Health Center Program:

Improved Oversight Needed to Ensure Grantee Compliance with Requirements

GAO-12-546: Published: May 29, 2012. Publicly Released: Jun 21, 2012.

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Debra A. Draper
(202) 512-7114
draperd@gao.gov

 

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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, HRSA’s policy is to terminate the health center’s grant.

HRSA’s 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. HRSA’s 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.
  • HRSA’s 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.

HRSA’s 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 HRSA’s experience with this process is too recent for GAO to make an overall assessment.

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 HRSA’s oversight. This report (1) describes HRSA’s 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 HRSA’s policies and procedures and available programwide data related to HRSA's oversight of health centers, interviewed HRSA officials, and reviewed documentation of HRSA’s oversight from 8 selected grantees that varied in their compliance experience, as well as other factors.

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 GAO’s 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. GAO’s analysis of all the evidence and HRSA’s planned implementation of the recommendations confirm the validity of the findings and conclusions.

For more information, contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To improve HRSA's ability to identify and address noncompliance with Health Center Program requirements, the Administrator of HRSA should 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.

    Agency Affected: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration

    Status: Open

    Comments: In response to our recommendation, HRSA indicated they plan to annually review the progressive action process, and make improvements as appropriate, to ensure ensure grantees address compliance issues in a timely manner. They indicated that managers review reports which outline the status of open issues of noncompliance, and specifically reports which highlight noncompliance issues grantees have repeatedly failed to adequately address. According to HRSA, initial reviews indicate the progressive action process is working effectively.

    Recommendation: To improve HRSA's ability to identify and address noncompliance with Health Center Program requirements, the Administrator of HRSA should require that when completing annual compliance reviews, project officers clearly document their basis for determining that grantees are in compliance with program requirements.

    Agency Affected: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration

    Status: Closed - Implemented

    Comments: In response to our recommendation, HRSA revised its annual compliance assessment procedures so that project officers must indicate their basis for determining a grantee is in compliance with a health center program requirement. As part of these procedures, HRSA requires that project officers enter comments in the compliance assessment system to document which information they used to determine that grantees are in compliance. Further, under the revised procedures, HRSA instituted business rules which prevent project officers from completing their compliance review without providing such information.

    Recommendation: To improve HRSA's ability to identify and address noncompliance with Health Center Program requirements, the Administrator of HRSA should clarify agency guidance and provide training, as needed, to better ensure that project officers are accurately and consistently assessing grantees' compliance with program requirements.

    Agency Affected: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration

    Status: Open

    Comments: In response to our recommendation, HRSA has made some progress to better ensure project officers accurately and consistently assess grantee compliance with health center program requirements. HRSA developed program requirement review sheets and training programs for 3 of the 19 program requirements. These sheets and training provide project officers with additional instructions on assessing grantee compliance with requirements. HRSA indicated that 3 more sheets are in the final stages of development, and they have a long-term plan for developing review sheets and training programs for the remaining 13 program requirements.

    Recommendation: To improve HRSA's ability to identify and address noncompliance with Health Center Program requirements, the Administrator of HRSA should ensure that site visit data contained in HRSA's electronic system are complete, reliable, and accurate to better target the use of available resources and to help ensure that all grantees have compliance-related site visits at regular and timely intervals.

    Agency Affected: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration

    Status: Closed - Implemented

    Comments: In response to our recommendation, HRSA developed new tools to ensure the reliability of data contained in its site visit data system. Specifically, it modified the site visit electronic data system by developing enhanced edit checks to eliminate duplicate site visit records, and developed new procedures which allow for editing and updating incorrect information. Additionally, HRSA established a policy that all health center program grantees will receive an operational site visit to assess compliance with all requirements at least once per project period or every three years.

    Recommendation: To improve HRSA's ability to identify and address noncompliance with Health Center Program requirements, the Administrator of HRSA should develop and implement procedures to ensure that instances of noncompliance with program requirements consistently result in the placement of a condition on a health center's grant.

    Agency Affected: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration

    Status: Closed - Implemented

    Comments: In response to our recommendation, HRSA developed new procedures to ensure that project officers consistently place conditions when they identify grantees that are not in compliance with program requirements. Specifically, HRSA developed and updated its standard operating procedures for placing conditions on grantees which requires project officers to issue conditions when they identify instances of grantee non-compliance outside of the annual compliance assessment process. Further, HRSA updated its site visit procedures to require that supervisors review all site visit reports before they are finalized and established a clear timeline for issuing conditions based on site visit findings.

    Recommendation: To improve HRSA's ability to identify and address noncompliance with Health Center Program requirements, the Administrator of HRSA should develop and implement a mechanism for recording, tracking, and following-up on instances when project officers are unable to determine compliance during the annual compliance review process.

    Agency Affected: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration

    Status: Closed - Implemented

    Comments: In response to our recommendation, HRSA enhanced its annual compliance assessment tool by providing project officers with the option to conclude that they need additional information in order to determine whether a grantee is in compliance with a health center program requirement. As part of this enhancement, HRSA issued revised procedures and guidance for project officers; which provided instructions on reaching such conclusions about grantee compliance, and for tracking and following up on these cases.

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