oversight

Ryan White Care Act: Improvements Needed in Oversight of Grantees

Published by the Government Accountability Office on 2012-06-11.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                             United States Government Accountability Office

GAO                          Report to Congressional Requesters




June 2012
                             RYAN WHITE CARE
                             ACT
                             Improvements Needed
                             in Oversight of
                             Grantees




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GAO-12-610
                                           June 2012

                                           RYAN WHITE CARE ACT
                                           Improvements Needed in Oversight of Grantees

Highlights of GAO-12-610, a report to
congressional requesters




Why GAO Did This Study                     What GAO Found
Each year, half a million people           The Department of Health and Human Services’ (HHS) Health Resources and
affected by human immunodeficiency         Services Administration (HRSA) does not consistently follow HHS regulations
virus (HIV) and acquired                   and guidance in its oversight of Ryan White Comprehensive AIDS Resources
immunodeficiency syndrome (AIDS)           Emergency Act of 1990 (CARE Act) grantees when conducting key elements of
receive services funded by CARE Act        grantee oversight, including routine monitoring and implementing restrictive
grants. HRSA, an agency within HHS,        drawdowns. Additionally, HRSA did not demonstrate a risk-based strategy for
awards CARE Act Part A grants to           selecting grantees for site visits. Project officers (POs) do not consistently
localities and Part B grants to states     document routine monitoring or follow up on that monitoring to help grantees
and territories. These grantees may
                                           address problems, as required by HHS and HRSA guidance. The purpose of
provide services themselves or may
                                           routine monitoring is to enable POs to answer grantee questions about program
contract with service providers. HRSA
POs monitor grantees, but grantees
                                           requirements, provide technical assistance (TA), and follow up on grantee
are to monitor their service providers.    corrective actions in response to previously provided TA. However, GAO found
PO oversight includes routine              that most POs did not document routine monitoring calls with grantees—only 4 of
monitoring, site visits, and monitoring    the 25 PO files GAO reviewed from 2010 and 8 of the 25 files GAO reviewed
of special award conditions, such as       from 2011 contained documentation of monitoring calls at least quarterly. HRSA
restrictive drawdown. GAO was asked        often did not follow HHS regulations and guidance in implementing restrictive
to 1) evaluate HRSA’s oversight of         drawdowns, a special award condition HRSA can place on grantees with serious
CARE Act grantees and 2) examine           problems. Restrictive drawdown requires that prior to spending any grant funds,
steps HRSA has taken to assist CARE        grantees must submit a request, along with documentation of the need, for funds
Act grantees in monitoring their service   for HRSA review. Six of the 52 Part A grantees and 13 of the 59 Part B grantees
providers. GAO conducted a review of       were placed on restrictive drawdown from 2008 through 2011. GAO found that
grantee files from 2010 and 2011 for       HRSA did not consistently provide grantees in GAO’s sample that were on
25 selected Part A and B grantees,         restrictive drawdown with the reasons the restrictive drawdown was
reviewed HHS and HRSA policies,            implemented, instructions for meeting the conditions of the restrictive drawdown,
interviewed HRSA officials, analyzed       or guidance on the types of corrective actions needed. This has limited the
HRSA data on site visits and               effectiveness of restrictive drawdown as a tool for improving grantee
interviewed grant officials from GAO’s     performance. Regarding the oversight of grantees through site visits, HRSA did
25 selected grantees and 6 selected
                                           not demonstrate a clear strategy for selecting the grantees it visited from 2008
service providers.
                                           through 2011. For example, HRSA did not appear to prioritize site visits to
What GAO Recommends                        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
GAO is making several                      valuable and effective form of oversight, GAO found that 44 percent of all
recommendations, including that            grantees did not receive a site visit from 2008 through 2011 while others received
HRSA implement key elements of             multiple visits.
grantee oversight consistent with
guidance, including restrictive            Grantees are required to oversee the service providers with whom they contract
drawdowns; develop a strategic             and in April 2011, HRSA issued the National Monitoring Standards for grantee
approach for selecting grantees for site   monitoring of service providers. The standards describe program and financial
visits; and work to identify grantees’     requirements and include 133 requirements for Part A grantees and 154
training needs in order to comply with     requirements for Part B grantees. Though the standards were intended to
the National Monitoring Standards.         improve grantee monitoring of service providers, some grantees said that a lack
HHS concurred with the                     of training and TA has hindered its implementation. Additionally, some grantees
recommendations.                           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
View GAO-12-610. For more information,     requirements.
contact Marcia Crosse, (202) 512-7114,
crossem@gao.gov.

                                                                                   United States Government Accountability Office
Contents


Letter                                                                                     1
               Background                                                                  6
               HRSA Does Not Consistently Follow Guidance on Oversight of
                 Grantees and Faces Other Challenges                                     15
               HRSA Recently Issued National Standards for Grantee Monitoring
                 of Service Providers, but HRSA’s Implementation Created
                 Challenges for Grantees                                                 30
               Conclusions                                                               36
               Recommendations for Executive Action                                      37
               Agency Comments and Our Evaluation                                        37

Appendix I     Reporting Requirements for Part A and Part B Grantees                     42



Appendix II    HRSA Site Visits of Part A and Part B Grantees                            45



Appendix III   Comments from the Department of Health and Human Services                 49



Appendix IV    GAO Contact and Staff Acknowledgments                                     77



Tables
               Table 1: Part A and Part B Grantees with the Most HRSA Site Visits,
                        2008-2011                                                        21
               Table 2: Summary of HRSA’s National Monitoring Standards for
                        Grantee Monitoring of Service Providers                          31
               Table 3: Examples of HRSA’s National Monitoring Standards and
                        Grantee Responsibilities for Part A and Part B Grantee
                        Monitoring of Service Providers, by Topic                        32
               Table 4: Reporting Requirements for Part A and Part B Grantees,
                        Fiscal Year 2012                                                 42
               Table 5: HRSA Site Visits of Part A Grantees, 2008-2011                   45
               Table 6: HRSA Site Visits of Part B Grantees, 2008-2011                   47




               Page i                                GAO-12-610 Ryan White CARE Act Oversight
Abbreviations

ADAP              AIDS Drug Assistance Program
AIDS              acquired immunodeficiency syndrome
CARE Act          Ryan White Comprehensive AIDS Resources Emergency
                    Act
DFI               Division of Financial Integrity
EHB               electronic handbook
EMA               eligible metropolitan area
HAB               HIV/AIDS Bureau
HHS               Department of Health and Human Services
HIV               human immunodeficiency virus
HRSA              Health Resources and Services Administration
MAI               Minority AIDS Initiative
NARA              National Archives and Records Administration
NASTAD            National Alliance of State and Territorial AIDS Directors
NOA               notice of award
OMB               Office of Management and Budget
PO                project officer
TA                technical assistance
TGA               transitional grant area



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Page ii                                        GAO-12-610 Ryan White CARE Act Oversight
United States Government Accountability Office
Washington, DC 20548




                                   June 11, 2012

                                   The Honorable Tom Harkin
                                   Chairman
                                   The Honorable Michael Enzi
                                   Ranking Member
                                   Committee on Health, Education, Labor and Pensions
                                   United States Senate

                                   The Honorable Richard Burr
                                   Ranking Member
                                   Subcommittee on Children and Families
                                   Committee on Health, Education, Labor and Pensions
                                   United States Senate

                                   The Honorable Tom Coburn
                                   Ranking Member
                                   Permanent Subcommittee on Investigations
                                   Committee on Homeland Security and Governmental Affairs
                                   United States Senate

                                   An estimated 1.2 million people in the United States are living with human
                                   immunodeficiency virus (HIV) infection in 2012, and approximately 50,000
                                   new infections occur annually. Since the first cases of acquired
                                   immunodeficiency syndrome (AIDS) were reported in June 1981, more
                                   than 600,000 people with AIDS have died. Each year, half a million
                                   uninsured or underinsured individuals and families affected by HIV/AIDS
                                   receive assistance funded by grants provided for in the Ryan White
                                   Comprehensive AIDS Resources Emergency Act of 1990 (CARE Act). 1
                                   CARE Act funds are distributed to grantees such as states, localities, and
                                   other public or nonprofit entities; these grantees may provide CARE Act
                                   program services themselves or may contract with service providers to


                                   1
                                    Pub. L. No. 101-381, 104 Stat. 576 (codified, as amended, at 42 U.S.C. §§ 300ff through
                                   300ff-121). The 1990 CARE Act added title XXVI to the Public Health Service Act. Unless
                                   otherwise indicated, references to the CARE Act refer to current title XXVI. The CARE Act
                                   programs have been reauthorized by the Ryan White CARE Act Amendments of 1996
                                   (Pub. L. No. 104-146, 110 Stat. 1346), the Ryan White CARE Act Amendments of 2000
                                   (Pub. L. No. 106-345, 114 Stat. 1319), the Ryan White HIV/AIDS Treatment
                                   Modernization Act of 2006 (Pub. L. No. 109-415, 120 Stat. 2767), and the Ryan White
                                   HIV/AIDS Treatment Extension Act of 2009 (Pub. L. No. 111-87, 123 Stat. 2885).




                                   Page 1                                        GAO-12-610 Ryan White CARE Act Oversight
offer the medical care or support services needed to achieve positive
medical outcomes. 2 The CARE Act is administered by the Department of
Health and Human Services’ (HHS) Health Resources and Services
Administration (HRSA). In fiscal year 2012, HRSA allocated over
$2.3 billion of its annual appropriation to CARE Act programs.

Members of Congress have asked questions about HRSA’s ability to
adequately oversee Ryan White grantees and service providers to ensure
that CARE Act funds are used properly and effectively. CARE Act
grantees are monitored by HRSA project officers (PO) and other grants
management officials, and federal regulations require grantees to monitor
their service providers’ compliance with program requirements. Grantees
or service providers found to be in violation of program or federal grants
management requirements are to receive technical assistance (TA) or
other corrective actions designed to bring them into compliance. 3 In this
report, we (1) evaluate how HRSA oversees CARE Act grantees and
(2) examine steps HRSA has taken to assist CARE Act grantees in
monitoring their service providers.

There are five primary parts (Parts A through D and Part F) of the CARE
Act under which HRSA awards grants. The types of entities eligible for
grants and types of services provided through the grants vary by part. In
fiscal year 2011, the majority of CARE Act grants are awarded under
Parts A and B. Part A grants are awarded to the eligible metropolitan
areas (EMAs) and transitional grant areas (TGAs) most severely affected
by the HIV/AIDS epidemic and comprise about 30 percent of CARE Act
grants. 4 Part B grants are awarded to states, the District of Columbia, and


2
 We use the term “grantees” to refer to organizations or entities that receive funding
directly from HRSA for CARE Act services, and the term “service providers” to refer to
organizations awarded contracts or subgrants from grantees to provide services or
arrange for another organization to provide services. Grantees may also provide services
themselves.
3
 HRSA defines technical assistance as the delivery of practical program and technical
support which may include necessary technical and nonfinancial assistance, fiscal and
program management assistance, operational and administrative support, and the
provision of information to grantees regarding the variety of resources available to them,
and how those resources can best be used to meet the health needs of their clients.
4
 EMAs are areas that have a population of 50,000 persons or more and had a cumulative
total of more than 2,000 new AIDS cases during the most recent 5-year period. TGAs are
areas that have a population of 50,000 persons or more and had a cumulative total of
1,000 to 1,999 new AIDS cases during the most recent 5-year period.




Page 2                                         GAO-12-610 Ryan White CARE Act Oversight
U.S. territories and associated jurisdictions and comprise about
55 percent of CARE Act grants. Part B also provides for grants under the
AIDS Drug Assistance Program (ADAP) through which drugs are
provided to eligible individuals with HIV/AIDS. 5 Our review was limited to
Part A and Part B grantees and their service providers.

To evaluate how HRSA oversees CARE Act grantees, we reviewed HHS
and HRSA policies and procedures, conducted a review of selected
grantee files, interviewed selected Part A and Part B grantees, HRSA
POs, and selected national organizations with HIV/AIDS expertise, and
reviewed HRSA data on site visits and staffing. First, we reviewed HHS
and HRSA policies and procedures for overseeing grantees and service
providers. We interviewed HRSA staff about policies and procedures for
overseeing grantees and service providers, as well as about coordination
among HRSA oversight personnel. Second, we selected a
nongeneralizable sample of 25 of the 111 Part A and Part B grantees—12
of the 52 Part A grantees and 13 of the 59 Part B grantees. 6 To select our
sample we divided all of the Part A and Part B grantees into two
categories based on whether or not they had been found to be in violation
of program or financial requirements from 2008 through 2011. We then
chose grantees from each of these two categories to reflect a range of
funding levels, geographic factors, and grant longevity. We reviewed the
files HRSA maintained for this nongeneralizable sample of 25 Part A and
Part B grantees. We reviewed these files for grant years 2010 and 2011. 7


5
 Title XXVI of the Public Health Service Act contains several parts which provide for
grants for various HIV/AIDS-related services. In addition to Parts A and B, Part C
provides for grants directly to public and private nonprofit entities to provide early
intervention services; Part D provides for grants to organizations for family-centered
medical and support services for women, infants, children, and youth with HIV/AIDS and
their families—including infected and affected family members; and Part F provides for
grants for demonstration and evaluation of models of quick response HIV/AIDS services
and electronic data systems, training of health care providers, and the Minority AIDS
Initiative (MAI). Part E does not provide for funding for HIV/AIDS Services but rather
includes provisions to address various administrative functions.
6
 The selected Part A grantees were Baltimore, Maryland; Baton Rouge, Louisiana;
Denver, Colorado; Detroit, Michigan; Indianapolis, Indiana; Las Vegas, Nevada; Memphis,
Tennessee; New York, New York; Phoenix, Arizona; St. Louis, Missouri; San Francisco,
California; and West Palm Beach, Florida. The selected Part B grantees were California,
Florida, Georgia, Louisiana, Maryland, Mississippi, Nebraska, New York, Nevada, Ohio,
Pennsylvania, Rhode Island, and South Carolina.
7
 The grant year for Part A is from March 1 through February 28. The Part B grant year is
from April 1 through March 31.




