HEALTH 

RESOURCES AND 

SERVICES 

ADMINISTRATION

Action Taken to Train 

and Oversee Grantee 

Monitoring Staff, but 

Certain Guidance 

Could Be Improved

Report to Congressional Requesters

September 2014

GAO-14-800

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-800, a report to 

congressional requesters

September 2014

HEALTH RESOURCES AND SERVICES 

ADMINISTRATION 

Action Taken to Train and Oversee Grantee 

Monitoring Staff, but Certain Guidance Could Be 

Improved

Why GAO Did This Study

In fiscal year 2013, HRSA awarded 

over $6 billion in grants, which 

accounted for over 80 percent of the 

agency’s appropriations. HRSA’s 

workforce—its staff and contractors— 

is responsible for monitoring the 

agency’s grantees to ensure they are 

financially sound, using federal funds 

appropriately, and in compliance with 

program requirements. In recent years, 

GAO has reported on weaknesses in 

HRSA’s monitoring of certain grant 

programs and made recommendations 

for the agency to improve grantee 

monitoring.

GAO was asked to review HRSA’s 

oversight mechanisms for its grantee 

monitoring workforce. This report 

examines (1) the extent to which 

HRSA has developed guidance for 

staff who monitor grantees; (2) the 

extent to which it implemented training 

for this staff; (3) HRSA’s oversight of 

its staff; and (4) its practices to ensure 

contractors who conduct grantee 

monitoring activities are qualified and 

carry out their work as appropriate. 

GAO reviewed HRSA training 

documentation and guidance related to 

grantee monitoring and interviewed 

HRSA officials. GAO also reviewed the 

contracts that HRSA identified as 

including grantee monitoring activities 

in fiscal year 2013.

What GAO Recommends

GAO recommends that HRSA develop 

a process to ensure that the guidance 

developed by its bureaus addresses all 

of the key components of grantee 

monitoring as established by the 

agency. HHS agreed with GAO’s 

recommendation and said HRSA has 

begun to take action to implement it. 

What GAO Found

In 2012, the Department of Health and Human Services’ (HHS) Health 

Resources and Services Administration (HRSA) began systematically developing 

guidance for the key staff involved in grantee monitoring—project officers in its 

programmatic bureaus and grants management specialists and financial integrity 

staff in its Office of Federal Assistance Management (OFAM). Specifically, HRSA 

issued the first agency-wide guidance written primarily for project officers in 

November 2012 and is in the process of developing new guidance and revising 

existing guidance for staff in OFAM. Additionally, HRSA required each of the 

bureaus to develop more detailed guidance for project officers by the end of 

2012. To assist the bureaus in systematically developing this guidance, HRSA 

provided a template outlining the minimum components to be included in the 

documents. While all of HRSA’s bureaus developed guidance for their project 

officers, GAO found that the bureaus’ guidance did not address all of the key 

components of grantee monitoring identified by HRSA, such as components 

related to conducting site visits. Although HRSA conducted reviews of the 

bureaus’ guidance, these reviews were not sufficient to ensure that the guidance 

addressed all required grantee monitoring components. Consequently, there is 

an increased possibility that project officers will not conduct, or document, all the 

monitoring activities required by HRSA, which puts the agency at risk for 

incomplete or insufficient grantee monitoring.

Since 2013, HRSA has implemented agency-wide training programs for key staff 

responsible for conducting monitoring of grantees—a project officer certification 

program, which the majority of project officers have completed, and a career 

development program for grants management specialists. Both programs include 

courses that cover material related to grantee monitoring. In addition to these 

training programs, the bureaus and OFAM offer formal and informal training 

related to grantee monitoring, such as training on specific grant program 

requirements.

HRSA has four main methods for overseeing its staff’s monitoring of grantees. 

According to HRSA officials, supervisors

• review information in, and reports from, HRSA’s online system for 

documenting grantee monitoring activities, such as staff’s assessments of 

grantee compliance;

• participate in staff interactions with grantees, such as monitoring calls;

• regularly communicate with staff in one-on-one and other meetings; and

• conduct annual performance appraisals to hold staff accountable for their 

monitoring responsibilities.

Additionally, HRSA has mechanisms in place to ensure that the contractors that 

conduct grantee monitoring activities are qualified, including reviewing staffing 

proposals prior to awarding the contract, requiring contractor staff to have 

specific qualifications, and requiring training for contractor staff. To oversee 

contractors’ work, HRSA staff regularly communicate with the contractors, review 

their deliverables, and obtain feedback from project officers and grantees on 

contractor performance.

View GAO-14-800. For more information, 

contact Debra A. Draper at (202) 512-7114 or 

draperd@gao.gov.
Page i GAO-14-800 HRSA Grantee Monitoring Workforce

Letter 1 

Background 5

HRSA Has Developed Guidance for Staff on Grantee Monitoring, 

but Bureau-Level Guidance Did Not Address All of the Key 

Components of Monitoring 7

HRSA Implemented Agency-Wide Training Programs for Grantee 

Monitoring Staff Beginning in 2013; Bureau-Level Training 

Varied 14

HRSA Has Four Main Methods for Overseeing Its Staff’s 

Monitoring of Grantees 17

HRSA Has Several Mechanisms in Place Designed to Ensure 

Contractors That Monitor Grantees Are Qualified and to 

Oversee Their Work 21

Conclusions 24

Recommendation for Executive Action 24

Agency Comments 24

Appendix I Health Resources and Services Administration Contracts with 

Grantee Monitoring Activities, Fiscal Year 2013 27

Appendix II Comments from the Department of Health and Human Services 29

Appendix III GAO Contact and Staff Acknowledgments 31

Table

Table 1: Examples of Performance Elements for Key Health 

Resources and Services Administration (HRSA) Staff with 

Grantee Monitoring Responsibilities 20

Figure

Figure 1: Extent to Which Bureaus’ Standard Operating 

Procedures (SOP) Addressed Components of Grantee 

Monitoring Specified by the Health Resources and 

Services Administration (HRSA) 12

Contents
Page ii GAO-14-800 HRSA Grantee Monitoring Workforce

Abbreviations

COR contracting officer’s representative

EHB Electronic Handbooks

HHS Department of Health and Human Services

HIV/AIDS human immunodeficiency virus and acquired 

 immunodeficiency syndrome

HRSA Health Resources and Services Administration

OFAM Office of Federal Assistance Management

SOP standard operating procedures

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page 1 GAO-14-800 HRSA Grantee Monitoring Workforce

441 G St. N.W.

Washington, DC 20548

September 23, 2014

Congressional Requesters

The Health Resources and Services Administration (HRSA), an agency

within the Department of Health and Human Services (HHS), is charged 

with improving access to health care services for people who are 

uninsured, isolated, or medically vulnerable and enhancing the capacity 

of the health care workforce. To carry out its mission, HRSA provides 

funding and support for a wide variety of programs, most commonly 

through grants. In fiscal year 2013, HRSA awarded over $6 billion in 

grants, which accounted for over 80 percent of the agency’s 

appropriations. Through these grants, HRSA provided financial support to 

more than 3,000 recipients, including organizations in every state. These 

grantees serve millions of people each year through programs that 

provide health care to uninsured individuals; people with human 

immunodeficiency virus and acquired immunodeficiency syndrome 

(HIV/AIDS); pregnant women, mothers, and children; people living in rural 

communities; and others.

