Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Monitoring of Ryan White CARE Act Title I 
and Title II Grantees 
INSPECTOR GENERAL 
MARCH 2004 
OEI-02-01-00640  O I G
FFICE OF  NSPECTOR  ENERAL

http://www.oig.hhs.gov/ 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, 
is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as 
the health and welfare of beneficiaries served by those programs.  This statutory mission is carried out 
through a nationwide network of audits, investigations, and inspections conducted by the following 
operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits examine the 
performance of HHS programs and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of HHS programs and operations in 
order to reduce waste, abuse, and mismanagement and to promote economy and efficiency throughout the 
Department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and program 
evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and the 
public.  The findings and recommendations contained in the inspections reports generate rapid, accurate, 
and up-to-date information on the efficiency, vulnerability, and effectiveness of departmental programs. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 
allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 
providers.  The investigative efforts of OI lead to criminal convictions, administrative sanctions, or civil 
monetary penalties.  The OI also oversees State Medicaid fraud control units which investigate and 
prosecute fraud and patient abuse in the Medicaid program. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering 
advice and opinions on HHS programs and operations and providing all legal support in OIGs internal 
operations.  The OCIG imposes program exclusions and civil monetary penalties on health care providers 
and litigates those actions within the Department.  The OCIG also represents OIG in the global settlement 
of cases arising under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops model compliance plans, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.  E X E C U T I V E  S U M M A R Y  
OBJECTIVE 
To assess the role of the project officer in monitoring the Ryan White CARE Act Title I and 
Title II grantees programmatic performance. 
BACKGROUND 
The Senate Finance Committee asked the Office of Inspector General (OIG) to review the 
Health Resources and Services Administrations (HRSAs) oversight of Ryan White 
Comprehensive AIDS Resources Emergency (CARE) Act Title I and Title II grantees and 
grantees oversight of their subgrantees. Hereinafter, these grantees are referred to as Title I 
and Title II grantees. As part of this request, the Committee asked OIG to also initiate audits of 
select grantees and subgrantees. 
The CARE Act provides funding to develop, organize, coordinate, and operate effective and 
cost-efficient health care and support services to medically underserved individuals and families 
affected by HIV/AIDS. Title I and Title II are the largest programs and are the focus of this 
inspection. Title I provides emergency relief grants to eligible metropolitan areas for 
community-based HIV-related services, and Title II provides grants to States, the District of 
Columbia, and the territories to improve the quality, availability, and organization of health care 
and support services. 
This report focuses on the role of the project officer in monitoring Title I and Title II grantees 
programmatic performance in fiscal year (FY) 2000.  We collected data in 2001 and 2002. 
The report does not address the role of the grants management officer, given that during the 
data collection period the grants management offices throughout HRSA were being 
consolidated, and it was, therefore, difficult to draw conclusions about their role. 
To assess project officers monitoring of Title I and Title II grantees, we compared their 
monitoring activities to the duties, as outlined in their position description, and in Monitoring 
Grants and Cooperative Agreements for Federal Personnel, the training manual used by 
Federal grants personnel.  We reviewed documents that project officers used to monitor 20 
grantees. We also interviewed these 20 grantees, HRSA officials, and the 17 project officers 
responsible for these 20 grantees. Overall, these project officers provide oversight of 38 of the 
51 Title I grants and 21 of the 54 Title II grants. This inspection also produced a companion 
report, entitled The Ryan White CARE Act Title I and Title II Grantees Monitoring of 
Subgrantees, OEI-02-01-00641. 
i
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  FINDINGS 
Title I and Title II project officers are not adequately monitoring the 20 selected 
grantees 
Project officers do not consistently have grantees required progress reports or 
prepare grantee status reports. We found that project officers had progress reports for 8 of 
the 10 Title I grantees but none of the 10 Title II grantees. Additionally, we found that project 
officers had prepared only 15 status reports for the 20 selected grantees. 
Project officers report limited monitoring of grantees fiscal performance. None of the 
project officers could provide any documentation showing that they track the fiscal 
performance of the 20 grantees. 
Not all project officers use the grantee application as a monitoring tool.  All 17 project 
officers report reviewing grantees annual applications; however, only 5 Title I project officers 
note that they use the application benchmarks to monitor grantees throughout the year. 
Project officers do not routinely conduct monitoring site visits, and therefore, do not 
verify information provided by grantees.  Project officers had site visit reports for 10 of the 
selected 20 grantees for the last 2 years.  Six of the 17 project officers note that travel 
