RYAN WHITE CARE 

ACT

Improvements Needed 

in Oversight of 

Grantees

Report to Congressional Requesters

June 2012

GAO-12-610

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United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-610, a report to 

congressional requesters

June 2012

RYAN WHITE CARE ACT

Improvements Needed in Oversight of Grantees

Why GAO Did This Study

Each year, half a million people 

affected by human immunodeficiency 

virus (HIV) and acquired 

immunodeficiency syndrome (AIDS) 

receive services funded by CARE Act 

grants. HRSA, an agency within HHS, 

awards CARE Act Part A grants to 

localities and Part B grants to states 

and territories. These grantees may 

provide services themselves or may 

contract with service providers. HRSA 

POs monitor grantees, but grantees 

are to monitor their service providers. 

PO oversight includes routine 

monitoring, site visits, and monitoring 

of special award conditions, such as 

restrictive drawdown. GAO was asked 

to 1) evaluate HRSA’s oversight of 

CARE Act grantees and 2) examine 

steps HRSA has taken to assist CARE 

Act grantees in monitoring their service 

providers. GAO conducted a review of 

grantee files from 2010 and 2011 for 

25 selected Part A and B grantees, 

reviewed HHS and HRSA policies, 

interviewed HRSA officials, analyzed 

HRSA data on site visits and 

interviewed grant officials from GAO’s 

25 selected grantees and 6 selected 

service providers.

What GAO Recommends

GAO is making several 

recommendations, including that 

HRSA implement key elements of 

grantee oversight consistent with 

guidance, including restrictive 

drawdowns; develop a strategic 

approach for selecting grantees for site 

visits; and work to identify grantees’ 

training needs in order to comply with 

the National Monitoring Standards. 

HHS concurred with the 

recommendations.

What GAO Found

The Department of Health and Human Services’ (HHS) Health Resources and 

Services Administration (HRSA) does not consistently follow HHS regulations 

and guidance in its oversight of Ryan White Comprehensive AIDS Resources 

Emergency Act of 1990 (CARE Act) grantees when conducting key elements of 

grantee oversight, including routine monitoring and implementing restrictive 

drawdowns. Additionally, HRSA did not demonstrate a risk-based strategy for 

selecting grantees for site visits. Project officers (POs) do not consistently 

document routine monitoring or follow up on that monitoring to help grantees 

address problems, as required by HHS and HRSA guidance. The purpose of 

routine monitoring is to enable POs to answer grantee questions about program 

requirements, provide technical assistance (TA), and follow up on grantee 

corrective actions in response to previously provided TA. However, GAO found 

that most POs did not document routine monitoring calls with grantees—only 4 of 

the 25 PO files GAO reviewed from 2010 and 8 of the 25 files GAO reviewed 

from 2011 contained documentation of monitoring calls at least quarterly. HRSA 

often did not follow HHS regulations and guidance in implementing restrictive 

drawdowns, a special award condition HRSA can place on grantees with serious 

problems. Restrictive drawdown requires that prior to spending any grant funds, 

grantees must submit a request, along with documentation of the need, for funds 

for HRSA review. Six of the 52 Part A grantees and 13 of the 59 Part B grantees 

were placed on restrictive drawdown from 2008 through 2011. GAO found that 

HRSA did not consistently provide grantees in GAO’s sample that were on 

restrictive drawdown with the reasons the restrictive drawdown was 

implemented, instructions for meeting the conditions of the restrictive drawdown, 

or guidance on the types of corrective actions needed. This has limited the 

effectiveness of restrictive drawdown as a tool for improving grantee 

performance. Regarding the oversight of grantees through site visits, HRSA did 

not demonstrate a clear strategy for selecting the grantees it visited from 2008 

through 2011. For example, HRSA did not appear to prioritize site visits to 

grantees based on the amount of time that had passed since a grantee’s last site 

visit. Although many HRSA POs GAO spoke with said that site visits were a 

valuable and effective form of oversight, GAO found that 44 percent of all 

grantees did not receive a site visit from 2008 through 2011 while others received 

multiple visits.

Grantees are required to oversee the service providers with whom they contract 

and in April 2011, HRSA issued the National Monitoring Standards for grantee 

monitoring of service providers. The standards describe program and financial 

requirements and include 133 requirements for Part A grantees and 154 

requirements for Part B grantees. Though the standards were intended to 

improve grantee monitoring of service providers, some grantees said that a lack 

of training and TA has hindered its implementation. Additionally, some grantees 

have found the requirement for annual site visits of service providers to be 

challenging. HRSA officials said that they believe they provided adequate training 

to grantees in implementing the standards, which did not represent new 

View GAO-12-610. For more information, requirements. contact Marcia Crosse, (202) 512-7114, 

crossem@gao.gov.
Page i GAO-12-610 Ryan White CARE Act Oversight

Letter 1 

Background 6

HRSA Does Not Consistently Follow Guidance on Oversight of 

Grantees and Faces Other Challenges 15

HRSA Recently Issued National Standards for Grantee Monitoring 

of Service Providers, but HRSA’s Implementation Created 

Challenges for Grantees 30

Conclusions 36

Recommendations for Executive Action 37

Agency Comments and Our Evaluation 37

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

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

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

Appendix IV GAO Contact and Staff Acknowledgments 77

Tables

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

2008-2011 21

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

Grantee Monitoring of Service Providers 31

Table 3: Examples of HRSA’s National Monitoring Standards and 

Grantee Responsibilities for Part A and Part B Grantee 

Monitoring of Service Providers, by Topic 32

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

Fiscal Year 2012 42

Table 5: HRSA Site Visits of Part A Grantees, 2008-2011 45

Table 6: HRSA Site Visits of Part B Grantees, 2008-2011 47

Contents
Page ii GAO-12-610 Ryan White CARE Act Oversight

Abbreviations

ADAP AIDS Drug Assistance Program

AIDS acquired immunodeficiency syndrome

CARE Act Ryan White Comprehensive AIDS Resources Emergency 

 Act

DFI Division of Financial Integrity

EHB electronic handbook

EMA eligible metropolitan area

HAB HIV/AIDS Bureau

HHS Department of Health and Human Services 

HIV human immunodeficiency virus

HRSA Health Resources and Services Administration

MAI Minority AIDS Initiative

NARA National Archives and Records Administration

NASTAD National Alliance of State and Territorial AIDS Directors

NOA notice of award

OMB Office of Management and Budget

PO project officer

TA technical assistance

TGA transitional grant area

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Page 1 GAO-12-610 Ryan White CARE Act Oversight

United States Government Accountability Office

Washington, DC 20548

June 11, 2012

The Honorable Tom Harkin

Chairman

The Honorable Michael Enzi

Ranking Member

Committee on Health, Education, Labor and Pensions

United States Senate

The Honorable Richard Burr

Ranking Member

Subcommittee on Children and Families

Committee on Health, Education, Labor and Pensions

United States Senate

The Honorable Tom Coburn

Ranking Member

Permanent Subcommittee on Investigations

Committee on Homeland Security and Governmental Affairs

United States Senate

An estimated 1.2 million people in the United States are living with human 

immunodeficiency virus (HIV) infection in 2012, and approximately 50,000 

new infections occur annually. Since the first cases of acquired 

immunodeficiency syndrome (AIDS) were reported in June 1981, more 

than 600,000 people with AIDS have died. Each year, half a million 

uninsured or underinsured individuals and families affected by HIV/AIDS 

receive assistance funded by grants provided for in the Ryan White 

Comprehensive AIDS Resources Emergency Act of 1990 (CARE Act).1

 

1

Pub. L. No. 101-381, 104 Stat. 576 (codified, as amended, at 42 U.S.C. §§ 300ff through 

300ff-121). The 1990 CARE Act added title XXVI to the Public Health Service Act. Unless 

otherwise indicated, references to the CARE Act refer to current title XXVI. The CARE Act 

programs have been reauthorized by the Ryan White CARE Act Amendments of 1996 

(Pub. L. No. 104-146, 110 Stat. 1346), the Ryan White CARE Act Amendments of 2000 

(Pub. L. No. 106-345, 114 Stat. 1319), the Ryan White HIV/AIDS Treatment 

Modernization Act of 2006 (Pub. L. No. 109-415, 120 Stat. 2767), and the Ryan White 

HIV/AIDS Treatment Extension Act of 2009 (Pub. L. No. 111-87, 123 Stat. 2885).

CARE Act funds are distributed to grantees such as states, localities, and 

other public or nonprofit entities; these grantees may provide CARE Act 

program services themselves or may contract with service providers to 

 
 

Page 2 GAO-12-610 Ryan White CARE Act Oversight

offer the medical care or support services needed to achieve positive 

medical outcomes.2

Members of Congress have asked questions about HRSA’s ability to 

adequately oversee Ryan White grantees and service providers to ensure 

that CARE Act funds are used properly and effectively. CARE Act 

grantees are monitored by HRSA project officers (PO) and other grants 

management officials, and federal regulations require grantees to monitor 

their service providers’ compliance with program requirements. Grantees 

or service providers found to be in violation of program or federal grants 

management requirements are to receive technical assistance (TA) or 

other corrective actions designed to bring them into compliance.

The CARE Act is administered by the Department of 

Health and Human Services’ (HHS) Health Resources and Services 

Administration (HRSA). In fiscal year 2012, HRSA allocated over 

$2.3 billion of its annual appropriation to CARE Act programs.

3

There are five primary parts (Parts A through D and Part F) of the CARE 

Act under which HRSA awards grants. The types of entities eligible for 

grants and types of services provided through the grants vary by part. In 

fiscal year 2011, the majority of CARE Act grants are awarded under 

Parts A and B. Part A grants are awarded to the eligible metropolitan 

areas (EMAs) and transitional grant areas (TGAs) most severely affected 

by the HIV/AIDS epidemic and comprise about 30 percent of CARE Act 

grants.

In this 

report, we (1) evaluate how HRSA oversees CARE Act grantees and 

(2) examine steps HRSA has taken to assist CARE Act grantees in 

monitoring their service providers.

4

 

2

We use the term “grantees” to refer to organizations or entities that receive funding 

directly from HRSA for CARE Act services, and the term “service providers” to refer to 

organizations awarded contracts or subgrants from grantees to provide services or 

arrange for another organization to provide services. Grantees may also provide services 

themselves. 

Part B grants are awarded to states, the District of Columbia, and 

3

HRSA defines technical assistance as the delivery of practical program and technical

support which may include necessary technical and nonfinancial assistance, fiscal and 

program management assistance, operational and administrative support, and the 

provision of information to grantees regarding the variety of resources available to them, 

and how those resources can best be used to meet the health needs of their clients.

4

EMAs are areas that have a population of 50,000 persons or more and had a cumulative 

total of more than 2,000 new AIDS cases during the most recent 5-year period. TGAs are 

areas that have a population of 50,000 persons or more and had a cumulative total of 

1,000 to 1,999 new AIDS cases during the most recent 5-year period. 
 

Page 3 GAO-12-610 Ryan White CARE Act Oversight

U.S. territories and associated jurisdictions and comprise about 

55 percent of CARE Act grants. Part B also provides for grants under the 

AIDS Drug Assistance Program (ADAP) through which drugs are 

provided to eligible individuals with HIV/AIDS.5

To evaluate how HRSA oversees CARE Act grantees, we reviewed HHS 

and HRSA policies and procedures, conducted a review of selected 

grantee files, interviewed selected Part A and Part B grantees, HRSA 

POs, and selected national organizations with HIV/AIDS expertise, and 

reviewed HRSA data on site visits and staffing. First, we reviewed HHS 

and HRSA policies and procedures for overseeing grantees and service 

providers. We interviewed HRSA staff about policies and procedures for 

overseeing grantees and service providers, as well as about coordination 

among HRSA oversight personnel. Second, we selected a 

nongeneralizable sample of 25 of the 111 Part A and Part B grantees—12 

of the 52 Part A grantees and 13 of the 59 Part B grantees.

Our review was limited to 

Part A and Part B grantees and their service providers.