To manage its grant programs, HRSA employs project officers in its 

programmatic bureaus and staff in its Office of Federal Assistance 

Management (OFAM).1 These staff are supplemented by contractors that 

perform a variety of tasks to support HRSA’s programs and operations.2

 

1

At the time of our review, HRSA had seven programmatic bureaus—the Bureau of 

Clinician Recruitment and Service, Bureau of Health Professions, Bureau of Primary 

Health Care, Healthcare Systems Bureau, HIV/AIDS Bureau, Maternal and Child Health 

Bureau, and the Office of Rural Health Policy—that each manage a portfolio of activities, 

including awarding grants, dealing with a specific area of health care services, systems, or 

workforce. In May 2014, HRSA combined the Bureau of Health Professions and the 

Bureau of Clinician Recruitment and Service into a single bureau called the Bureau of 

Health Workforce. Throughout this report, we use the term “bureaus” to refer to the seven 

organizational components that existed at the time of our review; HRSA considers the 

Office of Rural Health Policy to be similar in function and organizational structure to the 

units with “bureau” in their titles. OFAM serves as a central office for administration and 

management of the agency’s grants and works in partnership with the programmatic 

bureaus.

HRSA’s workforce—its staff and contractors—is responsible for 

2

For more information on HRSA’s staffing and its use of contractors, see GAO, Health 

Resources and Services Administration: Review of Internal Communication Mechanisms, 

Staffing, and Use of Contracts, GAO-14-52 (Washington, D.C.: Dec. 3, 2013).
 

Page 2 GAO-14-800 HRSA Grantee Monitoring Workforce

monitoring grantees. Specifically, they are responsible for collecting and 

assessing information from reports, audits, site visits, and other sources 

to ensure that grantees are in compliance with the terms of their grants. 

The effective monitoring of grantees is critical to ensure that they are 

financially sound, in compliance with programmatic and administrative 

requirements, and appropriately utilizing federal funds. In addition, 

monitoring is essential to ensure that grantees receive the support and 

assistance they need so that funding is used as effectively as possible for 

the populations HRSA serves. However, in 2012 we reported on 

weaknesses in HRSA’s monitoring of certain grant programs. Specifically, 

we reported that HRSA did not consistently follow HHS regulations and 

guidance in its monitoring of grantees under the Ryan White 

Comprehensive AIDS Resources Emergency Act of 1990, as amended.3

We also reported that HRSA’s monitoring of its Health Center Program 

grantees was insufficient to ensure that the agency consistently identified 

all instances of grantee noncompliance with program requirements.4

You asked us to review HRSA’s management and oversight mechanisms, 

including the systems HRSA has in place to train and oversee its 

workforce responsible for monitoring grantees. In this report, we examine 

(1) the extent to which HRSA has developed guidance for its staff 

responsible for monitoring grantees; (2) the extent to which HRSA has 

implemented training for its staff responsible for monitoring grantees; 

(3) HRSA’s oversight of its staff responsible for monitoring grantees; and 

(4) what practices, if any, HRSA has in place to ensure that the 

contractors conducting grantee monitoring activities are qualified and 

carry out their work as appropriate.

We 

recommended actions to improve HRSA’s monitoring of these grantees. 

HHS concurred with our recommendations, some of which have already 

been implemented by HRSA.

To examine the extent to which HRSA has developed guidance for its 

staff responsible for monitoring grantees, we reviewed guidance that 

HRSA developed related to monitoring grantees, including standard 

operating procedures (SOP) developed by HRSA’s programmatic 

 

3

See GAO, Ryan White CARE Act: Improvements Needed in Oversight of Grantees, 

GAO-12-610 (Washington, D.C.: June 11, 2012).

4

See GAO, Health Center Program: Improved Oversight Needed to Ensure Grantee 

Compliance with Requirements, GAO-12-546 (Washington, D.C.: May 29, 2012).
 

Page 3 GAO-14-800 HRSA Grantee Monitoring Workforce

bureaus and OFAM.5 We assessed HRSA’s guidance on grantee 

monitoring against federal internal control standards related to 

monitoring,6 as well as standards that HRSA established for the guidance 

developed by its bureaus. In addition, we conducted interviews with 

HRSA officials, including representatives from HRSA’s SOP workgroup—

assembled by HRSA to facilitate the bureaus’ development of guidance 

on monitoring grantees—and leadership of OFAM and each of the 

bureaus about guidance for staff on grantee monitoring at both the 

agency and bureau level. We also conducted interviews with groups of

four to six project officers and their supervisors from each of four selected 

bureaus—the Bureau of Health Professions,7 the Bureau of Primary 

Health Care, the HIV/AIDS Bureau, and the Maternal and Child Health 

Bureau—in order to gain their perspectives and experiences with HRSA’s 

guidance on grantee monitoring.8 The four selected bureaus had the 

largest number of project officers and active grants and the greatest 

amount of grant awards in fiscal year 2013.9

To examine the extent to which HRSA has implemented training for its 

staff responsible for monitoring grantees, we reviewed documentation of 

HRSA’s training, including training materials and announcements, and 

We selected project officers 

that varied in their level of HRSA experience (including new project 

officers hired after June 1, 2013) and the number of grants that they 

monitored.

 

5

We reviewed SOPs that were issued by the bureaus as of April 2014 and by OFAM as of 

July 2014.

6

See GAO, Standards for Internal Control in the Federal Government, 

GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999).

7

In May 2014, HRSA combined the Bureau of Health Professions with the Bureau of 

Clinician Recruitment and Service to create the Bureau of Health Workforce.

8

We conducted a total of nine group interviews—four with project officers based in 

HRSA’s headquarters, one with project officers who worked in locations other than 

HRSA’s headquarters, and four with supervisors.

9

In selecting these bureaus, we excluded project officers that exclusively monitored block 

grants, and also excluded information related to block grants from the numbers of active 

grants and grant awards. A block grant is a type of grant where funding recipients have 

substantial discretion over the type of activities to support, with minimal federal 

administrative requirements, restrictions, and monitoring. After these exclusions, the four 

selected bureaus, together, employed approximately 86 percent of HRSA’s project officers 

and oversaw 87 percent of HRSA grants, which accounted for nearly 98 percent of nonblock grant funding.
 

Page 4 GAO-14-800 HRSA Grantee Monitoring Workforce

HRSA’s mechanisms for tracking and evaluating training. We assessed 

HRSA’s training practices against leading federal practices for workforce 

training.10

To examine HRSA’s oversight of its staff responsible for monitoring 

grantees, we reviewed HRSA’s written policies and documentation 

related to oversight of staff, including sample performance appraisals and 

performance elements for staff with grantee monitoring responsibilities. 

We discussed methods used to oversee staff responsible for grantee 

monitoring during our interviews with HRSA, OFAM, and bureau 

leadership, as well as during our project officer and supervisor small 

group interviews.

In addition, we interviewed HRSA officials, including 

representatives from the HRSA Learning Institute—the training center 

HRSA established in 2010—and leadership from OFAM and each of the 

bureaus. We also used our small group interviews with project officers 

and their supervisors to gain their perspectives and experience with the 

training HRSA has implemented related to grantee monitoring.

To examine what practices, if any, HRSA has in place to ensure that the 

contractors conducting grantee monitoring activities are qualified and 

carry out their work as appropriate, we reviewed and analyzed the 13 

contracts HRSA identified as including grantee monitoring activities, such 

as grantee site visits and financial reviews, in fiscal year 2013.11

 

10See GAO, Human Capital: A Guide for Assessing Strategic Training and Development 

Efforts in the Federal Government, 

See 

appendix I for more information on each of the contracts we reviewed. We 

also discussed oversight of contractors during our interviews with HRSA 

and OFAM leadership, leaders from the Bureau of Primary Health Care 

and the HIV/AIDS Bureau—the two bureaus that used contractors to 

conduct grantee monitoring activities in fiscal year 2013—as well as our 

small group interviews with project officers and supervisors from these 

two bureaus. In addition, we interviewed representatives from the 

contractors with the two largest contracts (based on dollar amount of 

GAO-04-546G (Washington, D.C.: March 2004).