Page 3                                        GAO-12-610 Ryan White CARE Act Oversight
Our file review included a review of the grantees’ reports for grant years
2010 and 2011 in response to requirements, located in HRSA’s Electronic
Handbook (EHB); review of external audit files for these grant years; and
review of the grantee’s PO files, which include important documentation
of site visits and routine monitoring, among other things, for these grant
years. To conduct this file review, we developed and used a data
collection instrument to determine if the files included evidence of
required monitoring and key monitoring documents. Third, we conducted
structured interviews with POs that had responsibility for monitoring
grantees selected for our file review about the grantee files, and obtained
their views on their roles and responsibilities and on HRSA’s policies and
procedures. 8 We also conducted structured interviews with all 25 of the
grantees selected for our file review to learn about how HRSA oversees
its grantees. In addition, we interviewed staff from national organizations
with HIV/AIDS expertise, including the Kaiser Family Foundation, the
National Alliance of State and Territorial AIDS Directors (NASTAD), the
Communities Advocating Emergency AIDS Relief Coalition, the ADAP
Advocacy Association, and the National Association of County and City
Health Officials. Fourth, we analyzed data provided by HRSA on its
oversight of grantees, including PO staffing and HRSA site visits. 9 To
assess the reliability of these data we compared the data provided to us
by HRSA with information provided to us by our selected 25 grantees
when possible. We asked HRSA to resolve discrepancies either within the
data or between the data and information provided by our selected
grantees. We generally found all of the data reliable for our purposes. We
also assessed HRSA grantee monitoring processes described in
documentary and testimonial evidence against relevant criteria, including
HHS policies, HRSA policies, Office of Management and Budget (OMB)
guidelines, and federal regulations for grants management. 10



8
 Within HRSA, POs from the HAB Division of Service Systems are responsible for the
oversight of Part A and B grantees. For purposes of this report, when we refer to HRSA
POs, we are referring to POs within that division.
9
 For the purposes of this report, we assessed HRSA site visits that included the grantee’s
PO or other HRSA staff. HRSA refers to these types of site visits as comprehensive site
visits and these visits are central to the agency’s routine monitoring of grantees. We did
not assess other types of site visits.
10
  CARE Act grants are subject to governmentwide uniform administrative requirements for
grants and cooperative agreements which for HHS are codified in title 45 of the Code of
Federal Regulations. In this report, these requirements are referred to as “federal
regulations.”




Page 4                                         GAO-12-610 Ryan White CARE Act Oversight
To examine steps HRSA has taken to assist CARE Act grantees in
monitoring their service providers, we conducted interviews of grantees
and service providers, interviewed HRSA staff, and reviewed HRSA
standards. First, we conducted structured interviews with all 25 of the
grantees selected for our file review and a nongeneralizable sample of
6 service providers to learn about how grantees monitor their service
providers. We included only those service providers that provide medical
services. 11 We selected our sample of 6 service providers based on the
grantees’ responses to our questions about frequency of service provider
site visits, the frequency and type of TA they provide to their service
providers. HRSA provided us with a spreadsheet listing all of the service
providers for each of our 25 grantees. We limited this list to service
providers that received at least $100,000 in CARE Act funding and
provided medical services. 12 We then selected one service provider from
this limited list for each of 6 grantees using the information indicated
above. Second, we interviewed HRSA staff about policies and procedures
for overseeing grantees and service providers. Third, we reviewed the
HRSA National Monitoring Standards, which were developed by HRSA to
help Part A and Part B grantees meet federal requirements for program
and financial monitoring of their service providers. These standards were
implemented in 2011.

We conducted this performance audit from April 2011 to June 2012 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


11
 We selected service providers from Indianapolis, Indiana; New York, New York; and
Phoenix, Arizona. We also selected service providers from Florida, Pennsylvania, and
Rhode Island.
12
  HRSA categorizes service providers by four broad service types—administrative
service, medical service, support service, and HIV counseling and testing. Administrative
services are those related to grants management and monitoring activities including the
development of management systems and preparation of reports. Medical services are
those outpatient and ambulatory care services that are part of essential medical care.
They can include, for example, oral health care and HIV/AIDS drug assistance. Support
services are nonmedical services tied to medical outcomes. They can include, for
example, client transportation to medical appointments and substance abuse residential
services. HIV counseling and testing includes the provision of voluntary HIV testing to help
people learn their HIV status. We excluded service providers that provided only HIV
counseling and testing, administrative services, and/or support services. Service providers
that provide medical services in addition to any of the excluded services were included in
our selection.




Page 5                                         GAO-12-610 Ryan White CARE Act Oversight
             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.


             Under the CARE Act, Part A and Part B grantees are awarded grants to
Background   provide a range of services—both medical and support—to uninsured
             and underinsured clients with HIV/AIDS. In fiscal year 2011, most
             CARE Act funding was distributed to grantees either as base or
             supplemental grants. Base grants are distributed by formula, which
             includes a grantee’s share of living HIV/AIDS cases. 13 Supplemental
             grants are generally awarded through a competitive process based on the
             demonstration of severe need and other criteria. Part A provides for
             grants to EMAs and TGAs. EMA and TGA funding is primarily provided
             through three categories of grants: (1) formula grants, (2) supplemental
             grants, and (3) Minority AIDS Initiative (MAI) grants. 14 Part B provides for
             grants to states, the District of Columbia, and U.S. territories and
             associated jurisdictions. These grants include (1) formula grants,
             (2) supplemental grants, (3) ADAP formula grants, 15 (4) ADAP




             13
              Part A and Part B formula grants are based on reported living HIV/AIDS cases as of
             December 31 in the most recent calendar year for which data are available.
             14
               MAI grants are supplemental grants awarded on a competitive basis to address
             disparities in access, treatment, care, and health outcomes.
             15
               Through ADAP grants, medications are provided for the treatment of HIV disease.
             Congress typically designates a portion of the Part B appropriation for ADAP each year. A
             formula based on the number of reported living HIV/AIDS cases in the most recent
             calendar year is used to award ADAP formula funds to states, the District of Columbia,
             and territories and associated jurisdictions. Additionally, 5 percent of the ADAP
             appropriation is to be reserved for supplemental grants to states and territories that have
             demonstrated severe need. ADAP funds may also be used to purchase health insurance
             for eligible clients covering medications and primary care services as long as the cost
             does not exceed the cost of otherwise providing ADAP medications covered by the
             program.




             Page 6                                         GAO-12-610 Ryan White CARE Act Oversight
supplemental grants, 16 (5) MAI grants, and (6) supplemental grants for
states with “emerging communities”. 17, 18 Part A and Part B grantees apply
for funding annually. 19

The PO is the HRSA official responsible for working with grantees in
overseeing the programmatic and technical aspects of the Part A and
Part B grants. Within HRSA, POs in the HIV/AIDS Bureau’s (HAB)
Division of Service Systems are responsible for the oversight of Part A
and Part B grantees. POs are supervised by HAB Division of Service
Systems branch chiefs, who are responsible for ensuring that POs are
meeting their oversight responsibilities. 20 The PO works with the HRSA
Office of Financial Assistance Management’s grants management
specialists (GMS). GMSs are responsible for providing nonprogrammatic
administrative assistance to grantees, including assistance in interpreting
provisions of grants administration, law, regulation and policy. These
provisions include how grantees can draw down grant funds and how
grantees are to administer and close out grants. GMSs are supervised by
Grants Management Officers. Additionally, within the Office of Federal
Assistance Management, staff in the Division of Financial Integrity (DFI)
provide TA and advice to the POs and GMSs.




16
  HRSA awarded $50 million in both 2011 and 2012 for ADAP emergency relief funding in
order to address states’ increased need for medications for CARE Act clients.
17
  “Emerging communities” are defined as metropolitan areas reporting between 500 and
999 cumulative AIDS cases over the most recent 5 years.
18
   The CARE Act provides that Part A and B base and supplemental grant funds are
available for obligation by the grantee for a 1-year period beginning on the first day of the
grant year. It also requires HRSA to cancel any unobligated balances at the end of the
grant year, recover funds that had been disbursed to grantees, and redistribute these
funds to grantees in need as supplemental grants. Grantees must estimate their
unobligated balances during the grant year and provide final amounts in their federal
financial report. Grantees may request to carryover funds for 1 additional grant year. See
GAO-09-984 and GAO-09-1020.
19
  The grant year for Part A is from March 1 through February 28. The Part B grant year is
from April 1 through March 31.
20
  Branch chiefs have sometimes been needed to serve as POs for some grantees due to
staffing shortages in recent years. According to a HRSA official, serving in these dual
roles is difficult and does not allow the time necessary to supervise and develop POs.




Page 7                                          GAO-12-610 Ryan White CARE Act Oversight
                     HRSA POs conduct their oversight of Part A and Part B grantees in
                     accordance with regulations and guidance. HHS grants management
                     regulations and guidance govern all HHS grants, including CARE Act
                     grants. The regulations and guidance provide for the creation of agency
                     and program-specific guidance. Where HRSA has not created specific
                     guidance, POs and GMS follow the overarching HHS regulation and
                     guidance. Therefore, POs follow HHS regulations and guidance and any
                     additional HRSA-specific grants management guidance when it is
                     available. HRSA officials told us POs are to follow the Division of Service
                     System Operations Manual (HRSA Operations Manual), which provides
                     guidance and protocols specifically for PO oversight of CARE Act Part A
                     and Part B grantees. The HRSA Operations Manual was first provided to
                     us in August 2011 and updated in December 2011. 21 Because the
                     updated HRSA Operations Manual was not in existence during the
                     majority of the period covered by our review, we primarily refer to HHS
                     grants management regulations and guidance in our evaluation of
                     HRSA’s oversight. HRSA’s grantee oversight includes several elements,
                     described below.


Routine Monitoring   HRSA POs are responsible for overseeing the Part A and Part B
                     programs by conducting routine monitoring of grantees’ performance and
                     compliance with statutory requirements, regulations, and guidance.
                     Routine monitoring includes regularly scheduled monitoring calls, reviews
                     of grantee reports, and the provision of TA to grantees. HHS guidance
                     indicates that monitoring activities are to be documented. This guidance
                     also indicates that the documentation is to include information about the
                     type of follow-up actions recommended or taken. We found that POs
                     were assigned an average of six Part A and Part B grantees to oversee at
                     a time. If during the course of routine monitoring a PO finds that a grantee
                     has not met its program or financial requirements, the PO is responsible
                     for determining, in consultation with his or her branch chief, whether a
                     grantee requires more intensive monitoring including a special condition
                     of award, such as restrictive drawdown. The PO is responsible for
                     monitoring any of these special conditions put in place. POs are HRSA’s
                     primary contact with Part A and Part B grantees, and they are to
                     communicate with their assigned grantees at least monthly. In addition to


                     21
                       The August 2011 version of the HRSA Operations Manual did not include all of the
                     information and policies that were included in the version provided to us in February 2012,
                     which was dated December 2011.




                     Page 8                                         GAO-12-610 Ryan White CARE Act Oversight
              a scheduled routine monitoring conference call with grantee
              management, POs are to respond to interim grantee e-mails and calls
              and to provide guidance and TA as needed.

              As part of routine monitoring, POs are also responsible for reviewing
              reports filed by grantees to fulfill HRSA’s annual reporting requirements.
              These reports are intended to help HRSA identify grantee problems with
              program implementation and ensure grantees’ compliance with federal
              statutes, regulations, and guidelines. In fiscal year 2012, Part A grantees
              are required to submit 11 different reports while Part B grantees are
              required to submit 16 reports. The reports contain important
              programmatic and financial information such as descriptions of funded
              services, annual expenditures, and grantee accomplishments and
              challenges in meeting program goals. POs are to provide feedback to
              grantees based on their review of these reports and provide written
              requests for changes to reports which are submitted through EHB. The
              PO and GMS are also responsible for reviewing grantee reports to ensure
              that grantees are spending funds in accordance with the grant terms and
              conditions and POs and GMSs are to coordinate in their review of
              grantees’ reports. Grantee reporting requirements are listed in appendix I.

              When a PO identifies a problem during routine monitoring the PO is to
              provide TA to help the grantee understand the changes needed to
              address the problem. TA is a targeted means of addressing a particular
              issue or problem and is provided to ensure that program implementation
              reflects the most recent requirements. The overall intent of TA is to assist
              the grantee in improving its capacity, effectiveness, and efficiency. A PO
              may provide the TA by phone, email, on-site or at grantee conferences.
              POs may provide the TA or assist grantees in obtaining TA from HRSA
              consultants. 22


Site Visits   In addition to their overall routine monitoring responsibilities, POs are to
              participate in site visits for Part A and Part B grantees. Site visits are
              intended to provide the PO with an opportunity to review the program,



              22
                HRSA contracts with consultants to provide TA to improve the performance of CARE Act
              grantees, and to assist them in addressing the HRSA priority areas with the goal of
              enhancing their performance as grantees. HRSA consultants may also conduct site visits
              focused on the priority areas. HRSA consultants are not federal employees, and are
              generally employed by management and/or health services consulting firms.




              Page 9                                      GAO-12-610 Ryan White CARE Act Oversight
and may act as a TA session for the grantee. HRSA guidance states that
site visits should be viewed as an opportunity to expand on information
grantees have provided in their CARE Act grant application, responses to
reporting requirements, and conference calls. During a site visit, the PO
may meet with grantee and service provider staff to obtain feedback on
how the program is functioning, visit various locations at which service
providers deliver services, and review grantee and service provider
program documentation. For the Part A and Part B programs, HRSA does
not have written guidance describing its policy for the selection of
grantees to visit; however, agency officials told us that they prioritize site
visits based on two elements—grantees without a recent site visit and
grantees with problems. In addition, a federal course which HRSA has
offered to all of its employees for several years and requires all new POs
to take indicates that agencies should determine which grantees to visit
based on an analysis of risk, which includes a consideration of grant
funding level as an indicator of potential risk, among other things. 23

When planning a site visit, POs are to provide advance notice in writing to
the grantee of the intended site visit along with a copy of the site visit
agenda and the tool the PO will be using to evaluate the grantee. The tool
addresses the priorities listed below during the site visit. If the site visit will
involve the review of a priority item in which the PO does not have
specialized training, such as clinical quality management, the PO can
consider bringing one or more HRSA consultants for the visit.

