriers, citing the MOU allowing express couriers to scan  material with radiation detection equipment. When we discussed the  content of the muster with CBP officials in headquarters in June 2017,  they acknowledged the muster was confusing and stated it needed to be  further clarified. Subsequent to our June 2017 meeting with CBP officials,  they provided additional data that suggested an increase in calls to the  Teleforensic Center. In July 2017, CBP officials told us they planned to  issue additional clarifications. Subsequently, in November 2017, CBP  issued an additional muster emphasizing its policy to call the Teleforensic  Center for all shipments of licensable radiological material.

CBP headquarters officials told us that they were unaware, until we  informed them, that selected airports were not calling the Teleforensic  Center to verify licenses and that licenses were not being verified for  some imported radiological material. This is because CBP does not have  a mechanism, such as a monitoring system, to ensure that all required  license verifications are occurring. Such a system could also conduct  checks to ensure CBP officials are following agency policy. The challenge  to creating such a system is that CBP houses the data necessary to  create it in separate systems that do not communicate with each other,  and these systems are currently run by different offices with differing  missions within CBP. Federal standards for internal control state that  management should establish and operate monitoring activities to monitor  the internal control system and evaluate the results. Until CBP develops  a monitoring system to help ensure that CBP officials comply with the  license verification policy, the agency will not have reasonable assurance  that it can identify activities that are inconsistent with its policy and take  corrective action as necessary.

CBP Policies and Procedures Are Not Effective at Ensuring Only Properly Licensed Radiological Material Is Imported

CBP policies and procedures are not effective at ensuring that only  properly licensed radiological material is imported into the United States.  Specifically, CBP’s procedures for identifying licensable radiological  material do not ensure that all shipments of radiological material are  identified and verified, resulting in the exclusion of a significant number of  shipments that possibly contained radioactive material during the 21- month period we reviewed. Moreover, CBP’s current policy and  procedures treat all radiological shipments with the same level of scrutiny  and do not target resources based on the risk of the material. Details  about these issues are omitted from this report because the information  was deemed to be sensitive by CBP.

CBP’s Procedures Do Not Ensure That All Shipments of Radiological Material Are Identified and Verified

CBP procedures for identifying licensable radiological material do not  effectively implement its policy to verify the license for all shipments of  licensable radiological material. We identified the following issues that  result in limitations in CBP’s procedures.

Specifically, the data system that CBP uses to implement its procedures  does not sufficiently identify all shipments of potentially dangerous  radiological materials. To implement its procedures, the agency chose to  use an existing data system designed to process all types of imports into  the United States. This system uses general customs information to  identify the contents of shipments. Consequently, of the 44,152  shipments that could contain licensable radiological material, the system  alerted CBP officials that they were required to verify relatively few  licenses from January 1, 2015, to September 30, 2016.

In addition, CBP’s license verification procedures do not currently target  the higher-risk radiological materials. CBP’s method for identifying the  contents of shipments does not include information that describes the  quantity of radiological material. Specifically, categories 1, 2, and 3  quantities of radiological material can cause permanent injury or death to  a person in contact with them for some period of time. As a result,  according to a senior CBP official, it is safer to assume all shipments of  radiological material are dangerous until proven otherwise.

Federal standards for internal control recommend that agencies design  control activities to achieve objectives and respond to risks. Until CBP  develops a robust system that can identify all shipments of radiological  material that pose risk, it will not have reasonable assurance that it has  the appropriate policies and procedures necessary to verify licenses for  these shipments. Furthermore, as we reported in December 2016, an  essential element of enterprise risk management is to examine risks  considering both the likelihood of the risk and the impact of the risk on the  mission, in order to help prioritize risk response. Although CBP officials  recognize that their current system and procedures have limitations and  do not allow them to fully implement the agency policy to verify all  shipments of radiological material that enter the United States, we found  that they have not developed a system nor revised their procedures to  address the issues we identified. Of particular concern is that CBP has not conducted a comprehensive assessment of (1) the information not  currently included in the automated alert to determine what additional  information would indicate shipments that may contain dangerous  material or (2) how to create a more risk-based approach that  distinguishes between higher- and lower-risk categories of radiological  materials. Until it conducts such an assessment, CBP will not know how  to adjust its current procedures to ensure that it is identifying all  shipments of potentially dangerous radiological material and targeting its  limited resources to those that pose the greatest risk.

CBP has implemented a policy and procedures intended to ensure that  the tens of thousands of shipments of potentially dangerous radiological  material imported through U.S. airports each year are properly licensed.  However, CBP’s procedures do not effectively implement CBP’s policy of  ensuring that only properly licensed radiological material gains entry to  the United States. This is because CBP does not have a monitoring  system to help ensure that CBP officials at airports nationwide are  complying with the license verification policy. Until CBP develops such a  system, the agency will not have reasonable assurance that it can identify  activities that are inconsistent with its policy and take corrective action as  necessary.