11In this report, we use the term “contracts” to refer to the collection of contracts, task 

orders, and blanket purchase agreements that HRSA used to obtain services from 

contractors who monitored grantees in fiscal year 2013.
 

Page 5 GAO-14-800 HRSA Grantee Monitoring Workforce

obligations), as well as the HRSA officials responsible for oversight of 

these contractors.12

We conducted this performance audit from July 2013 to September 2014 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

HRSA provides grants to a variety of entities using the HHS grant 

management process, which consists of seven phases. The first five 

phases of the grant management process cover the planning of the grant 

funding opportunity through the awarding of the grant funds.13 The sixth 

phase of the process, which occurs postaward, is the monitoring phase 

during which HRSA is to review grantees to identify potential problems 

and areas of noncompliance with programmatic and administrative 

requirements that must be addressed by the grantee. This monitoring 

continues for as long as HRSA retains a financial interest in the grantee’s 

activities and is followed by the seventh and final phase—closeout.14

Within HRSA, the grants management process, including grantee 

monitoring, is a coordinated effort of project officers located in the 

programmatic bureaus, and grants management specialists and financial 

integrity staff in OFAM.

 

12An obligation is a definite commitment that creates a legal liability for the payment of 

goods and services ordered or received. We considered both fiscal year 2012 and 2013 

obligations because work carried out in fiscal year 2013 may have been a result of funds 

obligated in fiscal year 2012. To determine the amount of obligations for each of the 13 

contracts we reviewed, we obtained data from the Federal Procurement Data SystemNext Generation, the primary government-wide contracting database, which provides 

information on government contracting actions and procurement trends.

13HRSA awards a grant through the issuance of a Notice of Award—which, among other 

things, sets forth the amount of funds granted, the terms and conditions of the award, and 

the effective date of the award.

14The closeout phase involves reviewing expiring grants to ensure that all requirements 

have been met; resolving any known business management issues, such as the proper 

disposition of property purchased with grant funds; and ensuring the grant file is complete.

Background
 

Page 6 GAO-14-800 HRSA Grantee Monitoring Workforce

• Project officers. The nearly 400 project officers within the bureaus 

have primary responsibility for the day-to-day monitoring of an 

assigned portfolio of grantees.15

• Grants management specialists. Located in OFAM’s Division of 

Grants Management Operations, grants management specialists are 

responsible for managing business and financial issues for a portfolio 

of grantees. For example, they review the Federal Financial Report, a 

required report to document the financial progress of a grant award, 

which includes information on the funds a grantee has received and 

how they were spent. Grants management specialists and project 

officers are expected to coordinate in monitoring grantees; for 

example, grants management specialists are responsible for 

approving or disapproving prior approval requests after the project 

officer’s initial review. As of June 2014, there were nearly 70 grants 

management specialists within OFAM.

Project officer monitoring activities 

include reviewing grantee reports on various topics to ensure 

performance requirements are met and to identify performance or 

financial problems; communicating with grantees regularly and 

documenting that communication; consulting with grantees on 

programmatic issues; and conducting and arranging for site visits. For 

example, project officers conduct the initial review of requests from 

grantees for prior approval of certain actions, such as carrying over 

unobligated funds to subsequent funding periods; review grantee 

progress and financial reports; and are generally expected to have at 

least quarterly contact with their grantees. They are expected to keep 

their supervisors and relevant OFAM staff informed regarding grantee 

performance and the need for any intervention.

• Financial integrity staff. Located in OFAM’s Division of Financial 

Integrity, financial integrity staff are responsible for the financial 

oversight and monitoring of grantees, which includes conducting or 

coordinating financial audits and reviews of grantees. For example, 

some financial integrity staff conduct program integrity analyses to 

ensure that financially at-risk grantees are identified for targeted 

intervention; others work with grantees to ensure the resolution of 

financial audit findings. As of June 2014, there were 34 financial 

integrity staff with grantee monitoring responsibilities. 

 

15The number of project officers is as of June 2014.
 

Page 7 GAO-14-800 HRSA Grantee Monitoring Workforce

HRSA supplements its staff with contractors that perform grantee 

monitoring activities such as conducting site visits to monitor compliance 

with grant requirements, or financial audits and reviews. Each contractor 

is overseen by a HRSA contracting officer’s representative (COR) who is 

generally located within the bureau or office that requested the grantee 

monitoring support, but works on behalf of the contracting officer. The 

COR is responsible for overseeing certain aspects of the contractor’s 

performance, including reviewing required reports and assessing 

timeliness of deliverables.

HRSA began systematically developing guidance for the key staff 

responsible for grantee monitoring in 2012. However, we found that 

guidance developed by the bureaus for project officers did not address all 

of the key components of grantee monitoring established by HRSA.

In 2012, HRSA began systematically developing guidance for project 

officers and staff in OFAM responsible for monitoring grantees. 

Specifically, HRSA issued the first agency-wide guidance written primarily 

for project officers in November 2012, and it required each of the bureaus 

to develop more detailed guidance for project officers by the end of 2012. 

In addition, HRSA is in the process of developing new guidance and 

revising existing guidance for grants management specialists and 

financial integrity staff in OFAM. Collectively, this guidance addresses the 

2007 HHS Awarding Agency Grants Administration Manual requirement 

for each agency to develop monitoring plans.16

 

16At the time of our review, HHS was in the process of revising and replacing this manual 

and other guidance related to grants with a new Grants Policy Administration Manual.

HRSA Has 

Developed Guidance 

for Staff on Grantee 

Monitoring, but 

Bureau-Level 

Guidance Did Not 

Address All of the Key 

Components of 

Monitoring

HRSA Began 

Systematically Developing 

Guidance in 2012 for the 

Key Staff Responsible for 

Grantee Monitoring
 

Page 8 GAO-14-800 HRSA Grantee Monitoring Workforce

Agency-wide guidance for project officers. HRSA issued its Grantee 

Oversight Manual in November 2012—the first agency-wide guidance 

developed primarily for project officers. This manual, updated in 2014, is 

intended to outline a common set of minimum requirements for monitoring 

grantees. It generally describes the roles and responsibilities of project 

officers and other staff responsible for conducting monitoring of grantees 

and builds on guidance that HRSA and HHS had previously developed. 

Prior to the issuance of the HRSA Grantee Oversight Manual, HRSA’s 

main source of guidance on monitoring of grantees was OFAM’s 2009 

Division of Grants Management Operations Operational and Procedures 

Manual; however, this manual was primarily written for grants 

management specialists in OFAM. Additionally, HRSA has periodically 

issued Grants Policy Operations Memoranda to provide guidance to staff 

on various topics, some of which are relevant to project officers’ 

monitoring of grantees, such as carrying forward unobligated funds to 

subsequent funding periods. Project officers also relied on the 

overarching HHS policies for guidance on monitoring of grantees, 

including the Awarding Agency Grants Administration Manual.

Bureau-specific guidance for project officers. In addition to developing 

the agency-wide guidance, HRSA required each of its bureaus to develop 

monitoring plans and document them in the form of SOPs. HRSA 

specified that these SOPs should supplement the Grantee Oversight 

Manual by including more detailed, program-specific monitoring 

requirements and be developed by the end of 2012. To assist the 

bureaus in systematically developing their SOPs, HRSA provided the 

bureaus with a template outlining the minimum components to be 

included in their documents and established a workgroup to facilitate 

implementation of the SOPs across the agency. At the time of our review, 

all of the bureaus had developed SOPs. Officials from four of the bureaus 

told us that, prior to the agency’s 2012 requirement to develop SOPs, 

they did not have any in place.