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;




23
 Monitoring Grants and Cooperative Agreements for Federal Personnel, Section 6-1.
According to HRSA, the HHS Office of Grants and Acquisition Policy and Accountability
worked with a contractor to develop a series of classes on federal grants management.
This manual corresponds with one of the classes in that series.




Page 10                                      GAO-12-610 Ryan White CARE Act Oversight
•    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; 24 and

•    document and report the impact of the grantees’ use of CARE Act
     funds including any program innovations and/or program successes.

Upon arrival at the site visit location, the PO is to meet with the grantee
leadership and the Part A or Part B program staff. During the initial
meeting, the PO is to review the intent of the visit and the site visit
agenda. This meeting is also an opportunity for the grantee to provide an
update on the status of the program and the delivery of services. During
the site visit, the PO is to take notes on the priorities listed above, and be
prepared to conduct an exit conference with the grantee leadership and
program staff to explain both preliminary positive and problem findings.
The PO is to prepare a site visit report to document his findings and
recommended corrective actions. Additionally, recommendations are to
be provided for follow-up TA if appropriate and any special action steps
that the PO will take to help the grantee address the site visit findings.
HRSA guidance updated during our review states that the site visit report
is to be provided to the grantee within 30 days of the visit.




24
  Medicaid is the federal-state program that covers acute health care, long-term care, and
other services for certain categories of low-income individuals. Medicare is the federal
health insurance program for people aged 65 and older, certain individuals with
disabilities, and individuals with end stage renal disease.




Page 11                                       GAO-12-610 Ryan White CARE Act Oversight
Single Audits          Part A and Part B grantees are subject to the requirements of the Single
                       Audit Act, as amended, and the act’s implementing OMB guidance. 25
                       These provisions require grantees that expend $500,000 or more in
                       federal awards in a fiscal year to have a single audit for that year
                       conducted by an independent auditor. HRSA’s Division of Financial
                       Integrity (DFI) reviews grantees’ single audit reports with findings related
                       to CARE Act programs along with corrective action plans provided by the
                       grantee in response to any audit findings. 26 Federal regulations require
                       HRSA to use single audits as a tool to monitor Part A and Part B grantee
                       compliance with program and financial requirements.


Restrictive Drawdown   In accordance with federal regulations, HRSA may impose special
                       restrictive conditions on a grantee’s award if HRSA determines that the
                       grantee violated program or financial requirements, or has insufficient
                       management systems or practices to ensure stewardship of grant funds
                       or achievement of award objectives. These issues may be identified
                       through routine monitoring activities, site visits, or single audits. One such
                       condition is called restrictive drawdown. 27 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. With each request, the grantee must submit supporting


                       25
                         The Single Audit Act as amended, 31 U.S.C. §§ 7502 et seq., requires states, local
                       governments, and nonprofit organizations expending $500,000 or more in federal awards
                       in a year to obtain an audit in accordance with the requirements set forth in the act. A
                       single audit consists of (1) an audit and opinions on the fair presentation of the financial
                       statements and the Schedule of Expenditures of Federal Awards; (2) gaining an
                       understanding of and testing internal control over financial reporting and the entity’s
                       compliance with laws, regulations, and contract or grant provisions that have a direct and
                       material effect on certain federal programs (i.e., the program requirements); and (3) an
                       audit and an opinion on compliance with applicable program requirements for certain
                       federal programs. We refer to these audits as single audits—they are also commonly
                       referred to as A-133 audits. See OMB Circular No. A-133.
                       26
                         DFI is responsible for notifying grantees of the adequacy of their proposed corrective
                       actions and for consulting with other HRSA staff, including POs, as needed.
                       27
                         The notice of award (NOA) is the official document that states the terms, conditions, and
                       amount of a grant award and is signed by the official who is authorized to obligate funds
                       on behalf of HRSA. An NOA shows the amount of federal funds available to the grantee
                       and is issued at the start of each grant year. A revised NOA may be issued during a grant
                       year to effect an action resulting in a change in the amount of support or other change in
                       the terms and conditions of award such as a restrictive drawdown.




                       Page 12                                         GAO-12-610 Ryan White CARE Act Oversight
                        documentation including all grantee invoices, and other financial
                        documents related to the request. 28 Upon PO review and approval of the
                        request and related documentation, HRSA is to make CARE Act funds
                        available to the grantee. In December 2011, during the course of our
                        review, HRSA created agency-specific guidance that specified the
                        reasons Part A and Part B grantees might be placed on restrictive
                        drawdown, how a grantee is to be notified of this special condition, and
                        under what conditions a grantee can be removed from restrictive
                        drawdown. However, this guidance was not in place during the period
                        covered by our review.


National Monitoring     Federal regulations require grantees to oversee their service providers. In
Standards for Grantee   April 2011 HRSA compiled existing requirements into a comprehensive
Monitoring of Service   document called the National Monitoring Standards. 29 The standards are
                        designed to help Part A and Part B grantees meet federal requirements
Providers
                        for program and financial management, and to improve program
                        efficiency. Prior to HRSA’s issuance of the standards, guidance on how to
                        ensure grantee compliance with program requirements and how to
                        monitor service providers was found in multiple sources. HRSA expects
                        the standards to provide direction to grantees for monitoring their own
                        compliance with CARE Act program and financial requirements and the
                        performance of their service providers.

                        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




                        28
                          Part A and Part B grantees that are not on restrictive drawdown are able to request
                        funds that they have available at any time during the grant year through the use of an
                        online form that is submitted to the HRSA Payment Management System. Additional
                        documentation is not required. Fund requests are reviewed and upon approval are
                        provided to the grantee the next business day.
                        29
                          HRSA states that the standards are based on administrative requirements for HHS grant
                        awards, Office of Management Budget principles, the HHS Grants Policy Statement, the
                        NOA and Conditions of Award for CARE Act grants, and HRSA program guidance.




                        Page 13                                        GAO-12-610 Ryan White CARE Act Oversight
                in monitoring grantee oversight of service providers. 30 The standards
                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.
                According to HRSA, the working group provided feedback on drafts of the
                standards. Additionally, according to HRSA, the standards were
                presented to all Part A and Part B grantees in a 2010 Grantee Meeting.
                Grantees were notified of their obligation to comply with these standards
                in fiscal year 2011.


Grantee Files   HRSA maintains three different grantee files to assist in its provision of
                oversight, monitoring, and TA to Part A and Part B grantees and there is
                a different record retention period for each of these three files. 31 Single
                audit reports and related financial documentation are maintained in hard
                copy audit files by HRSA’s DFI. HRSA’s record management program
                requires these files to be kept onsite at HRSA for at least 2 years after the
                final close of the audit or upon resolution of any adverse audit findings.
                The files are then to be sent to the Federal Records Centers to be
                maintained for an additional 4 years. 32 The EHB includes the NOA and
                official grantee reports in response to CARE Act grantee reporting
                requirements listed in appendix I. It is maintained electronically by the
                HRSA Division of Grants Management Operations and the Division of
                Service Systems and documents in EHB are accessed by POs and other
                grants management staff as part of their routine monitoring
                responsibilities. Currently, HRSA maintains the EHB for 6 years, but is



                30
                  U.S. Department of Health and Human Services Office of Inspector General. “Monitoring
                of Ryan White CARE Act Title I & II Grantees.” (Washington, D.C.: U.S. Government
                Printing Office, 2004). http://oig.hhs.gov/oei/reports/oei-02-01-00640.pdf and U.S.
                Department of Health and Human Services Office of Inspector General. “The Ryan White
                CARE Act Title I & II Grantee’s Monitoring of Subgrantees.” (Washington, D.C.: U.S.
                Government Printing Office, 2004). http://oig.hhs.gov/oei/reports/oei-02-01-00641.pdf.
                31
                  Under the Federal Records Act, agencies are to manage the creation, maintenance,
                use, and disposition of records in order to achieve adequate and proper documentation of
                the policies and transactions of the federal government and effective and economical
                management of agency operations. 44 U.S.C. chapters 21, 29, 31, and 33. Accordingly,
                to ensure that they have appropriate recordkeeping systems with which to manage and
                preserve their records, agencies develop records management programs that include,
                among other things, specified retention periods for agency records.
                32
                  Federal Records Centers across the United States store and provide access to inactive
                or permanent records pending their disposition according to the approved records
                retention periods.




                Page 14                                       GAO-12-610 Ryan White CARE Act Oversight
                              working to finalize a record retention period. Additionally, PO files, which
                              include the only documentation of routine monitoring, site visits, and TA,
                              and duplicate copies of the required grantee reports that are also found in
                              EHB, are maintained in hard copy by the PO. During the course of our
                              review, HRSA officials told us that HRSA’s record management program
                              requires these files to be maintained for the current and previous grant
                              year, after which they were to be destroyed. 33 The December 2011
                              update to HRSA’s Operations Manual now suggests that POs should
                              maintain copies of site visit reports for at least 5 years, and that any
                              documents related to issues under investigation not be discarded.
                              However, this change does not apply to other key documentation in PO
                              files, such as regularly scheduled conference calls and copies of relevant
                              e-mails.

                              HRSA does not consistently follow HHS or its own guidance for grantee
HRSA Does Not                 oversight when monitoring CARE Act grantees. A lack of records and
Consistently Follow           frequent changes in PO assignments further challenge HRSA’s ability to
                              oversee grantees and to assist them with program implementation.
Guidance on
Oversight of Grantees
and Faces Other
Challenges
HRSA Does Not                 HRSA did not consistently follow guidance for documenting routine
Consistently Follow           monitoring, prioritizing grantee site visits, reviewing annual single audit
Applicable Guidance for       findings, or clearly communicating with grantees about the restrictive
                              drawdown process.
Grantee Oversight
HRSA Did Not Consistently     POs do not consistently document routine monitoring or follow up on that
Document Routine Monitoring   monitoring to help grantees address problems. HHS guidance indicates
                              that monitoring activities performed in order to evaluate grantees’
                              programmatic performance, including any discussions with grantees,
                              should be documented. This guidance also indicates that documentation
                              of monitoring actions is to include information about the type of follow-up
                              actions recommended or taken. However, we found that most of the PO
                              files that we reviewed did not contain documentation of routine monitoring


                              33
                                Although HRSA’s record management program requires these records to be kept for
                              2 years, the grantee records made available to us typically included information for less
                              than 2 full grant years.




                              Page 15                                        GAO-12-610 Ryan White CARE Act Oversight
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. 34 Though most of the files we reviewed
contained documentation of e-mails between POs and grantees indicating
that communication was taking place, HRSA POs are to conduct and
document regularly scheduled calls. Despite the lack of documentation in
PO files, most grantees we interviewed reported having regular
communication, via phone or e-mail, with their POs. Seventeen of the
25 grantees confirmed that their PO conducted regularly scheduled
conference calls, and 7 noted that these calls included a set agenda.

Most grantees said they had received feedback at least once from a PO
on a required report, but eight noted that such feedback was uncommon.
Grantees submit numerous reports throughout the year containing
important programmatic and financial information. HHS guidance states
that monitoring is to include a review of reports, and that review of reports
may help officials identify performance or financial issues that require
follow-up. Further, HRSA POs are to review and provide feedback and
guidance to grantees on program and fiscal reports. However, seven
grantees said that feedback on reports was not specific or timely. Only
four grantees told us that they received PO comments on their reports
during monthly monitoring calls, though HRSA states that reporting
requirements are to be discussed during routine calls, which are intended
to provide POs with an opportunity to provide such feedback. While a lack
of feedback might indicate that a PO had no concerns about a grantee’s
reports, POs may be missing opportunities to use the information
provided in reports to better communicate with grantees about their
compliance with program requirements and help grantees make
improvements. Seven grantees stated that they would appreciate
receiving more feedback on the reports they submit to ensure they were
meeting HRSA’s standards.




34
  Early in our review, HRSA told us that POs were to conduct quarterly conference calls
with their grantees. In June 2011, POs were told that they were to contact their grantees
monthly using a conference call template covering a set of monitoring topics. Because this
change occurred after the start of our review period, we assessed files based on calls at
least quarterly. HRSA later told us, however, that POs have always had to conduct and
document monthly calls with grantees, but that this was not consistently adhered to prior
to June 2011.




Page 16                                       GAO-12-610 Ryan White CARE Act Oversight
Some grantees told us that TA was not helpful because POs sometimes
provide conflicting or delayed guidance. TA is a key step toward
addressing grantee challenges with program implementation identified
during routine monitoring. Though eight grantees described occasions
when they received helpful TA from HRSA staff or contractors, eight
noted that PO responses to their questions were sometimes delayed or
inconsistent with past verbal guidance provided by their current or a past
PO, making it difficult for them to understand what changes were needed.
For example, one grantee told us it takes an excessive amount of time for
their PO to answer their questions, and another said that PO
responsiveness varied.

Further, four of the 25 grantees said they were told that HRSA could not
provide needed TA due to budget constraints, forcing the grantees to
seek TA from other sources or using their own administrative funds.
Three of those grantees told us that they hired TA providers using their
administrative funds, but one added that the TA cost $30,000 out of their
limited administrative budget, which they noted might not be an option for
many grantees. The CARE Act requires that grantees spend no more
than 10 percent of their grant on administrative activities, which include
TA and service provider monitoring activities. Three other grantees told
us they turned to NASTAD for TA when HRSA could not provide it or
when PO responses to their questions were delayed. 35 Some grantees
noted that HRSA had provided assistance through national TA calls and
webinars, and one added that calls and webinars were a useful substitute
for on-site TA when travel funds are limited. One grantee explained that
they received helpful TA from their PO by phone after a planned TA visit
by the PO was cancelled by HRSA due to constrained travel funds.