restrictions implemented within their division prevent them from conducting site visits. 
Title II project officers are not involved in the process of setting special conditions to 
address vulnerabilities. Six of the eight Title I and none of the nine Title II project officers 
are involved in the process of setting special conditions of award. Special conditions change 
the grant requirements described in the notice of grant award to address specific vulnerabilities. 
Project officers, however, do report having frequent contact with grantees. Both Title I 
and Title II project officers report having frequent telephone and electronic mail (email) contact 
with grantees, and that they have more frequent contact with grantees who have issues or 
problems. 
Project officers do not focus on grantees monitoring of subgrantees. Only 5 of the 17 
project officers report that they routinely review documents that subgrantees submit to the 
grantee. 
ii
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  Neither Title I nor Title II project officers can describe a standard corrective action 
process. None of the project officers had corrective action plans for any of the 20 selected 
grantees. Title I and Title II project officers were either unable to describe or gave inconsistent 
descriptions of a corrective action process. 
HRSA provides limited support to project officers to systematically monitor 
grantees 
Little guidance or training is provided on how project officers should monitor.  The 
HIV/AIDS Bureau provides little guidance to project officers about how to specifically monitor 
Title I and Title II grantees.  As a result, project officers monitor grantees differently. 
HRSA has initiated few corrective actions.  HRSA does not frequently initiate corrective 
actions when grantees fail to meet grant requirements. Interviews with project officers provide 
additional evidence that the Bureau is reluctant to take action against grantees when there is a 
problem. 
Little continuity exists among project officers. Six of the 20 grantees say that a high 
turnover rate among project officers hinders monitoring. In addition, project officers are 
rotated every 2 years, making it unlikely that they ever conduct two monitoring site visits of the 
same grantee. 
Coordination between Title I and Title II project officers is limited.  Most project 
officers note that they do not coordinate monitoring activities with the project officers from the 
other Title, even though the two Titles often fund the same subgrantees and have overlapping 
geographic areas. 
RECOMMENDATIONS 
The findings are based on documents from 10 Title I and 10 Title II grantees and interviews 
with project officers who are responsible for 38 of the 51 Title I grants and 21 of the 54 Title II 
grants. These findings indicate that HRSA needs to strengthen its oversight of Title I and Title 
II grantees.  We are aware that since this inspection was conducted, HRSA has consolidated 
its grants management offices, relocated most Title II monitoring responsibilities from regional 
offices to headquarters, and redefined the Office of Field Operations as the Office of 
Performance Review. These changes may better position the agency to address the following 
recommendations. Specifically, we recommend that HRSA: 
	 Specify and enforce standards and guidelines for how project officers should monitor 
grantees 
  Address ongoing training for project officers 
iii
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640    Standardize a corrective action process and address grantee issues more formally 
  Increase frequency and comprehensiveness of site visits 
  Improve project officer continuity 
  Improve coordination between Title I and Title II oversight staff 
Agency Comments 
We received comments on our draft report from HRSA. The full text of these comments can 
be found in Attachment C. HRSA concurs with our recommendations, and adds that significant 
administrative changes have occurred since this inspection was conducted. These changes may 
better position the agency to address the grantee monitoring activities discussed in this report. 
HRSA also describes several concerns with this report. In general, HRSA is concerned that 
the report does not distinguish between HRSA and the HIV/AIDS Bureau, the agency directly 
responsible for administering the Ryan White CARE Act.  At the time data were collected, Title 
I grantees were monitored from the HIV/AIDS Bureau in the Rockville headquarters office, 
while Title II grantees were monitored from the Office of Field Operations in regional offices 
and outside of the HIV/AIDS Bureau.  Instances where we address HRSA are meant to 
include both the HIV/AIDS Bureau and the Office of Field Operations. Additionally, HRSA is 
concerned that the report does not distinguish between Title I and Title II project officers. We 
do make distinctions in the report between the two, however, where differences were apparent 
in the data analysis. 
Finally, HRSA is concerned that our report does not address the role of the Grants 
Management Officer in monitoring CARE Act grants, adding that administrative restructuring of 
the Grants Management Office occurred in October 2003.  We note in the report that the 
scope of our inspection is limited to the role of the project officer, and agree that the Grants 
Management Officer perspective would provide a more complete evaluation.  However, during 
an interview conducted as part of the study design we were told that the office would be 
consolidated in June 2002.  This interview was conducted in December 2001, and the decision 
to limit the scope of the inspection was made at that time. 
iv
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  T A B L E  O F  C O N T E N T S  
EXECUTIVE SUMMARY ...................................................... i