In addition to SOPs, HRSA officials described other sources of guidance 

developed by the bureaus, such as site visit guides, policy notices, 

frequently asked questions, checklists, and templates.17

 

17Several project officers we interviewed said that they also rely on legislation that 

establishes requirements for the programs they work on as a key source of guidance for 

monitoring grantees.

Project officers 

and supervisors we interviewed generally found the guidance on grantee 
 

Page 9 GAO-14-800 HRSA Grantee Monitoring Workforce

monitoring to be helpful, and one project officer who had been with HRSA 

for over 10 years stated that the level of guidance provided to project 

officers has significantly improved in recent years. However, a few project 

officers and supervisors we interviewed identified areas where they could 

use additional guidance, such as guidance on specific requirements for 

certain programs and additional guidance on the information that should 

be entered into HRSA’s Electronic Handbooks (EHB)—the agency’s 

online system for documenting grantee monitoring activities.

Guidance for OFAM staff. OFAM has also developed new guidance for 

grants management specialists and financial integrity staff. The agency is 

in the process of replacing the 2009 Division of Grants Management 

Operations Operational and Procedures Manual for grants management 

specialists with a series of SOPs. In addition to making necessary 

updates, HRSA officials said that this approach would allow them greater 

flexibility in revising and updating the written guidance in the future. As of 

July 2014, OFAM had developed 4 SOPs for grants management 

specialists related to grantee monitoring—such as “Reviewing Financial 

Reports”—and indicated plans to develop approximately 10 more. HRSA 

officials said that staff can still rely on the guidance provided by the 

Operational and Procedures Manual during the transition to SOPs. In 

addition to the guidance for grants management specialists, OFAM’s 

Division of Financial Integrity has 3 SOPs related to grantee monitoring 

for financial integrity staff—”Audit Resolution,” “Special Reviews,” and 

“EHB Financial Assessments”—all of which were developed or revised 

since 2013.

While HRSA’s bureaus have developed bureau-level guidance for project 

officers on monitoring of grantees, we found that the bureaus’ SOPs did 

not address all of the key components of grantee monitoring identified by 

HRSA. Federal internal control standards state that management is 

responsible for developing detailed policies to fit their agency’s 

operations.18

 

18

HRSA specified the detail that bureaus should include in 

their SOPs by providing a template outlining the key components of 

monitoring that should, at a minimum, be included. The key components 

of monitoring identified in the template fall into three main categories—

communication, reviewing grantee reports, and conducting site visits.

GAO/AIMD-00-21.3.1.

Bureau-Level Guidance 

Did Not Address All of the 

Key Components of 

Grantee Monitoring
 

Page 10 GAO-14-800 HRSA Grantee Monitoring Workforce

Across the 13 SOPs that were developed by the bureaus as of April 2014, 

we found that the SOPs most thoroughly addressed the components 

related to communication and least thoroughly addressed those related to 

conducting site visits.19 Specifically, 7 of the 13 SOPs fully addressed the 

six key components related to communication; each of the remaining 6 

SOPs did not fully address one communication component.20 The 

communication components that were not fully addressed by the SOPs 

were specifying the frequency and purpose of communication with 

grantees (3 SOPs), the process for communicating concerns or 

noncompliance (1 SOP), and coordinating with OFAM (2 SOPs). For 

reviewing grantee reports, 5 of the 13 SOPs fully addressed the five key 

components.21 Of the 8 remaining SOPs, the majority did not fully 

address at least two components and only one of these SOPs addressed 

the component on documentation of grantee compliance.22 Of the 10 

SOPs for which the site visit components were applicable, none fully 

addressed all nine key site visit components.23

 

19HRSA gave the bureaus flexibility in determining how to organize their SOPs. To the 

extent that the bureaus opted to divide their SOPs into multiple sections and document 

them separately, we looked at all of the sections as a single SOP. For example, if a 

bureau had multiple sections for the same grant program, we looked at them collectively 

as a whole. Likewise, if a bureau had one overarching section, as well as separate 

sections for four different grant programs, we considered the bureau to have four SOPs, 

each made up of the overarching section and the specific section for that program.

More than half of the 

20We considered a component fully addressed if a given SOP included all of the 

information specified in the template for that component, and partially addressed if a given 

SOP included some, but not all, of the specified information. For example, we considered 

the communication component on specifying the frequency and purpose of 

communication with grantees to be fully addressed if the SOP covered both the frequency 

and purpose of grantee communication, partially addressed if only one of these was

covered, and not addressed if neither were covered.

21One of the 5 SOPs fully addressed four of the key components related to reviewing 

grantee reports; the fifth component was not applicable. Specifically, the grantee requests 

for prior approvals component was not applicable because this SOP was specific to a 

program for which HRSA has not provided funding to grantees since 1997. Therefore, 

there are no grantee requests that would require prior approval.

22The template specifies that the SOPs need to address the processes for documenting 

grantee compliance, including a clear designation of compliance or noncompliance. The 7 

SOPs that did not address this component were not explicit that project officers need to do 

this.

23The site visit components were only applicable for 10 of the 13 SOPs because 3 SOPs 

were specific to programs that do not include site visits as part of their monitoring 

approach.
 

Page 11 GAO-14-800 HRSA Grantee Monitoring Workforce

SOPs did not fully address at least four of the nine site visit components, 

and 1 SOP did not address any of them. Additionally, one component in 

particular—requirements for tracking site visits—was not addressed by 

any of the SOPs.24

 

24The template specifies that the SOPs need to address the processes for inputting data 

for identification of, and tracking, site visits and site visit reports in a centralized location 

accessible to all relevant staff. While HRSA’s EHB may have the functionality that allows 

for this sort of tracking, none of the SOPs explicitly addressed it.

(See fig. 1 for information about the extent to which 

the SOPs addressed each of the key components of grantee monitoring 

by category.)
 

Page 12 GAO-14-800 HRSA Grantee Monitoring Workforce

Figure 1: Extent to Which Bureaus’ Standard Operating Procedures (SOP) Addressed Components of Grantee Monitoring 

Specified by the Health Resources and Services Administration (HRSA)
 

Page 13 GAO-14-800 HRSA Grantee Monitoring Workforce

Notes: We considered a component fully addressed if a given SOP included all of the information 

specified by HRSA for that component in its template for developing SOPs; partially addressed if a 

given SOP included some, but not all, of the information; and not addressed if the SOP did not 

include the information specified in the template.

a

The grantee requests for prior approvals component was only applicable for 12 of the 13 SOPs 

because 1 SOP was specific to a program for which HRSA has not provided funding to grantees 

since 1997. Therefore, there are no grantee requests that would require prior approval.

b

The site visit components were only applicable for 10 of the 13 SOPs because 3 SOPs were specific 

to programs that do not include site visits in their monitoring approach.

Members of HRSA’s SOP workgroup told us that they conducted an 

initial, high-level review of the bureaus’ SOPs to assess their consistency 

with the template, but the review was not formal or in-depth. Additionally, 

leaders from each of the bureaus reported having processes for internally 

developing and reviewing the SOPs, such as establishing internal 

workgroups, soliciting participation and feedback from project officers, 

reviewing the HRSA template, and conducting reviews at the bureauleadership level. However, neither the SOP workgroup’s review nor those 

done by the bureaus ensured that the SOPs addressed all required 

grantee monitoring components. Because the SOPs do not include the 

level of detail specified by HRSA in the template, there is an increased 

possibility that project officers will not conduct, or appropriately document, 

all of the required monitoring activities, which puts HRSA at greater risk 

for having incomplete or ineffective grantee monitoring.
 