6 To select our 

sample we divided all of the Part A and Part B grantees into two 

categories based on whether or not they had been found to be in violation 

of program or financial requirements from 2008 through 2011. We then 

chose grantees from each of these two categories to reflect a range of 

funding levels, geographic factors, and grant longevity. We reviewed the 

files HRSA maintained for this nongeneralizable sample of 25 Part A and 

Part B grantees. We reviewed these files for grant years 2010 and 2011.7

 

5

Title XXVI of the Public Health Service Act contains several parts which provide for 

grants for various HIV/AIDS-related services. In addition to Parts A and B, Part C 

provides for grants directly to public and private nonprofit entities to provide early 

intervention services; Part D provides for grants to organizations for family-centered 

medical and support services for women, infants, children, and youth with HIV/AIDS and 

their families—including infected and affected family members; and Part F provides for 

grants for demonstration and evaluation of models of quick response HIV/AIDS services 

and electronic data systems, training of health care providers, and the Minority AIDS 

Initiative (MAI). Part E does not provide for funding for HIV/AIDS Services but rather 

includes provisions to address various administrative functions.

6

The selected Part A grantees were Baltimore, Maryland; Baton Rouge, Louisiana; 

Denver, Colorado; Detroit, Michigan; Indianapolis, Indiana; Las Vegas, Nevada; Memphis, 

Tennessee; New York, New York; Phoenix, Arizona; St. Louis, Missouri; San Francisco, 

California; and West Palm Beach, Florida. The selected Part B grantees were California, 

Florida, Georgia, Louisiana, Maryland, Mississippi, Nebraska, New York, Nevada, Ohio, 

Pennsylvania, Rhode Island, and South Carolina. 

7

The grant year for Part A is from March 1 through February 28. The Part B grant year is 

from April 1 through March 31.
 

Page 4 GAO-12-610 Ryan White CARE Act Oversight

Our file review included a review of the grantees’ reports for grant years 

2010 and 2011 in response to requirements, located in HRSA’s Electronic 

Handbook (EHB); review of external audit files for these grant years; and 

review of the grantee’s PO files, which include important documentation 

of site visits and routine monitoring, among other things, for these grant 

years. To conduct this file review, we developed and used a data 

collection instrument to determine if the files included evidence of 

required monitoring and key monitoring documents. Third, we conducted 

structured interviews with POs that had responsibility for monitoring 

grantees selected for our file review about the grantee files, and obtained 

their views on their roles and responsibilities and on HRSA’s policies and 

procedures.8 We also conducted structured interviews with all 25 of the 

grantees selected for our file review to learn about how HRSA oversees 

its grantees. In addition, we interviewed staff from national organizations 

with HIV/AIDS expertise, including the Kaiser Family Foundation, the 

National Alliance of State and Territorial AIDS Directors (NASTAD), the 

Communities Advocating Emergency AIDS Relief Coalition, the ADAP 

Advocacy Association, and the National Association of County and City 

Health Officials. Fourth, we analyzed data provided by HRSA on its 

oversight of grantees, including PO staffing and HRSA site visits.9 To 

assess the reliability of these data we compared the data provided to us 

by HRSA with information provided to us by our selected 25 grantees 

when possible. We asked HRSA to resolve discrepancies either within the 

data or between the data and information provided by our selected 

grantees. We generally found all of the data reliable for our purposes. We 

also assessed HRSA grantee monitoring processes described in 

documentary and testimonial evidence against relevant criteria, including 

HHS policies, HRSA policies, Office of Management and Budget (OMB) 

guidelines, and federal regulations for grants management.10

 

8

Within HRSA, POs from the HAB Division of Service Systems are responsible for the 

oversight of Part A and B grantees. For purposes of this report, when we refer to HRSA 

POs, we are referring to POs within that division. 

9

For the purposes of this report, we assessed HRSA site visits that included the grantee’s 

PO or other HRSA staff. HRSA refers to these types of site visits as comprehensive site 

visits and these visits are central to the agency’s routine monitoring of grantees. We did 

not assess other types of site visits. 

10CARE Act grants are subject to governmentwide uniform administrative requirements for 

grants and cooperative agreements which for HHS are codified in title 45 of the Code of 

Federal Regulations. In this report, these requirements are referred to as “federal 

regulations.” 
 

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

To examine steps HRSA has taken to assist CARE Act grantees in 

monitoring their service providers, we conducted interviews of grantees 

and service providers, interviewed HRSA staff, and reviewed HRSA 

standards. First, we conducted structured interviews with all 25 of the 

grantees selected for our file review and a nongeneralizable sample of 

6 service providers to learn about how grantees monitor their service 

providers. We included only those service providers that provide medical 

services.11 We selected our sample of 6 service providers based on the 

grantees’ responses to our questions about frequency of service provider 

site visits, the frequency and type of TA they provide to their service 

providers. HRSA provided us with a spreadsheet listing all of the service 

providers for each of our 25 grantees. We limited this list to service 

providers that received at least $100,000 in CARE Act funding and 

provided medical services.12

We conducted this performance audit from April 2011 to June 2012 in 

accordance with generally accepted government auditing standards. 

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

sufficient, appropriate evidence to provide a reasonable basis for our 

We then selected one service provider from 

this limited list for each of 6 grantees using the information indicated 

above. Second, we interviewed HRSA staff about policies and procedures 

for overseeing grantees and service providers. Third, we reviewed the 

HRSA National Monitoring Standards, which were developed by HRSA to 

help Part A and Part B grantees meet federal requirements for program 

and financial monitoring of their service providers. These standards were 

implemented in 2011.

 

11We selected service providers from Indianapolis, Indiana; New York, New York; and 

Phoenix, Arizona. We also selected service providers from Florida, Pennsylvania, and 

Rhode Island.

12HRSA categorizes service providers by four broad service types—administrative 

service, medical service, support service, and HIV counseling and testing. Administrative

services are those related to grants management and monitoring activities including the 

development of management systems and preparation of reports. Medical services are 

those outpatient and ambulatory care services that are part of essential medical care.

They can include, for example, oral health care and HIV/AIDS drug assistance. Support 

services are nonmedical services tied to medical outcomes. They can include, for 

example, client transportation to medical appointments and substance abuse residential 

services. HIV counseling and testing includes the provision of voluntary HIV testing to help 

people learn their HIV status. We excluded service providers that provided only HIV 

counseling and testing, administrative services, and/or support services. Service providers 

that provide medical services in addition to any of the excluded services were included in 

our selection.
 

Page 6 GAO-12-610 Ryan White CARE Act Oversight

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

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Under the CARE Act, Part A and Part B grantees are awarded grants to 

provide a range of services—both medical and support—to uninsured 

and underinsured clients with HIV/AIDS. In fiscal year 2011, most 

CARE Act funding was distributed to grantees either as base or 

supplemental grants. Base grants are distributed by formula, which 

includes a grantee’s share of living HIV/AIDS cases.13 Supplemental 

grants are generally awarded through a competitive process based on the 

demonstration of severe need and other criteria. Part A provides for 

grants to EMAs and TGAs. EMA and TGA funding is primarily provided 

through three categories of grants: (1) formula grants, (2) supplemental 

grants, and (3) Minority AIDS Initiative (MAI) grants.14 Part B provides for 

grants to states, the District of Columbia, and U.S. territories and 

associated jurisdictions. These grants include (1) formula grants, 

(2) supplemental grants, (3) ADAP formula grants,15 (4) ADAP 

 

13Part A and Part B formula grants are based on reported living HIV/AIDS cases as of 

December 31 in the most recent calendar year for which data are available. 

14MAI grants are supplemental grants awarded on a competitive basis to address 

disparities in access, treatment, care, and health outcomes.

15Through ADAP grants, medications are provided for the treatment of HIV disease. 

Congress typically designates a portion of the Part B appropriation for ADAP each year. A 

formula based on the number of reported living HIV/AIDS cases in the most recent 

calendar year is used to award ADAP formula funds to states, the District of Columbia, 

and territories and associated jurisdictions. Additionally, 5 percent of the ADAP 

appropriation is to be reserved for supplemental grants to states and territories that have 

demonstrated severe need. ADAP funds may also be used to purchase health insurance 

for eligible clients covering medications and primary care services as long as the cost 

does not exceed the cost of otherwise providing ADAP medications covered by the 

program.

Background 
 

Page 7 GAO-12-610 Ryan White CARE Act Oversight

supplemental grants,16 (5) MAI grants, and (6) supplemental grants for 

states with “emerging communities”.17,18 Part A and Part B grantees apply 

for funding annually.19

The PO is the HRSA official responsible for working with grantees in 

overseeing the programmatic and technical aspects of the Part A and 

Part B grants. Within HRSA, POs in the HIV/AIDS Bureau’s (HAB) 

Division of Service Systems are responsible for the oversight of Part A 

and Part B grantees. POs are supervised by HAB Division of Service 

Systems branch chiefs, who are responsible for ensuring that POs are 

meeting their oversight responsibilities.20 The PO works with the HRSA 

Office of Financial Assistance Management’s grants management 

specialists (GMS). GMSs are responsible for providing nonprogrammatic 

administrative assistance to grantees, including assistance in interpreting 

provisions of grants administration, law, regulation and policy. These 

provisions include how grantees can draw down grant funds and how 

grantees are to administer and close out grants. GMSs are supervised by 

Grants Management Officers. Additionally, within the Office of Federal 

Assistance Management, staff in the Division of Financial Integrity (DFI) 

provide TA and advice to the POs and GMSs.

 

16HRSA awarded $50 million in both 2011 and 2012 for ADAP emergency relief funding in 

order to address states’ increased need for medications for CARE Act clients.

17“Emerging communities” are defined as metropolitan areas reporting between 500 and 

999 cumulative AIDS cases over the most recent 5 years. 

18The CARE Act provides that Part A and B base and supplemental grant funds are 

available for obligation by the grantee for a 1-year period beginning on the first day of the 

grant year. It also requires HRSA to cancel any unobligated balances at the end of the 

grant year, recover funds that had been disbursed to grantees, and redistribute these 

funds to grantees in need as supplemental grants. Grantees must estimate their 

unobligated balances during the grant year and provide final amounts in their federal 

financial report. Grantees may request to carryover funds for 1 additional grant year. See 

GAO-09-984 and GAO-09-1020.

19The grant year for Part A is from March 1 through February 28. The Part B grant year is 

from April 1 through March 31.

20Branch chiefs have sometimes been needed to serve as POs for some grantees due to 

staffing shortages in recent years. According to a HRSA official, serving in these dual 

roles is difficult and does not allow the time necessary to supervise and develop POs.
 

Page 8 GAO-12-610 Ryan White CARE Act Oversight

HRSA POs conduct their oversight of Part A and Part B grantees in 

accordance with regulations and guidance. HHS grants management 

regulations and guidance govern all HHS grants, including CARE Act 

grants. The regulations and guidance provide for the creation of agency 

and program-specific guidance. Where HRSA has not created specific 

guidance, POs and GMS follow the overarching HHS regulation and 

guidance. Therefore, POs follow HHS regulations and guidance and any 

additional HRSA-specific grants management guidance when it is 

available. HRSA officials told us POs are to follow the Division of Service 

System Operations Manual (HRSA Operations Manual), which provides 

guidance and protocols specifically for PO oversight of CARE Act Part A 

and Part B grantees. The HRSA Operations Manual was first provided to 

us in August 2011 and updated in December 2011.21 Because the 

updated HRSA Operations Manual was not in existence during the 

majority of the period covered by our review, we primarily refer to HHS 

grants management regulations and guidance in our evaluation of 

HRSA’s oversight. HRSA’s grantee oversight includes several elements, 

described below.

HRSA POs are responsible for overseeing the Part A and Part B 

programs by conducting routine monitoring of grantees’ performance and 

compliance with statutory requirements, regulations, and guidance. 