INTRODUCTION .............................................................1

FINDINGS  ..................................................................8

Title I and Title II project officers are not adequately monitoring 

selected grantees  ...........................................................8

HRSA provides limited support to project officers 

to systematically monitor grantees  ..............................................13

RECOMMENDATIONS ...................................................... 16

APPENDICES .............................................................. 18

Appendix A:  HRSA/HAB Organizational Structure  ................................18

Appendix B: OIG Grants Oversight Framework ...................................19

Appendix C: Agency Comments  ..............................................20

ACKNOWLEDGMENTS ..................................................... 31

v
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  I N T R O D U C T I O N  
OBJECTIVE 
To assess the role of the project officer in monitoring the Ryan White CARE Act Title I and 
Title II grantees programmatic performance. 
BACKGROUND 
In a letter dated August 2001, the Senate Finance Committee asked the Office of Inspector 
General (OIG) to review the Health Resources and Services Administrations (HRSAs) 
oversight of Ryan White Comprehensive AIDS Resources Emergency (CARE) Act grantees 
and grantees oversight of their subgrantees. News accounts have highlighted several instances 
of questionable spending by grantees and subgrantees that are now subject to Federal and 
State investigations.  As a result, the Committee is concerned that HRSA may not be exerting 
clear and consistent oversight over its CARE Act grantees nor requiring, or otherwise 
monitoring, grantees oversight of their subgrantees. 
As part of this request, the Committee asked OIG to also initiate audits of select grantees and 
subgrantees.  The purpose of these audits is to evaluate grantees administration of CARE Act 
funds and their oversight of subgrantees, and to assess subgrantees fiscal capability and 
performance. This report focuses on the role of the project officer in monitoring Title I and 
Title II grantees programmatic performance. The report does not address the role of the 
grants management officer, given that, during the data collection period, the grants management 
offices throughout HRSA were being consolidated, and it was, therefore, difficult to draw 
conclusions about their role.  The focus on the project officers role in monitoring the 
programmatic performance also complements the financial audits being concurrently conducted 
within OIG. 
This report is a companion report to The Ryan White CARE Act Title I and Title II 
Grantees Monitoring of Subgrantees, OEI-02-01-00641, which focuses on how Title I and 
Title II grantees monitor subgrantees. We organized the reports in this way, as opposed to by 
Title, to better respond to the Senate Finance Committees two-part request, and because the 
overall findings apply to both Title I and Title II. 
The CARE Act 
The CARE Act (Pub. L. 101-381) was passed in 1990, and reauthorized in 1996 (as Pub. L. 
104-146) and in 2000 (as Pub. L. 106-345).  The legislation provides funding to States 
1 
HRSA Monitoring of CARE Act Grantees  OEI-02-01-00640  and other public and nonprofit entities to develop, organize, coordinate, and operate effective 
and cost-efficient health care and support services to medically underserved individuals and 
families affected by HIV/AIDS. The CARE Act distributes resources to various entities under 
four Titles and Part F. Title I and Title II are the largest programs and are the focus of this 
inspection. 
Title I 
Title I provides emergency relief grants to eligible metropolitan areas disproportionately 
affected by the HIV/AIDS epidemic.  The Title I grantee is the Mayor or chief elected official. 
This official typically designates administrative authority for the CARE Act to the city or county 
health department, which may also be called the grantee. The grantee designates a planning 
council that is responsible for prioritizing the allocation of funds and makes awards to 
subgrantees according to the planning councils decisions.  Subgrantees may include hospitals, 
community-based organizations, hospices, ambulatory care facilities, community health centers, 
migrant health centers, homeless health centers, and substance abuse treatment and mental 
health programs. 
Title I funding includes formula and supplemental components. Formula grants are awarded 
based on the estimated number of people living with AIDS in the eligible metropolitan area over 
the most recent 10-year period.  Supplemental grants are awarded competitively based on a 
demonstration of severe need and other criteria. In fiscal year 2001, 51 eligible metropolitan 
areas in 21 States, Puerto Rico, and the District of Columbia were awarded $604 million in 
formula and supplemental funds. 
Title II 
Title II provides grants to States, the District of Columbia, and the territories to improve the 
quality, availability, and organization of health care and support services for individuals and 
families with HIV/AIDS.  The grantee for Title II is the Governor, and the administrative agency 
is the State Department of Health, which may also be the grantee. States distribute Title II 
funds to subgrantees, which are typically public or nonprofit providers and community-based 
organizations. The grantee distributes funds either directly or through consortia that are 
responsible for prioritizing Title II funds in their area.  In fiscal year 2001, the States, the District 
of Columbia, and the territories were awarded $845 million in Title II grants. 
A portion of each States Title II funds must be used to establish an AIDS Drug Assistance 
Program (ADAP) to provide medications to low-income individuals with HIV/AIDS and their 
families. In fiscal year (FY) 2001, the ADAP portion of the Title II award totaled $571 million. 
2
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  Federal Oversight 
The HIV/AIDS Bureau in HRSA is responsible for implementing Title I and Title II. At the 
time that the inspection was conducted, these programs were managed differently. The 
Bureaus Division of Service Systems was responsible for monitoring and oversight of Title I 
grantees and ADAP.  The Office of Field Operations, which included the 10 regional offices, 
was responsible for Title II grantees as well as other grants (see Figure 1 and Appendix A). 
Figure 1: Monitoring Responsibilities 
(Regional Responsibility Italicized) 
CARE Act Program 
Responsibility  Title I  Title II  Title II ADAP 
Program  Division of  Office of Field  Division of Service 
Monitoring  Service Systems - Operations - Systems -
Project Officer  Project Officer  Representative 
Fiscal  Division of Service Systems - Grants Management Officer 
Monitoring 
In January 2003, HRSA announced that the Bureaus Division of Service Systems would be 
responsible for both Title I and Title II. The Office of Field Operations, which had 
responsibility for Title II grantees, became the Office of Performance Review, and now serves 
as the focal point for reviewing and enhancing performance of HRSA-supported programs. 
Project Officer Monitoring Role 
The monitoring role of the project officer is described in the HIV/AIDS Bureau position 
description, and Monitoring Grants and Cooperative Agreements for Federal Personnel, 
the training manual used by Federal grants personnel (hereinafter referred to as the Grants 
Training Manual). According to Chapter 1.1 of the Grants Training Manual: 