Page 14 GAO-14-800 HRSA Grantee Monitoring Workforce

Since 2013, HRSA has implemented agency-wide training programs for 

key staff responsible for monitoring grantees, including a project officer 

certification program and a training program for grants management 

specialists.25 HRSA’s project officer certification program, launched in 

May 2013, includes a standard set of seven courses that were to be 

completed by all experienced project officers by April 30, 2014.26 Under 

the program, new project officers hired after June 1, 2013, are to 

complete 40 hours of self-study and in-person training within 6 months of 

being hired. HRSA reported that 86 percent of experienced project 

officers completed the certification program by the April 2014 deadline 

and that 90 percent of new project officers completed the program by 

June 2014.27

HRSA also initiated a new training program for grants management 

specialists in 2014. HRSA officials described this as a career 

development program with tracks at the entry, mid-career, or advancedcareer level; staff work with their supervisors to determine which track is 

most appropriate. Officials said that each level offers grants management 

courses with a focus on monitoring. For example, there are courses that 

cover grants management specialist responsibilities, coordinating with 

After the initial certification, all project officers are required 

to meet annual continuing education requirements. Both the new and 

experienced project officer training includes courses that cover material 

related to grantee monitoring. For example, these courses cover the 

goals of grantee monitoring, project officer responsibilities, sources of 

information, and helpful tips for effective monitoring of grantees. Project 

officers, supervisors, and bureau-leadership officials we interviewed said 

they were generally satisfied with the certification program, and that the 

level of training it provides is sufficient and helpful.

 

25For information on practices used by other federal agencies to train the workforce 

responsible for overseeing grants, see GAO, Grant Workforce: Agency Training Practices 

Should Inform Future Government-wide Efforts, GAO-13-591 (Washington, D.C.: June 28, 

2013).

26HRSA defined experienced project officers as those that were on board as of June 1, 

2013, and new project officers as those that were hired after that date.

27Many experienced project officers located outside of HRSA’s headquarters had difficulty 

completing the certification program by the deadline due to unanticipated issues in 

scheduling two vendor-offered courses for these staff. Officials reported that 95 percent of 

the experienced project officers in headquarters had completed the certification as of the 

April 2014 deadline.

HRSA Implemented 

Agency-Wide Training 

Programs for Grantee 

Monitoring Staff 

Beginning in 2013; 

Bureau-Level Training 

Varied
 

Page 15 GAO-14-800 HRSA Grantee Monitoring Workforce

project officers, and various types of reports that grants management 

specialists are responsible for reviewing.28

According to HRSA officials, these training programs were developed 

based on the competencies for project officers and grants management 

specialists, respectively.29 Additionally, HRSA officials told us that they 

track individuals’ completion of the training and plan to evaluate its 

effectiveness, which is consistent with federal leading practices for 

workforce training.30

 

28HRSA does not have a formal certification or career development program for its 

financial integrity staff. However, HRSA officials explained that there are specific 

credentials required of certain financial integrity staff. Specifically, to be hired for an 

accounting or auditor position, individuals must have at least 24 college accounting 

credits.

For example, HRSA officials told us that they run 

monthly reports for tracking project officer completion of the certification 

program and they provide these reports to the bureaus. Officials said that 

they also are tracking grants management specialists’ completion of 

training and working closely with OFAM to encourage staff participation 

and provide them with resources and information related to the training. 

HRSA plans to use a variety of mechanisms to evaluate the effectiveness

of the training programs and assess outstanding training needs. For 

example, staff have the opportunity to complete course evaluations and 

respond to periodic surveys on their training needs. HRSA also conducts 

annual reviews of all of the courses they offer, including the courses in 

the project officer and grants management specialist training programs, to 

evaluate their effectiveness and make any necessary changes. Officials 

explained that these reviews consist of a team of experts reviewing 

multiple sources of information, including staff evaluations of the courses 

and staff surveys on the extent to which they have applied what they 

learned. HRSA officials said that they had completed course evaluations 

for the project officer and grants management specialist training programs 

and would be using the results to plan training for 2015. In addition for the 

project officer certification program, HRSA plans to hold sessions in 

29Competencies describe measurable patterns of knowledge, skills, abilities, behaviors, 

and other characteristics that an individual needs to perform work roles or occupational 

functions successfully. Understood another way, competencies specify what the person 

needs to do the job successfully. See GAO-13-591. 

30Federal leading practices for workforce training identify four components of the training 

and development process and elements to look for in assessing agencies’ training efforts. 

These components include planning, design and development, implementation, and 

evaluation. See GAO-04-546G. 
 

Page 16 GAO-14-800 HRSA Grantee Monitoring Workforce

September 2014 for project officers to provide feedback and suggestions 

for improving the program. Officials noted that moving forward, the focus 

for project officer training will be on continuing education as all existing 

project officers should have a foundation of knowledge from completing 

the initial certification.

In addition to agency-wide training programs, the bureaus provided their 

own training—such as training on specific grant programs—to varying 

degrees. Three bureaus—the Bureau of Health Professions, the Bureau 

of Primary Health Care, and the HIV/AIDs Bureau—provided some formal 

training on grantee monitoring in 2013. These bureaus, which 

represented three of the four largest bureaus at HRSA in 2013, offered 

trainings ranging from a single course on grantee performance to a series 

of courses on specific grant program requirements and monitoring 

activities, such as financial monitoring and site visits. Officials from the 

HIV/AIDs Bureau said they had mechanisms in place for formally tracking 

and evaluating the training they offered. Leadership from three of the four 

bureaus that did not provide formal training related to grantee monitoring 

explained that their bureaus are relatively small. Thus, the officials 

indicated that their project officers benefit from frequent communication 

with their supervisors in lieu of formal training.31

Officials from all of the bureaus described various informal training 

mechanisms in place that help provide project officers with the knowledge 

and skills to conduct their work, including one-on-one meetings between 

project officers and their supervisors, mentoring programs, and having 

new project officers shadow more experienced project officers on site 

visits prior to conducting them. For example, the Bureau of Health 

Professions developed a tool for new project officers that specifies 

timelines for completing certain tasks that will prepare them for their role 

as project officers within the bureau, such as reviewing key bureau and 

HRSA guidance, shadowing a senior project officer and identifying a 

mentor, and reviewing bureau resources. In addition, supervisors we 

spoke with generally agreed that it is their responsibility to provide on-theLeadership from the 

remaining bureau that did not provide formal training said that because 

the bureau has many different programs with different requirements, it 

would not make sense to offer formal bureau-wide training.

 

31Leadership from one of these bureaus (the Office of Rural Health Policy) told us that 

they plan to begin offering formal training in the future.
 

Page 17 GAO-14-800 HRSA Grantee Monitoring Workforce

job training to project officers, particularly related to program-specific 

grant requirements. While project officers and supervisors we interviewed 

generally felt that the training provided by HRSA and the bureaus related 

to grantee monitoring was sufficient, a few identified areas where project 

officers could use more training; for example, training on financial 

monitoring, effectively conducting monitoring calls with a large number of 

grantees, and documenting monitoring activities in EHB. A few more 

experienced project officers told us that training on grantee monitoring 

has improved significantly in recent years.