We found that 6 of the 25 grantee files we reviewed from 2010 and just 2
of the 25 files from 2011 contained documentation of TA reports and that
few files contained documentation of PO discussions of corrective actions
with grantees. HHS guidance states that monitoring activities and any
resulting follow-up on identified performance issues must be documented,
and issues are to be addressed as soon as possible by providing TA and
ensuring grantees take needed corrective actions. Three grantees told us


35
  HRSA currently has a 3-year cooperative agreement with NASTAD to provide TA to
ADAPs regarding issues including client waiting lists, cost containment, and other financial
challenges. NASTAD also maintains a listserv to facilitate peer-to-peer TA between Part B
grantees.




Page 17                                        GAO-12-610 Ryan White CARE Act Oversight
that PO follow-up on TA was vague or delayed, though two grantees told
us that their POs did conduct follow-up on TA in monthly conference calls.
Two grantees told us that though they informed HRSA in writing of their
proposed action steps in response to TA recommendations, HRSA did
not provide feedback on their proposed corrective actions. Another
grantee said that they were unable to address site visit findings due to a
lack of timely TA related to the findings.

Some grantees said that their need for TA was exacerbated by the lack of
a current program manual. For example, one grantee explained that a
manual would help them with matters such as grantee reports. HRSA
officials confirmed that the most recent Part A and Part B manuals were
issued in 2006, and stated that these printed manuals were not updated
to reflect the 2009 CARE Act reauthorization. While HRSA officials stated
that policies and procedures had been made available on the CARE Act
website, they acknowledged that information for grantees is not available
in the form of a comprehensive program manual similar to the printed
manual that was last provided in 2006. Seven grantees noted that more
written guidance, including an up-to-date electronic program manual,
would help them with many of their routine questions or TA needs, which
often revolve around questions about CARE Act program requirements.
Two grantees added that such written guidance would be especially
beneficial for new grantee staff or newer grantees. Further, one of the
service providers we spoke with stated that it did not find the HRSA
website to be helpful because links were not always kept up to date. 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. 36 HRSA officials said that they recently
issued a survey to obtain feedback from grantees about HRSA’s program
operations and processes, including the frequency and timeliness of PO
communication with grantees and their satisfaction with TA provided by
HRSA through conference calls, the HRSA website, and HRSA


36
  The Comptroller General of the United States’ Domestic Working Group. Guide to
Opportunities for Improving Grant Accountability (Washington, D.C.: October 2005). The
Domestic Working Group was established in 2001 and is chaired by the Comptroller
General of the United States. This group consists of 19 federal, state, and local audit
organizations. The purpose of the group is to identify current and emerging challenges of
mutual interest and explore opportunities for greater collaboration within the
intergovernmental audit community. Providing a guide to address grant accountability was
one such challenge.




Page 18                                       GAO-12-610 Ryan White CARE Act Oversight
                               contractors. They said that they plan to use the results of this survey to
                               improve their interactions with grantees.

HRSA Did Not Prioritize Site   HRSA did not follow its own policies for selecting the grantees it visited
Visits Strategically           from 2008 through 2011, and varied in its timeliness for providing site visit
                               follow-up. According to HRSA officials, the agency cannot visit all of its
                               111 Part A and Part B grantees each year due to staff and budget
                               constraints. Therefore, it is necessary for HRSA to be strategic in
                               selecting which grantees to visit in any given year. HRSA does not have
                               written guidance describing its policy for the selection of grantees to visit;
                               however, agency officials told us that they prioritize site visits based on
                               two elements—grantees without a recent site visit and grantees with
                               problems. In addition, the Monitoring Grants and Cooperative
                               Agreements for Federal Personnel manual, which accompanies a federal
                               course which HRSA has offered to its employees for several years and
                               requires all new POs to take suggests that agencies should determine
                               which grantees to visit based on an analysis of risk, which may include
                               the two elements HRSA told us it uses, as well as a consideration of grant
                               funding level, among other things. However, our review of HRSA site visit
                               data suggests that HRSA did not consistently select the grantees it visited
                               based on these three elements.

                               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. In addition, 6 of the
                               25 grantees we interviewed told us that there had been a significant
                               amount of time between HRSA site visits they had received or since their
                               most recent site visit, ranging from 5 to 12 years. One of these grantees
                               said that its first HRSA site visit after 12 years led to the grantee being
                               placed on restrictive drawdown. Grantee officials said that they believed
                               that if HRSA had not waited 12 years to conduct a site visit there would
                               have been far fewer findings because they would have been making
                               necessary adjustments with each periodic site visit. An additional
                               indication that HRSA does not consider time since last visit when
                               scheduling site visits is the fact that HRSA does not maintain a
                               centralized list of site visits that have been conducted. In order to provide
                               data on their site visits for the purpose of our review, HRSA extracted
                               data from travel records. Without centralized site visit data, HRSA would
                               not be able to readily track this element when determining which grantees
                               to visit



                               Page 19                                 GAO-12-610 Ryan White CARE Act Oversight
Second, HRSA did not always appear to prioritize site visits based on a
grantee’s history of problems. Based on HRSA data, we found that
30 percent of all Part A and Part B grantees with a history of problems did
not receive a single HRSA site visit from 2008 through 2011. 37 In addition,
only three of the nine Part A and Part B grantees with the most HRSA site
visits from 2008 through 2011 had been placed on restrictive drawdown.
While HRSA visited these grantees three or more times, other grantees
that were placed on restrictive drawdown received two or fewer HRSA
site visits during these 4 years. Although HRSA officials told us that
restrictive drawdown is not the only indication of grantee problems, they
said they impose it when the grantee has a history of serious problems.
We found that some grantees with numerous site visits had not been
placed on restrictive drawdown, while other grantees with fewer site visits
had. In fact, two grantees that were placed on restrictive drawdown in
2011 did not have a HRSA site visit at any time from 2008 through 2011.

Third, some of the grantees that HRSA visited most during these 4 years
had relatively small grant awards, indicating fewer people being served by
that grantee, which suggests that the agency did not prioritize site visits
based on grant funding level. For instance, the Virgin Islands received
approximately $1 million in 2011 CARE Act Part B funding, based on an
estimated 568 living HIV/AIDS cases at the end of 2009, but HRSA
conducted six site visits there over 4 years. In contrast, California
received the second largest 2011 grant award, approximately
$150 million, based on an estimated 117,869 living HIV/AIDS cases at the
end of 2009, but HRSA did not conduct any site visits there over the
4 years. See table 1 for the Part A and Part B grantees with the most
HRSA site visits and their 2011 grant award and estimated HIV/AIDS
cases, and see appendix II for a complete listing of this information for all
Part A and Part B grantees. HRSA officials explained that the Virgin
Islands had been placed on restrictive drawdown and had a history of
severe problems that included both fiscal and administrative issues and
problems with service delivery. However, other Part B grantees, with
significantly larger grant awards, and a history of problems during the
period covered by our review did not receive a HRSA site visit.
Furthermore, the District of Columbia, which received approximately


37
  We considered a grantee to have a history of problems if it had been placed on
restrictive drawdown, had a relevant finding in their annual single audit, or both from 2008
through 2011, based on data HRSA provided. HRSA officials noted that there could be
other indications of grantee problems.




Page 20                                         GAO-12-610 Ryan White CARE Act Oversight
$21 million in 2011 CARE Act Part B funding based on an estimated
17,250 living HIV/AIDS cases at the end of 2009, had a history of
problems and would require HRSA to spend little in travel funds to
conduct site visits, but received only one visit over the 4 years. HRSA
officials stated that there is no direct correlation between the amount of
grant funding and the size of a grantee’s problems. However, because
the Part A and Part B grant awards are based on the number of reported
living HIV/AIDS cases in each metropolitan area or state, the grantees
with larger awards serve more affected people.

Table 1: Part A and Part B Grantees with the Most HRSA Site Visits, 2008-2011

                                                   Estimated living        Total number of HRSA
                                                                  a
                              2011 grant award     HIV/AIDS cases          site visits, 2008 - 2011
    Part A grantees
                   b                                                                                     c
    Caguas, P.R.                    $1.5 million                 1,310                               6
    Detroit, MI                     $8.9 million                 9,341                               3
    Memphis, TN                     $6.5 million                 6,911                               3
    Middlesex, NJ                   $2.5 million                 2,831                               3
                                                                                                         c
    Ponce, P.R.                     $1.8 million                 1,929                               7
                                                                                                         c
    San Juan, P.R.                  $15 million                 11,291                               9
    Part B grantees
    Pennsylvania                    $43 million                 33,661                               3
                                                                                                         c
    Puerto Rico                     $31 million                 18,172                             10
    Virgin Islands                  $1.2 million                   568                               6
Source: GAO analysis of HRSA data

Note: For Part A, 2011 grant awards ranged from approximately $1.8 million to $121 million. For
Part B, 2011 grant awards ranged from the statutory minimum of $50,000 for U.S. territories other
than Guam and the Virgin Islands to $162 million. See app. II for the number of HRSA site visits for all
Part A and B grantees.
a
 Estimated living HIV/AIDS cases as of December 31, 2009. These case counts were used to
calculate the 2011 grant award.
b
 Caguas, Puerto Rico lost its classification as a TGA before the 2011 grant year, so the award
amount listed is from grant year 2010, the estimated living HIV/AIDS cases are as of December 31,
2008, and the total number of site visits are from 2008 through grant year 2010.
c
 HRSA officials explained that when HRSA staff made trips to Puerto Rico, they generally tried to
include stops at one or multiple Part A grantees and/or the Part B grantee. For example, a March
2009 trip to Puerto Rico included a site visit to the Part B grantee, to the San Juan Part A grantee,
and to the Caguas Part A grantee. From 2008 through 2011, HRSA made 12 separate trips to Puerto
Rico.

Furthermore, HRSA often was not timely in providing site visit follow-up to
grantees. HHS guidance states that agencies are to document in writing
site visit reports to grantees as soon as possible after completion of the
visit. At the time of our file review, HRSA did not have guidance for POs


Page 21                                              GAO-12-610 Ryan White CARE Act Oversight
                               specifying time frames with which to provide site visit reports. Our file
                               review for grant years 2010 and 2011 found that 12 of the PO files for the
                               13 grantees that received site visits that occurred during that time period
                               contained a copy of the site visit report. However, many of the grantees
                               we interviewed that had a HRSA site visit during the period of our review
                               said that it took HRSA a long time to provide the site visit report.
                               Specifically, 15 of the 25 grantees we interviewed told us they had a
                               HRSA site visit from 2008 through 2011. Eight of those 15 grantees said
                               that it took over 30 days to receive the site visit report; it took HRSA
                               4 months or longer to provide 6 of those grantees with the site visit report.
                               In a December 2011 update to its Operations Manual, which was not in
                               place during the majority of the period covered by our review, HRSA
                               specified that POs are to provide site visit reports to grantees within
                               30 days of the visit.

POs Did Not Always Review      Some POs we interviewed said that they were not always aware of
Annual Single Audit Findings   grantees’ single audit findings or corrective actions developed in
                               response to audit findings. According to HHS guidance, HRSA is to
                               review annual single audit reports as part of its grantee oversight, and
                               may use annual single audit information in decisions about implementing
                               special award conditions such as restrictive drawdowns. Though DFI is
                               the HRSA division primarily responsible for helping to ensure that
                               grantees take appropriate corrective actions in response to single audit
                               findings, POs, within HAB, are responsible for providing overall
                               monitoring of grantees’ compliance with program requirements. We have
                               found in past work that audits may provide important information on
                               grantee performance and can serve as an accountability mechanism to
                               help determine whether grantees used funds in accordance with program
                               rules and regulations. 38 For this reason, PO monitoring could be
                               enhanced by the timely review of single audit findings.

                               However, some POs told us that DFI does not consistently share
                               information about single audit findings and corrective actions. Though
                               POs are able to access a summary of a grantee’s HRSA-related single
                               audit findings in EHB, the EHB summary does not specify whether the
                               findings are related to CARE Act programs in particular, which might
                               make it difficult for POs to determine whether the audit contains



                               38
                                GAO, Single audit: Survey of CFO Act Agencies, GAO-02-376 (Washington, D.C.:
                               March 2002).




                               Page 22                                    GAO-12-610 Ryan White CARE Act Oversight
information pertinent to their monitoring efforts without explanation from
DFI. DFI officials told us they may contact POs or other HRSA staff to
help review and ensure the adequacy of grantee corrective actions, but
according to POs they do not always do so. Given their knowledge of
grantees through routine monitoring activities, POs could provide DFI with
valuable input regarding grantees’ corrective actions. However, one PO
told us that DFI did not notify her when the grantees in her portfolio had
audit findings, and another told us that DFI did not consistently share
grantee corrective action plans in response to audit findings with her,
though DFI might on occasion alert her if there was an issue with a
grantee audit. One PO reported that she was recently consulted by DFI to
provide input into a grantee’s audit findings, but added that this was the
first time such consultation had occurred. HRSA officials said that they
have enhanced the ways in which DFI communicates audit information to
POs through EHB by including citations about audit findings specific to
CARE Act programs along with grantee corrective actions designed to
address the findings. HRSA officials said that they began doing this as of
April 30, 2012.

The lack of consistent communication about single audit findings across
HRSA divisions limits opportunities for POs to incorporate single audit
information into their monitoring and help HRSA ensure that grantees
take timely and effective corrective actions, as required. This is especially
important given that HRSA may on occasion use single audit findings as
a basis for implementing restrictive drawdowns, which require POs to
work with grantees in reviewing financial information as part of grantees’
drawdown requests, even if the restrictive drawdown was recommended
by DFI. In addition, opportunities for POs to help grantees implement
timely corrective actions may also be affected by the lengthy time frames
of the single audit process. For example, DFI officials told us that a
grantee may be cited for a repeat finding in an audit before they have had
time to correct the finding from the prior year’s audit. We previously
reported that in the Single Audit process it could take 15 months or more
from the end of the fiscal year in which an audit finding is initially identified
before a grantee’s corrective action plan is approved by the responsible
federal agency. 39 Thus, in some cases, grantees may not have the
opportunity to correct audit findings and POs may not have the



39
  GAO, Federal Grants: Improvements Needed in Oversight and Accountability
Processes, GAO-11-773T (Washington, D.C.: June 2011).