[M]onitoring is the process by which the programmatic and business 
management performance of a grant is continuously reviewed by the program 
official and the grants official. Monitoring methods include: 
(1) conducting telephone checkups; (2) reviewing requests for prior approval; 
(3) reviewing audits, financial status reports, progress reports, 
3
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  and other written documents; and (4) conducting site visits. 
The Grants Training Manual also states that whereas the grants management officer has primary 
responsibility for ensuring grantees submission of all required reports and for monitoring the 
financial aspects of the grant, the project officer has primary responsibility for monitoring the 
grantees programmatic performance. Project officers review progress reports to ensure they 
contain minimum requirements, and are also expected to review the financial information in 
financial reports and relate it to the programmatic information in progress reports.  The Grants 
Training Manual adds that the basic purpose of monitoring is to evaluate whether or not the 
recipient is carrying out the project in accordance with the Notice of Grant Award, and that 
grant and program officers monitor recipient performance and compliance against the elements 
that make up the grant agreement. 
HRSA further specifies the duties and responsibilities of Title I and Title II project officers in the 
following position description. The activities outlined below are those that are critical to 
monitoring both Title I and Title II grantees. Specifically, the project officer: 
1.  Serves as a project officer for up to 12 grants.  This includes the development of program 
guidance and notice of availability of funds, preparation of correspondence, alerting applicants 
of the application status, managing the grant objective review process, participating in the 
review of applications and providing telephone and on-site technical assistance to grantees, 
and conducting on-site program reviews. 
2. Provides a monitoring role to the grants assigned by being the focal contact point for all 
inquiries from the grantees.  Maintains contact and is looked to as the expert on program 
requirements and on the status of assigned projects. 
3. Monitors, evaluates, and provides general technical assistance to grantees, and 
coordinates and implements technical assistance to grantees. 
4. Schedules and conducts site visits to assess the fulfillment of the grantees responsibilities. 
Makes recommendations regarding problems and program modifications. Monitors progress 
in addressing identified issues or problems and makes recommendations for continued funding 
or action to be taken, as appropriate. 
OIG Oversight Framework 
As part of its focus on grants oversight, OIG has developed an oversight framework that 
establishes monitoring fundamentals for Federal grants (see Appendix B).  This framework is 
based on the Grants Administration Manual and the Grants Training Manual. The framework 
focuses on four areas: (1) requirements developed by the 
4
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  Operating Division that address program and financial progress; (2) reports generated by the 
grantee that are collected by the Operating Division; (3) review and verification of report 
information; and (4) enforcement authority used by the Operating Division to address identified 
issues.  We used this framework to assess HRSAs oversight of Title I and Title II grantees. 
METHODOLOGY and ANALYSIS 
To assess project officers monitoring of Title I and Title II grantees, we compared how they 
are monitoring these grantees to the duties as outlined in their position description, the Grants 
Training Manual, Federal requirements, and our oversight framework.  We present our findings 
for Title I and Title II together because project officers from both Titles are expected to monitor 
their grantees in a similar fashion and because the general findings apply to both Titles.  We 
highlight differences between Title I and Title II when appropriate.  Note that for the purposes 
of this report, we use the term subgrantees to refer to all sub-awardees of a grantee. 
We collected information about how project officers monitor grantees from several data 
sources: (1) a review of documents from 20 grantees, (2) interviews with the 17 project officers 
who are responsible for these grantees, (3) interviews with the 20 grantees, and (4) interviews 
with HRSA program officials. 
Selection of Grantees 
This inspection is based on 10 of the 51 Title I grantees and 10 of the 54 Title II grantees. We 
selected these grantees based on several factors. Specifically, we ranked each Title I and Title 
II grantee separately according to funding level and grant longevity. We then selected 5 
grantees that were in the upper 10, and 5 in the lower 10, for each factor and from each Title. 
Further, we aimed to select at least one grantee from each area where HRSA has a regional 
office. We also included an eligible metropolitan area and its corresponding State for half of the 
grantees, and we made an effort to minimize our overlap with the grantees that were selected 
by the Office of Audit Services. We did not select the grantees based on their performance. In 
total, the 20 selected grantees represent 38 percent of Title I funds and 41 percent of Title II 
funds. A list of the selected Title I and Title II grantees is provided on the next page. 
5
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640   Title I  Title II 
Los Angeles, CA
 California 
Atlanta, GA
 Georgia 
Minneapolis, MN
 Minnesota 
Philadelphia, PA
 Pennsylvania 
New York, NY
 New York 
Kansas City, MO
 Alabama 
West Palm Beach, FL
 Massachusetts 
Norfolk, VA
 New Mexico 
Seattle, WA
 South Carolina 
Las Vegas, NV
 Utah 
Document Review 
We reviewed key documents to assess the project officers monitoring of Title I and Title II 
grantees. To do this, we requested documentation from each of the project officers who are 
responsible for the 20 selected grantees. According to our framework, the Grants Training 
Manual, and the project officer position description, project officers should have access to key 
monitoring information and documents.  We did not request the documentation from the official 
grantee file that is maintained by the grants management office because the focus of this 
inspection is on the project officer as opposed to the grants officer. We reviewed the 
information that was provided by each of the project officers using a structured instrument. The 
documents we reviewed included grant applications, progress reports, fiscal reports, site visit 
reports, corrective action plans, and other documents used to monitor grantees.  We also 
reviewed the site visit protocols for Title I and Title II. 
Interviews 
In total, at the time the inspection was conducted, there were 12 Title I project officers and 30 
Title II project officers.1 We conducted interviews with the 17 project officers who were 
responsible for monitoring the 20 selected grantees. Eight of these project officers were from 
Title I, and nine were from Title II. These project officers were responsible for monitoring a 
total of 38 of all 51 Title I grantees and 21 of all 54 Title II grantees. In our interviews, we 
asked project officers how they monitor their grantees and how they identify and address 
grantee issues.  We conducted these interviews in April 2002. 
1
These numbers are based on the information provided by the HIV/AIDS Bureau as of November 2001. 
6