Similar to the bureaus, OFAM officials described additional training for 

their staff related to monitoring grantees. For example, OFAM officials 

told us they have offered training related to the new SOPs for grants 

management specialists, such as sessions on federal financial reviews, 

and they plan to provide training on each of the additional SOPs as they 

are developed and rolled out to staff. Officials said that the expectation is 

that all staff participate in these trainings and that they are tracking staff 

completion. OFAM officials said they also provide training to financial 

integrity staff on changing requirements and relevant topics, such as 

consistent treatment of audit findings, on an as-needed basis.

HRSA has four main methods for overseeing project officers, grants 

management specialists, and financial integrity staff that are responsible 

for monitoring its grantees—supervisors reviewing information in, and 

reports from, EHB; participating in staff interactions with grantees; 

communicating regularly with staff; and conducting performance 

appraisals.

Reviewing information in, and reports from, EHB. HRSA officials and 

supervisors we interviewed identified reviewing information in, and reports 

from, EHB as one of the main methods for overseeing staff responsible 

for monitoring grantees; EHB is the agency’s online system for 

documenting grantee monitoring activities, as well as corresponding and 

exchanging documents with grantees. There are three main ways that 

supervisors use EHB for oversight purposes.

• Supervisors review certain documents or decisions made by staff 

about grantees for quality, accuracy, and completeness; the EHB 

system requires supervisory review and approval to occur before 

certain grant-related actions can be taken. Examples of items 

requiring supervisory review and approval in EHB include project 

officers’ assessments of grantee compliance, noncompliant grantees’ 

HRSA Has Four Main 

Methods for 

Overseeing Its Staff’s 

Monitoring of 

Grantees
 

Page 18 GAO-14-800 HRSA Grantee Monitoring Workforce

plans and time frames to address their noncompliance, and grantee 

prior approval requests, as well as certain financial assessments that 

are completed by financial integrity staff. Additionally, officials told us 

that there are multiple levels of required supervisory review and 

approval in EHB for certain monetary actions made by grants 

management specialists. In reviewing staff’s work, supervisors told us 

that they consider the documentation used to support staff’s 

recommendations. For example, when reviewing a project officer’s 

assessments of grantee compliance, a supervisor may review the 

reports submitted by the grantee, which also are to be documented in 

EHB. In doing so, the supervisor is able to determine if the EHB 

record includes the necessary documentation and if that 

documentation supports the project officer’s assessment, and then 

provide feedback to the project officer.

• Supervisors also spot-check staff’s day-to-day activities in EHB to 

oversee their work. For example, at any time a project officer’s 

supervisor can access a grantee’s EHB record to assess whether a 

project officer has communicated with the grantee at the required 

intervals and documented that communication. By reviewing the 

documentation of the communications, the supervisor can determine 

the information the project officer and grantee discussed. Supervisors 

can also see whether site visit reports have been entered or uploaded 

into EHB within the established time frames, and can review the audit 

reports completed by financial integrity staff, including reviewing the 

supporting materials from EHB.

• Supervisors also use EHB-generated reports to oversee staff. 

According to the HRSA officials we spoke with, supervisors generate 

EHB reports to review information, such as the number and types of 

tasks in a staff member’s queue, the timeliness of task completion, 

and whether anything is overdue.32

Participating in interactions with grantees. Supervisors provide 

oversight of staff by participating in some of their interactions with 

grantees. According to HRSA officials, supervisors may participate in 

 

32Additionally, OFAM and two bureaus have created snapshot reports in EHB called 

“dashboards,” which can be used for oversight purposes. For example, a dashboard can 

provide information on the status of certain types of assignments within an office or 

bureau, providing information on the total number of assignments that need review; how 

many have not been started or are in progress; and how many are on target to be 

completed on time.
 

Page 19 GAO-14-800 HRSA Grantee Monitoring Workforce

monitoring calls between project officers and grantees. Supervisors may 

also review project officers’ email or other written correspondence in 

advance of it being sent to grantees, or may be copied on email 

exchanges between project officers and grantees, so that they are 

cognizant of grantee interactions. In addition, supervisors may participate 

in grantee site visits with project officers. According to officials, 

participating in these interactions allows supervisors to observe how the 

staff interact with the grantees, how they handle any problems that come 

up, and the customer service staff provide. If they identify any problems 

or concerns with these interactions, supervisors told us they discuss it 

with their staff.

Communicating regularly with staff. Supervisors use regular 

communications with staff as another oversight method. For example, 

according to HRSA officials, supervisors hold individual, one-on-one, 

meetings with members of their staff on a regular basis, ranging from 

weekly to quarterly. Two officials said that the frequency of one-on-one 

meetings varies based on the staff’s experience. Topics discussed during 

these meetings include updates on the grantees that the staff is 

responsible for monitoring, any grantee compliance issues, upcoming or 

recent site visits, and submissions from grantees. In preparation for these 

meetings, officials we interviewed reported that supervisors often review 

the staff’s EHB documentation, and then discuss it during their meetings. 

Officials from one bureau stated that supervisors use EHB information to 

guide conversations with their staff during their one-on-one meetings to 

discuss grantee progress, concerns, and best practices. In addition to 

one-on-one meetings, some supervisors hold regular group meetings with 

all of their staff responsible for grantee monitoring, where, among other 

things, staff can report on any issues they are encountering with their 

grantees or ask questions of their peers or supervisors.

Conducting performance appraisals. HRSA also uses its annual 

performance appraisal process to hold its staff accountable for their 

grantee monitoring responsibilities. The performance appraisals for all 

staff with responsibility for monitoring grantees include performance 

elements related to monitoring. The specific elements upon which staff 

are assessed are based on the roles and responsibilities for their job 

function, and can vary by individual. Table 1 provides examples of 

performance elements related to monitoring for the three key positions 

with responsibility for grantee monitoring. In addition, supervisors and 

bureau and office leadership also are held accountable through their 

performance appraisals for their oversight of the staff who perform 

grantee monitoring activities. For example, HRSA officials told us bureau 
 

Page 20 GAO-14-800 HRSA Grantee Monitoring Workforce

and office leadership are held accountable for overseeing the monitoring 

of grantees through the business acumen element of their appraisal, 

under which they are expected to ensure program integrity and 

responsible stewardship of resources.

Table 1: Examples of Performance Elements for Key Health Resources and Services Administration (HRSA) Staff with 

Grantee Monitoring Responsibilities 

Job function Examples of performance elements related to monitoring grantees

Project officer • Monitors, reviews, and tracks the performance of grantees against baseline and established 

targets to achieve the overall bureau goals.

• Contacts grantees on a quarterly basis to support program compliance.

• Conducts and properly documents site visits, including taking follow-up actions as needed.

• Anticipates, plans for, and takes appropriate, timely actions to correct, enforce, and/or 

mitigate adverse grantee outcomes.

• Ensures and properly documents that programmatic objectives have been met and that any 

required programmatic report is received and accepted in accordance with applicable policies 

and procedures.

Grants management specialist • Monitors grantee submissions, such as required reports, for timeliness and compliance with 

grants policy and follows up on late actions.

• Processes grantee requests requiring prior approvals in a timely manner, no later than 

30 days after receipt.

• Records all correspondence and pertinent documents in official files and communicates with 

relevant HRSA staff as necessary.

Financial integrity staff • Performs and completes financial assessments [of grantees] using established review 

procedures and within established timeframes. Ensures financial assessments conform to 

standards. These standards include making sure financial assessments are accurate, 

complete, self-explanatory, and grammatically correct. 

• Closes 90 percent of the assigned [grantee] audit reports [of normal complexity] within 

6 months of issuance.

• Prepares draft and final reports that completely fulfill the objective of the review [of grantee 

issues] and are thoroughly researched and accurate, including any findings and 

recommendations if appropriate.