Page 23                                    GAO-12-610 Ryan White CARE Act Oversight
                            opportunity to help ensure that the grantee corrects audit findings before
                            the following year’s audit is conducted.

                            Though single audits may contain information important to PO monitoring
                            of grantees such as an assessment of how grantees are monitoring their
                            service providers or whether the grantee is properly documenting client
                            eligibility, some grantees told us that neither POs nor other HRSA staff
                            generally communicate with them about single audits. Six grantees said
                            that they did not recollect having any communication with HRSA about
                            audit findings, though five others noted they had discussed audit findings
                            with HRSA staff on at least one occasion, including one who said they
                            discussed their annual single audit with HRSA staff during a site visit.
                            Three POs told us that grantees sometimes initiate communication about
                            their single audits. For example, one PO said that although she generally
                            does not get involved with the audits or receive information from DFI, she
                            had been contacted by one of her grantees regarding an audit finding,
                            and therefore reviewed the proposed corrective actions as part of her
                            routine monitoring.

HRSA Did Not Clearly        HRSA often did not communicate or document the reasons for
Communicate with Grantees   implementing a restrictive drawdown. Only 2 of the 11 grantees from our
about the Restrictive       sample of 25 that were on restrictive drawdown said that HRSA
Drawdown Process            communicated the reasons they were placed on restrictive drawdown. In
                            five cases, the grantee said they only learned about the restrictive
                            drawdown upon receiving a new NOA, without prior warning or
                            explanation from their PO or other HRSA staff. Though the issuance of a
                            new NOA is the official means of notifying the grantee of the new
                            condition on their grant award, NOAs do not enumerate the reasons for
                            the restrictive drawdown. Though HRSA officials stated that grantees
                            were notified verbally or in some cases by e-mail about their restrictive
                            drawdown status, we found that the PO files for many of the 11 grantees
                            in our sample that were on restrictive drawdown did not contain
                            documentation of the reasons the restrictive drawdown was imposed.
                            Federal regulations state that when an agency implements a condition on
                            a grantee award such as a restrictive drawdown, it is to notify the grantee
                            of the nature of the condition and the reason it is being imposed, and
                            HHS guidance states that the agency is to document the reasons for use




                            Page 24                                GAO-12-610 Ryan White CARE Act Oversight
of the condition in the grant file. 40 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. 41

HRSA also has not consistently provided grantees placed on restrictive
drawdown with instructions about how to meet the conditions for drawing
down funds. HHS guidance states that the agency is to explain the nature
of, and requirements for meeting, the conditions of the restrictive
drawdown. However, 5 of the 11 sampled grantees that were on
restrictive drawdown told us that HRSA did not provide clear instructions
at the time the restriction was imposed for submitting drawdown requests
or the supporting documentation they were required to submit with each
request. Four grantees said that when they were first put on restrictive
drawdown, they had to repeatedly submit their drawdown requests to
their PO before clear expectations were established. One grantee said
that they believed that HRSA was “making up the rules about restrictive
drawdown as they went along,” and another stated that they received no
guidance or written instruction specifying the documentation required as
part of a drawdown request, which caused delays in the processing of
their requests.

Further, HRSA has not consistently provided grantees with guidance on
the types of corrective actions needed, including time frames for making
the required changes, in order to have the restrictive drawdown removed.
Federal regulations state that needed corrective actions and timelines are
to be explained to the grantee at the time a restrictive drawdown is
implemented. Most of the grantees in our sample said that they were not
given a written set of action steps or specific corrective actions needed in



40
  Federal regulations also specify that when the agency awarding a federal grant imposes
conditions on a grantee award such as restrictive drawdowns, the agency will notify the
grantee in writing of the nature of the condition, the reasons for imposing it, the required
corrective actions and time frames for completing them, and the method for requesting
reconsideration of the conditions. HRSA’s recently issued guidance, though not in effect
during the period of our review, also states that POs are to document their reasons for
recommending that a grantee be placed on restrictive drawdown.
41
  Though HRSA has reported that, in accordance with HHS guidance, the GMO/GMS and
PO work together in monitoring grantees through activities including reviews of grantee
reports and drawdown requests related to restrictive drawdowns, most of the grantees we
interviewed told us that they had minimal interaction with their GMS. Though GMO/GMSs
and POs may work together to resolve grantee issues within HRSA, HRSA told us that
POs are the HRSA staff with the most direct interaction with grantees.




Page 25                                        GAO-12-610 Ryan White CARE Act Oversight
order to have the restrictive drawdown removed. For example, one
grantee told us that although they are willing to do what is needed to have
the restriction removed, HRSA has not provided them with a set of
requirements and timelines either verbally or in writing. Another grantee
said that HRSA did not offer training to the grantee on the requirements
for its restrictive drawdown until over a year after the condition was
imposed. A third grantee stated that though after the restrictive drawdown
process they made a change that will help them hold their service
providers more accountable, the process would have been more
beneficial had they been given a clear picture of the end goals at the
outset.

HRSA officials said that when a restrictive drawdown is lifted, the grantee
is to be notified through a new NOA which is signed by the GMO. HRSA’s
recently issued guidance states that the agency will revisit a grantee’s
restrictive drawdown status once the grantee completes steps such as
submitting documentation of compliance with corrective actions,
completing recommended TA, and implementing a corrective action plan
developed as part of a site visit. However, HRSA has lifted the restrictive
drawdown condition for only two of the grantees in our sample since this
guidance was in place, and it is unclear whether HRSA provided grantees
with a clear plan for the removal of the condition even upon completion of
recommended TA or corrective actions. One grantee explained that each
time they made the changes requested by HRSA, they were given a new
set of requirements to meet. For example, according to a TA report by
HRSA consultants about 1 month after the restrictive drawdown was
implemented, the grantee had taken important steps to address its
financial challenges. Further, documents provided by the grantee indicate
that following the consultant TA report, the PO indicated he would
recommend that the grantee be removed from restrictive drawdown.
However, despite documenting its ongoing work to address its financial
challenges, the grantee was told more than a month later that further
steps would be required before the condition would be removed, and the
grantee remained on restrictive drawdown for approximately 4 more
months. The grantee stated that they were not clearly told what they
could do to have the condition removed despite repeated requests for that
information, and that the costs to the program of remaining on restrictive
drawdown interfered with the possible benefits.

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


Page 26                               GAO-12-610 Ryan White CARE Act Oversight
using this updated language on NOAs for grantees placed on restrictive
drawdown after May 1, 2012. HRSA officials said that grantees are to be
informed in writing of all conditions on their awards and how to proceed in
order to have the conditions removed. They said that, where that is not
occurring, they will work to ensure that it does.

We found that HRSA did not always provide grantees with additional TA
or time to correct deficiencies before placing them on restrictive
drawdown. HHS guidance states that an agency will generally afford the
grantee an opportunity to correct any deficiencies before imposing
conditions such as restrictive drawdown. Two grantees told us they were
placed on restrictive drawdown after a site visit, but one noted that they
were not given an opportunity to address the site visit findings before
being placed on restrictive drawdown. The grantee stated that they
submitted a corrective action plan in response to site visit findings
approximately 2 months after receiving the site visit report, but according
to HRSA the grantee was placed on restrictive drawdown right after the
plan was submitted, suggesting the grantee did not have an opportunity
to implement the corrective action plan before the condition was put in
place.

HRSA has stated that the restrictive drawdown process is a means of
doing more intensive monitoring of grantees experiencing problems with
program implementation, financial management, or other administrative
issues. Two of the grantees in our sample told us that they had more
frequent communication with their PO during monitoring calls or through
e-mails after restrictive drawdown was implemented. In some cases,
however, the restrictive drawdown process may have exacerbated a
grantee’s existing challenges. For example, one grantee said they were
told that they were put on restrictive drawdown because they had an
unobligated balance that resulted from not spending funds at a quick
enough pace. However, the grantee told us that, in part due to a lack of
clear instructions from HRSA, the restrictive drawdown process caused
further delays in their ability to spend grant funds and therefore
aggravated the unobligated balance problem. In another case, a HRSA
financial TA consultant reported that the restrictive drawdown itself was
causing delays in a grantee’s ability to spend its grant funds, which the
consultant feared might lead to a finding in the grantee’s next single audit.




Page 27                                 GAO-12-610 Ryan White CARE Act Oversight
HRSA’s Lack of Records       HRSA’s lack of records and frequent staff changes in PO assignments
and Changes in PO            further challenge the agency’s oversight of grantees. HRSA officials told
Assignments Further          us that records of grantee oversight are located across three types of the
                             agency’s files— HRSA’s EHB, which includes official NOAs and required
Challenge Its Oversight of   reports, annual single audit reports, and PO files, which include
CARE Act Grantees            monitoring documentation, such as notes from routine calls and TA, and
                             site visit reports—not just those documents available electronically in
                             HRSA’s EHB. Therefore, we consider all three of these files together to
                             be a complete record of grantee oversight. While conducting our file
                             review, we found that this complete oversight record was only maintained
                             for the current and previous grant years because, prior to that, consistent
                             with its records management program, HRSA destroyed documentation
                             of grantee monitoring only available in the paper PO files. At the time of
                             our 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, which was only approximately a year and a half of documentation.
                             Therefore, HRSA’s ability to correct previously noted problems with
                             grantee performance could be limited because easily accessible
                             documentation of such problems was not maintained. In fact, a HRSA
                             official told us that he believed that one grantee with a history of problems
                             should be placed on restrictive drawdown. However, HRSA did not take
                             this step because they had destroyed the site visit reports containing
                             findings that would have supported placement on restrictive drawdown. In
                             a December 2011 update to HRSA’s Operations Manual, which was not
                             in place during the majority of our review, HRSA specified that POs are to
                             maintain copies of site visit reports for at least 5 years, and any
                             documents related to issues under investigation for as long as necessary.
                             However, this change does not apply to other key documentation in PO
                             files, such as regularly scheduled conference calls and copies of relevant
                             emails.

                             Furthermore, frequent PO changes in monitoring assignments could
                             compound the challenges created by HRSA’s lack of long-standing
                             documentation and possibly limit HRSA’s institutional memory for a given
                             grantee. Specifically, according to HRSA data, from 2008 through 2011,




                             Page 28                                 GAO-12-610 Ryan White CARE Act Oversight
93 of the 111 Part A and Part B grantees had at least two or three
different POs and 2 grantees had four different POs during this time. 42

HRSA’s frequent changes in PO assignments could leave a recently
transitioned PO and his new grantee at a disadvantage. For example,
during our file review, we found that one of the grantees in our sample, a
grantee with a history of problems that had been placed on restrictive
drawdown, was missing documentation of monitoring calls for the 2010
grant year. That grantee’s current PO began monitoring the grantee near
the beginning of the 2011 grant year and she explained that she did not
receive documentation of any monitoring calls that had occurred under
the previous PO.

Some of the grantees we interviewed said that frequent PO changes
resulted in variation in HRSA oversight. Eight of the 25 grantees we
spoke with expressed concern about changes in their POs and 13
described the variation in PO monitoring styles that grantees had to
adjust to when a new PO was assigned. For example, 1 grantee that had
three POs from 2008 through 2011 told us that the PO changes resulted
in delayed responses from HRSA and contradictory information being
provided by different POs, which created confusion for the grantee and
delays in funding distribution to service providers. Conversely, a grantee
that had one PO during this time period told us that having a
knowledgeable PO who serves for a long period of time creates better
management of the grant because the PO develops important institutional
memory about the grantee and its program.




42
  Four Part A grantees lost their classification as TGAs before the 2011 grant year. Of
these four grantees, one had a single PO from 2008 through 2011, two had two POs
during this time period, and one had three POs during this time period.




Page 29                                        GAO-12-610 Ryan White CARE Act Oversight
                           Federal regulations require grantees to oversee service providers and, in
HRSA Recently Issued       April 2011, HRSA issued the National Monitoring Standards, a
National Standards         compilation of requirements for grantee monitoring of service providers.
                           Some grantees said that their implementation of the standards was
for Grantee                hindered by insufficient HRSA assistance and the annual site visit
Monitoring of Service      requirement.
Providers, but HRSA’s
Implementation
Created Challenges
for Grantees
Grantees Monitor Service   Federal regulations require grantees to oversee service providers. HRSA
Providers and HRSA         told us that grantees are required to report to HRSA on their approach to
Recently Issued National   service provider monitoring activities in annual grant applications. HRSA
                           also verifies this information through grantee site visits and a review of a
Standards                  list of service providers, which grantees are required to submit annually. 43
                           The number of service providers for Part A and Part B grantees ranges
                           greatly. For example, Nebraska had only 3 service providers in 2011,
                           whereas New York had 83 providers. Grantees we interviewed said they
                           use a variety of tools to monitor their service providers, including frequent
                           phone and e-mail communication, monthly service provider meetings, site
                           visits, training, or reviews of financial and program reports. Specifically,
                           most of the 25 grantees we interviewed told us that they are in at least
                           monthly, if not daily, communication with their service providers. In
                           addition, all but four grantees conduct service provider site visits at least
                           annually. Of the four grantees that were not conducting site visits
                           annually, two large states conducted site visits every 2 years, with one of
                           those states visiting service providers with performance issues more
                           frequently; one midsize state conducted site visits every 3 years; and one
                           small state had not conducted site visits in many years. However, all but
                           one of these grantees were in the process of beginning annual site visits
                           at the time of our interview.

                           In April 2011, HRSA issued the National Monitoring Standards, which it
                           describes as a compilation of existing requirements for grantee
                           monitoring of Part A and Part B service providers. The standards include


                           43
                             This list of service providers is called the Consolidated List of Contractors. For a
                           description of this reporting requirement, see app. I.




                           Page 30                                          GAO-12-610 Ryan White CARE Act Oversight
133 requirements for Part A grantees and 154 requirements for Part B
grantees. These standards describe program and financial requirements,
program-only requirements, and financial-only requirements. (See
table 2.)