In addition, CBP’s procedures for identifying licensable radiological  material do not ensure that all shipments of radiological material are  identified and verified. This is the result of CBP’s automated alert, which  currently does not include all relevant information needed to identify such  shipments. Additionally, CBP procedures do not distinguish between  high-risk categories of radiological materials and lower-risk categories;  therefore CBP cannot target its limited resources to the shipments that  pose the greatest risk. CBP has not conducted a comprehensive  assessment of the information not currently included in the automated  alert and does not know which shipments pose the greatest risk. A  comprehensive assessment could help CBP gain a better understanding  of information not currently included in the automated alert, and it could  better position the agency to make appropriate changes to its existing  system and procedures, as well as target its limited resources toward the  quantities of material that pose the greatest risk.

We are making the following three recommendations to CBP:

The Commissioner of CBP should develop a monitoring system to  help ensure that CBP officials comply with license verification policies  and procedures. (Recommendation 1)

The Commissioner of CBP should conduct a comprehensive  assessment of information not included in the automated alert to  determine what information is needed to identify licensable  radiological material. (Recommendation 2)

The Commissioner of CBP should develop a system that better  identifies shipments of radiological material that pose the greatest risk  and revise CBP’s policies and procedures as necessary to verify  licenses for these shipments. (Recommendation 3)

We provided a draft of this product to the Department of Homeland  Security (DHS) and NRC for review and comment. DHS provided written  comments, reproduced in appendix I, in which it concurred with our three  recommendations. DHS stated that it will take the following actions,  among others, to address our recommendations: (1) include a monitoring  process in an updated version of its policy addressing license verification,  (2) conduct a comprehensive assessment of information not included in  the automated alert to determine what information is associated with  dangerous material, and (3) develop an intelligence-driven process that  identifies shipments of radiological materials that pose the greatest threat.  In addition, DHS and NRC provided technical comments, which we  incorporated as appropriate.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Homeland Security, the Chairman of the  U.S. Nuclear Regulatory Commission, 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 concerning this report, please  contact me at (202) 512-3841 or trimbled@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 significant contributions to this report  are listed in appendix II.

Appendix I: Comments from the Department of Homeland Security

Appendix II: GAO Contact and Staff Acknowledgments

In addition to the individual named above, Ned Woodward, Assistant  Director; Jeffrey Barron; Richard Burkard; Kendall Childers; Cindy Gilbert;  Cynthia Norris; Danny Royer; Jerry Sandau; Travis Schwartz; and Kiki  Theodoropoulos made key contributions to this report.

Tens of thousands of shipments containing radiological material—which terrorists could use to make a dirty bomb—enter the U.S. each year through airports across the country. The Nuclear Regulatory Commission and some states issue licenses for import and possession of the material, and U.S. Customs and Border Protection is responsible for verifying shipments entering the country are authorized or licensed.

However, we found that CBP failed to verify licenses for some shipments and that its processes do not ensure that all shipments are identified. We recommended that CBP develop systems to improve shipment verification and identification.


Mental Health: Leading Practices for State Programs to Certify Peer Support Specialists

As the peer support workforce has grown, there has been increased attention to standardizing the competencies of peer support specialists through certification.

The 21st Century Cures Act included a provision for GAO to conduct a study to identify best practices related to training and certification in peer support programs in selected states that receive funding from SAMHSA. This report, among other things, describes leading practices for certifying peer support specialists identified by program officials in selected states.

GAO interviewed state program officials in six selected states and reviewed online, publicly available information about their peer support programs. GAO selected the states in part based on the state's certification program being well-established (at least 2 years old), use of SAMHSA funding for peer support, and stakeholder recommendations. The six selected states—Florida, Georgia, Michigan, Oregon, Pennsylvania, and Texas--are among the 41 states and the District of Columbia that, as of July 2016, had programs to certify peer support specialists. In addition to the state program officials, GAO interviewed SAMHSA officials and 10 stakeholders familiar with peer support specialist certification, including mental health researchers and officials from training organizations, among others.

GAO provided a draft of this report to HHS for review and comment. The Department did not have any comments.

According to officials from the Substance Abuse and Mental Health Services Administration (SAMHSA) within the Department of Health and Human Services (HHS), shortages in the behavioral health workforce are a key reason that individuals with mental illnesses do not receive needed treatment. In recent years, there has been an increased focus on using peer support specialists—individuals who use their own experience recovering from mental illness to support others—to help address these shortages. Program officials GAO interviewed in selected states generally cited six leading practices for certifying that peer support specialists have a basic set of competencies and have demonstrated the ability to support others.

Federal data and academic research show an unmet need for behavioral  health services—that is, for services that address mental health or  substance use issues. Specifically, based on its annual survey of  behavioral health issues, the Substance Abuse and Mental Health  Services Administration (SAMHSA) within the Department of Health and  Human Services (HHS) estimated that 10.4 million adults in 2016 had a  serious mental illness; however, only 6.7 million adults received treatment  for these issues in the past year. Serious mental illnesses—including  schizophrenia and bipolar disorders—substantially interfere with a  person’s major life activities such as maintaining interpersonal  relationships and employment. Further, a recent study covering the period  2008-2014 found that more than 50 percent of adults with co-occurring  mental health and substance use disorders (such as alcohol and opioid  use disorders) received neither mental health care nor substance use  treatment in the prior year.

