HRSA Uses Three Main Methods to Oversee Grantee Compliance and Has a Process to Address Noncompliance

HRSA primarily relies on three main methods to oversee grantees’  compliance with Health Center Program requirements: annual compliance  reviews, site visits, and routine communications. Additionally, when  HRSA identifies noncompliance with these requirements, the agency has  a recently revised process to address this with its grantees. HRSA provides guidance to project officers for determining whether  grantees are meeting each of the 19 program requirements. HRSA’s Process for Identifying Noncompliance Is Insufficient, and It Is Too Soon to Assess the Revised Process for Addressing Noncompliance

HRSA’s process for identifying noncompliance is insufficient as annual  compliance reviews do not identify all instances of noncompliance and  the extent to which HRSA uses site visits to assess compliance is  unclear, but appears to be limited. Moreover, HRSA’s project officers do  not consistently identify and document grantee noncompliance. Our analysis of 48 compliance decisions that project officers  made during their fiscal year 2011 annual compliance reviews for our  eight selected grantees found that in 43 cases (90 percent) project  officers determined grantees were in compliance with requirements.However, in 23 of these 43 cases (53 percent), we were unable to find  sufficient information to support the project officer’s compliance decision  and the project officers did not indicate that they were unable to clearly  determine compliance, which is what HRSA guidance instructs them to do  if they are uncertain about whether or not the grantee demonstrated  compliance, for example:
Project officers determined that all eight selected health center  grantees were in compliance with the after hours coverage  requirement. While HRSA requires project officers to document their basis for finding a  grantee out of compliance with a requirement, it does not require project  officers to document their basis for finding a grantee in compliance. As noted  earlier, HRSA’s guidance indicates that project officers are to document  these instances when compliance is unclear by writing a comment in a  text field of the evaluation tool, but HRSA has no centralized or  automated mechanism to ensure this occurs. The lack of such a  mechanism, coupled with the lack of documentation of project officers’  basis for finding a grantee in compliance, limits HRSA’s ability to  determine whether a project officer decided a grantee was in compliance  with a requirement because the file contained evidence demonstrating  compliance, or because the project officer was unsure about compliance  and simply defaulted to an affirmative compliance decision without  including documentation of his or her concerns. However, there may be other instances that we were  unable to identify based on the available data. HRSA’s data indicate that 58 grantees, or 5 percent of all health  center grantees, had site visits to review compliance with all 19 program  requirements during this time period. (6 percent) had a site visit that may have assessed compliance with some  of the 19 program requirements. HRSA’s Ability to Address Noncompliance Is Unclear As the Agency’s Process Has Recently Changed

The extent to which HRSA’s revised process—the progressive action  process—is adequately resolving conditions or terminating grantee  funding is unclear because HRSA’s experience with this revised process  is too recent to make any overall assessment. Despite these efforts, however, HRSA’s oversight is  insufficient to ensure that it consistently identifies all instances of grantee  noncompliance with Health Center Program requirements. This is especially problematic because project officers  we interviewed had different interpretations of what constitutes  compliance with certain requirements and therefore, when they should  place a condition on a health center’s grant. Finally, HRSA’s recently revised process for addressing grantee  noncompliance with the 19 program requirements seems to provide both  the agency and grantees with a uniform structure for addressing  compliance deficiencies. Periodically assess whether its new progressive action process for  addressing grantee noncompliance, including the time frames allotted  for grantees to respond, is working as intended and make any needed  improvements to the process. While HHS concurred with our recommendations and indicated that the  report’s findings were helpful in informing ongoing efforts to improve  oversight of the Health Center Program, it did not concur with what it  characterized as some of the central conclusions drawn from the report’s  findings. Appendix I: Characteristics of Selected Health Center Grantees

As part of our assessment of the extent to which the Health Resources  and Services Administration’s (HRSA) process identifies and addresses  noncompliance with Health Center Program requirements, we reviewed  HRSA’s oversight of eight selected health center grantees. 2.)
Why GAO Did This Study

Under the Health Center Program, HRSA provides grants to eligible health centers. HRSA is responsible for overseeing over 1,100 health center grantees to ensure their compliance with Health Center Program requirements. GAO was asked to examine HRSAs oversight. This report (1) describes HRSAs oversight process and (2) assesses the extent to which the process identifies and addresses noncompliance with what HRSA refers to as the 19 key program requirements. GAO reviewed and analyzed HRSAs policies and procedures and available programwide data related to HRSA's oversight of health centers, interviewed HRSA officials, and reviewed documentation of HRSAs oversight from 8 selected grantees that varied in their compliance experience, as well as other factors.

What GAO Found

The Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) relies on three main methods to oversee grantees compliance with the 19 key program requirements.
Annual compliance reviews. HRSA project officers review available information, including that submitted by grantees, to determine whether the grantee is in compliance with each of the 19 program requirements.
Site visits. HRSA and its consultants visit grantees to review documentation, meet with officials, and tour the health center. Some of these visits are intended to assess compliance with some or all program requirements.
Routine communications. Project officers communicate with grantees via phone and e-mail to learn about issues that may affect their compliance.
When HRSA identifies noncompliance with program requirements, it uses a process, implemented in April 2010, to address this with a grantee. This process provides a grantee with defined time frames for addressing any identified noncompliance. If a grantee is unable to correct the compliance issue by the end of the process, HRSAs policy is to terminate the health centers grant.
HRSAs ability to identify grantees noncompliance with Health Center Program requirements is insufficient.
HRSA does not require project officers to document their basis for determining that a grantee is in compliance with a requirement. When project officers are uncertain about compliance, HRSA instructs them to consider a grantee in compliance and to note the lack of certainty in a text field of their evaluation tool. However, HRSA has no centralized mechanism to ensure this occurs. Thus, it is unclear whether project officers' decisions that a grantee is in compliance with a requirement are because there was sufficient evidence demonstrating compliance or the project officer failed to document that compliance was uncertain.
The number of compliance-related visits conducted may be limited. HRSAs available data indicates that only 11 percent of grantees had a compliance-related site visit from January through October 2011; less than half of which had a visit that assessed compliance with all 19 program requirements.
HRSAs project officers do not consistently identify and document grantee noncompliance. Project officers GAO interviewed had different interpretations of what constitutes compliance with some program requirements and therefore when they should cite a grantee for noncompliance.
HRSAs process for addressing grantee noncompliance with program requirements seems to provide both the agency and grantees with a uniform structure for addressing noncompliance. However, the extent to which this process is adequately resolving grantee noncompliance or terminating grantee funding is unclear because HRSAs experience with this process is too recent for GAO to make an overall assessment.

What GAO Recommends

GAO recommends that, among other things, HRSA improve its documentation of compliance decisions, strengthen its ability to consistently identify and cite grantee noncompliance, and periodically assess whether its new process for addressing grantee noncompliance is working as intended. HHS concurred with all of GAOs recommendations, and stated that HRSA has already begun implementing many of them. HHS, however, did not concur with what it characterized as certain conclusions drawn from the findings. HHS based its comments on only some of the evidence. GAOs analysis of all the evidence and HRSAs planned implementation of the recommendations confirm the validity of the findings and conclusions.