Ryan White Care Act: Improvements Needed in Oversight of Grantees

Highlights

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 grantees—only 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 GAO’s 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 grantee’s 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.

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 HRSA’s 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 GAO’s 25 selected grantees and 6 selected service providers.

Recommendations

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.

Recommendations for Executive Action

Agency Affected	Recommendation	Status
Health Resources Administration	In order to improve HRSA's oversight of Part A and Part B grantees, the Administrator of HRSA should 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.	Closed – Implemented HRSA must oversee Part A and Part B grantees in accordance with applicable regulations and guidance. However, in 2012, GAO found that HRSA did not consistently follow HHS and HRSA guidance in carrying out key elements of grantee oversight. Specifically, GAO found that HRSA did not consistently document routine monitoring, including technical assistance; did not consistently provide timely site visit follow-up; did not consistently communicate about Annual Single Audit findings as part of its grantee monitoring activities; and did not clearly communicate with grantees about the restrictive drawdown process. A restrictive drawdown is a special award condition HRSA can put in place for grantees found to be in violation of program or financial requirements; it requires grantees to obtain prior approval before spending grant funds. GAO recommended that 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. In response to GAO's recommendation, HRSA took several steps to better align its grantee oversight processes with HHS and HRSA guidance. First, HRSA improved the functionality of its Electronic Handbook (EHB) for grantee monitoring to enable Project Officers (PO) to better document their oversight and monitoring activities including monthly calls, emails, and technical assistance; and developed Standard Operating Procedures with requirements for documenting routine monitoring, including technical assistance. In addition, HRSA developed a new site visit module for planning, executing, and following up on site visits in EHB and provided guidance that site visit reports should be issued within 30 days of the visit. HRSA also developed processes to ensure Single Audit information is communicated to POs via EHB so they are able to review it as part of their monitoring activities. Finally, HRSA modified the language in the grantee Notice of Award to indicate the reason for implementing a drawdown restriction, instructions on how to request funds, and the process for having the restriction removed. HRSA further implemented an improved restrictive drawdown procedure to enhance communication with grantees about the restriction as well as a webinar to alert grantees to these changes. These actions help ensure that HRSA provides effective oversight of CARE Act grantees in accordance with relevant HHS and HRSA guidance.
Health Resources Administration	In order to improve HRSA's oversight of Part A and Part B grantees, the Administrator of HRSA should assess and revise its record retention management program so that complete grantee files are available for a period of time that HRSA determines will satisfy all of the agency's grantee oversight needs.	Closed – Implemented The Department of Health and Human Services? Health Resources and Services Administration (HRSA) is responsible for conducting oversight of Ryan White CARE Act Part A and Part B grantees in accordance with regulations and guidance, which includes the requirement to maintain a complete grantee oversight record. GAO found that HRSA's lack of records challenged the agency's oversight of grantees. In 2012, HRSA officials told GAO that records of grantee oversight were located across three types of the agency's files, some of which were electronic and some of which were in paper. However, GAO found that the grantee's complete oversight record, which included all three of these agency files, was only maintained for the current and previous grant years because, prior to that, HRSA destroyed documentation of grantee monitoring that was only available in some of the paper files. At the time of GAO?s file review midway through the 2011 grant year, all three grantee files were only available for the first half of grant year 2011 and grant year 2010. Therefore, GAO determined that HRSA's ability to correct previously noted problems with grantee performance could be limited because easily accessible documentation of those problems was not maintained. GAO recommended that HRSA assess and revise its record management program to ensure that complete grantee files are available for a period of time that satisfies all of the agency's grantee oversight needs. In response to GAO's recommendation, HRSA took several steps to better align its grantee record retention management with its oversight needs. First, in 2012 and 2013, HRSA staff, including its Project Officers (PO) responsible for conducting grantee oversight, completed training on records management. This training included information on how to upload paper documentation of monitoring activities into HRSA?s Electronic Handbook (EHB), which would serve as the official grantee record. In 2013, HRSA also provided staff and POs with updated Standard Operating Procedures to provide guidance on the available tools in the EHB for integrated electronic management of grantee monitoring. HRSA has also required POs to use EHB to track grantee conditions, to prepare and provide progress updates, and reports, and to document PO follow-up. Additionally, in 2014, HRSA assessed, revised, and updated the records management policies for POs and staff. HRSA's update of the records management schedule requires POs and staff to maintain all aspects of the grant files in the EHB for 6 years after the grant is closed. HRSA's actions in 2013 and 2014 should help ensure that HRSA has the documentation needed to conduct monitoring of grantees and provide effective oversight in accordance with relevant HHS and HRSA guidance.