Table 2: Summary of HRSA’s National Monitoring Standards for Grantee Monitoring
of Service Providers

                                              Number of Part A     Number of Part B
Type of National Monitoring Standard               standards            standards
Program and financial monitoring standards                   19                   19
Program-only monitoring standards                            51                   65
Financial-only monitoring standards                          63                   70
Total                                                       133                 154
Source: HRSA



According to HRSA, these standards consist of preexisting requirements
for program and financial management, monitoring, and reporting that are
based on federal statutes, regulations, and program guidance and
consolidates these requirements into one location to assist grantees.
Table 3 provides examples of the standards.




Page 31                                      GAO-12-610 Ryan White CARE Act Oversight
Table 3: Examples of HRSA’s National Monitoring Standards and Grantee Responsibilities for Part A and Part B Grantee
Monitoring of Service Providers, by Topic

                                                                                          Examples of grantee responsibilities to
National Monitoring                                                                       ensure service provider compliance with
                                                                                 a
Standards topic                  Example of a standard from selected topics               the standard
Examples of program and financial monitoring standards
Access to care                   Grantee must ensure that services are provided by        •    Review provider eligibility policies.
                                 the service provider regardless of the current or past   •    Investigate any relevant provider
                                 health condition of clients.                                  complaints.
Eligibility                      Grantee must ensure that service providers screen        •    Establish an EMA, TGA, or statewide
                                 and reassess client eligibility as specified by the           process for determining client eligibility.
                                 EMA, TGA, state, or ADAP every 6 months.                 •    Conduct service provider site visits to
                                                                                               review client files for appropriate
                                                                                               documentation of eligibility.
Monitoring                       Grantee service provider monitoring activities are       •    Use a combination of program reports,
                                 expected to include annual site visits.                       annual site visits, client satisfaction
                                                                                               reviews, technical assistance, and chart
                                                                                               reviews to monitor service provider
                                                                                               program compliance.
Examples of program-only monitoring standards
Core medical services            Grantee must ensure that oral health services            •    Develop a request for proposal and
                                 include diagnostic, preventive, and therapeutic               contract for the provision of oral health
                                 dental care that is in compliance with dental practice        that specifies program requirements,
                                 laws, includes evidence-based clinical decisions, is          including that services cover diagnostic,
                                 based on an oral health treatment plan, adheres to            preventive, and therapeutic oral health
                                 specified service caps, and is provided by licensed           services.
                                 and certified dental professionals.                      •    Review client charts for compliance with
                                                                                               contract and program requirements.
Support services                 Grantee must ensure that health education and risk       •    Develop a request for proposal and
                                 reduction services are provided to educate clients            contract that defines risk reduction
                                 living with HIV about HIV transmission and how to             counseling.
                                 reduce the risk of HIV transmission.                     •    Review provider data to determine
                                                                                               compliance with contract.
Other service requirements       Grantee must ensure that service providers set           •    Track and report the amount and
                                 aside specific amounts for care of women, infants,            percentage of CARE Act funds
                                 children, and youth based on the population’s                 expended for each population group
                                 relative percentage of the total number of persons            separately.
                                                                             b
                                 living with AIDS in the EMA, TGA, or state.
Examples of financial-only monitoring standards
Limitations on uses of funding   Grantee must ensure that service providers assign        •    Maintain file documentation on all
                                 appropriate expenses as administrative expenses,              service providers, including current
                                 such as usual and recognized overhead activities              operating budgets and allocation reports
                                                                        c
                                 (rent, utilities, and facility costs).                        that include sufficient detail to identify
                                                                                               and calculate administrative expenses.
                                                                                          •    Review service provider expense reports
                                                                                               to ensure that all administrative costs are
                                                                                               allowable.




                                           Page 32                                            GAO-12-610 Ryan White CARE Act Oversight
                                                                                             Examples of grantee responsibilities to
National Monitoring                                                                          ensure service provider compliance with
                                                                                     a
Standards topic                 Example of a standard from selected topics                   the standard
Income from fees for services   Grantee must ensure that service providers are               •     Establish and implement a process to
performed                       using third party funds, such as Medicaid, the                     ensure that service providers maximize
                                Children’s Health Insurance Program, Medicare, and                 third party reimbursements by, for
                                private insurance, to maximize program income and                  example, requiring service providers to
                                ensure that Ryan White is the payer of last resort.                document in client files how each client
                                                                                                   was screened for and enrolled in eligible
                                                                                                   insurance programs.
Imposition and assessment of    Grantee must ensure that no charges are imposed              •     Review service provider discount fee
client charges                  on clients with incomes below 100 percent of the                   policy, criteria, and forms.
                                                      d
                                Federal Poverty Level.                                       •     Review client files and documentation of
                                                                                                   actual charges and payments.
                                          Source: HRSA
                                          a
                                           This table lists examples of HRSA’s National Monitoring Standards and is not an exhaustive list of
                                          each standard.
                                          b
                                           A women, infants and children waiver is available if the grantee can document that funds sufficient to
                                          meet the needs of these population groups are being provided through other federal or state
                                          programs.
                                          c
                                           Grantees must ensure that service providers adhere to the requirement that aggregated
                                          administrative expenses do not total more than 10 percent of CARE Act service dollars.
                                          d
                                           Federal poverty level refers to the federal poverty guidelines which are used to establish eligibility for
                                          certain federal assistance programs. HHS publishes these guidelines on an annual basis, updating
                                          the guidelines to reflect changes in the cost of living and variations according to family size.



Implementation of                         More than half of the 25 grantees from our sample said that they found
Monitoring Standards                      the training and/or TA HRSA has provided on the National Monitoring
Hindered by Insufficient                  Standards to be insufficient because it has not answered all of their
                                          questions about HRSA’s expectations for how they should implement the
Assistance from HRSA and                  standards. According to HRSA officials, HRSA has offered two webinars,
Challenged by the Annual                  a national TA call, and workshops at an all-grantees meeting to assist
Site Visit Requirement                    grantees. Some grantees told us HRSA also discussed the standards
                                          during a recent administrative meeting. Further, 5 of the 10 POs we
                                          interviewed told us they had discussed implementation of the standards
                                          with grantees during routine monitoring. Five grantees told us they had
                                          asked for more in-depth TA on the standards but had not received it. One
                                          grantee, however, did receive additional TA by phone from a HRSA
                                          branch chief targeted to all Part A and Part B providers in the grantee’s
                                          state. Although HRSA stated that it would provide sample tools to
                                          demonstrate how grantees could best meet certain standards, several
                                          grantees indicated that HRSA had not done so. According to most
                                          grantees, inadequate training, TA, or both makes it more difficult to
                                          understand HRSA’s expectations and be assured that they are
                                          adequately implementing the standards, which they were required to put
                                          into practice immediately upon their release in April 2011. HRSA officials


                                          Page 33                                                GAO-12-610 Ryan White CARE Act Oversight
said that they believe that the webinars, conference call, and
presentations they have made at grantee meetings have provided
grantees with useful assistance in implementing the standards. They
further noted that the standards do not represent new requirements and
therefore should have been familiar to grantees. However, in its survey of
grantees, discussed earlier in this report, HRSA asked grantees about
their training needs and any additional information needs they might have
regarding a variety of issues, including the standards.

Seven grantees expressed particular concern about the annual site visit
requirement outlined in the standards, which two of them noted is
especially challenging for grantees with a large number of providers
across a large geographic area or in states with limited staff resources.
Two of those grantees said that the new standard would require them to
change site visit processes that had proven effective over time. They told
us that they conduct routine site visits based on an assessment of risk; if
they determine through regular monitoring that a provider has more
performance issues than other providers, they will prioritize a site visit to
that provider or visit that provider more frequently. They said that the
requirement to visit every service provider annually, regardless of their
performance, will not allow them to continue with this approach. One
grantee with approximately 140 service providers told us that meeting the
annual site visit requirement would be impossible given the grantee’s
large number of providers and limited staff and administrative resources.
One grantee told us the administrative burden of this requirement is
exacerbated by the chart review requirements which will require grantees
to spend more time reviewing provider documents on site, while
sacrificing other monitoring activities focused on the quality of provider
services. Two grantees noted that the annual site visit standard is more
stringent than HRSA’s own standard for site visits to grantees, and that
HRSA therefore may not have a good sense of the time and resources
required to conduct annual site visits of all service providers. Despite
these concerns, several grantees told us they are taking steps to comply
with the requirement.

NASTAD has written that the standards will require some grantees to
largely restructure current monitoring systems and force them to focus on
administrative reviews rather than an assessment of the quality of
services being delivered by service providers, and that the standards are
inconsistent with the National HIV/AIDS Strategy’s goal of streamlining




Page 34                                 GAO-12-610 Ryan White CARE Act Oversight
grant administration and reporting requirements. 44 NASTAD has further
noted that the annual site visit requirement will be especially difficult for
grantees during a time when grantees are experiencing reductions in
funding and staff, and that the requirement will force grantees to dedicate
limited staff resources toward monitoring activities rather than service
delivery. According to NASTAD, grantees may also find it difficult to
conduct all required provider monitoring activities using only the
10 percent of their CARE Act grant allowed for administrative costs. 45
Many grantees also told us that the standards increase the administrative
burden on their programs. HRSA responded to NASTAD that grantees
should review their current use of administrative resources to ensure they
are efficiently using resources to meet all of the monitoring standards,
which are simply meant to provide clarity about existing requirements. In
light of grantees’ ongoing concerns, however, NASTAD has
recommended that HRSA explore alternatives to the annual site visit
requirement, including requiring a site visit every 2 years instead of
annually. In response to NASTAD’s recommendations, HRSA has stated
that annual provider site visits are a programmatic requirement developed
based on federal regulations permitting HRSA to set the frequency of
monitoring activities, including site visits. HRSA also stated that the site
visit requirement, which is consistent for all Part A and Part B grantees, is
based on HHS OIG recommendations that HRSA set standards for
grantee monitoring of service providers that include some consideration
of regular site visits. 46 NASTAD has written that because HRSA has


44
  The National HIV/AIDS strategy is a national plan for reducing new HIV infections,
improving access to care and health outcomes for people living with HIV, and reducing
HIV-related health disparities. It is coordinated by the White House Office of National
AIDS Policy. The July 2010 National HIV/AIDS Strategy Federal Implementation Plan
outlines key steps for achieving strategic goals, including increasing coordination of HIV
program across the federal government and between federal agencies and state,
territorial, local, and tribal governments.
45
  The CARE Act requires that grantees spend no more than 10 percent of their grant on
administrative activities, which include TA and service provider monitoring activities.
42 U.S.C. §§ 300ff-14(h), 300ff-28(b)(3). The cost of conducting service provider site visits
must therefore be included in that 10 percent of the grant.
46
  U.S. Department of Health and Human Services. Office of Inspector General.
“Monitoring of Ryan White CARE Act Title I & Title II Grantees” (Washington, D.C.: U.S.
Government Printing Office, 2004). http://oig.hhs.gov/oei/reports/oei-02-01-00640.pdf and
U.S. Department of Health and Human Services. Office of Inspector General. “The Ryan
White CARE Act Title I and Title II Grantees’ Monitoring of of Subgrantees” (Washington,
D.C.: U.S. Government Printing Office, 2004).
http://oig.hhs.gov/oei/reports/oei-02-01-00641.pdf




Page 35                                         GAO-12-610 Ryan White CARE Act Oversight
              authority to set the frequency of monitoring activities, it should consider
              alternatives to the annual site visit requirement.

              In response to grantee concerns about the standards, HRSA officials
              have stated that TA may be requested through individual POs, and that it
              will provide future webinars focused on common grantee concerns,
              including the annual site visit requirement and eligibility documentation.
              HRSA officials further told us that they are encouraging collaboration
              between Part A and Part B grantees to jointly conduct site visits of
              providers that are funded by both Parts A and B to ease the burden of the
              site visit requirement. At least one larger grantee told us they will take
              advantage of that opportunity for collaboration. Some grantees stated that
              the standards are a helpful tool, and a few noted that the standards will
              help them better communicate with their service providers.


              Effective oversight of CARE Act grantees and service providers is critical
Conclusions   to the CARE Act’s mission of providing help for uninsured or underinsured
              individuals and families affected by HIV/AIDS. However, our findings
              show that deficiencies in HRSA’s oversight may compromise its ability to
              ensure that this program is meeting its objectives or that CARE Act funds
              are being spent properly. Even though HHS and HRSA guidance exists
              regarding the documentation and follow-up of the key elements of grantee
              oversight including routine monitoring, the provision of TA, site visits, and
              restrictive drawdown, HRSA project officers are not always following
              these guidelines. If a grantee is struggling, the lack of systematic
              provision and documentation of assistance to improve the grantee’s
              performance, and not retaining such documentation over time, present a
              great challenge to ensuring that such problems do not recur. Many HRSA
              POs we spoke with said that site visits are a valuable and effective
              oversight tool. 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. Another challenge is
              the lack of an updated and electronically available comprehensive
              program manual for grantees. Grantees said that such a manual would
              likely decrease their need to consult with POs over relatively routine
              issues. Currently, grantees must frequently seek assistance from POs
              because there is not a current and complete source of written information
              that is readily available to guide their efforts. While HRSA’s compilation of
              133 Part A and 154 Part B monitoring standards does provide grantees
              with an exhaustive set of guidelines for ensuring that their service
              providers are meeting program requirements, our findings on HRSA’s


              Page 36                                 GAO-12-610 Ryan White CARE Act Oversight
                      own oversight of grantees provide evidence of how important training and
                      follow-up are to ensure that these requirements are consistently followed.
                      HRSA has provided training to assist grantees in carrying out the
                      standards, but grantees said that they wanted more guidance and
                      training. Among the issues about which HRSA surveyed its grantees, was
                      the additional information its grantees needed regarding the standards.


                      In order to improve HRSA’s oversight of Part A and Part B grantees, we
Recommendations for   recommend that the Administrator of HRSA:
Executive Action
                      •   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.

                      •   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.

                      •   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.

                      •   Update and maintain a program manual for grantees.

                      •   Use the results of HRSA’s survey of grantees to identify grantees’
                          training needs to allow them to comply with the National Monitoring
                          Standards.