Routine monitoring includes regularly scheduled monitoring calls, reviews 

of grantee reports, and the provision of TA to grantees. HHS guidance 

indicates that monitoring activities are to be documented. This guidance 

also indicates that the documentation is to include information about the 

type of follow-up actions recommended or taken. We found that POs 

were assigned an average of six Part A and Part B grantees to oversee at 

a time. If during the course of routine monitoring a PO finds that a grantee 

has not met its program or financial requirements, the PO is responsible 

for determining, in consultation with his or her branch chief, whether a 

grantee requires more intensive monitoring including a special condition 

of award, such as restrictive drawdown. The PO is responsible for 

monitoring any of these special conditions put in place. POs are HRSA’s 

primary contact with Part A and Part B grantees, and they are to 

communicate with their assigned grantees at least monthly. In addition to

 

21The August 2011 version of the HRSA Operations Manual did not include all of the 

information and policies that were included in the version provided to us in February 2012, 

which was dated December 2011.

Routine Monitoring
 

Page 9 GAO-12-610 Ryan White CARE Act Oversight

a scheduled routine monitoring conference call with grantee 

management, POs are to respond to interim grantee e-mails and calls 

and to provide guidance and TA as needed.

As part of routine monitoring, POs are also responsible for reviewing 

reports filed by grantees to fulfill HRSA’s annual reporting requirements. 

These reports are intended to help HRSA identify grantee problems with 

program implementation and ensure grantees’ compliance with federal 

statutes, regulations, and guidelines. In fiscal year 2012, Part A grantees 

are required to submit 11 different reports while Part B grantees are 

required to submit 16 reports. The reports contain important 

programmatic and financial information such as descriptions of funded 

services, annual expenditures, and grantee accomplishments and 

challenges in meeting program goals. POs are to provide feedback to 

grantees based on their review of these reports and provide written 

requests for changes to reports which are submitted through EHB. The 

PO and GMS are also responsible for reviewing grantee reports to ensure 

that grantees are spending funds in accordance with the grant terms and 

conditions and POs and GMSs are to coordinate in their review of 

grantees’ reports. Grantee reporting requirements are listed in appendix I.

When a PO identifies a problem during routine monitoring the PO is to 

provide TA to help the grantee understand the changes needed to 

address the problem. TA is a targeted means of addressing a particular 

issue or problem and is provided to ensure that program implementation 

reflects the most recent requirements. The overall intent of TA is to assist 

the grantee in improving its capacity, effectiveness, and efficiency. A PO 

may provide the TA by phone, email, on-site or at grantee conferences. 

POs may provide the TA or assist grantees in obtaining TA from HRSA 

consultants.22

In addition to their overall routine monitoring responsibilities, POs are to 

participate in site visits for Part A and Part B grantees. Site visits are 

intended to provide the PO with an opportunity to review the program, 

 

22HRSA contracts with consultants to provide TA to improve the performance of CARE Act 

grantees, and to assist them in addressing the HRSA priority areas with the goal of 

enhancing their performance as grantees. HRSA consultants may also conduct site visits 

focused on the priority areas. HRSA consultants are not federal employees, and are 

generally employed by management and/or health services consulting firms. 

Site Visits
 

Page 10 GAO-12-610 Ryan White CARE Act Oversight

and may act as a TA session for the grantee. HRSA guidance states that 

site visits should be viewed as an opportunity to expand on information 

grantees have provided in their CARE Act grant application, responses to 

reporting requirements, and conference calls. During a site visit, the PO 

may meet with grantee and service provider staff to obtain feedback on 

how the program is functioning, visit various locations at which service 

providers deliver services, and review grantee and service provider 

program documentation. For the Part A and Part B programs, HRSA does 

not have written guidance describing its policy for the selection of 

grantees to visit; however, agency officials told us that they prioritize site 

visits based on two elements—grantees without a recent site visit and 

grantees with problems. In addition, a federal course which HRSA has 

offered to all of its employees for several years and requires all new POs 

to take indicates that agencies should determine which grantees to visit 

based on an analysis of risk, which includes a consideration of grant 

funding level as an indicator of potential risk, among other things.23

When planning a site visit, POs are to provide advance notice in writing to 

the grantee of the intended site visit along with a copy of the site visit 

agenda and the tool the PO will be using to evaluate the grantee. The tool 

addresses the priorities listed below during the site visit. If the site visit will 

involve the review of a priority item in which the PO does not have 

specialized training, such as clinical quality management, the PO can 

consider bringing one or more HRSA consultants for the visit.

According to HRSA guidance, POs are to focus on the following priorities 

during the grantee site visit (listed below in order of highest to lowest 

priority):

• assure grantee compliance with CARE Act provisions and HRSA 

guidance by reviewing compliance with the basic funding 

requirements, such as the presence of an adequate plan for the use 

of grant funds and administrative, program, and financial 

requirements;

 

23Monitoring Grants and Cooperative Agreements for Federal Personnel, Section 6-1. 

According to HRSA, the HHS Office of Grants and Acquisition Policy and Accountability 

worked with a contractor to develop a series of classes on federal grants management. 

This manual corresponds with one of the classes in that series.
 

Page 11 GAO-12-610 Ryan White CARE Act Oversight

• assure basic functioning of the Part A and Part B programs by 

reviewing, for example, the grantee’s ability to disburse funds to 

service providers in a timely fashion and the grantee’s ability to 

conduct program and financial monitoring of service providers;

• assure access to care by reviewing the grantee’s clinical quality 

management processes and the grantee’s assessment of unmet need 

for HIV/AIDS services in their jurisdiction;

• assure coordinated systems of care by reviewing the grantee’s efforts 

to coordinate with other CARE Act programs, HIV counseling, testing 

and prevention programs in their area, and other programs that 

provide access to HIV/AIDS treatment including Medicaid and 

Medicare;24 and

• document and report the impact of the grantees’ use of CARE Act 

funds including any program innovations and/or program successes.

Upon arrival at the site visit location, the PO is to meet with the grantee 

leadership and the Part A or Part B program staff. During the initial 

meeting, the PO is to review the intent of the visit and the site visit 

agenda. This meeting is also an opportunity for the grantee to provide an 

update on the status of the program and the delivery of services. During 

the site visit, the PO is to take notes on the priorities listed above, and be 

prepared to conduct an exit conference with the grantee leadership and 

program staff to explain both preliminary positive and problem findings. 

The PO is to prepare a site visit report to document his findings and 

recommended corrective actions. Additionally, recommendations are to 

be provided for follow-up TA if appropriate and any special action steps 

that the PO will take to help the grantee address the site visit findings. 

HRSA guidance updated during our review states that the site visit report 

is to be provided to the grantee within 30 days of the visit.

 

24Medicaid is the federal-state program that covers acute health care, long-term care, and 

other services for certain categories of low-income individuals. Medicare is the federal 

health insurance program for people aged 65 and older, certain individuals with 

disabilities, and individuals with end stage renal disease.
 

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

Part A and Part B grantees are subject to the requirements of the Single 

Audit Act, as amended, and the act’s implementing OMB guidance.25

These provisions require grantees that expend $500,000 or more in 

federal awards in a fiscal year to have a single audit for that year 

conducted by an independent auditor. HRSA’s Division of Financial 

Integrity (DFI) reviews grantees’ single audit reports with findings related 

to CARE Act programs along with corrective action plans provided by the 

grantee in response to any audit findings.26 Federal regulations require 

HRSA to use single audits as a tool to monitor Part A and Part B grantee 

compliance with program and financial requirements.

In accordance with federal regulations, HRSA may impose special 

restrictive conditions on a grantee’s award if HRSA determines that the 

grantee violated program or financial requirements, or has insufficient 

management systems or practices to ensure stewardship of grant funds 

or achievement of award objectives. These issues may be identified 

through routine monitoring activities, site visits, or single audits. One such 

condition is called restrictive drawdown.27

 

25The Single Audit Act as amended, 31 U.S.C. §§ 7502 et seq., requires states, local 

governments, and nonprofit organizations expending $500,000 or more in federal awards 

in a year to obtain an audit in accordance with the requirements set forth in the act. A 

single audit consists of (1) an audit and opinions on the fair presentation of the financial 

statements and the Schedule of Expenditures of Federal Awards; (2) gaining an 

understanding of and testing internal control over financial reporting and the entity’s 

compliance with laws, regulations, and contract or grant provisions that have a direct and 

material effect on certain federal programs (i.e., the program requirements); and (3) an 

audit and an opinion on compliance with applicable program requirements for certain 

federal programs. We refer to these audits as single audits—they are also commonly 

referred to as A-133 audits. See OMB Circular No. A-133. 

Restrictive drawdown requires 

that prior to spending any grant funds, grantees must submit a request for 

funds for HRSA review by the 20th of each month, for the upcoming 

month, or no less than 10 days before the grantee intends to expend the 

funds. With each request, the grantee must submit supporting 

26DFI is responsible for notifying grantees of the adequacy of their proposed corrective 

actions and for consulting with other HRSA staff, including POs, as needed. 

27The notice of award (NOA) is the official document that states the terms, conditions, and 

amount of a grant award and is signed by the official who is authorized to obligate funds 

on behalf of HRSA. An NOA shows the amount of federal funds available to the grantee 

and is issued at the start of each grant year. A revised NOA may be issued during a grant 

year to effect an action resulting in a change in the amount of support or other change in 

the terms and conditions of award such as a restrictive drawdown.

Single Audits

Restrictive Drawdown
 

Page 13 GAO-12-610 Ryan White CARE Act Oversight

documentation including all grantee invoices, and other financial 

documents related to the request.28 Upon PO review and approval of the 

request and related documentation, HRSA is to make CARE Act funds 

available to the grantee. In December 2011, during the course of our 

review, HRSA created agency-specific guidance that specified the 

reasons Part A and Part B grantees might be placed on restrictive 

drawdown, how a grantee is to be notified of this special condition, and 

under what conditions a grantee can be removed from restrictive 

drawdown. However, this guidance was not in place during the period 

covered by our review.

Federal regulations require grantees to oversee their service providers. In 

April 2011 HRSA compiled existing requirements into a comprehensive 

document called the National Monitoring Standards.29

HRSA officials told us that the national monitoring standards were 

developed in response to two HHS Office of Inspector General reports 

that identified the need for a specific standard regarding the frequency 

and nature of grantee monitoring of service providers and a clear PO role 

The standards are 

designed to help Part A and Part B grantees meet federal requirements 

for program and financial management, and to improve program 

efficiency. Prior to HRSA’s issuance of the standards, guidance on how to 

ensure grantee compliance with program requirements and how to 

monitor service providers was found in multiple sources. HRSA expects 

the standards to provide direction to grantees for monitoring their own 

compliance with CARE Act program and financial requirements and the 

performance of their service providers.

 

28Part A and Part B grantees that are not on restrictive drawdown are able to request

funds that they have available at any time during the grant year through the use of an 

online form that is submitted to the HRSA Payment Management System. Additional 

documentation is not required. Fund requests are reviewed and upon approval are 

provided to the grantee the next business day.

29HRSA states that the standards are based on administrative requirements for HHS grant

awards, Office of Management Budget principles, the HHS Grants Policy Statement, the 

NOA and Conditions of Award for CARE Act grants, and HRSA program guidance.

National Monitoring 

Standards for Grantee 

Monitoring of Service 

Providers
 

Page 14 GAO-12-610 Ryan White CARE Act Oversight

in monitoring grantee oversight of service providers.30 The standards 

were compiled by HRSA with assistance from a national team of financial 

and program experts and a working group of Part A and Part B grantees. 

According to HRSA, the working group provided feedback on drafts of the 

standards. Additionally, according to HRSA, the standards were 

presented to all Part A and Part B grantees in a 2010 Grantee Meeting. 

Grantees were notified of their obligation to comply with these standards 

in fiscal year 2011.

HRSA maintains three different grantee files to assist in its provision of 

oversight, monitoring, and TA to Part A and Part B grantees and there is 

a different record retention period for each of these three files.

31 Single 

audit reports and related financial documentation are maintained in hard 

copy audit files by HRSA’s DFI. HRSA’s record management program 

requires these files to be kept onsite at HRSA for at least 2 years after the 

final close of the audit or upon resolution of any adverse audit findings. 