According to SAMHSA, workforce shortages are a key driver of the unmet  need for behavioral health services; 55 percent of counties in the United  States do not have any practicing behavioral health workers. In light of these issues, SAMHSA officials and other experts have called for using  peer support specialists to help address shortages in the behavioral  health workforce. Peer support specialists are individuals who use their  own personal, lived experience recovering from mental illnesses to  support others in their recovery.

In recent years, states have increased their focus on recovery as part of  mental health services, and this has included utilizing peer support  specialists. A nationwide study found that 41 states and the District of  Columbia had established programs to train and certify these workers,  and two other states were in the process of developing such a program  as of July 2016. As the peer support specialist workforce continues to  grow, there has been increased attention to standardizing the profession  through certification.

The 21st Century Cures Act included a provision for us to conduct a study  of peer support specialist programs in states that receive funding from  SAMHSA and identify best practices in these states related to training  and credential requirements for peer support specialist programs. This  report describes  (1) programs for certifying peer support specialists in selected  states and  (2) leading practices for certifying peer support specialists  identified by program officials in selected states.

To describe programs for certifying peer support specialists in selected  states, we selected six states to illustrate aspects of, and variations in, the  certification programs that states have developed for peer support  specialists. The results from our sample cannot be generalized to other  state peer support specialist programs. We selected our sample states  using five criteria, specifically (1) recommendations from SAMHSA  officials, researchers in the field of peer support, and national-level mental  health organizations on states with well-established programs; (2)  SAMHSA data that indicated that a state had reported using SAMHSA’s  Community Mental Health Services Block Grant for peer support  generally; (3) the age of the state’s certification program was at least 2  years old; (4) geographic diversity across the United States; and (5) the  prevalence of serious mental illness among adults in the state. Using  these criteria, we selected the following six states for our sample: Florida,  Georgia, Michigan, Oregon, Pennsylvania, and Texas.

We then reviewed information from the selected states describing  certification requirements for their peer support specialist programs,  including policy manuals and guidelines for becoming a peer support  specialist, training materials, and information on certification renewal.  Additionally, to understand general training practices to inform our  discussions with state program officials, we reviewed our previous reports  on assessing training and development efforts and key principles for  effective workforce planning. We similarly reviewed the National  Commission for Certifying Agencies’ Standards for the Accreditation of  Certification Programs to provide similar guidance. Finally, we  interviewed individuals with responsibilities related to the peer support  specialist programs in the selected states, including state program  officials and staff from independent certification boards and consumer  advocacy groups. (See app. I for a complete list of those we  interviewed.) During these discussions we obtained information on,  among other things, the respective state’s program’s screening, training,  and certification requirements.

To describe leading practices for certifying peer support specialists  identified by program officials in the six selected states, we interviewed  SAMHSA officials about information related to the training and  certification of these specialists, including information on core  competencies that apply to them that SAMHSA identified beginning in  2015. We collected information from the six selected states on their  certification practices through a questionnaire we developed and follow- up interviews with state officials. This included asking their opinions on  what they considered to be leading practices in the areas of screening,  training, and certification requirements for a state peer support specialist  program. We then analyzed information obtained from our interviews with  officials from the selected states to determine which leading practices  they consistently identified for certifying peer support specialists. For the  purposes of this report, we included a practice as a leading practice if it  was identified by state officials from the majority (at least four) of the  selected states. We then examined information from the six selected  states to determine whether they were currently applying the identified  leading practices, even if a particular state had not identified the practice  as a leading practice during the interview.

We also interviewed 10 stakeholders about leading practices. (See app. I  for a complete list of those we interviewed.) To select the stakeholders,  we utilized information from our preliminary research on the topic of peer  support certification and requested recommendations from researchers  and SAMHSA officials. We ensured that the provided recommendations  represented researchers or academic institutions, training or consulting  organizations, associations, and advocacy organizations, interviewing at  least one stakeholder from each area to obtain a mix of perspectives. We  also included some stakeholders that were currently or formerly under  contract with the Department of Veterans Affairs—the largest employer of  peer support specialists in the United States—to provide training for its  peer support specialists. To confirm the applicability of the leading  practices identified by the six states, we shared them with the  stakeholders we interviewed. We also examined the extent to which the  identified leading practices aligned with those identified by the Defense  Centers of Excellence for Psychological Health and Traumatic Brain  Injury (now the Psychological Health Center of Excellence), within the  Defense Health Agency of the Department of Defense.

We conducted this performance audit from November 2017 to November  2018 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.