Source: HRSA. │ GAO-14-800

Note: The specific performance elements an individual is rated on can vary based on the individual’s 

assignments and the requirements of the grant programs for which they conduct monitoring. For 

example, the specific elements for financial integrity staff vary depending on whether they are 

responsible for financial assessments of grantees, special grantee reviews, or working with grantees 

to resolve audit findings.
 

Page 21 GAO-14-800 HRSA Grantee Monitoring Workforce

HRSA has several mechanisms in place designed to ensure that HRSA 

contractors that conduct grantee monitoring activities are qualified and to 

oversee the work performed by these contractors. HRSA officials told us 

that the agency’s process for awarding contracts is designed to ensure 

the contractors that conduct grantee monitoring activities are qualified. As 

part of the process for awarding such contracts, HRSA considers staffing 

proposals and the expectations outlined in the statement of work—a 

section of the contract solicitation that describes the specific tasks 

required of the contractor. For all 13 contracts that HRSA identified as 

including grantee monitoring activities in fiscal year 2013, the personnel 

proposed by contractors were a factor in HRSA’s evaluation and selection 

of the contractors. For each of these contracts, HRSA required 

prospective contractors to submit staff résumés and, for some contracts, 

also required letters of commitment or other information regarding the 

expertise and qualifications for certain staff designated as “key 

personnel”—contractor staff who are proposed to lead the work, such as 

the project director. Officials told us they considered the experience of 

these individuals when evaluating the potential contractors.

For some contracts, HRSA identified specific qualifications required for 

contractor staff. Nine of the 13 contracts—4 used by OFAM for financial 

reviews and 5 used by programmatic bureaus for grantee monitoring—

included specific requirements for the qualifications or characteristics of 

contractor staff. For example, the OFAM contracts included information 

on educational requirements, years of experience, and skill sets needed 

for certain positions including senior financial analysts and senior 

auditors. One of the bureau contracts required contractor site visit staff to 

have specific clinical experience, as well as experience with 

administrative and management information systems, fiscal management, 

and familiarity with the support services available for the population 

served by the grant.

Additionally, almost all of the contracts (12 of 13) included a clause that 

specifies procedures for the contractor to follow if it makes a change to 

key personnel. For example, some contracts stated that if the contractor 

needed to change any key personnel, it would need to notify HRSA in 

advance in writing and provide justification for the change. The contractor 

would then need to receive written consent from HRSA to make the 

change in personnel.

HRSA Has Several 

Mechanisms in Place 

Designed to Ensure 

Contractors That 

Monitor Grantees Are 

Qualified and to 

Oversee Their Work
 

Page 22 GAO-14-800 HRSA Grantee Monitoring Workforce

After a contractor is selected, HRSA has other mechanisms designed to 

ensure that the contractor staff conducting grantee site visits are qualified 

to conduct this monitoring activity. For example, some of the contracts 

used by the HIV/AIDS Bureau and the Bureau of Primary Health Care 

stated that the contractor is responsible for providing training to its staff. 

One contract specified that contractor staff must achieve a particular 

score on a posttraining assessment before they are considered eligible to 

perform site visits. HRSA officials and the contractors we spoke to 

explained that development of this training is a joint effort; that is, HRSA

and the contractor work together to develop the training and ensure it 

covers the necessary information. Contractor staff may also attend HRSA 

webinars or other trainings offered to grantees that discuss grant program 

requirements.

In addition to training, HRSA has resources available for contractor staff 

that conduct site visits. For example, contractor staff have access to site 

visit guides, which help to ensure that the staff are knowledgeable about 

the requirements of the grant programs for which they are conducting site 

visits. Additionally, HRSA officials and contractors we interviewed told us 

that new contractor staff may shadow more experienced contractor staff 

during site visits, allowing them to observe an actual site visit prior to 

being responsible for conducting one on their own. HRSA officials also 

stated that when possible, HRSA project officers attend the site visits to 

help new contractor staff understand what to look for when assessing a 

grantee’s compliance with program requirements. HRSA officials and one 

of the contractors we interviewed told us that HRSA staff also provide 

input to contractors about the staff available or selected for grantee 

monitoring activities, such as site visits; however, the contractor is 

ultimately responsible for selecting its staff and assigning them to 

particular assignments. Specifically, officials said that when there is a 

specific need for a particular type of expertise among the contractor staff 

conducting grantee monitoring activities, HRSA officials may recommend 

to the contractor that certain individuals be added to the roster of 

contractor staff available to provide services or assigned to conduct a 

particular site visit.

HRSA officials reported several mechanisms they use to oversee 

contractors’ work, including regular communications with contractors, the 

review of contractors’ deliverables, and the collection of feedback from 

project officers and grantees on contractor performance.
 

Page 23 GAO-14-800 HRSA Grantee Monitoring Workforce

• The contracts we reviewed all required regular communications 

between HRSA and contractors for the purpose of, among other 

things, discussing the status of the contractor’s work or any problems 

the contractor encountered with the grantees. For example, several 

contracts required contractors to provide monthly progress reports to 

HRSA staff on the status of their accomplishments for the month and 

any problems encountered. CORs and contractors we spoke with 

stated they have standing meetings ranging in frequency from weekly 

to monthly and have more frequent informal communication as 

needed to carry out the day-to-day activities of the contract. 

Additionally, the contractor we spoke with that conducts site visits of 

Bureau of Primary Health Care grantees told us that it has quarterly 

meetings with representatives from the bureau, which include 

discussion of the site visit process and any grantee trends staff are 

seeing during the site visits.

• CORs and other HRSA officials review contractor deliverables, such 

as routine progress reports and site visit reports, to assess timeliness 

and quality of the products. The CORs we interviewed said they 

regularly rely on project officers, who have the programmatic 

expertise, to review and provide feedback on site visit reports 

submitted by contractor staff. Contractor staff are then responsible for 

making any necessary revisions to the reports. Officials also said that 

CORs work with financial integrity staff when reviewing certain 

contractor deliverables, such as financial ratio analyses to assess 

grantees’ financial health and viability, as they have expertise related 

to these financial reviews.

• For at least some contracts, contractors collect feedback from 

grantees and project officers that interact with the contractor staff. For 

these contracts, grantees have the opportunity to provide feedback on 

contractor staff site visit performance by completing a postvisit survey. 

Contractors for the HIV/AIDS Bureau and the Bureau of Primary 

Heath Care told us that they administer such surveys to grantees. 

Additionally, the Bureau of Primary Heath Care contractor we spoke 

with sends project officers a similar postvisit survey about their 

experiences with contractor staff, while the HIV/AIDS Bureau 

contractor we spoke with solicits contractor staff feedback from 

debriefing calls with the project officer after the site visit is completed.
 

Page 24 GAO-14-800 HRSA Grantee Monitoring Workforce

HRSA uses a large portion of its appropriations—over 80 percent in fiscal 

year 2013—to award grants to external entities. As a grant-making 

agency, HRSA is responsible for monitoring its grantees to ensure that 

they are meeting the requirements of their grants. Effectively monitoring 

grantees is essential to ensure that government funds are being used 

appropriately and efficiently. In the past few years, HRSA has taken steps 

to increase and improve its guidance and training related to monitoring 

grantees, including implementing new training programs for key staff 

responsible for grantee monitoring and developing SOPs for these staff at 

both the agency and bureau level. These efforts reflect HRSA’s recent 

emphasis on systematically providing guidance and training on grantee 

monitoring. To assist with the development of the SOPs, HRSA provided 

its bureaus with a template outlining the key components of grantee 

monitoring that should be addressed in the guidance. However, we found 

that the bureau-level SOPs did not address all of the key components of 

grantee monitoring specified in that template; the lack of detailed policies 

is inconsistent with federal standards for internal control. Because HRSA 

did not ensure that the bureaus’ SOPs included the required information 

and detail, and thus provided comprehensive guidance to staff 

responsible for monitoring grantees, the agency has put itself at risk for 

incomplete or ineffective grantee monitoring, which could jeopardize its 

stewardship of federal dollars.