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640 We also interviewed the 20 selected Title I and Title II grantees.  We asked them about how 
HRSA monitors their grant activities in order to understand their perspective and to verify 
project officers responses.  We conducted these interviews between March and May 2002. 
Finally, we interviewed key program officials at the HIV/AIDS Bureau and at the former Office 
of Field Operations.  These interviews provided mostly background information about Title I 
and Title II and how the programs are administered. We conducted these interviews in 
December 2001. 
Limitations 
This inspection focuses on the role of the project officer in monitoring the programmatic 
activities of the grantee. It does not address the grants management officers role in monitoring 
the grantees fiscal performance.  One of the reasons that we limited the scope of the inspection 
is that the grants management office was being restructured at the time of the inspection. As of 
December 2002, HRSA consolidated the grants management office in the HIV/AIDS Bureau 
with the grants management offices in the other Bureaus. 
Standards 
We conducted this inspection in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
7
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  F I N D I N G S  
Title I and Title II project officers are not adequately monitoring the 
20 selected grantees 
Not all project officers have grantees progress reports or prepare grantee status 
reports 
We found that not all project officers have progress reports for the 20 selected grantees. 
According to 45 CFR  92.40 (1) and (2), grantees are required to prepare and submit 
progress reports (sometimes called technical or performance reports). Project officers are 
responsible for reviewing and maintaining these progress reports.  Based on our documentation 
review, we found that project officers had progress reports for 8 of the 10 Title I grantees but 
none of the 10 Title II grantees.  In addition, 5 of the 20 selected grantees were not sure 
whether their project officer routinely reviews their progress reports because they seldom 
receive feedback. 
Contrary to our document review findings, all 17 project officers say that they review every 
grantees progress report and that they rely on them to monitor grantees. They typically note 
that they check the reports to see whether they are consistent with the goals and objectives 
stated in the grantees application. Four believe, however, that the reports are not useful, do 
not provide a complete or current picture of what is happening, and are more for 
documentation purposes.  As one project officer notes, it is important to do it, but they write 
what they want you to see. 
In addition, as part of their monitoring role, HRSA expects both Title I and Title II project 
officers to prepare quarterly grantee status reports.  The grantee status report is important 
because it is where the project officer documents grantee progress in budgeting and meeting 
service goals. Based on our documentation review, we found that project officers had only 15 
status reports for the 20 grantees. 
Project officers report limited monitoring of grantees fiscal performance 
According to Chapters 1.1.2 and 3.2.3 of the Grants Training Manual, project officers are 
required to coordinate with the grants management specialists who are responsible for 
collecting and reviewing grantees fiscal reports.  Chapter 3.2.3 of the Grants Training Manual 
also specifies that project officers are required to monitor grantee goals and objectives, and 
also to analyze and explain cost overruns. However, we found that none of the project officers 
provided any documentation showing that they track the fiscal performance of the selected 
grantees. HRSA officials explain that fiscal monitoring is the 
8
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  role of the grants specialists and that project officers do not get involved, unless there is a 
problem or a grantee wants to carry over unspent grant funds into the next grant cycle. 
Several project officers report that they review the fiscal reports submitted by their grantees. 
Specifically, four mention that they review budgets and/or track overspending and 
underspending, and that this information gives them a complete picture of how the program is 
working. Five report that they typically do not get very involved in monitoring grantees fiscal 
performance, except when there is evidence of financial distress, or when the grantee has a 
carryover request. 
According to the Chapter 1.1.5 of the Grants Training Manual, the project officer is also 
responsible for working with the grants management specialist to make appropriate 
recommendations for actions that could either help the grantee overcome financial distress or 
protect the financial interests of the agency if overcoming the financial distress is not possible. 
Adverse audit findings may indicate that the grantee is in financial distress. None of the project 
officers mention that they had copies or did any review of audits submitted by the grantee.  Our 
discussions with the grants management specialists further revealed that they review a sample of 
audits and findings, but approximately 2 years after the grant is awarded.  Another official notes 
that no one in the Bureau reviews grantees audits. 
Not all project officers use the grantee application as a monitoring tool 
According to HRSA project officer duties outlined in the position description, one of the 
primary responsibilities of project officers is to review grantee applications.  The Grants 
Training Manual further states that the most important document against which compliance is 
measured (and, therefore, the most important monitoring benchmark) is the approved grant 
application. 
We found that all 17 project officers report that they review grantees annual applications. 
However, they report performing somewhat different types of reviews and not all use it to 
monitor their grantees.  Only five of the eight Title I project officers note that they use the 
application benchmarks to monitor grantees throughout the year. They note that it is an 
important tool to help identify the grantees strengths and weaknesses that they then follow up 
on during the year.  Title II project officers commonly report that they review the application 
only to see whether it is complete and meets the statutory requirements.  In contrast, none of 
the Title II project officers mentions that they use the application as a monitoring tool. As one 
Title II project officer points out, the application does not really say much, partly because the 
grantee can note that there is no change from their previous application. 
9
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  Title I and Title II project officers do not routinely conduct monitoring site visits 
and, therefore, do not verify information provided by grantees 
Project officer duties include scheduling and conducting site visits to monitor the grantees 
performance.  Although there is no written policy for site visits, HRSA expects project officers 
to conduct a formal site visit to each grantee every 18 months. Project officers had site visit 
reports for only 10 of the 20 selected grantees for the last 2 years. They conducted a total of 
15 site visits over 4 years for these 20 grantees (see Figure 1). Site visits are the best way that 
project officers verify the information that grantees submit about their programs.  Because site 
visits are not regularly conducted, project officers must rely on information that grantees self-
report that is not verified in any way. 
Figure 1