SAMHSA defines a peer provider as “a person who uses his or her lived  experience of recovery from mental illness and/or addiction, plus skills  learned in formal training, to deliver services in behavioral health settings  to promote mind-body recovery and resilience.” Generally, peer providers  are known as “peer support specialists” in mental health settings. Peer  support specialists are distinguished from traditional mental health service  providers by their lived experience recovering from mental illness. People  with serious mental illness generally receive longer term and more  intensive treatment—either in a primary care or specialty setting—and  peer support specialists may play a key role in the recovery process for  these individuals.

Peer support specialists work in a variety of settings, including clinical  settings such as hospital emergency rooms, independent peer-run  organizations, and on support teams in housing agencies that help  eligible low-income families and persons with disabilities find rental  housing. They can also deliver a varied set of services, including sharing  of experience, goal-setting, developing coping and problem solving  strategies to help individuals self-manage their mental illnesses, and  linking individuals to desired resources like transportation or volunteer  opportunities. Importantly, the services provided by peer support  specialists complement, but do not replace, clinical services.

Like other behavioral health specialties, the requirements for certifying  peer support specialists vary by state, and certification bodies range from  state government entities to independent non-profit organizations. The  development of state-level peer support specialist certification programs  was largely driven by another HHS agency, the Centers for Medicare &  Medicaid Services, which in 2007 recognized peer support services as an  evidence-based mental health model of care and established minimum  requirements for states seeking federal Medicaid reimbursement for peer  support services. One of these requirements is that peer support  specialists complete a training and certification program as defined by the  state. Another requirement is that peer support specialists receive  supervision from a “competent mental health professional,” which may be  provided through direct oversight or periodic care consultation. The state  defines the amount, scope, and duration of the supervision as well as  who is considered a competent mental health professional.

States have used the flexibility allowed by the Centers for Medicare &  Medicaid Services to create their own programs to certify peer support  specialists. Some of these state peer support specialist programs are  assessment-based certificate programs—programs that provide training  and then evaluate whether applicants achieved the learning objectives of  that training through an examination in order to receive certification. Other  programs are professional certification programs—programs that evaluate  applicants against predetermined standards of knowledge, skills, or  competencies. In professional certification programs, the certifying body  is independent from, and is not responsible for, the training process.

SAMHSA supports the peer support specialist field through training,  technical assistance, and grant funding. For example:

From 2009 to 2014, SAMHSA partnered with stakeholders, such as  the National Association for State Mental Health Program Directors, to  gather nationally-recognized experts and stakeholders from across  the United States for an annual meeting. These meetings, known as  the “Pillars of Peer Support,” aimed to identify and create consensus  around factors that facilitate the use of peer support services in state  mental health systems of care.

In 2015, SAMHSA developed core competencies defining the critical  knowledge, skills, and abilities needed by anyone who provides peer  support services through a technical assistance project. According  to officials, the core competencies were developed in response to  inconsistencies in the training and certification of peer support  specialists that emerged as states began to develop their programs.  SAMHSA’s core competencies reflected the five foundational  principles of peer support identified by consumers and other  stakeholders: services should be (1) recovery oriented; (2) person- centered; (3) voluntary; (4) relationship-focused; and (5) trauma  informed. In addition to developing the core competencies, the  project provides trainings and offers technical assistance to states,  counties, providers, and other stakeholders.

Funding for Peer Support Specialist Programs

Although Medicaid provides the largest share of funding for state mental  health agencies, followed by state funds, SAMHSA also provides grant  funding that states can use for both the service and administrative  components of their peer support specialist programs. For example,  SAMHSA’s Center for Mental Health Services funds peer support  programs through its administration of the Community Mental Health  Services Block Grant, which provides flexible funding to the states to  support services and related support activities for individuals with serious  mental illness. While the Community Mental Health Services Block Grant  accounted for less than 1 percent of total revenues received by state  mental health agencies in fiscal year 2015, the flexibility of the funds  allows them to be expended to pay for services that Medicaid and other  health insurance will not pay for, such as training and developing  standards. In fiscal year 2018, 40 states and the District of Columbia  reported using the funds from the Community Mental Health Services  Block Grant for peer support.

SAMHSA also provides discretionary grants directly to domestic nonprofit  organizations that aim to expand the capacity of peer support providers.  These discretionary grants, including the Statewide Consumer Network  Program grants, have helped establish recovery-oriented, consumer- driven services at the state level. SAMHSA also provides block and  discretionary grants focused on substance use through its Center for  Substance Abuse Treatment and Center for Substance Abuse  Prevention, both of which have been used for peer recovery coaches.

While most states use SAMHSA grants and state general funds to  develop and sustain their peer support programs, as of 2016, 41 states  and the District of Columbia were receiving federal Medicaid  reimbursement for the services provided by peer support specialists.  Georgia was the first state to receive federal Medicaid payment for peer  support services in 1999, and additional state Medicaid programs began  to provide coverage of peer support after the Center for Medicare &  Medicaid Services issued guidance in 2007 on the requirements for  federal payment for such services. In addition to meeting the minimum  requirements for peer support services—including training and  certification, supervision, and care coordination—states that bill for peer  support services under the Medicaid program must comply with all  Medicaid regulations and policies.

