oversight

Administration of Family Planning Grants Awarded to Genesee Family Planning Program, Inc.

Published by the Government Accountability Office on 1977-12-13.

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

                            DOCUREIqT FPSURE
04527 - [B13494752]   (Restricted)
[Administration of Family Planning Grants Awa:ded to Geaases
Family Planning Program, Inc. ]. HRD-78-24; B- 4031(5),. December
13, 1977. 3 pp. + 2 enclosures (10 pp.).
Report to Rep. Barber B. Conable, Jr.; Rep.    Prank Horton; by
Elmer B. Staats, Comptroller General.
Issue Area: Health Programs: Efficiency and Effectiteness of
    Grantees and contractors in Providing Treatment Services
     (1215).
Contact: Human Resources Div.
Budget Function: Health: Health Caze Services (551).
Organizaticn Concerned: Department of Health, Education, and
    Welfare; Genesee Region Family Planning :Progzan, Inc,       :
    Rochester, BY.
Congressional Relevance: Rep. Barber B. Conable, Jr.; Rep. Frank
    Horton.
Authority: Public Health Service Act, as amended, title X (42
    U.S.C. 300 et seq.).
          Genesee Region Family Planning Prograw, Inc., of
 Rochester, New York, is a consolidated grantee responsible for
 developing, organizing, administering, coordinating, and funding
 seven family planning projects in the Genesee area of upstate
 New York. Questions were raised about the administration of one
 of the projects, Planned Parenthood--Rochester, by the
administration office (core office) of the region.
Findings/Conclusions: Allegations of inefficiency in
administration and improper allocation of Federal funds by the
core office were inaccurate. The office allocated funds to the
seven participating projects equitably. The Genesee Region was
in general compliance with the Department of Health, Education,
and welfare's (HEW's) family planning program regulations and
has made services available to its seven projects in accordance
with its plan of operations presented to HEW. Administrative
costs incurred by the Geneses Region exceeded HEW guidelines,
but other family planning projects in the HEW region also
exceeded the guidelines. although no serious administrative
inefficiencies were found, questions were raised about the
effectiveness of the Genesee Region in Oroviding services.
Cooperation between the projects and the core office was found
to be inadequate. Although HEW has encouraged consolidating
family planning projects and single grant awards, it has not
established guidelines for management or an adequate system for
monitoring the grants. Recommendations: The Secretary of HER
should direct that the Regional Health Administrator require the
projects and the core office which make up the Genesee Region to
reevaluate the core office's role and to assist such projects by
designing admiListrative guidelines and improving HBW's review
of applications for consolidated family planning program grants
and monitoring of activities carried out under such grants.
                      COMPNROLLER GENERAL OP TZI             UNITED NTATEa
     ~i,     ~~~)I~     2WASHINTON.              O.C.    UI

                  tSTRerTgrd          ot to be    rpqe.,td       c}pJ
                                                                 ;v$         the
                                                                               aC.'eral
              A¢COLtnPt      · '..               .........--.      , tA,)eSK;cO   approval
              by the w..a oi _.,_u..l
B-164031(5)                                                          Wl


The Honorable Barber B. Conable, Jr.
The Conorable Frank Horton
House of Representatives
     As reques':ed in your March 28, 1977, letter and as
subsequently agreed with your offices, we reviewed the ad-
ministration of a grant for family planning services' awarded
to the Genesee Region Family Planning Program, Inc., of
Rochester, :ew York (Genesee Region) by the Department of
Health, Education:. and Welfare (HEW). Funds were provided
under title X. Public Health Service Act, as amended
(42 U.S.C. 330 et seq.). We also made a limited review of
the procedures used by HEW region II, to review and approve
the Genesee Region's application for family planning funds
and region II's monitoring of the grantee's operations.
     As Instructed by your offices, we did not obtain official
written comments from HEW, but the matters included in this
report were discussed with HEW regional and headquarters
officials. Our observations, conclusions, and recommenda-
tions are summarized below. More detailed information is
contained in enclosure I.
BACKGROUND
     Genesee Region is a consolidated grantee responsible for
developing, organizing, adminis ering, coordinating, and fund-
ing seven family planning projects in the Genesee area of
upstate New York. These projects are (1) Planned Parenthood
of Rochester and Monroe County, Inc. (Planned Parenthood--
Rochester), (2) Orleans County Family Planning Services,
Inc., (3) Wayne County Rural Comprehensive Health Program,
(4) Planned Parenthood of Ontario County, Inc., (5) Yates
County Family Planning Services, Inc., (6) Livingston County
Health Department, and (7) Planned Parenthood of the South.rn
Tier, Inc. Your request was prompted by questions raised by
one of the seven projects, Planned Parenthood--Rochester,
which generally alleged inefficient use of grant funds by the
administration office, or core office, of the Genesee Region.