To help ensure complete and effective monitoring of grantees, we 

recommend that the Administrator of HRSA develop a process, either at 

the agency or bureau level, to ensure that bureaus’ SOPs address all of 

the key components of grantee monitoring as established by the agency.

We provided a draft of this report to HHS for comment. In its written 

comments, reproduced in appendix II, HHS concurred with our 

recommendation. In addition, HHS provided information on its plans for 

implementing the recommendation, stating that HRSA officials had 

already begun to take action. 

We are sending copies of this report to the Secretary of Health and 

Human Services and the Administrator of HRSA. In addition, the report 

will be available at no charge on the GAO website at http://www.gao.gov. 

Conclusions

Recommendation for 

Executive Action

Agency Comments
 

Page 25 GAO-14-800 HRSA Grantee Monitoring Workforce

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7114 or at draperd@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix III.

Debra A. Draper

Director, Health Care
Page 26 GAO-14-800 HRSA Grantee Monitoring Workforce

List of Requesters

The Honorable Lamar Alexander

Ranking Member

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Tom Coburn

Ranking Member

Committee on Homeland Security and Governmental Affairs

United States Senate

The Honorable Michael B. Enzi

Ranking Member

Subcommittee on Children and Families

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Richard Burr

Ranking Member

Subcommittee on Primary Health and Aging

Committee on Health, Education, Labor, and Pensions

United States Senate
Appendix I: Health Resources and Services 

Administration Contracts with Grantee 

Monitoring Activities, Fiscal Year 2013

Page 27 GAO-14-800 HRSA Grantee Monitoring Workforce

Amount of obligations

Contractor Contract purpose

Health Resources 

and Services 

Administration 

(HRSA) bureau or 

office FY 2012 FY 2013

Brown & Company, 

CPAs 

To assist HRSA’s Division of Financial Integrity in 

conducting financial ratio analyses to assess grantees’ 

ability to manage federal funds in accordance with federal 

grants management rules and regulations.

Office of Federal 

Assistance 

Management

$30,060 $0

Brown & Company, 

CPAs 

To assist HRSA’s Division of Financial Integrity in 

conducting financial assessments to assess grantees’ 

ability to manage federal funds in accordance with federal 

grants management rules and regulations.

Office of Federal 

Assistance 

Management

$12,780 $0

Brown & Company, 

CPAs 

To assist HRSA’s Division of Financial Integrity with 

conducting follow-up on grantees that are delinquent in 

the completion of their financial audit.

Office of Federal 

Assistance 

Management

$11,160 $0

Claxton and 

Company, P.C.

To conduct a limited scope review of a Bureau of Primary 

Health Care grantee to determine if the grantee has 

financial systems adequate to support the grant awards 

received, has the financial capability to perform grant 

activities, and has adequate policies and procedures in 

place to meet the program guidelines and terms and 

conditions of the grant.

Office of Federal 

Assistance 

Management

$58,561 $0

Claxton and 

Company, P.C.

To conduct a limited scope review to determine if a 

Bureau of Primary Health Care and Office of Rural Health 

Policy grantee used grant funds in accordance with grant 

terms and conditions and grant laws and regulations; is 

properly allocating and monitoring grant funds; has 

adequate internal controls in place, including, but not 

limited to, for disbursements of funds, procurement 

procedures, and allowable costs; and if there are conflicts 

of interest involving the grantee’s Chief Executive Officer.

Office of Federal 

Assistance 

Management

$52,586 $0

Claxton and 

Company, P.C.

To conduct a limited scope review to determine if a 

Bureau of Primary Health Care grantee has adequate 

financial systems in place, has spent grant funds properly, 

has adequate policies and procedures in place to meet 

program guidelines, and is addressing previously 

identified issues.

Office of Federal 

Assistance 

Management

$49,167 $0

Dixon Group, Inc. To provide logistical support and conduct diagnostic 

compliance site visits to grantees.

HIV/AIDS Bureau $428,335 $0

Global Evaluation & 

Applied Research 

Solutions

To provide technical assistance and conduct diagnostic 

compliance site visits to grantees.

HIV/AIDS Bureau $2,480,090 $3,304,972

Jaybro Group, LLC To conduct a limited scope review of an HIV/AIDS Bureau 

grantee in response to concerns about the grantee’s use 

of grant funds.

Office of Federal 

Assistance 

Management

$75,774 $0

Appendix I: Health Resources and Services 

Administration Contracts with Grantee 

Monitoring Activities, Fiscal Year 2013
Appendix I: Health Resources and Services 

Administration Contracts with Grantee 

Monitoring Activities, Fiscal Year 2013

Page 28 GAO-14-800 HRSA Grantee Monitoring Workforce

Amount of obligations

Contractor Contract purpose

Health Resources 

and Services 

Administration 

(HRSA) bureau or 

office FY 2012 FY 2013

Management 

Solutions Consulting 

Group, Inc.

To provide assistance and support to grantees and HRSA 

staff by providing on-site visits, including visits to assess 

compliance with program requirements; document 

reviews; and consultation to new and existing grantees.

Bureau of Primary 

Health Care

$13,356,664 $9,798,176

Olshesky Design 

Group, LLC

To provide School-Based Health Center Capital Program 

application review support, ensure grantees are in 

compliance with federal requirements, and analyze 

grantees’ progress in implementing funded projects.

Bureau of Primary 

Health Care

$289,531 $0

Seamon Corporation To provide logistical support and conduct site visits to 

assess grantee compliance.

HIV/AIDS Bureau $0 $796,346

Stantec Consulting 

Services, Inc.

To provide support for application reviews, assess 

compliance with federal requirements, and provide 

postaward oversight.

Bureau of Primary 

Health Care

$584,347 $0

Source: HRSA and the Federal Procurement Data System-Next Generation. │ GAO-14-800

Legend: FY = fiscal year.

Notes: The term “contracts” refers to the collection of contracts, task orders, and blanket purchase 

agreements that HRSA used to obtain services from contractors who monitored grantees in fiscal 

year 2013.

We included contract obligations for both fiscal years 2012 and 2013 because work carried out in 

fiscal year 2013 may have been a result of funds obligated in fiscal year 2012. The amount of 

obligations represents the total amount of the contract and is not limited to obligations related to 

grantee monitoring activities.
Appendix II: Comments from the Department 

of Health and Human Services

Page 29 GAO-14-800 HRSA Grantee Monitoring Workforce

Appendix II: Comments from the Department 

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

of Health and Human Services

Page 30 GAO-14-800 HRSA Grantee Monitoring Workforce
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 31 GAO-14-800 HRSA Grantee Monitoring Workforce

Debra A. Draper, (202) 512-7114 or draperd@gao.gov

In addition to the contact named above, Michelle B. Rosenberg, 

Assistant Director; Jill K. Center; Kathleen Diamond; 

Cathleen J. Hamann; Emily Loriso; Kaitlin McConnell; Julie T. Stewart; 

and Jennifer M. Whitworth made key contributions to this report.

Appendix III: GAO Contact and Staff 

Acknowledgments

GAO Contact

Acknowledgments

(291136)
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