The files are then to be sent to the Federal Records Centers to be 

maintained for an additional 4 years.32

 

30U.S. Department of Health and Human Services Office of Inspector General. “Monitoring 

of Ryan White CARE Act Title I & II Grantees.” (Washington, D.C.: U.S. Government

Printing Office, 2004). 

The EHB includes the NOA and 

official grantee reports in response to CARE Act grantee reporting 

requirements listed in appendix I. It is maintained electronically by the 

HRSA Division of Grants Management Operations and the Division of 

Service Systems and documents in EHB are accessed by POs and other 

grants management staff as part of their routine monitoring 

responsibilities. Currently, HRSA maintains the EHB for 6 years, but is 

http://oig.hhs.gov/oei/reports/oei-02-01-00640.pdf and U.S. 

Department of Health and Human Services Office of Inspector General. “The Ryan White 

CARE Act Title I & II Grantee’s Monitoring of Subgrantees.” (Washington, D.C.: U.S. 

Government Printing Office, 2004). http://oig.hhs.gov/oei/reports/oei-02-01-00641.pdf. 

31Under the Federal Records Act, agencies are to manage the creation, maintenance, 

use, and disposition of records in order to achieve adequate and proper documentation of 

the policies and transactions of the federal government and effective and economical 

management of agency operations. 44 U.S.C. chapters 21, 29, 31, and 33. Accordingly, 

to ensure that they have appropriate recordkeeping systems with which to manage and 

preserve their records, agencies develop records management programs that include, 

among other things, specified retention periods for agency records. 

32Federal Records Centers across the United States store and provide access to inactive

or permanent records pending their disposition according to the approved records 

retention periods.

Grantee Files
 

Page 15 GAO-12-610 Ryan White CARE Act Oversight

working to finalize a record retention period. Additionally, PO files, which 

include the only documentation of routine monitoring, site visits, and TA, 

and duplicate copies of the required grantee reports that are also found in 

EHB, are maintained in hard copy by the PO. During the course of our 

review, HRSA officials told us that HRSA’s record management program 

requires these files to be maintained for the current and previous grant

year, after which they were to be destroyed.33

HRSA does not consistently follow HHS or its own guidance for grantee 

oversight when monitoring CARE Act grantees. A lack of records and 

frequent changes in PO assignments further challenge HRSA’s ability to 

oversee grantees and to assist them with program implementation.

The December 2011 

update to HRSA’s Operations Manual now suggests that POs should 

maintain copies of site visit reports for at least 5 years, and that any 

documents related to issues under investigation not be discarded. 

However, this change does not apply to other key documentation in PO 

files, such as regularly scheduled conference calls and copies of relevant 

e-mails.

HRSA did not consistently follow guidance for documenting routine 

monitoring, prioritizing grantee site visits, reviewing annual single audit 

findings, or clearly communicating with grantees about the restrictive 

drawdown process.

POs do not consistently document routine monitoring or follow up on that 

monitoring to help grantees address problems. HHS guidance indicates 

that monitoring activities performed in order to evaluate grantees’ 

programmatic performance, including any discussions with grantees, 

should be documented. This guidance also indicates that documentation 

of monitoring actions is to include information about the type of follow-up 

actions recommended or taken. However, we found that most of the PO 

files that we reviewed did not contain documentation of routine monitoring 

 

33Although HRSA’s record management program requires these records to be kept for 

2 years, the grantee records made available to us typically included information for less 

than 2 full grant years.

HRSA Does Not 

Consistently Follow 

Guidance on 

Oversight of Grantees 

and Faces Other 

Challenges 

HRSA Does Not 

Consistently Follow 

Applicable Guidance for 

Grantee Oversight

HRSA Did Not Consistently 

Document Routine Monitoring
 

Page 16 GAO-12-610 Ryan White CARE Act Oversight

calls—of the 25 PO files for grantees in our sample, only 4 PO files 

contained documentation of monitoring calls at least quarterly in the 2010 

grant files we reviewed, and only 8 contained documentation of quarterly 

calls in the 2011 grant files.34

Most grantees said they had received feedback at least once from a PO 

on a required report, but eight noted that such feedback was uncommon. 

Grantees submit numerous reports throughout the year containing 

important programmatic and financial information. HHS guidance states 

that monitoring is to include a review of reports, and that review of reports 

may help officials identify performance or financial issues that require 

follow-up. Further, HRSA POs are to review and provide feedback and 

guidance to grantees on program and fiscal reports. However, seven 

grantees said that feedback on reports was not specific or timely. Only 

four grantees told us that they received PO comments on their reports 

during monthly monitoring calls, though HRSA states that reporting 

requirements are to be discussed during routine calls, which are intended

to provide POs with an opportunity to provide such feedback. While a lack 

of feedback might indicate that a PO had no concerns about a grantee’s 

reports, POs may be missing opportunities to use the information 

provided in reports to better communicate with grantees about their 

compliance with program requirements and help grantees make 

improvements. Seven grantees stated that they would appreciate 

receiving more feedback on the reports they submit to ensure they were 

meeting HRSA’s standards.

Though most of the files we reviewed 

contained documentation of e-mails between POs and grantees indicating 

that communication was taking place, HRSA POs are to conduct and 

document regularly scheduled calls. Despite the lack of documentation in 

PO files, most grantees we interviewed reported having regular 

communication, via phone or e-mail, with their POs. Seventeen of the 

25 grantees confirmed that their PO conducted regularly scheduled 

conference calls, and 7 noted that these calls included a set agenda.

 

34Early in our review, HRSA told us that POs were to conduct quarterly conference calls 

with their grantees. In June 2011, POs were told that they were to contact their grantees 

monthly using a conference call template covering a set of monitoring topics. Because this 

change occurred after the start of our review period, we assessed files based on calls at 

least quarterly. HRSA later told us, however, that POs have always had to conduct and 

document monthly calls with grantees, but that this was not consistently adhered to prior 

to June 2011.
 

Page 17 GAO-12-610 Ryan White CARE Act Oversight

Some grantees told us that TA was not helpful because POs sometimes 

provide conflicting or delayed guidance. TA is a key step toward 

addressing grantee challenges with program implementation identified 

during routine monitoring. Though eight grantees described occasions 

when they received helpful TA from HRSA staff or contractors, eight 

noted that PO responses to their questions were sometimes delayed or 

inconsistent with past verbal guidance provided by their current or a past 

PO, making it difficult for them to understand what changes were needed. 

For example, one grantee told us it takes an excessive amount of time for 

their PO to answer their questions, and another said that PO 

responsiveness varied.

Further, four of the 25 grantees said they were told that HRSA could not 

provide needed TA due to budget constraints, forcing the grantees to 

seek TA from other sources or using their own administrative funds. 

Three of those grantees told us that they hired TA providers using their 

administrative funds, but one added that the TA cost $30,000 out of their 

limited administrative budget, which they noted might not be an option for 

many grantees. The CARE Act requires that grantees spend no more 

than 10 percent of their grant on administrative activities, which include 

TA and service provider monitoring activities. Three other grantees told 

us they turned to NASTAD for TA when HRSA could not provide it or 

when PO responses to their questions were delayed.35

We found that 6 of the 25 grantee files we reviewed from 2010 and just 2 

of the 25 files from 2011 contained documentation of TA reports and that 

few files contained documentation of PO discussions of corrective actions 

with grantees. HHS guidance states that monitoring activities and any 

resulting follow-up on identified performance issues must be documented, 

and issues are to be addressed as soon as possible by providing TA and 

ensuring grantees take needed corrective actions. Three grantees told us 

Some grantees 

noted that HRSA had provided assistance through national TA calls and 

webinars, and one added that calls and webinars were a useful substitute 

for on-site TA when travel funds are limited. One grantee explained that 

they received helpful TA from their PO by phone after a planned TA visit 

by the PO was cancelled by HRSA due to constrained travel funds.

 

35HRSA currently has a 3-year cooperative agreement with NASTAD to provide TA to 

ADAPs regarding issues including client waiting lists, cost containment, and other financial 

challenges. NASTAD also maintains a listserv to facilitate peer-to-peer TA between Part B 

grantees.
 

Page 18 GAO-12-610 Ryan White CARE Act Oversight

that PO follow-up on TA was vague or delayed, though two grantees told 

us that their POs did conduct follow-up on TA in monthly conference calls. 

Two grantees told us that though they informed HRSA in writing of their 

proposed action steps in response to TA recommendations, HRSA did 

not provide feedback on their proposed corrective actions. Another 

grantee said that they were unable to address site visit findings due to a 

lack of timely TA related to the findings.

Some grantees said that their need for TA was exacerbated by the lack of 

a current program manual. For example, one grantee explained that a 

manual would help them with matters such as grantee reports. HRSA 

officials confirmed that the most recent Part A and Part B manuals were 

issued in 2006, and stated that these printed manuals were not updated 

to reflect the 2009 CARE Act reauthorization. While HRSA officials stated 

that policies and procedures had been made available on the CARE Act 

website, they acknowledged that information for grantees is not available 

in the form of a comprehensive program manual similar to the printed 

manual that was last provided in 2006. Seven grantees noted that more 

written guidance, including an up-to-date electronic program manual, 

would help them with many of their routine questions or TA needs, which 

often revolve around questions about CARE Act program requirements. 

Two grantees added that such written guidance would be especially 

beneficial for new grantee staff or newer grantees. Further, one of the 

service providers we spoke with stated that it did not find the HRSA 

website to be helpful because links were not always kept up to date. The 

Comptroller General of the United States’ Domestic Working Group found 

that establishing departmentwide policies and procedures on an internet 

site is beneficial to grantees because it allows grantees to find detailed 

information in a single location.36

 

36The Comptroller General of the United States’ Domestic Working Group. Guide to 

Opportunities for Improving Grant Accountability (Washington, D.C.: October 2005). The 

Domestic Working Group was established in 2001 and is chaired by the Comptroller 

General of the United States. This group consists of 19 federal, state, and local audit 

organizations. The purpose of the group is to identify current and emerging challenges of 

mutual interest and explore opportunities for greater collaboration within the 

intergovernmental audit community. Providing a guide to address grant accountability was 

one such challenge.

HRSA officials said that they recently 

issued a survey to obtain feedback from grantees about HRSA’s program 

operations and processes, including the frequency and timeliness of PO 

communication with grantees and their satisfaction with TA provided by 

HRSA through conference calls, the HRSA website, and HRSA 
 

Page 19 GAO-12-610 Ryan White CARE Act Oversight

contractors. They said that they plan to use the results of this survey to 

improve their interactions with grantees.

HRSA did not follow its own policies for selecting the grantees it visited 

from 2008 through 2011, and varied in its timeliness for providing site visit 

follow-up. According to HRSA officials, the agency cannot visit all of its 

111 Part A and Part B grantees each year due to staff and budget 

constraints. Therefore, it is necessary for HRSA to be strategic in 

selecting which grantees to visit in any given year. HRSA does not have 

written guidance describing its policy for the selection of grantees to visit; 

however, agency officials told us that they prioritize site visits based on 

two elements—grantees without a recent site visit and grantees with 

problems. In addition, the Monitoring Grants and Cooperative 

Agreements for Federal Personnel manual, which accompanies a federal 

course which HRSA has offered to its employees for several years and 

requires all new POs to take suggests that agencies should determine 

which grantees to visit based on an analysis of risk, which may include 

the two elements HRSA told us it uses, as well as a consideration of grant 

funding level, among other things. However, our review of HRSA site visit 

data suggests that HRSA did not consistently select the grantees it visited 

based on these three elements.