Number of Grantees that had Site Visit Reports (n=20)

1999  2000  2001  2002  Total 
Title I  1  3  0  2  6 
Title II  0  1  4  4  9 
Source: OEI Documentation Review, 2002 
Our review of the 15 site visit reports from Title I and Title II shows that none of these reports 
included a completed checklist that is part of HRSAs recommended site visit protocol. In 
order to understand what project officers do on-site, we asked them to describe their site visit 
activities. We found that project officers perform different types of reviews. Seven of the 17 
project officers note that they review the grantees contract and/or a sample of contracts.  Four 
review the grantees procedure manuals, grievance policies, and hiring practices. Seven of the 
17 mention reviewing fiscal information, including budgets and invoices, and other documents. 
Only one project officer describes conducting a review of administrative, fiscal, and data 
systems. 
We also found several differences between Title I and Title II project officers approaches to 
site visits. In general, Title I project officers review a greater number of documents and seem 
to focus on challenging grantees and asking them tough questions.  In contrast, Title II project 
officers see their role as a broker or resource who monitors by listening to concerns and 
making suggestions. Title II project officers are also more likely to focus on building 
relationships with the grantee. 
Six of the 17 project officers note that travel restrictions implemented within their division 
prevent them from conducting site visits according to the 18-month schedule. Six project 
officers further explain that site visits are not seen as a priority by HRSA 
10
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  officials. As one project officer notes, senior staff does not understand the need to get out 
face-to-face.  Project officers commonly emphasize the value of site visits, which are the only 
way to find out what the grantee is really doing with their grant money. Seven of the 17 
specifically mention the lack of site visits as a primary concern with HRSAs oversight of 
grantees.  They add that more site visits would be helpful and would improve the operation of 
their program. 
Title II project officers are not involved in the process of setting special conditions 
to address vulnerabilities 
A special condition is a unique requirement on the grant to address a vulnerability and is an 
important aspect of monitoring grantee performance, because it changes the requirements of the 
grant established by the notice of award. As part of the application process, project officers 
may recommend that the grants management office set a special condition on the grant award, 
which is lifted when the grantee meets the condition.  We found that not all project officers are 
involved in the process of setting special conditions of award. 
Seven of the eight Title I project officers report that they submit recommendations such as 
setting a special condition to the grants management office, which generally trusts our 
professional judgment and usually follows our lead. In contrast, only one of the nine Title II 
project officers report that they make recommendations to this office.  In fact, three Title II 
project officers suggest that they are not involved in the process or that their comments do not 
have any bearing on special conditions that are set.  Further, our documentation review shows 
that six of the eight Title I project officers had documentation about setting a condition of 
award, and none of the nine Title II project officers had such documentation. 
Project officers, however, do report having frequent contact with grantees 
A key responsibility of project officers is to maintain constant contact with grantees.  Both Title 
I and Title II project officers report having frequent contact with grantees, primarily through 
telephone calls and electronic mail.  Almost all project officers report discussing the grant with 
each of their grantees at least monthly, and often more frequently. Project officers also report 
that they have more frequent contact with grantees that have issues or problems.  Grantees 
generally confirm project officers responses.  Fifteen of the 20 selected grantees report 
discussing the grant with the project officer at least monthly. Five of the grantees say that their 
contact has been less frequent and more sporadic. 
Fourteen of the 17 project officers note that frequent communication is what they rely on to 
know whether a grantee is misusing funds. They explain the importance of talking to 
11
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  various people involved in the grant, following up on any complaints, and encouraging those 
involved to discuss any problems. 
Title I and Title II project officers do not focus on grantees monitoring of 
subgrantees 
Since there is no written standard governing project officer review of subgrantees, we asked 
the 17 project officers how they monitored subgrantee activity.  We found that only five project 
officers report that they routinely review documentation that subgrantees submit to the grantee. 
Project officers more commonly note that they review site visit reports, contracts, corrective 
action plans, and/or audits conducted by the grantee, but only when they go on-site or when 
there is a problem. Only two project officers specifically mention that they review the protocols 
that grantees use to monitor their subgrantees, and one mentions conducting a record review of 
a sample of case files. Additionally, 7 of the 20 selected grantees say that their project officer 
reviews any documentation about how they monitor their subgrantees. 
At the same time, 16 of the 17 project officers generally believe that grantees monitoring of 
subgrantees is at least somewhat effective.  Five of these project officers add that grantees are 
bound by State or city regulations and/or have good reporting and monitoring systems in place. 
However, four comment that oversight is mixed, and that grantees monitoring of subgrantees 
varies. 
Neither Title I nor Title II project officers can describe a standard corrective action 
process 
Corrective actions are the monitoring plans or technical assistance provisions created by the 
awarding agency in response to grantee vulnerabilities identified through monitoring. Our 
document review found that none of the project officers had corrective action plans for any of 
the 20 selected grantees. We did not determine whether there was a need for a corrective 
action to be put in place; however, we are aware that at least one grantee had issues that would 
warrant corrective actions.  In total, Title II project officers report that none of their 21 grantees 
that they currently monitor have corrective action plans, while Title I project officers report they 
have corrective action plans for a total of 5 of the 38 grantees that they currently monitor. 
Based on our discussions, neither Title I nor Title II project officers could describe a standard 
corrective action process. Seven of the nine Title II project officers were unable to describe a 
corrective action process at all. Title I and Title II project officers commonly report that they 
have not used a corrective action and do not have experience with the process. The Title I 
project officers were inconsistent in their descriptions and offered explanations, including 
technical assistance to formal letters with timelines for correcting potential vulnerabilities. 
12
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  HRSA provides limited support to project officers to systematically 
monitor grantees 
Little guidance is provided on how project officers should monitor 
The HIV/AIDS Bureau provides little guidance to project officers about how to specifically 
monitor Title I and Title II grantees. We found that, beyond the HIV/AIDS Bureau project 
officer position description and the site visit protocol discussed below, there are no specific 
guidelines for how project officers should monitor. Further, project officers have differing ideas 
about their role, particularly regarding the monitoring of fiscal information and the monitoring of 
subgrantees. As a result, project officers monitor grantees differently, depending upon their 
skills, competency, expertise, and commitment. 
Specifically, 4 of the 17 project officers note that more standardization and guidance would be 
helpful. They state that setting standards and more explicit guidelines would allow monitoring to 
be applied more consistently. One of the four project officers suggests that guidelines would be 
particularly useful if they describe how grantees should monitor subgrantees and how project 
officers should monitor grantees fiscal performance. 
Further, we found that the site visit protocol for Titles I and II, which provides some guidance 