Health Resources Administration	In order to improve HRSA's oversight of Part A and Part B grantees, the Administrator of HRSA should develop a strategic, risk-based approach for selecting grantees for site visits that better targets the use of available resources to ensure that HRSA visits grantees at regular and timely intervals.	Closed – Implemented HRSA must conduct its oversight of Part A and Part B grantees in accordance with regulations and guidance, which includes conducting site visits. GAO found that HRSA did not have written guidance describing its policy for the selection of grantees to visit. While agency officials told us that they prioritize site visits based on two elements grantees without a recent site visit and grantees with problems, we found that HRSA did not prioritize its site visits in this manner. Specifically, we found that 44 percent of all grantees did not receive a site visit from 2008 through 2011, while others received multiple visits. GAO recommended that HRSA develop a strategic, risk-based approach for selecting grantees for site visits that better targets the use of available resources to ensure that HRSA visits grantees at regular and timely intervals. In response to GAO's recommendation, HRSA developed a risk-based site visit selection strategy that uses four key criteria to prioritize visits: 1) emergent and critical public health and clinical challenges; 2) fiscal and/or administrative challenges within a program, jurisdiction, or grantee administrative agency; 3) non-compliance with statutory and programmatic requirements and oversight; and 4) technical assistance needs. In addition, beginning in 2012, HRSA implemented a policy that all Part A and Part B grantees will receive a comprehensive program review site visits at least once every five years.
Health Resources Administration	In order to improve HRSA's oversight of Part A and Part B grantees, the Administrator of HRSA should update and maintain a program manual for grantees.	Closed – Implemented HRSA is responsible for conducting routine monitoring of grantees which includes providing technical assistance to ensure that program implementation meets current requirements. However, in 2012, GAO found that grantees sometimes received delayed or conflicting guidance, making it difficult to understand what changes were needed to meet program requirements. In addition, GAO found that HRSA did not provide grantees with a comprehensive, electronic program manual to help meet their routine TA needs, including questions about program requirements. The Comptroller General of the United States' Domestic Working Group found that establishing departmentwide policies and procedures on an internet site is beneficial to grantees because it allows grantees to find detailed information in a single location. As a result, GAO recommended that HRSA update and maintain a program manual for grantees in order to improve its oversight of grantees. In response to GAO's recommendation, HRSA created updated Program Manuals for Parts A and B of the Ryan White program and posted the manuals on HRSA's technical assistance website. HRSA also developed standard operating procedures for updating the program manuals. HRSA's actions fulfill GAO's recommendation that the agency maintain an updated program manual to better oversee grantees and help meet grantees' routine technical assistance needs.
Health Resources Administration	In order to improve HRSA's oversight of Part A and Part B grantees, the Administrator of HRSA should use the results of HRSA's survey of grantees to identify grantees' training needs to allow them to comply with the National Monitoring Standards.	Closed – Implemented Federal regulations require grantees to oversee their service providers and, in April 2011, HRSA issued the National Monitoring Standards, a compilation of requirements for grantee monitoring of service providers. Some Ryan White CARE Act Part A and B grantees said that their implementation of the standards was hindered by insufficient HRSA assistance. Beginning in 2011, Part A and Part B grantees were required to use the HRSA-issued National Monitoring Standards to monitor their service providers. The National Monitoring Standards were issued by HRSA to provide program and financial requirements for service providers based on federal statutes, regulations, and program guidance. According to HRSA, these standards consist of preexisting requirements which were consolidated into one location to assist grantees. Part A and Part B grantees interviewed by GAO said that they found the training and technical assistance (TA) HRSA provided on the National Monitoring Standards to be insufficient because it did not answer all of their questions about HRSA's expectations for how they should implement the standards. HRSA officials told GAO that they had recently issued a survey to obtain feedback from grantees about HRSA's program operations and processes, including their satisfaction with TA and training provided by HRSA on the National Monitoring Standards. GAO recommended that HRSA use the results of this survey to identify Part A and Part B grantees' training needs related to the standards. To address this recommendation, HRSA took several actions using the results of its survey of grantees. In November 2012, HRSA provided feedback on the results of the survey to Part A and B grantees. In 2013, HRSA drafted an action plan based on the results of the grantee survey that addressed areas that needed improvement. Also in 2013, HRSA updated the National Monitoring Standards, posted updates to the HRSA training website, and provided a webinar for grantees on the changes. HRSA also worked with specific grantees that expressed challenges with implementing the standards.