First, HRSA did not prioritize site visits based on the amount of time that 

had passed since a grantee’s last visit. Specifically, although many HRSA 

POs we spoke with said that site visits were a valuable and effective form 

of oversight, we found that 44 percent of all Part A and Part B grantees 

did not receive a site visit from 2008 through 2011. In addition, 6 of the 

25 grantees we interviewed told us that there had been a significant 

amount of time between HRSA site visits they had received or since their 

most recent site visit, ranging from 5 to 12 years. One of these grantees 

said that its first HRSA site visit after 12 years led to the grantee being 

placed on restrictive drawdown. Grantee officials said that they believed 

that if HRSA had not waited 12 years to conduct a site visit there would 

have been far fewer findings because they would have been making 

necessary adjustments with each periodic site visit. An additional 

indication that HRSA does not consider time since last visit when 

scheduling site visits is the fact that HRSA does not maintain a 

centralized list of site visits that have been conducted. In order to provide 

data on their site visits for the purpose of our review, HRSA extracted 

data from travel records. Without centralized site visit data, HRSA would 

not be able to readily track this element when determining which grantees 

to visit

HRSA Did Not Prioritize Site 

Visits Strategically 
 

Page 20 GAO-12-610 Ryan White CARE Act Oversight

Second, HRSA did not always appear to prioritize site visits based on a 

grantee’s history of problems. Based on HRSA data, we found that 

30 percent of all Part A and Part B grantees with a history of problems did 

not receive a single HRSA site visit from 2008 through 2011.37

Third, some of the grantees that HRSA visited most during these 4 years 

had relatively small grant awards, indicating fewer people being served by 

that grantee, which suggests that the agency did not prioritize site visits 

based on grant funding level. For instance, the Virgin Islands received 

approximately $1 million in 2011 CARE Act Part B funding, based on an 

estimated 568 living HIV/AIDS cases at the end of 2009, but HRSA 

conducted six site visits there over 4 years. In contrast, California 

received the second largest 2011 grant award, approximately 

$150 million, based on an estimated 117,869 living HIV/AIDS cases at the 

end of 2009, but HRSA did not conduct any site visits there over the 

4 years. See table 1 for the Part A and Part B grantees with the most 

HRSA site visits and their 2011 grant award and estimated HIV/AIDS 

cases, and see appendix II for a complete listing of this information for all 

Part A and Part B grantees. HRSA officials explained that the Virgin 

Islands had been placed on restrictive drawdown and had a history of 

severe problems that included both fiscal and administrative issues and 

problems with service delivery. However, other Part B grantees, with 

significantly larger grant awards, and a history of problems during the 

period covered by our review did not receive a HRSA site visit. 

Furthermore, the District of Columbia, which received approximately 

In addition, 

only three of the nine Part A and Part B grantees with the most HRSA site 

visits from 2008 through 2011 had been placed on restrictive drawdown. 

While HRSA visited these grantees three or more times, other grantees 

that were placed on restrictive drawdown received two or fewer HRSA 

site visits during these 4 years. Although HRSA officials told us that 

restrictive drawdown is not the only indication of grantee problems, they 

said they impose it when the grantee has a history of serious problems. 

We found that some grantees with numerous site visits had not been 

placed on restrictive drawdown, while other grantees with fewer site visits 

had. In fact, two grantees that were placed on restrictive drawdown in 

2011 did not have a HRSA site visit at any time from 2008 through 2011.

 

37We considered a grantee to have a history of problems if it had been placed on 

restrictive drawdown, had a relevant finding in their annual single audit, or both from 2008 

through 2011, based on data HRSA provided. HRSA officials noted that there could be 

other indications of grantee problems.
 

Page 21 GAO-12-610 Ryan White CARE Act Oversight

$21 million in 2011 CARE Act Part B funding based on an estimated 

17,250 living HIV/AIDS cases at the end of 2009, had a history of 

problems and would require HRSA to spend little in travel funds to 

conduct site visits, but received only one visit over the 4 years. HRSA 

officials stated that there is no direct correlation between the amount of 

grant funding and the size of a grantee’s problems. However, because 

the Part A and Part B grant awards are based on the number of reported 

living HIV/AIDS cases in each metropolitan area or state, the grantees 

with larger awards serve more affected people.

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

2011 grant award

Estimated living 

HIV/AIDS cases

Total number of HRSA 

site visits, 2008 - 2011 a

Part A grantees

Caguas, P.R. $1.5 million b 1,310 6

Detroit, MI

c

$8.9 million 9,341 3 

Memphis, TN $6.5 million 6,911 3 

Middlesex, NJ $2.5 million 2,831 3 

Ponce, P.R. $1.8 million 1,929 7

San Juan, P.R.

c

$15 million 11,291 9

Part B grantees

c

Pennsylvania $43 million 33,661 3 

Puerto Rico $31 million 18,172 10

Virgin Islands

c

$1.2 million 568 6 

Source: GAO analysis of HRSA data

Note: For Part A, 2011 grant awards ranged from approximately $1.8 million to $121 million. For 

Part B, 2011 grant awards ranged from the statutory minimum of $50,000 for U.S. territories other 

than Guam and the Virgin Islands to $162 million. See app. II for the number of HRSA site visits for all 

Part A and B grantees.

a

Estimated living HIV/AIDS cases as of December 31, 2009. These case counts were used to 

calculate the 2011 grant award.

b

Caguas, Puerto Rico lost its classification as a TGA before the 2011 grant year, so the award 

amount listed is from grant year 2010, the estimated living HIV/AIDS cases are as of December 31, 

2008, and the total number of site visits are from 2008 through grant year 2010.

c

HRSA officials explained that when HRSA staff made trips to Puerto Rico, they generally tried to 

include stops at one or multiple Part A grantees and/or the Part B grantee. For example, a March 

2009 trip to Puerto Rico included a site visit to the Part B grantee, to the San Juan Part A grantee, 

and to the Caguas Part A grantee. From 2008 through 2011, HRSA made 12 separate trips to Puerto 

Rico.

Furthermore, HRSA often was not timely in providing site visit follow-up to 

grantees. HHS guidance states that agencies are to document in writing 

site visit reports to grantees as soon as possible after completion of the 

visit. At the time of our file review, HRSA did not have guidance for POs 
 

Page 22 GAO-12-610 Ryan White CARE Act Oversight

specifying time frames with which to provide site visit reports. Our file 

review for grant years 2010 and 2011 found that 12 of the PO files for the 

13 grantees that received site visits that occurred during that time period 

contained a copy of the site visit report. However, many of the grantees 

we interviewed that had a HRSA site visit during the period of our review 

said that it took HRSA a long time to provide the site visit report. 

Specifically, 15 of the 25 grantees we interviewed told us they had a 

HRSA site visit from 2008 through 2011. Eight of those 15 grantees said 

that it took over 30 days to receive the site visit report; it took HRSA 

4 months or longer to provide 6 of those grantees with the site visit report. 

In a December 2011 update to its Operations Manual, which was not in 

place during the majority of the period covered by our review, HRSA 

specified that POs are to provide site visit reports to grantees within 

30 days of the visit.

Some POs we interviewed said that they were not always aware of 

grantees’ single audit findings or corrective actions developed in 

response to audit findings. According to HHS guidance, HRSA is to 

review annual single audit reports as part of its grantee oversight, and 

may use annual single audit information in decisions about implementing 

special award conditions such as restrictive drawdowns. Though DFI is 

the HRSA division primarily responsible for helping to ensure that 

grantees take appropriate corrective actions in response to single audit 

findings, POs, within HAB, are responsible for providing overall 

monitoring of grantees’ compliance with program requirements. We have 

found in past work that audits may provide important information on 

grantee performance and can serve as an accountability mechanism to 

help determine whether grantees used funds in accordance with program 

rules and regulations.38

However, some POs told us that DFI does not consistently share 

information about single audit findings and corrective actions. Though 

POs are able to access a summary of a grantee’s HRSA-related single 

audit findings in EHB, the EHB summary does not specify whether the 

findings are related to CARE Act programs in particular, which might 

make it difficult for POs to determine whether the audit contains 

For this reason, PO monitoring could be 

enhanced by the timely review of single audit findings.

 

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

March 2002).

POs Did Not Always Review 

Annual Single Audit Findings
 

Page 23 GAO-12-610 Ryan White CARE Act Oversight

information pertinent to their monitoring efforts without explanation from 

DFI. DFI officials told us they may contact POs or other HRSA staff to 

help review and ensure the adequacy of grantee corrective actions, but 

according to POs they do not always do so. Given their knowledge of 

grantees through routine monitoring activities, POs could provide DFI with 

valuable input regarding grantees’ corrective actions. However, one PO 

told us that DFI did not notify her when the grantees in her portfolio had 

audit findings, and another told us that DFI did not consistently share 

grantee corrective action plans in response to audit findings with her, 

though DFI might on occasion alert her if there was an issue with a 

grantee audit. One PO reported that she was recently consulted by DFI to 

provide input into a grantee’s audit findings, but added that this was the 

first time such consultation had occurred. HRSA officials said that they 

have enhanced the ways in which DFI communicates audit information to 

POs through EHB by including citations about audit findings specific to 

CARE Act programs along with grantee corrective actions designed to 

address the findings. HRSA officials said that they began doing this as of 

April 30, 2012.

The lack of consistent communication about single audit findings across 

HRSA divisions limits opportunities for POs to incorporate single audit 

information into their monitoring and help HRSA ensure that grantees 

take timely and effective corrective actions, as required. This is especially 

important given that HRSA may on occasion use single audit findings as 

a basis for implementing restrictive drawdowns, which require POs to 

work with grantees in reviewing financial information as part of grantees’ 

drawdown requests, even if the restrictive drawdown was recommended 

by DFI. In addition, opportunities for POs to help grantees implement 

timely corrective actions may also be affected by the lengthy time frames 

of the single audit process. For example, DFI officials told us that a 

grantee may be cited for a repeat finding in an audit before they have had 

time to correct the finding from the prior year’s audit. We previously 

reported that in the Single Audit process it could take 15 months or more 

from the end of the fiscal year in which an audit finding is initially identified 

before a grantee’s corrective action plan is approved by the responsible 

federal agency.39

 

39GAO, Federal Grants: Improvements Needed in Oversight and Accountability 

Processes, 

Thus, in some cases, grantees may not have the 

opportunity to correct audit findings and POs may not have the 

GAO-11-773T (Washington, D.C.: June 2011).
 

Page 24 GAO-12-610 Ryan White CARE Act Oversight

opportunity to help ensure that the grantee corrects audit findings before 

the following year’s audit is conducted.

Though single audits may contain information important to PO monitoring 

of grantees such as an assessment of how grantees are monitoring their 

service providers or whether the grantee is properly documenting client 

eligibility, some grantees told us that neither POs nor other HRSA staff 

generally communicate with them about single audits. Six grantees said 

that they did not recollect having any communication with HRSA about 

audit findings, though five others noted they had discussed audit findings 

with HRSA staff on at least one occasion, including one who said they 

discussed their annual single audit with HRSA staff during a site visit. 

Three POs told us that grantees sometimes initiate communication about 

their single audits. For example, one PO said that although she generally 

does not get involved with the audits or receive information from DFI, she 

had been contacted by one of her grantees regarding an audit finding, 

and therefore reviewed the proposed corrective actions as part of her 

routine monitoring.

HRSA often did not communicate or document the reasons for 

implementing a restrictive drawdown. Only 2 of the 11 grantees from our 

sample of 25 that were on restrictive drawdown said that HRSA 

communicated the reasons they were placed on restrictive drawdown. In 

five cases, the grantee said they only learned about the restrictive 

drawdown upon receiving a new NOA, without prior warning or 

explanation from their PO or other HRSA staff. Though the issuance of a 

new NOA is the official means of notifying the grantee of the new 

condition on their grant award, NOAs do not enumerate the reasons for 

the restrictive drawdown. Though HRSA officials stated that grantees 

were notified verbally or in some cases by e-mail about their restrictive 

drawdown status, we found that the PO files for many of the 11 grantees 

in our sample that were on restrictive drawdown did not contain 

documentation of the reasons the restrictive drawdown was imposed. 