regarding how project officers should conduct site visits, could be more specific. The protocols 
have a list of questions to indicate whether there is evidence that the grantee has certain internal 
controls in place. For example, it confirms whether the grantee has defined program and fiscal 
administrative responsibilities, and whether the grantee has provided an organization chart.  The 
protocols do not provide guidance on which documents to review on-site or how to assess how 
the grantee is actually implementing its policies and procedures.  Seven of the 17 project 
officers suggest that the site visit standards and protocols should be revisited, to perhaps make 
them more prescriptive and better tools for project officers to uncover underlying grantee 
issues. 
No ongoing training is offered for project officers 
Project officers do not receive ongoing training on how to monitor their grantees. Six project 
officers comment that HRSA could provide more training to make monitoring more effective. 
One notes that project officers are mostly self-taught, and that they are not given guidance. 
Another project officer suggests that they could use training about how to ask questions that 
better investigate what grantees are doing and to identify potential problems.  Three project 
officers comment that promoting more exchange of information between project officers would 
be valuable. 
13
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  HRSA officials also recognize the need to enhance training. As one official notes, project 
officer training needs to be updated and focused on core issues as well as program specific 
issues.  The official further notes the need to standardize and make the information that project 
officers provide to grantees consistent, so that they will represent the agency with a single voice. 
Another official reports that project officer training needs to be improved, specifically focusing 
on closer contract monitoring and attention to detail. 
HRSA has initiated few corrective actions 
Interviews with HRSA officials indicate that the HIV/AIDS Bureau does not frequently initiate 
corrective actions (other than providing technical assistance) for grantees that fail to meet 
requirements. HRSA officials on only two occasions have sent a letter to the chief elected 
official of the grant addressing their non-compliance. In addition, for only two grantees have 
they ever restricted the drawdown of the grant funds. 
Interviews with project officers provide additional evidence that the Bureau is reluctant to take 
action against grantees when there is a problem.  Seven of the 17 project officers express this 
concern. As one project officer comments, the Bureau sees its role as collaborative and does 
not believe it has any authority to enforce compliance with grant requirements.  Another project 
officer notes that we receive little support when we find something wrong.  One grantee 
further notes that there is little follow up and no real consequences if a grantee is doing 
something wrong. 
Little continuity exists among project officers 
Six of the 20 grantees note that there is a high turnover rate among project officers, and that 
turnover hinders monitoring. One grantee explains that it has had five project officers in the 
past 4 years, while another mentions going a number of months without a project officer. A 
third adds that they do not know their current project officer.  Grantees commonly note that 
continuity is important to understanding the complexities of the grant and is key to effective 
monitoring. Additionally, two HRSA officials note that the turnover rate is particularly high for 
Title II project officers, making monitoring difficult. 
Little continuity also exists between Title I project officers and the grantees they monitor. We 
found that these project officers are rotated among grantees every 2 years, making it unlikely 
that they ever conduct two monitoring site visits of the same grantee. Three project officers 
from both Titles suggest that more contact with the prior project officer of the grant would help 
compensate for the lack of continuity. 
14
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  Coordination between Title I and Title II project officers is limited 
Prior to December 2002, Title I and Title II were managed differently, which made 
coordination between project officers difficult. Title I project officers were located in a central 
office and were typically responsible for only Title I grantees.  They generally monitored 
between 4 and 5 grantees and reported that they spend almost 100 percent of their time on 
Title I grantees. In contrast, Title II project officers were located in the regions and were 
responsible for a number of other programs, including Health Centers, National Health Service 
Corps, State Primary Care, Maternal and Child Health Block Grants, and Community Access 
Programs. Title II project officers typically managed between 1 and 6 Title II grantees and 
reported that they spend between 5 and 20 percent of their time on Title II grantees. 
Twelve of the 17 project officers confirm that they do not coordinate their monitoring activities 
in any way with the project officers from the other Title. Although the two Titles often fund the 
same subgrantees and have overlapping geographic areas, there is little communication between 
project officers. As one project officer comments, the two programs are very disconnected 
and there are turf issues.  A HRSA official notes that coordination between headquarters and 
Title I and Title II and ADAP does not happen very often and needs attention. 
15
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  R E C O M M E N D A T I O N S  
The findings are based on documents from 10 Title I and 10 Title II grantees and interviews 
with project officers who are responsible for 38 of the 51 Title I grants and 21 of the 54 Title II 
grants. These findings indicate that HRSA needs to strengthen its oversight of Title I and Title 
II grantees.  We are aware that since this inspection was conducted, HRSA has consolidated 
its grants management offices, relocated most Title II monitoring responsibilities from regional 
offices to headquarters, and redefined the Office of Field Operations as the Office of 
Performance Review. These changes may better position the agency to address the following 
recommendations. Specifically, we recommend that HRSA: 
	 Specify and enforce standards and guidelines for how project officers should monitor 
grantees 
  Address ongoing training for project officers 
  Standardize a corrective action process and address grantee issues more formally 
  Increase frequency and comprehensiveness of site visits 
  Improve project officer continuity 
  Improve coordination between Title I and Title II oversight staff 
Agency Comments 
We received comments on our draft report from HRSA. The full text of these comments can 
be found in Attachment C. HRSA concurs with our recommendations, and adds that significant 
administrative changes have occurred since this inspection was conducted. These changes may 
better position the agency to address the grantee monitoring activities discussed in this report. 
HRSA also describes several concerns with this report. In general, HRSA is concerned that 
the report does not distinguish between HRSA and the HIV/AIDS Bureau, the agency directly 
responsible for administering the Ryan White CARE Act.  At the time data were collected, Title 
I grantees were monitored from the HIV/AIDS Bureau in the Rockville headquarters office, 
while Title II grantees were monitored from the Office of Field Operations in regional offices 
and outside of the HIV/AIDS Bureau.  Instances where we address HRSA are meant to 
include both the HIV/AIDS Bureau and the Office of Field Operations. Additionally, HRSA is 
concerned that the report does not distinguish 
16
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  between Title I and Title II project officers.  We do make distinctions in the report between the 
two, however, where differences were apparent in the data analysis. 
Finally, HRSA is concerned that our report does not address the role of the Grants 
Management Officer in monitoring CARE Act grants, adding that administrative restructuring of 
the Grants Management Office occurred in October 2003.  We note in the report that the 
scope of our inspection is limited to the role of the project officer, and agree that the Grants 
Management Officer perspective would provide a more complete evaluation.  However, during 
an interview conducted as part of the study design we were told that the office would be 
consolidated in June 2002.  This interview was conducted in December 2001, and the decision 
to limit the scope of the inspection was made at that time. 
17
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  Appendix A 
HRSA/HAB ORGANIZATIONAL STRUCTURE

