HHS grants management  regulations and guidance govern all HHS grants, including CARE Act  grants. POs may provide the TA or assist grantees in obtaining TA from HRSA  consultants. According to HRSA guidance, POs are to focus on the following priorities  during the grantee site visit (listed below in order of highest to lowest  priority): assure grantee compliance with CARE Act provisions and HRSA  guidance by reviewing compliance with the basic funding  requirements, such as the presence of an adequate plan for the use  of grant funds and administrative, program, and financial  requirements; assure basic functioning of the Part A and Part B programs by  reviewing, for example, the grantee’s ability to disburse funds to  service providers in a timely fashion and the grantee’s ability to  conduct program and financial monitoring of service providers; assure access to care by reviewing the grantee’s clinical quality  management processes and the grantee’s assessment of unmet need  for HIV/AIDS services in their jurisdiction; assure coordinated systems of care by reviewing the grantee’s efforts  to coordinate with other CARE Act programs, HIV counseling, testing  and prevention programs in their area, and other programs that  provide access to HIV/AIDS treatment including Medicaid and  Medicare; and document and report the impact of the grantees’ use of CARE Act  funds including any program innovations and/or program successes. Restrictive drawdown requires  that prior to spending any grant funds, grantees must submit a request for  funds for HRSA review by the 20th of each month, for the upcoming  month, or no less than 10 days before the grantee intends to expend the  funds. HRSA officials told us that the national monitoring standards were  developed in response to two HHS Office of Inspector General reports  that identified the need for a specific standard regarding the frequency  and nature of grantee monitoring of service providers and a clear PO role  in monitoring grantee oversight of service providers.were compiled by HRSA with assistance from a national team of financial  and program experts and a working group of Part A and Part B grantees. HRSA Does Not Consistently Follow Guidance on Oversight of Grantees and Faces Other Challenges

HRSA does not consistently follow HHS or its own guidance for grantee  oversight when monitoring CARE Act grantees. POs do not consistently document routine monitoring or follow up on that  monitoring to help grantees address problems. However, we found that most of the PO  files that we reviewed did not contain documentation of routine monitoring  calls—of the 25 PO files for grantees in our sample, only 4 PO files  contained documentation of monitoring calls at least quarterly in the 2010  grant files we reviewed, and only 8 contained documentation of quarterly  calls in the 2011 grant files. HRSA did not follow its own policies for selecting the grantees it visited  from 2008 through 2011, and varied in its timeliness for providing site visit  follow-up. First, HRSA did not prioritize site visits based on the amount of time that  had passed since a grantee’s last visit. Specifically, although many HRSA  POs we spoke with said that site visits were a valuable and effective form  of oversight, we found that 44 percent of all Part A and Part B grantees  did not receive a site visit from 2008 through 2011. We found that some grantees with numerous site visits had not been  placed on restrictive drawdown, while other grantees with fewer site visits  had. HRSA often did not communicate or document the reasons for  implementing a restrictive drawdown. According to HRSA, 6 of the 52 Part A  grantees and 13 of the 59 Part B grantees were on restrictive drawdown  from 2008 through 2011. HRSA also has not consistently provided grantees placed on restrictive  drawdown with instructions about how to meet the conditions for drawing  down funds. HRSA officials said that HRSA is revising the restrictive drawdown  language to be included in the NOA to include the reasons for the  restriction, needed corrective actions, and the type of documentation  required for the drawdown requests to be processed, and would begin  using this updated language on NOAs for grantees placed on restrictive  drawdown after May 1, 2012. HRSA Recently Issued National Standards for Grantee Monitoring of Service Providers, but HRSA’s Implementation Created Challenges for Grantees

Federal regulations require grantees to oversee service providers and, in  April 2011, HRSA issued the National Monitoring Standards, a  compilation of requirements for grantee monitoring of service providers. HRSA  also verifies this information through grantee site visits and a review of a  list of service providers, which grantees are required to submit annually. The standards include  133 requirements for Part A grantees and 154 requirements for Part B  grantees. Despite  these concerns, several grantees told us they are taking steps to comply  with the requirement. However, in visiting some grantees multiple times while not  visiting others, seemingly without regard to the size of the grantee or  presence of problems, HRSA demonstrated a lack of a strategic, risk- based approach for selecting grantees for site visits. HRSA has provided training to assist grantees in carrying out the  standards, but grantees said that they wanted more guidance and  training. Recommendations for Executive Action