Federal regulations state that when an agency implements a condition on 

a grantee award such as a restrictive drawdown, it is to notify the grantee 

of the nature of the condition and the reason it is being imposed, and 

HHS guidance states that the agency is to document the reasons for use 

HRSA Did Not Clearly 

Communicate with Grantees 

about the Restrictive 

Drawdown Process
 

Page 25 GAO-12-610 Ryan White CARE Act Oversight

of the condition in the grant file.40 According to HRSA, 6 of the 52 Part A 

grantees and 13 of the 59 Part B grantees were on restrictive drawdown 

from 2008 through 2011.41

HRSA also has not consistently provided grantees placed on restrictive 

drawdown with instructions about how to meet the conditions for drawing 

down funds. HHS guidance states that the agency is to explain the nature 

of, and requirements for meeting, the conditions of the restrictive 

drawdown. However, 5 of the 11 sampled grantees that were on 

restrictive drawdown told us that HRSA did not provide clear instructions 

at the time the restriction was imposed for submitting drawdown requests 

or the supporting documentation they were required to submit with each 

request. Four grantees said that when they were first put on restrictive 

drawdown, they had to repeatedly submit their drawdown requests to 

their PO before clear expectations were established. One grantee said 

that they believed that HRSA was “making up the rules about restrictive 

drawdown as they went along,” and another stated that they received no 

guidance or written instruction specifying the documentation required as 

part of a drawdown request, which caused delays in the processing of 

their requests.

Further, HRSA has not consistently provided grantees with guidance on 

the types of corrective actions needed, including time frames for making 

the required changes, in order to have the restrictive drawdown removed. 

Federal regulations state that needed corrective actions and timelines are 

to be explained to the grantee at the time a restrictive drawdown is 

implemented. Most of the grantees in our sample said that they were not 

given a written set of action steps or specific corrective actions needed in 

 

40Federal regulations also specify that when the agency awarding a federal grant imposes 

conditions on a grantee award such as restrictive drawdowns, the agency will notify the 

grantee in writing of the nature of the condition, the reasons for imposing it, the required 

corrective actions and time frames for completing them, and the method for requesting 

reconsideration of the conditions. HRSA’s recently issued guidance, though not in effect 

during the period of our review, also states that POs are to document their reasons for 

recommending that a grantee be placed on restrictive drawdown. 

41Though HRSA has reported that, in accordance with HHS guidance, the GMO/GMS and 

PO work together in monitoring grantees through activities including reviews of grantee 

reports and drawdown requests related to restrictive drawdowns, most of the grantees we 

interviewed told us that they had minimal interaction with their GMS. Though GMO/GMSs 

and POs may work together to resolve grantee issues within HRSA, HRSA told us that 

POs are the HRSA staff with the most direct interaction with grantees.
 

Page 26 GAO-12-610 Ryan White CARE Act Oversight

order to have the restrictive drawdown removed. For example, one 

grantee told us that although they are willing to do what is needed to have 

the restriction removed, HRSA has not provided them with a set of 

requirements and timelines either verbally or in writing. Another grantee 

said that HRSA did not offer training to the grantee on the requirements 

for its restrictive drawdown until over a year after the condition was 

imposed. A third grantee stated that though after the restrictive drawdown 

process they made a change that will help them hold their service 

providers more accountable, the process would have been more 

beneficial had they been given a clear picture of the end goals at the 

outset. 

HRSA officials said that when a restrictive drawdown is lifted, the grantee 

is to be notified through a new NOA which is signed by the GMO. HRSA’s 

recently issued guidance states that the agency will revisit a grantee’s 

restrictive drawdown status once the grantee completes steps such as 

submitting documentation of compliance with corrective actions, 

completing recommended TA, and implementing a corrective action plan 

developed as part of a site visit. However, HRSA has lifted the restrictive 

drawdown condition for only two of the grantees in our sample since this 

guidance was in place, and it is unclear whether HRSA provided grantees 

with a clear plan for the removal of the condition even upon completion of 

recommended TA or corrective actions. One grantee explained that each 

time they made the changes requested by HRSA, they were given a new 

set of requirements to meet. For example, according to a TA report by 

HRSA consultants about 1 month after the restrictive drawdown was 

implemented, the grantee had taken important steps to address its 

financial challenges. Further, documents provided by the grantee indicate 

that following the consultant TA report, the PO indicated he would 

recommend that the grantee be removed from restrictive drawdown. 

However, despite documenting its ongoing work to address its financial 

challenges, the grantee was told more than a month later that further 

steps would be required before the condition would be removed, and the 

grantee remained on restrictive drawdown for approximately 4 more 

months. The grantee stated that they were not clearly told what they 

could do to have the condition removed despite repeated requests for that 

information, and that the costs to the program of remaining on restrictive 

drawdown interfered with the possible benefits.

HRSA officials said that HRSA is revising the restrictive drawdown 

language to be included in the NOA to include the reasons for the 

restriction, needed corrective actions, and the type of documentation 

required for the drawdown requests to be processed, and would begin 
 

Page 27 GAO-12-610 Ryan White CARE Act Oversight

using this updated language on NOAs for grantees placed on restrictive 

drawdown after May 1, 2012. HRSA officials said that grantees are to be 

informed in writing of all conditions on their awards and how to proceed in 

order to have the conditions removed. They said that, where that is not 

occurring, they will work to ensure that it does.

We found that HRSA did not always provide grantees with additional TA 

or time to correct deficiencies before placing them on restrictive 

drawdown. HHS guidance states that an agency will generally afford the 

grantee an opportunity to correct any deficiencies before imposing 

conditions such as restrictive drawdown. Two grantees told us they were 

placed on restrictive drawdown after a site visit, but one noted that they 

were not given an opportunity to address the site visit findings before 

being placed on restrictive drawdown. The grantee stated that they 

submitted a corrective action plan in response to site visit findings 

approximately 2 months after receiving the site visit report, but according 

to HRSA the grantee was placed on restrictive drawdown right after the 

plan was submitted, suggesting the grantee did not have an opportunity 

to implement the corrective action plan before the condition was put in 

place. 

HRSA has stated that the restrictive drawdown process is a means of 

doing more intensive monitoring of grantees experiencing problems with 

program implementation, financial management, or other administrative 

issues. Two of the grantees in our sample told us that they had more 

frequent communication with their PO during monitoring calls or through 

e-mails after restrictive drawdown was implemented. In some cases, 

however, the restrictive drawdown process may have exacerbated a 

grantee’s existing challenges. For example, one grantee said they were 

told that they were put on restrictive drawdown because they had an 

unobligated balance that resulted from not spending funds at a quick 

enough pace. However, the grantee told us that, in part due to a lack of 

clear instructions from HRSA, the restrictive drawdown process caused 

further delays in their ability to spend grant funds and therefore 

aggravated the unobligated balance problem. In another case, a HRSA 

financial TA consultant reported that the restrictive drawdown itself was 

causing delays in a grantee’s ability to spend its grant funds, which the 

consultant feared might lead to a finding in the grantee’s next single audit.
 

Page 28 GAO-12-610 Ryan White CARE Act Oversight

HRSA’s lack of records and frequent staff changes in PO assignments 

further challenge the agency’s oversight of grantees. HRSA officials told 

us that records of grantee oversight are located across three types of the 

agency’s files— HRSA’s EHB, which includes official NOAs and required 

reports, annual single audit reports, and PO files, which include 

monitoring documentation, such as notes from routine calls and TA, and 

site visit reports—not just those documents available electronically in 

HRSA’s EHB. Therefore, we consider all three of these files together to 

be a complete record of grantee oversight. While conducting our file 

review, we found that this complete oversight record was only maintained 

for the current and previous grant years because, prior to that, consistent 

with its records management program, HRSA destroyed documentation 

of grantee monitoring only available in the paper PO files. At the time of 

our file review midway through the 2011 grant year, all three grantee files 

were only available for the first half of grant year 2011 and grant year 

2010, which was only approximately a year and a half of documentation. 

Therefore, HRSA’s ability to correct previously noted problems with 

grantee performance could be limited because easily accessible 

documentation of such problems was not maintained. In fact, a HRSA 

official told us that he believed that one grantee with a history of problems 

should be placed on restrictive drawdown. However, HRSA did not take 

this step because they had destroyed the site visit reports containing 

findings that would have supported placement on restrictive drawdown. In 

a December 2011 update to HRSA’s Operations Manual, which was not 

in place during the majority of our review, HRSA specified that POs are to 

maintain copies of site visit reports for at least 5 years, and any 

documents related to issues under investigation for as long as necessary. 

However, this change does not apply to other key documentation in PO 

files, such as regularly scheduled conference calls and copies of relevant 

emails.

Furthermore, frequent PO changes in monitoring assignments could 

compound the challenges created by HRSA’s lack of long-standing 

documentation and possibly limit HRSA’s institutional memory for a given 

grantee. Specifically, according to HRSA data, from 2008 through 2011, 

HRSA’s Lack of Records 

and Changes in PO 

Assignments Further 

Challenge Its Oversight of 

CARE Act Grantees
 

Page 29 GAO-12-610 Ryan White CARE Act Oversight

93 of the 111 Part A and Part B grantees had at least two or three 

different POs and 2 grantees had four different POs during this time.42

HRSA’s frequent changes in PO assignments could leave a recently 

transitioned PO and his new grantee at a disadvantage. For example, 

during our file review, we found that one of the grantees in our sample, a 

grantee with a history of problems that had been placed on restrictive 

drawdown, was missing documentation of monitoring calls for the 2010 

grant year. That grantee’s current PO began monitoring the grantee near 

the beginning of the 2011 grant year and she explained that she did not

receive documentation of any monitoring calls that had occurred under 

the previous PO.

Some of the grantees we interviewed said that frequent PO changes 

resulted in variation in HRSA oversight. Eight of the 25 grantees we 

spoke with expressed concern about changes in their POs and 13 

described the variation in PO monitoring styles that grantees had to 

adjust to when a new PO was assigned. For example, 1 grantee that had 

three POs from 2008 through 2011 told us that the PO changes resulted 

in delayed responses from HRSA and contradictory information being 

provided by different POs, which created confusion for the grantee and 

delays in funding distribution to service providers. Conversely, a grantee 

that had one PO during this time period told us that having a 

knowledgeable PO who serves for a long period of time creates better 

management of the grant because the PO develops important institutional 

memory about the grantee and its program.

 

42Four Part A grantees lost their classification as TGAs before the 2011 grant year. Of 

these four grantees, one had a single PO from 2008 through 2011, two had two POs 

during this time period, and one had three POs during this time period.
 

Page 30 GAO-12-610 Ryan White CARE Act Oversight

Federal regulations require grantees to oversee service providers and, in 

April 2011, HRSA issued the National Monitoring Standards, a 

compilation of requirements for grantee monitoring of service providers. 

Some grantees said that their implementation of the standards was 

hindered by insufficient HRSA assistance and the annual site visit 

requirement.

Federal regulations require grantees to oversee service providers. HRSA 

told us that grantees are required to report to HRSA on their approach to 

service provider monitoring activities in annual grant applications. HRSA 

also verifies this information through grantee site visits and a review of a 

list of service providers, which grantees are required to submit annually.43

In April 2011, HRSA issued the National Monitoring Standards, which it 

describes as a compilation of existing requirements for grantee 

monitoring of Part A and Part B service providers. The standards include 

The number of service providers for Part A and Part B grantees ranges 

greatly. For example, Nebraska had only 3 service providers in 2011, 

whereas New York had 83 providers. Grantees we interviewed said they 

use a variety of tools to monitor their service providers, including frequent 

phone and e-mail communication, monthly service provider meetings, site 

visits, training, or reviews of financial and program reports. Specifically, 

most of the 25 grantees we interviewed told us that they are in at least 

monthly, if not daily, communication with their service providers. In 

addition, all but four grantees conduct service provider site visits at least 

annually. Of the four grantees that were not conducting site visits 

annually, two large states conducted site visits every 2 years, with one of 

those states visiting service providers with performance issues more 

frequently; one midsize state conducted site visits every 3 years; and one 

small state had not conducted site visits in many years. However, all but 

one of these grantees were in the process of beginning annual site visits 

at the time of our interview.