Administrator 
Bureau of  HIV/AIDS 
Bureau of  Maternal and Child 
Primary Health  Bureau 
Health  Health Bureau 
Care 
Division of Community Based 
Programs 
HRSA STAFF OFFICES 
Office of Communications 
Office of Policy and Program 
Office of Equal Opportunity and Civil Rights 
Development 
Office of Management and Program Support 
Office of Legislation 
Office of Planning and Evaluation 
Division of Service 
Office of Information Technology 
Systems 
Office of Performance Review* 
Office of Minority Health 
Officer of Rural Health Policy  Office for the Advancement 
Office of Special Programs  of Telehealth 
Office of Financial Policy and Oversight 
Office of International Health Affairs 
Office of Program Support 
*formerly Office of Field Operations 
Office of Science and 
Epidemiology 
Division of Training and 
Technical Assistance 
18
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  Appendix B 
OIG Grants Oversight Framework 
Requirements 
	 What performance and financial requirements has the Operating Division developed for 
the grantee? 
  Do grantees receive the performance and financial requirements? 
  Do grantees fully understand the performance and financial requirements? 
Reports 
  Are performance and financial reports received in a timely manner? 
  Are performance and financial reports clearly presented and complete? 
  Are audits completed in a timely fashion? 
	 Is the Operating Division sharing reports, as appropriate, with the Department and 
Office of Audit Services? 
Reviews 
	 Has the Operating Division designated responsibilities for the grants management and 
program officers? 
  Are performance and financial reports reviewed in a timely fashion? 
  Are there criteria for evaluating performance and financial reports? 
  How is information in performance and financial reports verified? 
  Are site visits conducted on schedule, with standard guidelines? 
  What other contact/communication is there between grantee and Operating Division? 
Enforcement 
  What enforcement authority does the Operating Division have? 
  Are there standards for addressing identified problems? 
  What actions has the Operating Division taken to address problems with grantees? 
19
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  Appendix C 
Agency Comments 
In this appendix, we present the full text of comments from the Health Resources and Services 
Administration (HRSA). 
20
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  21
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  22
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  HRSA Monitoring of CARE Act Grantees  HRSA Monitoring of CARE Act Grantees  25
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  26
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  27
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  28
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  29
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  30
HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640  A C K N O W L E D G M E N T S  
This report was prepared under the direction of John I. Molnar, Regional Inspector General for 
Evaluation and Inspections in New York, and Jodi D. Nudelman, Assistant Regional Inspector 
General. Other principal Office of Evaluation and Inspections staff who contributed include: 
Vincent Greiber, Project Leader  Alan Levine, Program Specialist 
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HRSA Monitoring of CARE Act Grantees   OEI-02-01-00640