                                                                                          HRD-78-24
                                                                                          (102025)
B-164031(5)


     As agreed, our efforts concentrated on
     -- assessing the reasonableness of project grant funds'
        allocation from the core office to the projects,
        amphasiziag administrative cost- of the core office
        and the effect of these costs tn direct family plan-
        ning servicesa
     ·--determining Genesee Region's compliance with applicable
        laws and its; plan of operations submitted to HEWN and
     -- investigating the responses to Congressman Conable,
        dated July 16, 1976, and to Planned Parenthood--
        Rochester, dated September 13, 1976, from officials
        of HEW headquarters and region II, respectively, for
        consistency concerning the projects' discussion of
        the core office performance.
SUMMARY
     We determined that allegations of inefficiency in admin-
istration and improper allocation of Federal funds by the core
office of the Genesee Region are inaccurate. The core office
allocated title X funds to the seven participating projects
equitably.
     We found the Geneses Region's operations in general
compliance with HEW's family planning program regulations.
Pe also concluded that the Geneses Region has continually
made available services to its seven projects in accordance
with its plan of operations as set forth in grant applica-
tions and documents requested by HEW at a meeting with the
Genesee Region on July 9, 1976.
     The administrative costs incurred by the Genesee Region
exceeded HEW guidelines. We noticed, however, that the ad-
ministrative costs incurred by other family planning proj-
ects, including consolidated grantees, in the HEW region also
exceeded HEW guidelines.
     Although we did not find serious inefficiencies in admin-
istration of the core office, we questioned the effectiveness
of the Genesee Region, especially its limited capability to
provide services needed by the projects. We believe that the
seven projects and the core office have not cooperated to im-
prove the core office's responsiveness to the needs of each
project.

                              2
 B-164031!5)


      The questionable usefulness of a consolidated grant
 arrangement for family planning projects in the Geneses
 might be due to a lack of direction from the projects    Region
                                                       and
 HEW's apparent "laissez faire" attitude toward consolidatedto
 grantees.   Although HEW has encouraged consolidating
planning projects and single grant awards, it has not family
lished (1) guidelines for managing and (2) an adequate estab-
for monitoring consolidated family planning program     system
                                                     grants.
     Finally, we did not find significant
HEW responses to Congressman Conable and toinconsistencies  in
                                             Planned Parenthood--
Rochester concerning discussion of the performance  of the core
office of Genesee Region by the projects. We learned,
that HEW region II's                                    however,
                     staff did not review the Genesee Region.
This review had been cited in the letter to Congressman
as the primary remedial action which would be taken.     Conable

RECOMMENDATIONS TO THE SECRETARY OF HEW
      We recommend that the Secretary of HEW direct that the
Regional Health Administrator require the projects and
                                                         the
core office which make up the Genesee Region to reevaluate
the core office's role and to assist such projects by
                                                       design-
ing administrative guidelines and improving HEW's review
applications for consolidated family planning program      of
                                                       grants
and monitoring of activities carried out under such grants.
     As agreed, your offices will make distribution
report to interested parties. Subsequently we will of this
                                                     send copies
to the Secretary of HEW and will also make copies available
for public distribution.
     We trust that the material provided herein is responsive
to your request.




                               Comptrcller General
                               of the united States

Enclosures - 2




                              3
ENCLOSURE I                                                                                          ENCLOSURE I

                   SUMMARY OF INFORMATION OBTAINED--
                    DESCRIPTION OF GENESEE REGION
               FAMLY PLANNING PROGRAM, XNC.
     The Genesee Region Family Planning Program, Inc.,
established November 1, 1972, to offer organized family was
planning services in the Finger Lakes area of New York. The
area consists cf 5,794 square miles, encompassing ten
counties--Chemung, Livingston, Monroe, Ontario, Orleans,
Schuyler, Seneca, Steuben, Wayne, and Yates. Except for
Monroe County, most of the area is rural
     An organization chart of the Genesee Region is illustrated
below.