 

43This list of service providers is called the Consolidated List of Contractors. For a 

description of this reporting requirement, see app. I. 

HRSA Recently Issued 

National Standards 

for Grantee 

Monitoring of Service 

Providers, but HRSA’s 

Implementation 

Created Challenges 

for Grantees

Grantees Monitor Service 

Providers and HRSA 

Recently Issued National 

Standards 
 

Page 31 GAO-12-610 Ryan White CARE Act Oversight

133 requirements for Part A grantees and 154 requirements for Part B 

grantees. These standards describe program and financial requirements, 

program-only requirements, and financial-only requirements. (See 

table 2.)

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

of Service Providers 

Type of National Monitoring Standard 

Number of Part A 

standards

Number of Part B 

standards

Program and financial monitoring standards 19 19

Program-only monitoring standards 51 65

Financial-only monitoring standards 63 70

Total 133 154

Source: HRSA

According to HRSA, these standards consist of preexisting requirements 

for program and financial management, monitoring, and reporting that are 

based on federal statutes, regulations, and program guidance and 

consolidates these requirements into one location to assist grantees. 

Table 3 provides examples of the standards.
 

Page 32 GAO-12-610 Ryan White CARE Act Oversight

Table 3: Examples of HRSA’s National Monitoring Standards and Grantee Responsibilities for Part A and Part B Grantee 

Monitoring of Service Providers, by Topic 

National Monitoring 

Standards topic Example of a standard from selected topicsa

Examples of grantee responsibilities to 

ensure service provider compliance with 

 the standard 

Examples of program and financial monitoring standards 

Access to care Grantee must ensure that services are provided by 

the service provider regardless of the current or past 

health condition of clients. 

• Review provider eligibility policies.

• Investigate any relevant provider 

complaints. 

Eligibility Grantee must ensure that service providers screen 

and reassess client eligibility as specified by the 

EMA, TGA, state, or ADAP every 6 months. 

• Establish an EMA, TGA, or statewide 

process for determining client eligibility.

• Conduct service provider site visits to 

review client files for appropriate 

documentation of eligibility. 

Monitoring Grantee service provider monitoring activities are 

expected to include annual site visits. 

• Use a combination of program reports, 

annual site visits, client satisfaction 

reviews, technical assistance, and chart 

reviews to monitor service provider 

program compliance. 

Examples of program-only monitoring standards 

Core medical services Grantee must ensure that oral health services 

include diagnostic, preventive, and therapeutic 

dental care that is in compliance with dental practice 

laws, includes evidence-based clinical decisions, is 

based on an oral health treatment plan, adheres to 

specified service caps, and is provided by licensed 

and certified dental professionals. 

• Develop a request for proposal and 

contract for the provision of oral health 

that specifies program requirements, 

including that services cover diagnostic, 

preventive, and therapeutic oral health 

services.

• Review client charts for compliance with 

contract and program requirements. 

Support services Grantee must ensure that health education and risk 

reduction services are provided to educate clients 

living with HIV about HIV transmission and how to 

reduce the risk of HIV transmission.

• Develop a request for proposal and 

contract that defines risk reduction 

counseling.

• Review provider data to determine 

compliance with contract. 

Other service requirements Grantee must ensure that service providers set 

aside specific amounts for care of women, infants, 

children, and youth based on the population’s 

relative percentage of the total number of persons 

living with AIDS in the EMA, TGA, or state.b

• Track and report the amount and 

percentage of CARE Act funds 

expended for each population group 

separately.

 

Examples of financial-only monitoring standards 

Limitations on uses of funding Grantee must ensure that service providers assign 

appropriate expenses as administrative expenses, 

such as usual and recognized overhead activities 

(rent, utilities, and facility costs).c

• Maintain file documentation on all 

service providers, including current 

operating budgets and allocation reports 

that include sufficient detail to identify 

and calculate administrative expenses.

 

• Review service provider expense reports 

to ensure that all administrative costs are 

allowable. 
 

Page 33 GAO-12-610 Ryan White CARE Act Oversight

National Monitoring 

Standards topic Example of a standard from selected topicsa

Examples of grantee responsibilities to 

ensure service provider compliance with 

 the standard 

Income from fees for services 

performed 

Grantee must ensure that service providers are 

using third party funds, such as Medicaid, the 

Children’s Health Insurance Program, Medicare, and 

private insurance, to maximize program income and 

ensure that Ryan White is the payer of last resort. 

• Establish and implement a process to 

ensure that service providers maximize 

third party reimbursements by, for 

example, requiring service providers to 

document in client files how each client 

was screened for and enrolled in eligible 

insurance programs. 

Imposition and assessment of 

client charges 

Grantee must ensure that no charges are imposed 

on clients with incomes below 100 percent of the 

Federal Poverty Level.

• Review service provider discount fee 

policy, criteria, and forms. d

• Review client files and documentation of 

actual charges and payments. 

Source: HRSA

a

This table lists examples of HRSA’s National Monitoring Standards and is not an exhaustive list of 

each standard.

b

A women, infants and children waiver is available if the grantee can document that funds sufficient to 

meet the needs of these population groups are being provided through other federal or state 

programs.

c

Grantees must ensure that service providers adhere to the requirement that aggregated 

administrative expenses do not total more than 10 percent of CARE Act service dollars.

d

Federal poverty level refers to the federal poverty guidelines which are used to establish eligibility for 

certain federal assistance programs. HHS publishes these guidelines on an annual basis, updating 

the guidelines to reflect changes in the cost of living and variations according to family size.

More than half of the 25 grantees from our sample said that they found 

the training and/or TA HRSA has provided on the National Monitoring 

Standards to be insufficient because it has not answered all of their 

questions about HRSA’s expectations for how they should implement the 

standards. According to HRSA officials, HRSA has offered two webinars, 

a national TA call, and workshops at an all-grantees meeting to assist 

grantees. Some grantees told us HRSA also discussed the standards 

during a recent administrative meeting. Further, 5 of the 10 POs we 

interviewed told us they had discussed implementation of the standards 

with grantees during routine monitoring. Five grantees told us they had 

asked for more in-depth TA on the standards but had not received it. One 

grantee, however, did receive additional TA by phone from a HRSA 

branch chief targeted to all Part A and Part B providers in the grantee’s 

state. Although HRSA stated that it would provide sample tools to 

demonstrate how grantees could best meet certain standards, several 

grantees indicated that HRSA had not done so. According to most 

grantees, inadequate training, TA, or both makes it more difficult to 

understand HRSA’s expectations and be assured that they are 

adequately implementing the standards, which they were required to put 

into practice immediately upon their release in April 2011. HRSA officials 

Implementation of 

Monitoring Standards 

Hindered by Insufficient 

Assistance from HRSA and 

Challenged by the Annual 

Site Visit Requirement
 

Page 34 GAO-12-610 Ryan White CARE Act Oversight

said that they believe that the webinars, conference call, and 

presentations they have made at grantee meetings have provided 

grantees with useful assistance in implementing the standards. They 

further noted that the standards do not represent new requirements and 

therefore should have been familiar to grantees. However, in its survey of 

grantees, discussed earlier in this report, HRSA asked grantees about 

their training needs and any additional information needs they might have 

regarding a variety of issues, including the standards.

Seven grantees expressed particular concern about the annual site visit 

requirement outlined in the standards, which two of them noted is 

especially challenging for grantees with a large number of providers 

across a large geographic area or in states with limited staff resources. 

Two of those grantees said that the new standard would require them to 

change site visit processes that had proven effective over time. They told 

us that they conduct routine site visits based on an assessment of risk; if 

they determine through regular monitoring that a provider has more 

performance issues than other providers, they will prioritize a site visit to 

that provider or visit that provider more frequently. They said that the 

requirement to visit every service provider annually, regardless of their 

performance, will not allow them to continue with this approach. One 

grantee with approximately 140 service providers told us that meeting the 

annual site visit requirement would be impossible given the grantee’s 

large number of providers and limited staff and administrative resources. 

One grantee told us the administrative burden of this requirement is 

exacerbated by the chart review requirements which will require grantees 

to spend more time reviewing provider documents on site, while 

sacrificing other monitoring activities focused on the quality of provider 

services. Two grantees noted that the annual site visit standard is more 

stringent than HRSA’s own standard for site visits to grantees, and that 

HRSA therefore may not have a good sense of the time and resources 

required to conduct annual site visits of all service providers. Despite 

these concerns, several grantees told us they are taking steps to comply 

with the requirement.

NASTAD has written that the standards will require some grantees to 

largely restructure current monitoring systems and force them to focus on 

administrative reviews rather than an assessment of the quality of 

services being delivered by service providers, and that the standards are 

inconsistent with the National HIV/AIDS Strategy’s goal of streamlining 
 

Page 35 GAO-12-610 Ryan White CARE Act Oversight

grant administration and reporting requirements.44 NASTAD has further 

noted that the annual site visit requirement will be especially difficult for 

grantees during a time when grantees are experiencing reductions in 

funding and staff, and that the requirement will force grantees to dedicate 

limited staff resources toward monitoring activities rather than service 

delivery. According to NASTAD, grantees may also find it difficult to 

conduct all required provider monitoring activities using only the

10 percent of their CARE Act grant allowed for administrative costs.45

Many grantees also told us that the standards increase the administrative 

burden on their programs. HRSA responded to NASTAD that grantees 

should review their current use of administrative resources to ensure they 

are efficiently using resources to meet all of the monitoring standards, 

which are simply meant to provide clarity about existing requirements. In 

light of grantees’ ongoing concerns, however, NASTAD has 

recommended that HRSA explore alternatives to the annual site visit 

requirement, including requiring a site visit every 2 years instead of 

annually. In response to NASTAD’s recommendations, HRSA has stated 

that annual provider site visits are a programmatic requirement developed 

based on federal regulations permitting HRSA to set the frequency of 

monitoring activities, including site visits. HRSA also stated that the site 

visit requirement, which is consistent for all Part A and Part B grantees, is 

based on HHS OIG recommendations that HRSA set standards for 

grantee monitoring of service providers that include some consideration 

of regular site visits.46

 

44The National HIV/AIDS strategy is a national plan for reducing new HIV infections, 

improving access to care and health outcomes for people living with HIV, and reducing

HIV-related health disparities. It is coordinated by the White House Office of National 

AIDS Policy. The July 2010 National HIV/AIDS Strategy Federal Implementation Plan 

outlines key steps for achieving strategic goals, including increasing coordination of HIV 

program across the federal government and between federal agencies and state, 

territorial, local, and tribal governments. 

NASTAD has written that because HRSA has 

45The CARE Act requires that grantees spend no more than 10 percent of their grant on 

administrative activities, which include TA and service provider monitoring activities. 

42 U.S.C. §§ 300ff-14(h), 300ff-28(b)(3). The cost of conducting service provider site visits 

must therefore be included in that 10 percent of the grant.

46U.S. Department of Health and Human Services. Office of Inspector General. 

“Monitoring of Ryan White CARE Act Title I & Title II Grantees” (Washington, D.C.: U.S. 

Government Printing Office, 2004). http://oig.hhs.gov/oei/reports/oei-02-01-00640.pdf and 

U.S. Department of Health and Human Services. Office of Inspector General. “The Ryan 

White CARE Act Title I and Title II Grantees’ Monitoring of of Subgrantees” (Washington, 

D.C.: U.S. Government Printing Office, 2004). 

http://oig.hhs.gov/oei/reports/oei-02-01-00641.pdf 
 

Page 36 GAO-12-610 Ryan White CARE Act Oversight

authority to set the frequency of monitoring activities, it should consider 

alternatives to the annual site visit requirement.

In response to grantee concerns about the standards, HRSA officials

have stated that TA may be requested through individual POs, and that it 

will provide future webinars focused on common grantee concerns, 

including the annual site visit requirement and eligibility documentation. 