Selected State Programs Generally Use Similar Processes for Certifying Peer Support Specialists, with Some Variation in Program Requirements

Programs in all six states that we reviewed generally use the same  process for screening, training, and ultimately certifying peer support  specialists. See figure 1 for an illustrated example of this process.

Although the six states’ programs generally use the same process for  certifying peer support specialists, as of May 2018 the programs varied in  the specific requirements applicants must meet for each of the three  stages of certification: screening, training, and certifying. See appendix  II for detailed information on state program requirements.

To determine applicants’ eligibility for peer support specialist certification,  all six state programs we reviewed have screening requirements  applicants must meet when applying for certification. These screening  requirements include requirements related to education, lived experience  with mental illness, prior work or volunteer experience, and letters of  recommendation. The extent to which each screening requirement was  used by each state varied, and the specifics of each requirement also  varied across the six programs we reviewed (see fig. 2).

Education. Five of the six states that we reviewed required a high school  diploma or equivalent. Officials from four of these states indicated that  this level of education was necessary given the skills needed by peer  support specialists, such as reading comprehension and communication  skills. In contrast, Oregon officials told us that they did not require a high  school diploma or equivalent; however, the officials noted that most of  their peer support specialists have at least a high school education.

Mental health experience. While all six state programs we reviewed  required applicants to have lived experience in recovery from mental  illness, the programs implemented this requirement in different ways.  Some required a mental health diagnosis, while others required a  minimum length of recovery time or required applicants to have received  services for a mental illness. Texas officials said they did not have a  specified length of recovery requirement due to the difficulty of pinpointing  the specific time a person began his or her recovery; rather, Texas  required applicants to self-identify as having experience living in recovery.

Prior work or volunteer experience. Three of the six state programs  required applicants to have prior relevant work or volunteer experience,  although the amount of experience required varies. For example, to start  the certification process, applicants in Michigan must be currently working  in a peer support specialist role and have been in that position for at least  10 hours a week for the past 3 months. In contrast, Georgia officials told  us that they found this requirement to be a barrier for some individuals  who have not been able to work; therefore, Georgia did not have this  requirement.

Letters of recommendation. Three of the six states required letters of  recommendation as another way to assess applicants’ readiness to  become peer support specialists. State officials stressed that the letter  should be a personal, work, or volunteer reference, rather than a clinical  reference.

To ensure the competence of the peer support specialist workforce, all six  state programs we reviewed required applicants to complete an initial  training, which we refer to as “core training.” The core training is the initial  training provided to applicants seeking to become certified peer support  specialists and, while the curricula may vary by state or training vendor,  its purpose is to convey the skills and competencies that peer support  specialists need to enter the workforce. Topics covered during the training  typically include ethics, recovery, sharing the recovery story, and  communication skills. (See app. III for an example of a peer support  specialist core training schedule.) While all six states require applicants to  attend core training, the length, cost, and curricula of these trainings  varied across the states, as figure 3 shows.

Length of training. All six programs required at least 40 hours of in- person core training, with Georgia and Pennsylvania requiring more than  70 hours. The six states required at least a week of core training to allow  sufficient time to cover a core curriculum of general peer-related  information, such as the meaning and role of peer support services, and  at times including role play, in an effort to develop the interpersonal skills  needed for an effective peer leadership.

Cost of training. All states but Florida charged applicants fees to attend  training. Training fees varied by state, ranging from $85 in Georgia to  $1,400 in Pennsylvania. These fees varied because what they covered  also varied. For example, state program officials from Michigan told us  that, among other things, the $600 fee covers the price of lodging for the  core training, consultant fees, materials, and college credit hours that can  be earned by attending the training and the graduation ceremony. In  contrast, state program officials from Georgia told us that the $85 they  charge covered the cost of producing the course manual and that all other  costs are covered by the state.

Training curriculum. Four of the six state programs had their own  approved core training curriculum to be used for applicants, while the  remaining two programs in Oregon and Pennsylvania allowed applicants  to select from approved training vendors—each of which had its own  training curricula.

To complete the certification process, all state programs we reviewed  assessed applicants’ knowledge of the concepts taught in the core  training through an examination. The applicants also had to sign and  abide by a code of ethics. However, as of May 2018, the state programs  varied as to who administered the certification examination, the type of  code of ethics applicants were required to sign, the frequency with which  certifications had to be renewed, and the continuing education  requirements certified peer support specialists had to meet. (See fig. 4.)

Examination. Four of the states we reviewed administered a single,  statewide exam that applicants must pass before becoming certified,  while in the remaining two states applicants had to pass an exam  administered by the approved training vendor. The exams included  multiple choice or essay questions. One training vendor responsible for  conducting training in at least two states told us that the vendor included  an oral evaluation component as part of the exam, in light of the  communication and interpersonal skills needed for the peer role.  Similarly, a state program official from Pennsylvania told us that  observational assessments are also used to determine an applicant’s  skills and knowledge.