                   ORGANIZATION CHART OF GINIuI RGION FAMILY PLANNING PROGRAM, INC.




                                                                Planned Parenthood of Rochester and Monroe County.1n.




                                                                Wayne County Rual Cpngrehenev Health Program




                                          .nciOl                          County Fami
                                                                         hYao             Pla nni   Srvic Inc.

                            klnpm    lxrutive      ~               WiLuvrn County Health Department

                                                            -               Prenthood of ota Southern Tier. Inc.
                                                                         wnCned




       learauryI      loo1fa                           Dirct
                                     At            ,                |'


                                                       Trainln
                                                       Education
ENCLOSURE I                                          ENCLOSURE I

     The board of directors is the policy setting body
of Genesee Region. Assisting the board in financial matters
is a budget and finance committee. In addition, an executive
committee handles any business, not specifically allocated
to other committees, between bimonthly meetings of the board.
     The board of directors appoints an executive director who
conducts the family planning program in accordance with board po-
licies. The executive director employs and supervises a staff
in the administrative office (known as the "core office")
who, among other responsibilities, allocate the Federal
grant funds and provide technical and professional assistance
to the projects (the local agencies which actually.deliver
the family planning services).
      Genesee Region has contracts with seven health projects
throughout the Genesee area. They are (1) Planned Parent-
hood of Rochester and Monroe County, Inc., (Planned Parenthood--
Roches'.tr), (2) Orleans County Family Planning Services, Inc.,
(3) Wayne County Rural Comprehensive Health Program, (4) Planned
Parenthood of Ontario County, Inc., (5) Yates County Family
Planning Services, Inc., (6) Livingston County Health Depart-
ment, and (7) Plenned Parenthood of the Southern Tier, Inc.
These projects are responsible to their own local boards of
directors.
ALLOCATION OF TITLE X
FUNDS APPEARS EQUITABLE
     Under title X of the Public Health Service Act, as amended
(42 U.S.C. 300 et seq.), "Population Research and Voluntary
Family Planning Program," the Secretary of HEW may award
grants and contracts to family, planning service providers.
HEW specifies that the awards be made available to public
or nonprofit agencies, institucions, organizations, or
consortia of eligible applicants acting jointly.
     The Genesee Region is one of several consolidated
family planning program grantees in New York State currently
receiving title X funding from HEW. In its earlier years,
the Genesee Region generally received the title X funds it
requested. Recently, however, Genesee Region's budgets and
funding requests for the fiscal years ended March 31, 1977,
and ending March 31, 1978, were reduced by about 16 and 11
percent, respectively.
        HEW recommended that each project share in the funding
cuts.     however, as a core office official stated, instead




                                2
ENCLOSURE I                                                                                   ENCLOSURE I

of across-the-board cuts, the Genesee Region
to allocate the funds among the projects from was allowed
                                               the total grant
amount.
     In fiscal year 1977, Geneses Region's executive
and finance committees allocated title X funds          and budget
patient workload, unmet need for clinic services,based  on current
on the project's budget. The allocation procedure   and  impact
with officials from all projects before final        was discussed
                                                implementation.
HEW approved the allocation with only a few
                                             minor adjustments.
     For fiscal year 1978, allocation of
made by the budget and finance committee. title  X funds was
projects to absorb the grant reduction, the In  selecting
                                             committee's
objective was to avoid reducing patient services.
     Our review of the allocation of title X funds
years 1977 and 1978 and the expenditures           for fiscal
                                         of the core office
from 1975 to 1977 disclosed that
      -- the core office, as shown below, absorbed
                                                   the largest
         Proportional reduction in funds (26 percent)
         and nearly the same (11 percent) as most of in 1977
                                                      the projects
         in 1978.