In order to improve HRSA’s oversight of Part A and Part B grantees, we  recommend that the Administrator of HRSA:
Ensure that the agency is implementing the key elements of grantee  oversight consistent with HHS and HRSA guidance, including routine  monitoring, the provision of technical assistance, site visits, and  restrictive drawdown. HHS described a wide array of TA  and training services that HRSA provides to grantees.
Why GAO Did This Study

Each year, half a million people affected by human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) receive services funded by CARE Act grants. HRSA, an agency within HHS, awards CARE Act Part A grants to localities and Part B grants to states and territories. These grantees may provide services themselves or may contract with service providers. HRSA POs monitor grantees, but grantees are to monitor their service providers. PO oversight includes routine monitoring, site visits, and monitoring of special award conditions, such as restrictive drawdown. GAO was asked to 1) evaluate HRSAs oversight of CARE Act grantees and 2) examine steps HRSA has taken to assist CARE Act grantees in monitoring their service providers. GAO conducted a review of grantee files from 2010 and 2011 for 25 selected Part A and B grantees, reviewed HHS and HRSA policies, interviewed HRSA officials, analyzed HRSA data on site visits and interviewed grant officials from GAOs 25 selected grantees and 6 selected service providers.

What GAO Found

The Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) does not consistently follow HHS regulations and guidance in its oversight of Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (CARE Act) grantees when conducting key elements of grantee oversight, including routine monitoring and implementing restrictive drawdowns. Additionally, HRSA did not demonstrate a risk-based strategy for selecting grantees for site visits. Project officers (POs) do not consistently document routine monitoring or follow up on that monitoring to help grantees address problems, as required by HHS and HRSA guidance. The purpose of routine monitoring is to enable POs to answer grantee questions about program requirements, provide technical assistance (TA), and follow up on grantee corrective actions in response to previously provided TA. However, GAO found that most POs did not document routine monitoring calls with granteesonly 4 of the 25 PO files GAO reviewed from 2010 and 8 of the 25 files GAO reviewed from 2011 contained documentation of monitoring calls at least quarterly. HRSA often did not follow HHS regulations and guidance in implementing restrictive drawdowns, a special award condition HRSA can place on grantees with serious problems. Restrictive drawdown requires that prior to spending any grant funds, grantees must submit a request, along with documentation of the need, for funds for HRSA review. Six of the 52 Part A grantees and 13 of the 59 Part B grantees were placed on restrictive drawdown from 2008 through 2011. GAO found that HRSA did not consistently provide grantees in GAOs sample that were on restrictive drawdown with the reasons the restrictive drawdown was implemented, instructions for meeting the conditions of the restrictive drawdown, or guidance on the types of corrective actions needed. This has limited the effectiveness of restrictive drawdown as a tool for improving grantee performance. Regarding the oversight of grantees through site visits, HRSA did not demonstrate a clear strategy for selecting the grantees it visited from 2008 through 2011. For example, HRSA did not appear to prioritize site visits to grantees based on the amount of time that had passed since a grantees last site visit. Although many HRSA POs GAO spoke with said that site visits were a valuable and effective form of oversight, GAO found that 44 percent of all grantees did not receive a site visit from 2008 through 2011 while others received multiple visits.
Grantees are required to oversee the service providers with whom they contract and in April 2011, HRSA issued the National Monitoring Standards for grantee monitoring of service providers. The standards describe program and financial requirements and include 133 requirements for Part A grantees and 154 requirements for Part B grantees. Though the standards were intended to improve grantee monitoring of service providers, some grantees said that a lack of training and TA has hindered its implementation. Additionally, some grantees have found the requirement for annual site visits of service providers to be challenging. HRSA officials said that they believe they provided adequate training to grantees in implementing the standards, which did not represent new requirements.

What GAO Recommends

GAO is making several recommendations, including that HRSA implement key elements of grantee oversight consistent with guidance, including restrictive drawdowns; develop a strategic approach for selecting grantees for site visits; and work to identify grantees training needs in order to comply with the National Monitoring Standards. HHS concurred with the recommendations.