Code of ethics. Like other health professions, peer support specialists  typically must agree to abide by a code of ethics. All six states we  reviewed required peer support specialists to sign a code of ethics before  becoming certified. Of the six states, the codes of ethics in Pennsylvania,  Georgia, Michigan, and Texas were unique to peer support specialists,  while Florida and Oregon used codes of ethics that also applied to other  workforces, such as substance use disorder professionals and community  health workers. Relatedly, five of the six states also had formal processes  in place to investigate and take action in the event that a peer violated the  code of ethics by, for example, disclosing confidential information. These  actions range from reprimand to revocation of certification.

Certification renewal. Three of the six states we reviewed required peer  support specialists, once certified, to renew their certifications every 1 to 3  years, while the remaining three states awarded lifetime certifications.

Continuing education. Five of the six states required certified peer  support specialists to meet annual continuing education requirements,  which ranged from approximately 10 hours per year to 36 hours every 2  years. According to some state program officials, requiring continuing  education ensures continued competence in the field of peer support or  provides specialized training, such as training for working with specific  populations (such as veterans) or incorporating additional approaches or  skill sets (such as training about the Wellness Recovery Action Plan).

State Officials Generally Cited Six Leading Practices for Certifying Peer Support Specialists

Officials from peer support specialist programs in selected states  generally cited six leading practices for certifying peer support specialists.  The 10 stakeholders—representing the perspectives of researchers,  training or consulting organizations, associations, and advocacy  organizations—we spoke with generally agreed that the six identified  leading practices should be incorporated into programs that certify peer  support specialists because the practices can lead to stronger quality of  services for individuals with serious mental illnesses.

Leading practice one: Systematic screening of applicants. Program  officials in five of the six selected states cited the importance of  systematic or detailed screening of applicants to become peer support  specialists as a leading practice. All six state programs assessed  applicants through a variety of approaches, including (1) using screening  questions about the applicants’ understanding of the peer role, (2)  conducting telephone interviews with applicants, (3) reviewing  applications with a standardized tool or scoring rubric, and (4) having  multiple people review applications for objectivity. Eight of the 10  stakeholders we interviewed confirmed that this was a leading practice,  though some cautioned that these requirements should not unnecessarily  exclude individuals with unique backgrounds or little work history. The  Defense Centers of Excellence for Psychological Health and Traumatic  Brain Injury, which in 2011 explored how to most effectively apply peer  support in the military environment as part of its ongoing mission, has  similarly identified systematic screening with defined selection criteria as  a best practice for peer support programs.

While work or volunteer experience can be used as a screening  requirement for applicants and was required by three of the states we  reviewed, four of the stakeholders we interviewed commented that  meeting these requirements can be challenging for individuals with a  history of mental illness who may have been previously unable to enter  the workforce. Research has shown that the stigma associated with  mental illness is a significant barrier to work for individuals with mental  illness and has shaped employer decisions about hiring or keeping a  person with mental illness in the workplace. These workplace barriers,  along with others, such as access to mental health treatment, contribute  to the relatively low workforce participation of adults with serious mental  illnesses. One stakeholder commented that peer support programs have  a responsibility not to contribute to barriers in the workplace for  individuals with mental illnesses.

Our review shows that some of the peer support specialist programs in  the six selected states are taking steps to address these barriers. For  example, Florida recently changed its requirements and now provisionally  certifies peer support specialists who meet all the certification  requirements except for the requirement to have 500 hours of work or  volunteer experience. After receiving the provisional certification, peer  support specialists have 1 year to complete the work or volunteer hours  necessary to upgrade to the full certification.

Leading practice two: Conducting core training in-person. Program  officials from five of the six selected states cited core training that is  conducted in-person, as opposed to online, as a leading practice. Three  program officials told us that core training should be done in-person to  foster relationship building and experiential learning to develop the  interpersonal skills a certified peer support specialist needs. All six state  programs had in-person core training, regardless of whether the training  was run by the state program itself or through approved vendors. For  example, Michigan hosts its core trainings at a retreat center where  participants are encouraged to stay for the week. Michigan program  officials told us that this creates a place for training participants from  across the state to network, discuss how their agencies work and the  types of issues they face as peer support specialists, and share best  practices. SAMHSA’s core competencies identify the importance of using  active listening skills, understanding when to share experiences and  when to listen, and using their own recovery story to inspire hope.

All 10 stakeholders we interviewed confirmed that providing in-person  training was a leading practice, though 3 commented that some of the  knowledge segments could be done online. Five stakeholders we  interviewed told us that observing the skills of peer support specialists  during training or incorporating observation as part of the certification  exam is important. One stakeholder explained that while written tests are  a good measure of basic knowledge, the tests cannot fully assess the  skills and competencies needed for certification. While 2 stakeholders  cited the increased costs of delivering and grading exams with an  observational component as the reasons many states use written exams  only, 1 stakeholder noted that including an observational component is a  more accurate assessment of whether or not people have developed  needed skills. Another stakeholder commented that using a written test  alone may allow individuals who are good test takers to become certified,  even if they lack the interpersonal skills needed to be a peer support  specialist.