                                   0celson              eofLnee
                                                           Reqion   aoily Planninq
                                                   [Odor
                                                    117 ellALi

                                 _ s        ealr    977                         Fisc7l year 1978
                                                                                             I Dif:erenci
 Geneso·   tegion                                   between funds                         between funds
                        Funds           Funds       requested and      Funds       Funds
      agenclog        requested                                                           requerted and
                                       apIroved        approved            requested
                                                                                  aproved   4Pproved
  lenn d Parenthood                      31,35              -26        144,033     $127,884       -11
    otf ochester and
    Monroe County,
Orlen County           253,913          21074              -17         231,233       206,100      -11
   Family Planning
        Countyc.
        icyne           94,161           75,329            -20
Wayne County aural                                                     68,983        61,000      -12
   Comp. Enalth
   Pnogra n             63,546          50,637             -20
Planned Parenthood                                                     61,463        51,120      -17
   of Ontario County,
   In.                   3,Coun3        77030              +21
Tates County Family                                                   104,265        92,025      -12
  Planning Services,
Lin.ton County         29000            25625
Livingston  county                                        -12          29,000        25,807      -11
  Heanth repatheont    22,540           19,846            -12
Planned Parenthood                                                     20,995        18,702      -11
  of the Couth-
  ern Tier, Inc.      179.426          155,615            -13         166.438           562      - 8
    motal             663.34 7     1746.389               -16       $826,1        5735,200      -11




                                                    3
 ENCLOSURE I
                                                     ENCLOSURE I

      -- from 1975-77 the core office reduced its expenditures
         by 36 percent, from $211,158 to $135,122, even
         title X funding within the total Genesee Region though
         for the same period was cut only 4.4 percent.    grant
         to the Genesee Region's fiscal year 1978 grant  According
         the funding restrictions resulted in cutbacks proposal,
                                                        in some
         professional positions by abolishing or converting
         them to part-time.
      --only Planned Parenthood--Rochester was discontented
        with the allocations made by the core office.
      In view of our findings, we believe that title
                                                     X funds
 awarded to the Genesee Region for fiscal years
 were reasonably allocated to the core office   1977 and 1975
                                              and the projects.
 HIGH ADMINISTRATIVE COSTS OF
 GENESEE REGION ARE NOT UNIQUE
      On October 1, 1976, HEW instituted a new reporting
                                                             system
 to monitor, among other things, adherence to
limit a grantee's administrative costs to 20   guidelines    which
                                               percent of total
 federally and nonfederally funded
by family planning grantees for thecosts.  Most data submitted
                                     period January to June
1977 showed administrative costs exceeded 20
                                               percent of total
cocts. Genesee Region's administrative costs
of total costs (4.4 percent incurred by the      were 28.6 percent
24.2 percent by the projects), while region   core  office and
administrative costs averaged 26.1 percent andII  and  the Nation's
of total costs, respectively. In addition,        25.6  percent
draft report to HEW by Analysis, Management, we   noted  in a
                                               and
In.., which evaluated the effectiveness of family Planning,
organizations in the Eastern United States,           planning
                                             that a consolidated
Irantee closely resembling Genesee Region had
administrative costs (39 percent) among the      the 1lghest
                                             granteies evaluated.
THE CORE OFFICE COMPLIES WITH
APPLICABLE FEDERAL GNT REGULATIONS
AND ITS NPLANOF OPERATIONS
     HEW's Bureau of Community Health Services,
Administration, which administers the domestic Health Services
funded family planning programs, began a programfederally
1970s to encourage consolidating or integrating in the
                                                 of individual
family planning project grants into larger umbrella
The Bureau assumed that through economies of         grants.
                                              scale
planning services would be provided more efficiently(1) family
effectively and (2) more resources would be           and
                                             available for
patient care services.



                                 4
ENCLOSURE I                                           ENCLOSUtRE I

     However, HEW has not established guidelines and regulations
ior the functions, organization, and the aspects of consolidated
grantees. Therefore, we could compare operations of the Gene-
see Region's core office only to (1) HEW's broadly stated
Federal family planning program grant regulations and (2) the
Genesee Region's plan of operations as stated in its grant
applications and related documents.
Compliance with HEW's family planning
program regulatlons and guidelines
     We found that the core office's oer'rcions have generally
followed the broadly stated HEW family glanning program regu-
lations.
     However, we found it difficult to determine the Genesee
Region's compliance with the guidelines, such as a 20-percent
limit on grantee administrative costs established by HEW for
the family planning program. According to HEW officials, using
these guidelines is presently discretionary for determining
appropriate levels of Region-approved grant support. Therefore,
although Genesee Region's ad:ainistrative program costs do not
comply with the guidelines, we cannot question such costs :ith-
out firm implementation of the guidelines by HEW in approving
grant support levels.
Compliance with Genesee Region plan
     In the fiscal year 1978 grant application, functions
of the core office were
     -- to provide a setting within which delegate agencies
        (projects) can best provide family planning services
        and
     -- to provide technical and professional assistance to
        the delegate agencies to meet local needs effectively
        and efficiently.
     In line with these functions, the core office has con-
tinued to make available grant-related and technical services
to projects and educational services for community groups.
EFFECTIVENESS OF THE CORE OFFICE
Not all the services provided by the core
office ara useful to all projects
     The core office guides projects in preparing budgets
and narratives for grant application for title X funds;