                      We provided a draft of this report to HHS for its review, and HHS provided
Agency Comments       written comments (see app III). HHS concurred with all five of our
and Our Evaluation    recommendations and indicated that HRSA will work to fully implement
                      the recommendations to improve oversight of Parts A and B of the CARE
                      Act program. HHS also offered some specific comments in response to
                      the report conclusions. HHS acknowledged that PO led site visits,
                      monitoring calls, single audit reports, and the imposition of restrictive
                      drawdown are central to HRSA’s routine monitoring, but added that the
                      agency’s overall oversight strategy is a multilayered approach that
                      involves review of items such as required grantee reports used for
                      postaward monitoring, site visits, monitoring calls, review of audit reports,
                      and the provision of technical assistance on all of these issues. Our



                      Page 37                                 GAO-12-610 Ryan White CARE Act Oversight
analysis included these elements, as well as a discussion of ways in
which these elements intersect. We interviewed HRSA and grantee staff
on these tools and describe in this report grantees’ observations on
HRSA’s provision of technical assistance and feedback on the large
number of reports that they must routinely provide to HRSA. Findings in
this report include a detailed discussion of issues in Ryan White program
oversight including both the execution and documentation of the elements
listed above.

HHS also acknowledged that HRSA’s documentation of grantee
monitoring should be strengthened, noting that during the period of
GAO’s review, HRSA did not maintain all documentation of oversight in
one centralized file. HHS stated that HRSA has instituted a new quality
improvement process, which strengthens both documentation standards
and communication with grantees. HHS said that this would be done
through an expansion of the use of the EHB as the primary centralized
location for documentation of oversight and monitoring, including site visit
reports. HHS said that this process will also include regular PO meetings
to provide training, and improvements in HRSA’s records management
practices. These steps appear to be consistent with the goals of our
recommendations. In follow-up to its comments, HRSA provided
additional information on the agency’s planned information technology
development efforts to improve and expand the functionality of EHB
between September 2012 and mid-2013.

HHS commented on statements by grantees we interviewed that
indicated that HRSA could not provide needed TA due to budget
constraints, forcing the four grantees to seek TA from other sources,
using their own administrative funds. HHS described a wide array of TA
and training services that HRSA provides to grantees. HHS also provided
information on the extent of grantees’ use of some of these services and
HRSA’s financial resources devoted to providing these services. HHS
acknowledged in this discussion that, due to competing demands for
HRSA’s TA, HRSA does, at times, recommend grantees utilize their
CARE Act funding for TA. In its comments relevant to TA, HHS also noted
our mention of the fact that three grantees had to turn to NASTAD for TA
when HRSA could not provide it or when PO responses to their questions
were delayed. HHS noted that HRSA has had a partnership with
NASTAD in place since 1998 to provide TA to grantees. However, as we
note in our report, the TA to be provided by NASTAD under this
partnership is for the purpose of assisting Part B grantees with their
ADAP. While several Part B grantees told us that they receive important



Page 38                                GAO-12-610 Ryan White CARE Act Oversight
assistance from NASTAD, there is no similar cooperative agreement in
place or HRSA-recognized organization to provide TA to Part A grantees.

HHS also commented on our finding that HRSA did not prioritize site
visits strategically. HHS stated that there can be indications of grantee
problems beyond those that we included in our site visit analysis, which
we acknowledged in the report. Many of the additional indicators of
grantee problems HHS listed in its comments, such as fiscal and
administrative challenges, are also issues that can cause grantees to
receive annual single audit findings or to be placed on restrictive
drawdown, the two indicators we used in our analysis. HHS then provided
extensive detail on the issues in Puerto Rico and the Virgin Islands that
led to grantees in those jurisdictions receiving significantly more site visits
than other grantees that had received substantially more funding. In our
discussion of HRSA’s site visits, we make the point that the size of the
grant did not appear to play a major role in HRSA’s decisions about which
grantees to visit, including among grantees experiencing problems. Many
POs we spoke with said that site visits were a valuable and effective form
of oversight. Because HRSA cannot visit all of its grantees each year, it
must work to ensure that it uses this valuable tool in such a way as to
gain as much benefit as possible. The Monitoring Grants and Cooperative
Agreements for Federal Personnel manual that we refer to in the report
and HHS cites in its comments lists several grant characteristics that
should be considered in selecting projects for on-site monitoring. “Cost
and Total Support” is the first issue listed in the manual. In our discussion,
we did not question the presence of serious issues in Puerto Rico and the
Virgin Islands. Our point is that even among grantees experiencing
problems, jurisdictions with much larger grants, such as the District of
Columbia, were not similarly prioritized for site visits, even though a site
visit to the District of Columbia would be of low cost to the agency.

HHS commented on the prevalence of HIV/AIDS in the Caribbean as a
justification for its numerous site visits, but we note that the size of Part A
and B CARE Act grants is based upon the number of HIV cases that exist
in the jurisdiction being served by the CARE Act grantee, thereby serving
as a proxy for the prevalence of the disease in that area. Data on HRSA’s
website indicate that CARE Act programs served 146 clients in the Virgin
Islands in 2008, while serving 16,203 in the District of Columbia during
the same period. HRSA’s pattern of site visits indicates that the agency
visited some grantees with smaller grants far more often than other
grantees with much larger grants, and thus a much higher prevalence of
disease, that also experienced challenges in administering their grants. In
its comments, HHS describes numerous elements of HRSA’s routine


Page 39                                  GAO-12-610 Ryan White CARE Act Oversight
monitoring and several instances of TA directed to the District of
Columbia. Nonetheless, it received one HRSA site visit during the period
covered by our review as compared to the Virgin Islands, which received
six HRSA site visits, as well as routine monitoring and TA. The District of
Columbia’s grant was approximately $21 million while the Virgin Islands’
grant was $1.2 million. This suggests that HRSA did not consider the size
of the grant in deciding which grantees to visit. While the size of the grant
would not be the only consideration in a strategic approach to scheduling
site visits, it should be a major consideration.

HHS’s comments also addressed the issue of PO’s awareness of single
audit findings. HHS described how, under HRSA’s process during the
time covered by our review, POs were to be informed about single audit
findings. HHS described an enhancement to HRSA’s process for ensuring
that POs are provided with a more detailed description of single audit
findings and corrective actions taken to address the findings. HHS said
that this improved process was put in place as of April 30, 2012, which
was after the period covered by our review.

In its comments, HHS also describes improvements to HRSA’s
documentation of and communication with grantees about the restrictive
drawdown process, issues which we already discuss in our report. If fully
implemented, these improvements have the potential to remedy many of
the issues we identified in our report.

In acknowledging our findings on HRSA’s records retention practices,
HHS said that HRSA was required to retain records according to
schedules approved by the National Archives and Records Administration
(NARA). However, it further noted that HRSA has engaged in a review of
its records management practices. HHS said that, in December 2011,
during the course of our review, HRSA formed a workgroup on records
management with program and grant staff across the agency to
streamline various retention schedules for program and grant record
retention practices. HHS said that HRSA will be providing additional
training and updated policies for the HAB POs and grants management
specialists on the contents of the official grant file. HHS said that HRSA
would seek approval for any changes to HRSA’s record retention policies.

In commenting on our discussion of the difficulty some grantees
expressed about meeting the requirement for an annual visit of their
service providers, HHS noted that HRSA is working with a small number
of grantees to provide flexibility in meeting the requirement, but did not
describe what that flexibility would entail. In discussions near the end of


Page 40                                 GAO-12-610 Ryan White CARE Act Oversight
our review, HRSA officials said that this would not include excusing
grantees from the requirement that they visit all of their service providers
annually, but could involve leveraging the efforts of other CARE Act
grantees.

HHS concluded its general comments on the report by again noting that
the department concurred with all five of our recommendations. HHS
further commented that HHS is already in the process of planning or
implementing many of our recommendations. In its comments, HHS
provided considerable detail on actions HRSA plans to take or has
already taken to implement our recommendations. The actions HHS
describes are generally responsive to our recommendations. However,
because these actions follow the conclusion of our review or are to be
implemented in the future, and sometimes without a designated time
frame, we are unable to evaluate them specifically.

HHS also provided technical comments, which we incorporated as
appropriate.


As agreed with your offices, unless you publicly announce the contents of
this report earlier, we plan no further distribution until 30 days from the
report date. At that time, we will send copies of this report to the
Administrator of HRSA and the appropriate congressional committees. 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 about this report, please contact
me at (202) 512-7114 or crossem@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 major contributions to
this report are listed in appendix IV.




Marcia Crosse
Director, Health Care




Page 41                                 GAO-12-610 Ryan White CARE Act Oversight
Appendix I: Reporting Requirements for
                                              Appendix I: Reporting Requirements for
                                              Part A and Part B Grantees



Part A and Part B Grantees

Table 4: Reporting Requirements for Part A and Part B Grantees, Fiscal Year 2012

                                                                                                       Date Due for
Reporting Requirement                                                             Part A     Part B    Fiscal Year 2012
                                                                                                                   a
AIDS Drug Assistance Program (ADAP) Quarterly Report                                                  July 29, 2011
The ADAP quarterly reports provide aggregate data for ADAP service                                    October 31, 2011
utilization.                                                                                          January 31, 2012
                                                                                                      April 30, 2012
Minority AIDS Initiative Annual Plan                                                                 Part A: October 17, 2011
The primary Purpose of the Part A MAI Annual Plan is to ensure funds are                               Part B: October 7, 2011
used to link minority clients to HIV Care services. The primary purpose of
the Part B MAI Annual Plan is to ensure funds are used to link minority
clients into ADAP services. The plan is to include a planned timeframe for
delivering services; a description of service goals and objectives; the racial
and ethnic communities to be served and the number of service units to be
provided during the reporting period.
Mid-year Progress Report                                                                              October 31, 2011
The primary purpose of the mid-year progress report is to inform POs of
progress made in administration of the Part B programs; to identify
accomplishments and challenges in meeting established goals and
objectives; and to address grantees’ need for technical assistance.
Maintenance of Effort Expenditures Report                                                             December 5, 2011
The maintenance of effort expenditures report is used to ensure grantees
have maintained level expenditures for two consecutive grant years. The
expenditures must be based on the local budget items.
Program Terms Report                                                                                 December 5, 2011
The program terms report includes a planned allocation report, budget and
budget narrative justification, an implementation plan, the Consolidated List
of Contractors and the Contract Review Certification.
•   The allocation report serves as a monitoring tool to track and monitor
    the use of funds. It identifies categories of services that are being
    delivered, changes in the type of services being provided over time and
    trends in the amount of CARE Act funds being used to deliver these
    services.
•   The budget and budget narrative justification serve as monitoring tools
    to track and monitor the use of CARE Act funds.
•   The implementation plan serves as a monitoring tool to verify
    implementation of approved medical and support services for the
    current grant year. The plan should include all the services and priorities
    reflected in the allocations report. All funded services must be included
    in the implementation plan.
•   The Consolidated List of Contractors serves as a list of all funded
    service providers for the current grant year.
•   The Contract Review Certification requires the grantee to certify that all
    grant funded service providers for the current grant year comply with
    CARE Act program requirements, and federal grants requirements.




                                              Page 42                                      GAO-12-610 Ryan White CARE Act Oversight
                                              Appendix I: Reporting Requirements for
                                              Part A and Part B Grantees




                                                                                                        Date Due for
Reporting Requirement                                                              Part A     Part B    Fiscal Year 2012
Unobligated Balance Estimate and Carryover Request                                                    Part A: January 1, 2012
The CARE Act provides that base and supplemental grant funds were                                       Part B: January 31, 2012
available for obligation by the grantee for a 1-year period beginning
on the first day of the grant year. It also requires HRSA to cancel any
unobligated balances at the end of the grant year, recover funds that had
been disbursed to grantees, and redistribute these funds to grantees
in need as supplemental grants. Grantees must estimate their unobligated
balances during the grant year and provide final amounts in their federal
financial report. Grantees may request to carryover funds for one additional
grant year.
Interim Federal Financial Report                                                                       January 3, 2012
The purpose of the interim financial report is to substantiate that the grantee
has obligated 75 percent of the awarded funds for the current grant year.
Ryan White HIV/AIDS Program Services Report                                                           March 15, 2012
The Ryan White HIV/AIDS program services report provides information on
services provided by grantees and service providers to HRSA. Additionally,
grantees and service providers use this report to provide information on
clients, including their demographic status, services received and HIV
clinical information.
Part A Comprehensive Plan                                                                              May 21, 2012
The comprehensive plan is a legislative requirement that is due every 3
years at the beginning of the grant year. The plan is to be used as a “road
map” for the maintenance and improvement of the grantee’s system of care.
Grantees are required to include appropriate strategies, goals and timelines.
Statewide Coordinated Statement of Need (SCSN)                                                         June 1, 2012
The SCSN is a written statement of need developed through a locally
chosen collaborative process with other CARE Act grant parts. The purpose
of the SCSN is to provide a collaborative mechanism to identify and address
significant HIV care issues related to the needs of people living with
HIV/AIDS, and to maximize coordination, integration, and effective linkages
across the CARE Act parts. The SCSN process should consider all CARE
Act resources within the state, including the amount of funds, as well as the
services these funds are support.
Final Expenditure Table, including MAI expenditures                                                   Part A: June 28, 2012
This expenditure table serves as a monitoring tool to identify the use of                               Part B: September 28, 2012
funds at the end of the grant period. It identifies service categories that have
been delivered, the use of carry-over funds and identifies trends in the
amount of CARE Act funds being used to deliver these services.
Federal Financial Report                                                                              Part A:July 30, 2012
The Federal Financial Report outlines the grantee’s outlays, unliquidated                               Part B: July 30, 2012
obligations, total federal share and final unobligated balance.
Annual Progress Report                                                                                Part A: June 28, 2012
The Annual Progress Report is to inform POs of the progress made in the                                 Part B: September 28, 2012
administration of Ryan White programs; to identify accomplishments and
challenges in meeting established goals and objectives; and to address
grantees’ need for technical assistance.