Leading practice three: Incorporating physical health and wellness  into training or continuing education. Program officials from five of the  six selected states cited the importance of emphasizing to peer support  specialists that they should help others manage their physical health—in  addition to their mental health—during core training or continuing  education as a leading practice. All six of the selected states incorporated  managing physical health conditions into their core training or continuing  education. (See text box.) In these trainings, peer support specialists  learn how to help others with access to needed care and prevention  services, set personal health goals to promote recovery and a wellness  lifestyle, and adopt healthy habits to prevent disease or lessen the impact  of existing chronic health conditions. The need for physical health- related training was identified after a 2006 report found that individuals  with serious mental illnesses were dying 25 years earlier than the general  population, largely due to treatable medical conditions caused by  modifiable risk factors, such as smoking and poor nutrition or obesity.  SAMHSA identified educating peers about health, wellness, recovery, and  recovery supports as a core competency.

All 10 stakeholders we interviewed confirmed that emphasizing the  importance of physical health was a leading practice, though 2  stakeholders commented that incorporating physical health and wellness  into trainings should only be done as continuing education.

Example of Leading Practice Three: Georgia Peer Support Whole Health and  Wellness Georgia determined it was important to incorporate physical health and wellness into  training for peer support specialists and was the first state to have related services— which it calls Peer Support Whole Health and Wellness—provided by certified peer  support specialists covered by Medicaid. These peer support specialists—who complete  additional training and are certified in Whole Health Action Management—receive  medical technical support from registered nurses and are trained to work in both primary  care and behavioral health settings. Georgia created the service using a SAMHSA- funded Transformation Transfer Initiative grant, which was designed to give states the  opportunity to increase their efforts to make their state behavioral health delivery systems  more consumer driven, among other things.

The SAMHSA-Health Resources and Services Administration Center for Integrated  Health Solutions adapted Georgia’s training, along with a training developed by New  Jersey, to publish a Whole Health Action Management Peer Support Training Participant  Guide in 2015. This adapted 2-day training aims to teach peers to use a person-centered  planning process to create a whole health goal and how to engage in peer support,  including Whole Health Action Management peer support groups, to meet that goal.

Leading practice four: Preparing organizations to effectively use  peers. Program officials from four of the six selected states cited efforts  to ready provider organizations—such as hospitals or drop-in centers—to  employ certified peer support specialists as a leading practice. State  program officials told us that organizational readiness includes making  sure staff understand the role of peer support specialists and can provide  appropriate supervision. (See text box.) Five of the selected states have  developed guidance or training for supervisors of peer support  specialists. Nine of the 10 stakeholders we interviewed confirmed that  this was a leading practice. SAMHSA identified using supervision  effectively and engaging in problem-solving strategies with a supervisor  as a core competency for this workforce.

Example of Leading Practice Four: Michigan Peer Liaisons  In order to help provider organizations understand the role of peer support specialists,  Michigan created an informal peer liaison role at all 46 of the local Community Mental  Health Services Programs tasked with coordinating mental health services. State officials  told us that these peer liaisons have telephone calls and in-person meetings to provide  informal feedback on technical assistance needs and share information on how certified  peer support specialists are doing in their roles and responsibilities. According to state  officials, peer liaisons have helped prepare mental health agencies to work with peer  support specialists and have helped the state identify what new trainings should be  developed to better help peer support specialists succeed in the workplace.

Many of the stakeholders we interviewed highlighted the importance of  having individuals in an organization who understand the peer support  role. Eight of the stakeholders we interviewed told us that supervisors  need to understand or be trained in the peer support role and skillset, with  three stakeholders commenting that supervisors need to be specifically  aware of the difference between peer support specialists and clinical  providers. For example, to achieve this the training and certifying  organization in Texas runs a twelve month program that helps provider  organizations effectively implement peer support services. The program,  which is designed as a learning community, focuses on changing  organizational culture, defining and clarifying the peer support specialist  role, and supervising these staff, among other things. Relatedly, three  stakeholders told us that there should be more than one peer support  specialist at each organization. One stakeholder noted that having  multiple peer support specialists at an agency provides built in support  and understanding of the peer role, which is important given that peer  support specialists typically have the lowest level of power in an organization. Another stakeholder noted that putting a single peer support  specialist in an organization can be isolating.

Leading practice five: Continuing education requirements specific to  peer support. Program officials from five of the six selected states  considered it a leading practice to require, after certification, peer support  specialists to take continuing education that is specific to the peer support  role. This is to ensure that peers maintain their competency and are  aware of new developments in the field. Five of the six selected states  required certified peer support specialists to maintain their competence  through continuing education, and all five of these states had a  requirement that the continuing education be specific to the peer support  role. (See text box.) All 10 stakeholders we interviewed confirmed that  this was a leading practice. The Defense Centers of Excellence for  Psychological Health and Traumatic Brain Injury similarly identified as a  best practice enabling continued learning through structured training.  SAMHSA identified seeking opportunities to increase knowledge and  skills of peer support as a core competency for peer support specialists.