                             5
 ENCLOSURE I
                                                       ENCLOSURE I

 prepares its own budget and other reports reviews
                                           1         documents
 prepared by the projects for mathematical accuracy,
 and reasonableness! verifies that assurances         consistency,
                                               and certifications
 required for the grant application are executeda
                                                   then submits
 and obtains approval of the grant application
                                                from the budget
 ant' finance committee and the board of directors
 i: to HEW.                                        before sending

     All projects use core office assistance in some
phases of the grant application process, depending    or all
needs. During the grant application process        on  their
the year, the core office serves as the HEW  and throughout
                                            liaison for the
whole Genesee Region.
     A staff consisting of a full-time and
a program evaluator, a nurse consultant, anda part-time educator,
sultant gives technical assistance to Genesee a financial con-
board of directors, and committees and other Region's projects,
                                              community agencies.
The larger pr,,Jects, however, have limited need
                                                 for the tech-
nical staff's services, particularly the educators'
Most small,- projects need and use such services,    skills.
some educators' services as too sophisticated.     but one views

      Furthermore, some technical services
similar to those offered by srme projects, offered   appear
Bureau of Family Planning, and HEW. Examplesthe  New   York State
include training and educating some segments    of  these   services
                                              of
nursing consultations, and evaluating projects.    the  community,
                                                    In a March
1976 review of the Genesee Regin's grant application,
HEW region II official noted that excluding                one
                                             one  project,
he found no movement among the projects to integrate
planning services with other comprehensive health        family
providers. In our opinion, the Genesee Re;gJn        service
to determine wh.:h services are most essential projects need
which services would be better performed by one to the projects,
                                                  of the projects
or obtainable from, or more economical to integrate
another family planning agency.                         with,

The projects are not working jointly to
achieve the goals of the consolidation
                                      -
     Our review also noted four occasions in
showed lack of interest in the consolidation which most projects
                                             goals. Some projects
did not respond when core office staff solicited
garding the                                      suggestions re-

     --regional health services plan,
     -- distribution of funds for fiscal year 1978,


                               6
ENCLOSURE I                                       ENCLOSURE I

      -- project participation in the Genesee Region decision-
         making process, and
     -- training the projects require.
     We believe that the most obvious means for addressing
the projects' problems is through the boards of directors
of the individual projects and the Genesee Region. in example
of limited effort by the boards of directors to resolve their
probleis jointly is the controversZ between the Genesee Re-
gion and Planned Parenthood--Rochester.
     HEW's grantee review and monitoring functions'ae
another obvious channel for addressing the projects' prob-
lems. To fulfill these functions, HEW regional officials
review the grant application document, obtain performance
reports, and make site visits. Although HEW attempted to
have regions jointly consider Planned Parenthood--Rochester's
concerns, it failed to follow up and assure resolving the
problems. Site visits might have helped HEW to better moni-
tor the operations of the grantee and resolve problems such
as the Planned Parenthood--Rochester/core office ronflict.
However, since September 1, 1976, the project officer Lnade
only three visits to Genesee Region, and the third site
visit made in July 1977 was about a special grant for se:v-
ices to teenagers.
     HEW can also assist a consolidated grantee by estab-
lishing guideln-es for administering a conso'idation, How-
ever, as discussed earlier, even though HEW encouraged such
consolidation, it does not have guidelines for it.
HEW DID NOT REVIEW THE DOCUMENTS
REUESTED FROM GENESEE REGION -
      Because of complaints about the core office by Planned
Parenthood--Rochester, region II's staff met with all proj-
ects on July 9, 1976, to determine if other projects had
similar complaints. HEW found that the six
did not have the same problem and stated so other  projects
                                             in separate
letters to Congressman Conable on July 16, 1976, and to
Planned Parenthood--Rochester on September 13, 1976.
     In the letter to Congressman Conable. HEW stated
it had requested that the Genesee Region p epare a morethat
                                                          de-
tailed plan ot operations to justify the present core of-
fice staff budget. This plan was to be reviewed by
and, if necessary, changes would be made in the grantHEWaward.



