Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

INSPECTOR GENERAL 

MARCH 2004 

OEI-02-01-00640 

Monitoring of Ryan White CARE Act Title I 

and Title II Grantees 
OFFICE OF INSPECTOR GENERAL


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 OIG’s 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. 
EXECUTIVE SUMMARY 

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 Administration’s (HRSA’s) 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. 

HRSA Monitoring of CARE Act Grantees i 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. 

HRSA Monitoring of CARE Act Grantees ii 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 

HRSA Monitoring of CARE Act Grantees iii 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. 

HRSA Monitoring of CARE Act Grantees iv OEI-02-01-00640 
TABLE OF CONTENTS 

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

HRSA Monitoring of CARE Act Grantees v OEI-02-01-00640 
INTRODUCTION 

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 Administration’s (HRSA’s) 

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 officer’s 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 Committee’s 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 

HRSA Monitoring of CARE Act Grantees 1 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 council’s 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 State’s 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. 

HRSA Monitoring of CARE Act Grantees 2 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 

Bureau’s 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 

Monitoring 

Division of 

Service Systems -

Project Officer 

Office of Field 

Operations -

Project Officer 

Division of Service 

Systems -

Representative 

Fiscal 

Monitoring 

Division of Service Systems - Grants Management Officer 

In January 2003, HRSA announced that the Bureau’s 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, 

HRSA Monitoring of CARE Act Grantees 3 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 

HRSA Monitoring of CARE Act Grantees 4 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 HRSA’s 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. 

HRSA Monitoring of CARE Act Grantees 5 OEI-02-01-00640 
 Title I 

Los Angeles, CA

Atlanta, GA

Minneapolis, MN

Philadelphia, PA

New York, NY

Kansas City, MO

West Palm Beach, FL

Norfolk, VA

Seattle, WA

Las Vegas, NV

Document Review 

Title II 

California 

Georgia 

Minnesota 

Pennsylvania 

New York 

Alabama 

Massachusetts 

New Mexico 

South Carolina 

Utah 

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. 

HRSA Monitoring of CARE Act Grantees 6 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 President’s Council on Integrity and Efficiency. 

HRSA Monitoring of CARE Act Grantees 7 OEI-02-01-00640 
FINDINGS 

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 

grantee’s 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 grantee’s 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 

HRSA Monitoring of CARE Act Grantees 8 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 grantee’s 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. 

HRSA Monitoring of CARE Act Grantees 9 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 selfreport 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 HRSA’s 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 grantee’s contract and/or a sample of contracts. Four 

review the grantee’s 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 

HRSA Monitoring of CARE Act Grantees 10 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 HRSA’s 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 

HRSA Monitoring of CARE Act Grantees 11 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. 

HRSA Monitoring of CARE Act Grantees 12 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. 

HRSA Monitoring of CARE Act Grantees 13 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. 

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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. 

HRSA Monitoring of CARE Act Grantees 15 OEI-02-01-00640 
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 

• 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 

HRSA Monitoring of CARE Act Grantees 16 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. 

HRSA Monitoring of CARE Act Grantees 17 OEI-02-01-00640 
Appendix A 

HRSA/HAB ORGANIZATIONAL STRUCTURE

HRSA STAFF OFFICES 

Office of Communications 

Office of Equal Opportunity and Civil Rights 

Office of Management and Program Support 

Office of Legislation 

Office of Planning and Evaluation 

Office of Information Technology 

Office of Performance Review* 

Office of Minority Health 

Officer of Rural Health Policy 

Office of Special Programs 

Office of Financial Policy and Oversight 

Office of International Health Affairs 

*formerly Office of Field Operations 

Bureau of 

Primary Health 

Care 

Bureau of 

Health 

HIV/AIDS 

Bureau 

Maternal and Child 

Health Bureau 

Office of Program Support 

Office of Policy and Program 

Development 

Division of Community Based 

Programs 

Office for the Advancement 

of Telehealth 

Administrator 

Division of Service 

Systems 

Office of Science and 

Epidemiology 

Division of Training and 

Technical Assistance 

HRSA Monitoring of CARE Act Grantees 18 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? 

HRSA Monitoring of CARE Act Grantees 19 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). 

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ACKNOWLEDGMENTS 

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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