Example of Leading Practice Five: Pennsylvania Continuing Education  Requirement As an added step to ensure that the peer support specialist workforce is competent,  Pennsylvania places some of the burden on provider agencies for ensuring that certified  peer support specialists meet continuing education requirements. The state requires its  licensed provider agencies to develop a staff training plan to ensure that each certified  peer specialist receives the continuing education they need. Pennsylvania also requires  these agencies to provide opportunities for certified peer specialists to network with other  certified peer specialists both within and outside the agency. The state monitors  compliance with these requirements through annual inspections. State officials told us  that this requirement serves as a safety net and assures them that certified peer support  specialists are up to date in their training.

Leading practice six: Engaging peers in the leadership and  development of certification programs. Program officials from four of  the six selected states cited having certified peer support specialists lead  or participate in the certification process of applicants as a leading  practice. State program officials told us that peers should lead in a variety  of ways, including helping screen applicants, developing curricula,  providing training, and serving as mentors or supervisors to other certified  peer support specialists. For example, Michigan concurrently runs its  continuing education courses and core training in the same location so  that experienced peer support specialists can mentor new peers. Officials  from all six selected states told us that certified peer support specialists in  their states participate in some part of the certification process. (See text  box.) The Defense Centers of Excellence for Psychological Health and  Traumatic Brain Injury similarly identified as a best practice leveraging the  unique experiences and benefits peer support specialists offer as peers  throughout a peer support specialist program, including in positions of  leadership. All 10 stakeholders we interviewed confirmed that this was a  leading practice.

Example of Leading Practice Six: Oregon Traditional Health Worker Commission  Through service on a statewide commission, peer support specialists in Oregon have a  leadership role in developing the education and training requirements for certified peer  support specialists and others. The Oregon Health Authority’s Traditional Health Worker  Commission promotes the role, engagement, and utilization of traditional health  workers—health workers who are certified by the state—in Oregon’s health care delivery  system. The commission includes member representatives of each type of traditional  health worker, including peer support specialists. In addition to developing the education  and training requirements for peer support specialists and other types of traditional health  workers, the commission developed the scope of practice to be used by provider  organizations that employ peer support specialists. On an ongoing basis, the commission  advises the Oregon Health Authority about the traditional health worker program and  ensures that the program is responsive to consumer and community health needs.  Oregon state officials consider having this advisory body with representation from the  peer community to be a best practice, commenting that the commission provides the  hands-on knowledge that the state can then implement through policy and rules.

We provided a draft of this report to HHS for review and comment. The  Department did not have any comments.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of the Department of Health and Human  Services, the Secretary of the Department of Defense, 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 should have any questions about this report, please  contact me at (202) 512-7114 or DeniganMacauleyM@gao.gov. Contact  points for our Office 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 IV.

Appendix I: List of Organizations and Individuals Interviewed

Appendix II: Summary of Peer Support Specialist Program Screening, Training, and Certification Requirements in Selected States

Recovery experience   Must have lived  experience with a  mental illness or  substance use disorder  and have been in  recovery for a minimum  of 2 years.  Must have been in  recovery for at least 1  year between diagnosis  of mental illness or  substance use disorder  and application for  training program.

Must have been  diagnosed with a mental  illness and been in  recovery for a minimum  of 1 year.

Must currently be or  formerly have been  receiving services for  mental illness or  substance use disorder.

Must currently be or  formerly have been  receiving services for a  mental illness.

Minimum of 12  months of work or  volunteer  experience within  the last 3 years   Not required  2 (type unspecified)

Must self-identify as  being in recovery from a  mental health challenge.

For the purposes of this report, we use the term “peer support specialist” to describe individuals who  use their own lived experience recovering from mental illnesses to support others in their recovery;  however, each state may have different titles in place for the certified role achieved through their peer  support specialist programs.

Appendix III: Example of a Peer Support Specialist Core Training

The training schedule below, developed by the Appalachian Consulting  Group, illustrates the content areas that may be included in core training  curriculum for peer support specialists seeking certification. The  Appalachian Consulting Group’s curriculum was used in the first  Medicaid-billable peer support specialist program in Georgia in 1999, and  since then the curriculum has been used to train peer support specialists  in 25 states. This training schedule is an example of the types of content  that could be included in such training, and is not an endorsement of a  particular training curriculum.

Appendix IV: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Tom Conahan (Assistant  Director), Summar Corley (Analyst-in-Charge), JoAnn Martinez (Analyst- in-Charge), Kaitlin Asaly, Muriel Brown, Krister Friday, and Emily Wilson  made key contributions to this report.

Federal and academic studies have reported that millions of American adults with serious mental illnesses, such as schizophrenia and bipolar disorders, go untreated each year. This is driven, in part, by a national shortage of behavioral health care professionals.

In recent years, states have increased use of peer support specialists—people who use their own experience recovering from mental illnesses to support others.

We looked at how 6 states certify that the specialists have basic competencies and the ability to support others. We found 6 leading practices, including training specialists in person and requiring continuing education.