                              7
ENCLOSURE I                                      ENCLOSURE I

     The plan of operations requested by NEW consisted of
"job descriptions, resumes for all c6re office employees,"
evaluation of the core office, the program evaluator an-
nual report, training and education plans for 1976-77, and
workshop reports on progress toward goals for 1976-77. How-
ever, although these documents were submitted by the core
office, HSW never reviewed them. An HEW official stated
that review of these papers was not done due to a significant
organizational change, that is, a new executive director at
Geneses Region's core office.
CONCLUSIONS
     Allegations of inefficieincies in administration and
improper allocation of Federal funds by the core office of
the Genesee Region and of inconsistency in HEW responses
to Congressman Conable and Planned Parenthood--Rochester
are inaccurate.
     We believe, however, that the controversy between the
Genesee Region and Planned Parenthood--Rochester resulted
from a lack of effort by the core office and the projects
to determine and satisfy their more important needs. While
the core office has made available services which are our-
lined in the Geneses Region's plans and stated functions,
not all such services are useful to the projects.
     Also, the Genesee Region does not have adequate di-
rection regarding its functions and organization. Although
HEW has encouraged consolidating family planning projects
and single grant awards; it has not established (1) guide-
lines for managing and (2) an adequate system for monitoring
consolidated family planning program grants.
RECOMMENDATIONS TO THE SECRETARY OF HEW
     Because of limited use of core office services and
the title X funds going to the core office, we recommend
that the Secretary of HEW direct the Regional Health Ad-
ministrator to require that the seven projects and core
office representatives reevaluate jointly the services
and functions of the core office. Such a reevaluation
should reach agreement on (1) the purpose of consolida-
tions; (2) the most effective use of the resources and
services of the core office; and (3) the capability of
the seven projects to coordinate and share individual
resources and services and to use services offered by
other community agencies, the Bureau of Family Planning
(New York State), and HEW, in addition to, or in lieu
of, the core office.
ENCLOSURS I                                      ENCLOSURE I

     We further recommend that the Secrtary direct the Re-
gional saelth Administrator to aasist  Genesee Region in its'
deliberations by designing administrative guidelines which
should specifically include (1) the benefits the Federal
Government obtains from a consolidated family planning
grant and (2) the means by which the Department can assure
that the administrative costs incurred by a consolidated
grantee do not detract from direct provision of family
planning services. Once guidelines have been established,
HEW should improve its review of applications for consoli-
dated family planning program grants and its monitoring
activities carried out under such grants for all regions.of




                             9
ENCLOSURE II                                                          ENCLOSURE II




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                                           March 28
                                           1 3   7 7


       Honorable Elmer S. Staats
       Comptroller General
       General Accounting Office
       441 G Street
       Washington, D. C. 20548

       Dear Elmers

      We recently had the opportunity to meet with Mrs.
                                                         Barbara
      Zartxran and Mr. Dave Cruthis of the Planned Parenthood
      Rochester and Monroe County, Inc. These meetings grew of
      out of correspondence we had with Mrs. Zartman regarding
      ner concern that federal family planning money should
                                                              be
      used primarily for patient services rather than to
                                                          maintain
      groups charged with providing these services.
      We share this concern over the use of these federal
      and are requesting that the General Accounting Officefunds
      investigate whether or not present law is being complied
      witn in these cases. The Department of Health, Education
      Welfare has commented on this situation in meetings         and
      officials of Planned Parenthood of Rochester as well with
                                                            as by
      letter. For your information, we are enclosing copies
                                                              of
      correspondence on this matter.

      Thank you for your assistance in this matter and we
                                                          look
      forward to receiving the results of the GAO investigation.

                                           Sincerely,




      Barber B. Conable, Jr.                                   Hoon




                                            10