                                              Page 43                                       GAO-12-610 Ryan White CARE Act Oversight
                                            Appendix I: Reporting Requirements for
                                            Part A and Part B Grantees




                                                                                                                Date Due for
Reporting Requirement                                                               Part A          Part B      Fiscal Year 2012
Report on Expenditures for Women, Infants, Children and Youth                                                 Part A: July 28, 2012
The report on expenditures for Women, Infants, Children and Youth is a                                          Part B: September 28, 2012
legislative requirement used to determine that a grantee allocates resources
for women, infants, children and youth at no less than the percentage
constituted by the ratio of the population of women, infants, children and
youth with HIV/AIDS to the general populations with HIV/AIDS.
                                                                                                                                            b
Minority AIDS Initiative Annual Report                                                                        Part A: January 31, 2013
Part A and B grantees receiving MAI funds must submit two components of                                         Part B: September 28, 2012
the MAI Report annually: (1) the MAI Annual Plan for the use of these funds,
and (2) the year-end MAI Annual Report documenting program outcomes.
Each MAI Report has two parts: (1) Web forms for standardized quantitative
and qualitative information and (2) an accompanying narrative providing
background information to explain the data submitted and a summary of
program accomplishments, challenges, and lessons.
                                            Source: HRSA.

                                            Note: The federal 2012 fiscal year was from October 1, 2011, through September 30, 2012. HRSA
                                            uses the federal fiscal year to determine when grantee reports are due. However, CARE Act grants
                                            have their own grant years. The grant year for Part A is from March 1 through February 28. The
                                            Part B grant year is from April 1 through March 31.
                                            a
                                             The July 29, 2011, AIDS Drug Assistance Program (ADAP) Quarterly Report is due in federal fiscal
                                            year 2011.
                                            b
                                             The Minority AIDS Initiative Annual Report for Part A grantees is due on January 31, 2012, which is
                                            in federal fiscal year 2013.




                                            Page 44                                             GAO-12-610 Ryan White CARE Act Oversight
Appendix II: HRSA Site Visits of Part A and
                                         Appendix II: HRSA Site Visits of Part A and
                                         Part B Grantees



Part B Grantees

Table 5: HRSA Site Visits of Part A Grantees, 2008-2011

                                                                                                                              Total
                                                Estimated                                                                  number
                                    2011 Grant      living Number of Number of Number of Number of                        of HRSA
                                        award HIV/AIDS HRSA site HRSA site HRSA site HRSA site                          site visits,
                                                         a
                                      (dollars)    cases visits, 2008 visits, 2009 visits, 2010 visits, 2011           2008 – 2011
Atlanta, GA                        $21,468,517       22,794              0             0              0            1              1
Austin, TX                           4,400,041        4,483              0             0              0            0              0
Baltimore, MD                       19,867,958       21,834              1             0              0            1              2
Baton Rouge, LA                      3,699,040        4,152              0             0              0            0              0
Bergen-Passaic, NJ                   4,044,886        4,296              0             0              1            0              1
Boston, MA                          13,769,366       14,992              0             0              0            0              0
               b                                                                                                                     c
Caguas, P.R.                         1,524,285        1,310              0             2              3            1             6
Charlotte-Gastonia, NC-SC            5,748,542        5,859              0             0              0            0              0
Chicago, IL                         25,986,577       27,451              0             1              1            0              2
Cleveland, OH                        3,997,596        4,252              0             0              2            0              2
Dallas, TX                          14,570,875       16,288              1             1              0            0              2
Denver, CO                           7,826,960        8,452              0             0              0            0              0
Detroit, MI                          8,924,079        9,341              1             1              1            0              3
                      b
Dutchess County, NY                  1,347,313        1,292              0             0              0            1              1
Fort Lauderdale, FL                 15,005,889       16,513              0             0              0            0              0
Fort Worth, TX                       3,864,078        4,082              0             0              0            0              0
Hartford, CT                         4,249,488        3,635              0             0              0            1              1
Houston, TX                         19,735,854       20,934              0             0              0            0              0
Indianapolis, IN                     3,908,947        4,124              0             1              0            0              1
Jacksonville, FL                     5,805,921        5,860              0             0              0            0              0
Jersey City, NJ                      5,074,144        5,089              0             0              1            0              1
Kansas City, MO                      4,288,671        4,567              0             0              0            0              0
Las Vegas, NV                        5,491,345        6,017              0             0              0            0              0
Los Angeles, CA                     40,064,159       43,264              1             0              0            0              1
Memphis, TN                          6,534,155        6,911              2             1              0            0              3
Miami, FL                           25,053,334       25,855              1             0              0            0              1
Middlesex-Somerset-Hunterdon,
NJ                                   2,503,584        2,831              0             3              0            0              3
Minneapolis-St. Paul, MN             5,608,011        5,722              0             0              0            0              0
Nashville, TN                        4,677,970        4,765              0             0              1            0              1
Nassau-Suffolk, NY                   6,441,136        6,030              0             0              0            0              0
New Haven, CT                        6,956,397        6,137              0             0              0            0              0
New Orleans, LA                      7,370,711        7,866              0             0              1            0              1




                                         Page 45                                           GAO-12-610 Ryan White CARE Act Oversight
                                            Appendix II: HRSA Site Visits of Part A and
                                            Part B Grantees




                                                                                                                                          Total
                                                   Estimated                                                                           number
                                       2011 Grant      living Number of Number of Number of Number of                                 of HRSA
                                           award HIV/AIDS HRSA site HRSA site HRSA site HRSA site                                   site visits,
                                                            a
                                         (dollars)    cases visits, 2008 visits, 2009 visits, 2010 visits, 2011                    2008 – 2011
New York, NY                           120,859,664        104,932                0             0              0               1                 1
Newark, NJ                              13,917,826         13,508                0             1              0               0                 1
Norfolk, VA                              5,986,127           6,179               1             0              0               0                 1
Oakland, CA                              6,789,146           7,576               0             1              0               0                 1
Orange County, CA                        5,968,395           6,572               1             0              0               0                 1
Orlando, FL                              8,313,970           9,791               0             0              1               0                 1
Philadelphia, PA                        24,102,413         25,047                0             0              0               0                 0
Phoenix, AZ                              8,257,524           9,073               1             0              0               0                 1
                                                                                                                                                   c
Ponce, P.R.                              1,842,886           1,929               1             3              3               0                7
Portland, OR                             3,742,527           4,210               0             0              1               0                 1
Riverside-San Bernardino, CA             7,356,532           8,742               1             0              0               0                 1
Sacramento, CA                           2,654,867           3,119               1             0              0               0                 1
Saint Louis, MO                          6,528,396           6,562               0             1              0               0                 1
San Antonio, TX                          4,413,440           4,657               0             0              0               0                 0
San Diego, CA                           11,765,451         12,844                0             0              1               0                 1
San Francisco, CA                       25,608,437         18,463                0             0              0               0                 0
San Jose, CA                             2,844,809           3,321               0             0              0               0                 0
                                                                                                                                                   c
San Juan, P.R.                          15,049,530         11,291                3             2              3               1                9
                  b
Santa Rosa, CA                           1,169,014           1,330               0             1              0               1                 2
Seattle, WA                              6,870,026           7,373               0             0              0               0                 0
Tampa-St. Petersburg, FL                 9,370,009         10,367                0             0              0               0                 0
                                   b
Vineland-Millville-Bridgeton, NJ          897,630               852              0             0              0               0                 0
Washington, DC                          31,006,866         34,715                0             1              0               0                 1
West Palm Beach, FL                      8,684,130           7,949               0             0              0               0                 0
                                            Source: GAO analysis of HRSA data.
                                            a
                                             Estimated living HIV/AIDS cases as of December 31, 2009. These case counts were used to
                                            calculate the 2011 grant award.
                                            b
                                             Caguas, P.R., Dutchess County, NY, Santa Rosa, CA, and Vineland-Millville-Bridgeton, NJ lost their
                                            classification as TGAs before the 2011 grant year, which began March 1, 2011, so the award amount
                                            is from grant year 2010 and the estimated living HIV/AIDS cases are as of December 31, 2008.
                                            c
                                             HRSA officials explained that when HRSA staff made trips to Puerto Rico that included stops at one
                                            or multiple Part A grantees and/or the Part B grantee. For example, a March 2009 trip to Puerto Rico
                                            included a site visit to the Part B grantee, to the San Juan Part A grantee, and to the Caguas Part A
                                            grantee. From 2008 through 2011, HRSA made 12 separate trips to Puerto Rico.




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                                         Appendix II: HRSA Site Visits of Part A and
                                         Part B Grantees




Table 6: HRSA Site Visits of Part B Grantees, 2008-2011

                                                                                                                                 Total
                                               Estimated                                                                   number of
                                   2011 Grant      living       Number of      Number of       Number of      Number of         HRSA
                                       award HIV/AIDS           HRSA site      HRSA site       HRSA site      HRSA site    site visits,
                                                        a
                                     (dollars)    cases        visits, 2008   visits, 2009    visits, 2010   visits, 2011 2008 – 2011
Alabama                           $18,809,782       10,941               0              0               0              0             0
Alaska                              1,134,180          658               0              0               0              0             0
American Samoa                         50,000             2              0              0               0              0             0
Arizona                            15,534,483       12,068               0              1               0              0             1
Arkansas                            8,373,354        4,992               0              1               0              0             1
California                        148,168,287      117,869               0              0               0              0             0
Colorado                           14,202,569       10,972               0              0               0              0             0
Connecticut                        14,571,752       11,068               0              0               0              0             0
Delaware                            5,790,675        3,087               1              0               0              0             1
District of Columbia               21,101,829       17,250               0              1               0              0             1
Federated States of Micronesia         50,000             6              0              0               0              0             0
Florida                           126,286,273       97,463               1              0               0              1             2
Georgia                            45,331,646       34,733               0              0               0              1             1
Guam                                  286,530             97             0              0               0              0             0
Hawaii                              3,583,940        2,228               0              0               0              0             0
Idaho                               1,315,589          780               0              0               0              0             0
Illinois                           41,738,721       32,322               0              1               0              0             1
Indiana                            11,811,918        8,689               0              1               0              0             1
Iowa                                2,933,874        1,759               1              0               0              0             1
Kansas                              3,656,596        2,825               0              0               0              0             0
Kentucky                            8,304,138        4,777               0              0               0              1             1
Louisiana                          23,144,643       17,644               0              0               1              1             2
Maine                               1,733,995        1,084               0              0               1              1             2
Marshall Islands                       50,000             1              0              0               0              0             0
Maryland                           40,187,548       34,379               0              0               0              0             0
Massachusetts                      20,457,176       16,929               0              0               0              1             1
Michigan                           17,823,185       14,216               0              1               0              0             1
Minnesota                           7,711,593        6,488               0              1               0              0             1
Mississippi                        12,080,715        8,334               0              0               1              0             1
Missouri                           14,157,823       11,584               0              0               0              0             0
Montana                               856,281          374               0              1               0              0             1
Northern Mariana Islands               50,000             10             0              0               0              0             0




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                          Appendix II: HRSA Site Visits of Part A and
                          Part B Grantees




                                                                                                                       Total
                                Estimated                                                                        number of
                    2011 Grant      living            Number of      Number of       Number of      Number of         HRSA
                        award HIV/AIDS                HRSA site      HRSA site       HRSA site      HRSA site    site visits,
                                         a
                      (dollars)    cases             visits, 2008   visits, 2009    visits, 2010   visits, 2011 2008 – 2011
Nebraska              2,728,244           1,609                0              0               0              0              0
Nevada                8,462,067           7,024                0              0               0              0              0
New Hampshire         1,507,461           1,139                0              0               1              0              1
New Jersey           46,624,149         35,467                 0              1               0              0              1
New Mexico            4,019,762           2,487                1              0               0              0              1
New York            162,437,735       130,091                  0              1               0              0              1
North Carolina       34,992,574         24,308                 0              0               0              0              0
North Dakota           378,141              187                0              0               0              0              0
Ohio                 24,817,612         16,997                 0              0               0              0              0
Oklahoma              8,431,948           4,840                0              1               0              0              1
Oregon                6,664,158           5,163                0              0               0              0              0
Pennsylvania         43,068,009         33,661                 0              3               0              0              3
                                                                                                                            b
Puerto Rico          31,376,731         18,172                 3              3               2              0           10
Republic of Palau       50,000                  3              0              0               0              0              0
Rhode Island          3,962,190           2,555                0              0               2              0              2
South Carolina       25,815,827         14,746                 0              0               0              2              2
South Dakota           883,908              403                0              0               0              0              0
Tennessee            20,350,806         15,578                 0              0               1              1              2
Texas                85,169,848         66,002                 0              0               0              0              0
Utah                  3,775,386           2,336                0              0               0              0              0
Vermont                893,492              403                0              0               0              1              1
Virgin Islands        1,161,007             568                1              3               2              0              6
Virginia             27,770,365         20,574                 1              0               0              0              1
Washington           13,896,285         10,734                 0              0               0              0              0
West Virginia         2,535,511           1,514                0              0               0              0              0
Wisconsin             8,910,774           5,131                0              0               0              0              0
Wyoming                728,630              240                0              0               0              0              0
                          Source: GAO analysis of HRSA data.
                          a
                           Estimated living HIV/AIDS cases as of December 31, 2009. These case counts were used to
                          calculate the 2011 grant award.
                          b
                           HRSA officials explained that HRSA staff made to Puerto Rico included stops at one or multiple
                          Part A grantees and/or the Part B grantee. For example, a March 2009 trip to Puerto Rico included a
                          site visit to the Part B grantee, to the San Juan Part A grantee, and to the Caguas Part A grantee.
                          From 2008 through 2011, HRSA made 12 separate trips to Puerto Rico.




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             Appendix III: Comments from the Department
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Department of Health and Human Services




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Appendix IV: GAO Contact and Staff
                  Appendix IV: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Marcia Crosse, (202) 512-7114 or crossem@gao.gov
GAO Contact
                  In addition to the contact named above, key contributors to this report
Acknowledgments   were Tom Conahan, Assistant Director; Romonda Bumpus; Cathleen
                  Hamann; Kathryn Richter; Sara Rudow; and Jennifer Whitworth.




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