HRSA officials further told us that they are encouraging collaboration 

between Part A and Part B grantees to jointly conduct site visits of 

providers that are funded by both Parts A and B to ease the burden of the 

site visit requirement. At least one larger grantee told us they will take 

advantage of that opportunity for collaboration. Some grantees stated that 

the standards are a helpful tool, and a few noted that the standards will 

help them better communicate with their service providers.

Effective oversight of CARE Act grantees and service providers is critical 

to the CARE Act’s mission of providing help for uninsured or underinsured 

individuals and families affected by HIV/AIDS. However, our findings 

show that deficiencies in HRSA’s oversight may compromise its ability to 

ensure that this program is meeting its objectives or that CARE Act funds 

are being spent properly. Even though HHS and HRSA guidance exists 

regarding the documentation and follow-up of the key elements of grantee 

oversight including routine monitoring, the provision of TA, site visits, and 

restrictive drawdown, HRSA project officers are not always following 

these guidelines. If a grantee is struggling, the lack of systematic 

provision and documentation of assistance to improve the grantee’s 

performance, and not retaining such documentation over time, present a 

great challenge to ensuring that such problems do not recur. Many HRSA 

POs we spoke with said that site visits are a valuable and effective 

oversight tool. However, in visiting some grantees multiple times while not 

visiting others, seemingly without regard to the size of the grantee or 

presence of problems, HRSA demonstrated a lack of a strategic, riskbased approach for selecting grantees for site visits. Another challenge is 

the lack of an updated and electronically available comprehensive 

program manual for grantees. Grantees said that such a manual would 

likely decrease their need to consult with POs over relatively routine 

issues. Currently, grantees must frequently seek assistance from POs 

because there is not a current and complete source of written information 

that is readily available to guide their efforts. While HRSA’s compilation of 

133 Part A and 154 Part B monitoring standards does provide grantees 

with an exhaustive set of guidelines for ensuring that their service 

providers are meeting program requirements, our findings on HRSA’s 

Conclusions 
 

Page 37 GAO-12-610 Ryan White CARE Act Oversight

own oversight of grantees provide evidence of how important training and 

follow-up are to ensure that these requirements are consistently followed. 

HRSA has provided training to assist grantees in carrying out the 

standards, but grantees said that they wanted more guidance and 

training. Among the issues about which HRSA surveyed its grantees, was 

the additional information its grantees needed regarding the standards.

In order to improve HRSA’s oversight of Part A and Part B grantees, we 

recommend that the Administrator of HRSA:

• Ensure that the agency is implementing the key elements of grantee 

oversight consistent with HHS and HRSA guidance, including routine 

monitoring, the provision of technical assistance, site visits, and 

restrictive drawdown.

• Assess and revise its record retention management program so that 

complete grantee files are available for a period of time that HRSA 

determines will satisfy all of the agency’s grantee oversight needs.

• Develop a strategic, risk-based approach for selecting grantees for 

site visits that better targets the use of available resources to ensure 

that HRSA visits grantees at regular and timely intervals.

• Update and maintain a program manual for grantees.

• Use the results of HRSA’s survey of grantees to identify grantees’ 

training needs to allow them to comply with the National Monitoring 

Standards.

We provided a draft of this report to HHS for its review, and HHS provided 

written comments (see app III). HHS concurred with all five of our 

recommendations and indicated that HRSA will work to fully implement 

the recommendations to improve oversight of Parts A and B of the CARE 

Act program. HHS also offered some specific comments in response to 

the report conclusions. HHS acknowledged that PO led site visits, 

monitoring calls, single audit reports, and the imposition of restrictive 

drawdown are central to HRSA’s routine monitoring, but added that the 

agency’s overall oversight strategy is a multilayered approach that 

involves review of items such as required grantee reports used for 

postaward monitoring, site visits, monitoring calls, review of audit reports, 

and the provision of technical assistance on all of these issues. Our 

Recommendations for 

Executive Action

Agency Comments 

and Our Evaluation
 

Page 38 GAO-12-610 Ryan White CARE Act Oversight

analysis included these elements, as well as a discussion of ways in 

which these elements intersect. We interviewed HRSA and grantee staff 

on these tools and describe in this report grantees’ observations on 

HRSA’s provision of technical assistance and feedback on the large 

number of reports that they must routinely provide to HRSA. Findings in 

this report include a detailed discussion of issues in Ryan White program 

oversight including both the execution and documentation of the elements 

listed above.

HHS also acknowledged that HRSA’s documentation of grantee 

monitoring should be strengthened, noting that during the period of 

GAO’s review, HRSA did not maintain all documentation of oversight in

one centralized file. HHS stated that HRSA has instituted a new quality 

improvement process, which strengthens both documentation standards 

and communication with grantees. HHS said that this would be done 

through an expansion of the use of the EHB as the primary centralized 

location for documentation of oversight and monitoring, including site visit 

reports. HHS said that this process will also include regular PO meetings 

to provide training, and improvements in HRSA’s records management 

practices. These steps appear to be consistent with the goals of our 

recommendations. In follow-up to its comments, HRSA provided 

additional information on the agency’s planned information technology 

development efforts to improve and expand the functionality of EHB 

between September 2012 and mid-2013.

HHS commented on statements by grantees we interviewed that 

indicated that HRSA could not provide needed TA due to budget 

constraints, forcing the four grantees to seek TA from other sources, 

using their own administrative funds. HHS described a wide array of TA 

and training services that HRSA provides to grantees. HHS also provided 

information on the extent of grantees’ use of some of these services and 

HRSA’s financial resources devoted to providing these services. HHS 

acknowledged in this discussion that, due to competing demands for 

HRSA’s TA, HRSA does, at times, recommend grantees utilize their 

CARE Act funding for TA. In its comments relevant to TA, HHS also noted 

our mention of the fact that three grantees had to turn to NASTAD for TA 

when HRSA could not provide it or when PO responses to their questions 

were delayed. HHS noted that HRSA has had a partnership with 

NASTAD in place since 1998 to provide TA to grantees. However, as we 

note in our report, the TA to be provided by NASTAD under this 

partnership is for the purpose of assisting Part B grantees with their 

ADAP. While several Part B grantees told us that they receive important 
 

Page 39 GAO-12-610 Ryan White CARE Act Oversight

assistance from NASTAD, there is no similar cooperative agreement in 

place or HRSA-recognized organization to provide TA to Part A grantees.

HHS also commented on our finding that HRSA did not prioritize site 

visits strategically. HHS stated that there can be indications of grantee 

problems beyond those that we included in our site visit analysis, which 

we acknowledged in the report. Many of the additional indicators of 

grantee problems HHS listed in its comments, such as fiscal and 

administrative challenges, are also issues that can cause grantees to 

receive annual single audit findings or to be placed on restrictive 

drawdown, the two indicators we used in our analysis. HHS then provided 

extensive detail on the issues in Puerto Rico and the Virgin Islands that 

led to grantees in those jurisdictions receiving significantly more site visits 

than other grantees that had received substantially more funding. In our 

discussion of HRSA’s site visits, we make the point that the size of the 

grant did not appear to play a major role in HRSA’s decisions about which 

grantees to visit, including among grantees experiencing problems. Many 

POs we spoke with said that site visits were a valuable and effective form 

of oversight. Because HRSA cannot visit all of its grantees each year, it 

must work to ensure that it uses this valuable tool in such a way as to 

gain as much benefit as possible. The Monitoring Grants and Cooperative 

Agreements for Federal Personnel manual that we refer to in the report 

and HHS cites in its comments lists several grant characteristics that 

should be considered in selecting projects for on-site monitoring. “Cost 

and Total Support” is the first issue listed in the manual. In our discussion, 

we did not question the presence of serious issues in Puerto Rico and the 

Virgin Islands. Our point is that even among grantees experiencing 

problems, jurisdictions with much larger grants, such as the District of 

Columbia, were not similarly prioritized for site visits, even though a site 

visit to the District of Columbia would be of low cost to the agency.

HHS commented on the prevalence of HIV/AIDS in the Caribbean as a 

justification for its numerous site visits, but we note that the size of Part A 

and B CARE Act grants is based upon the number of HIV cases that exist 

in the jurisdiction being served by the CARE Act grantee, thereby serving 

as a proxy for the prevalence of the disease in that area. Data on HRSA’s 

website indicate that CARE Act programs served 146 clients in the Virgin 

Islands in 2008, while serving 16,203 in the District of Columbia during 

the same period. HRSA’s pattern of site visits indicates that the agency 

visited some grantees with smaller grants far more often than other 

grantees with much larger grants, and thus a much higher prevalence of 

disease, that also experienced challenges in administering their grants. In 

its comments, HHS describes numerous elements of HRSA’s routine 
 

Page 40 GAO-12-610 Ryan White CARE Act Oversight

monitoring and several instances of TA directed to the District of 

Columbia. Nonetheless, it received one HRSA site visit during the period 

covered by our review as compared to the Virgin Islands, which received 

six HRSA site visits, as well as routine monitoring and TA. The District of 

Columbia’s grant was approximately $21 million while the Virgin Islands’ 

grant was $1.2 million. This suggests that HRSA did not consider the size 

of the grant in deciding which grantees to visit. While the size of the grant 

would not be the only consideration in a strategic approach to scheduling 

site visits, it should be a major consideration.

HHS’s comments also addressed the issue of PO’s awareness of single 

audit findings. HHS described how, under HRSA’s process during the 

time covered by our review, POs were to be informed about single audit 

findings. HHS described an enhancement to HRSA’s process for ensuring 

that POs are provided with a more detailed description of single audit 

findings and corrective actions taken to address the findings. HHS said 

that this improved process was put in place as of April 30, 2012, which 

was after the period covered by our review. 

In its comments, HHS also describes improvements to HRSA’s 

documentation of and communication with grantees about the restrictive 

drawdown process, issues which we already discuss in our report. If fully 

implemented, these improvements have the potential to remedy many of 

the issues we identified in our report.

In acknowledging our findings on HRSA’s records retention practices, 

HHS said that HRSA was required to retain records according to 

schedules approved by the National Archives and Records Administration 

(NARA). However, it further noted that HRSA has engaged in a review of 

its records management practices. HHS said that, in December 2011, 

during the course of our review, HRSA formed a workgroup on records 

management with program and grant staff across the agency to 

streamline various retention schedules for program and grant record 

retention practices. HHS said that HRSA will be providing additional 

training and updated policies for the HAB POs and grants management 

specialists on the contents of the official grant file. HHS said that HRSA

would seek approval for any changes to HRSA’s record retention policies. 

In commenting on our discussion of the difficulty some grantees 

expressed about meeting the requirement for an annual visit of their 

service providers, HHS noted that HRSA is working with a small number 

of grantees to provide flexibility in meeting the requirement, but did not 

describe what that flexibility would entail. In discussions near the end of 
 

Page 41 GAO-12-610 Ryan White CARE Act Oversight

our review, HRSA officials said that this would not include excusing 

grantees from the requirement that they visit all of their service providers 

annually, but could involve leveraging the efforts of other CARE Act

grantees.

HHS concluded its general comments on the report by again noting that 

the department concurred with all five of our recommendations. HHS

further commented that HHS is already in the process of planning or 

implementing many of our recommendations. In its comments, HHS 

provided considerable detail on actions HRSA plans to take or has 

already taken to implement our recommendations. The actions HHS 

describes are generally responsive to our recommendations. However, 

because these actions follow the conclusion of our review or are to be 

implemented in the future, and sometimes without a designated time 

frame, we are unable to evaluate them specifically.

HHS also provided technical comments, which we incorporated as 

appropriate.

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies of this report to the 

Administrator of HRSA and the appropriate congressional committees. In 

addition, the report is available at no charge on the GAO website at 

http://www.gao.gov. 

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

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

Offices of Congressional Relations and Public Affairs may be found on 

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

this report are listed in appendix IV.

Marcia Crosse

Director, Health Care
Appendix I: Reporting Requirements for 

Part A and Part B Grantees

Page 42 GAO-12-610 Ryan White CARE Act Oversight

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

Reporting Requirement Part A Part B

Date Due for 

Fiscal Year 2012

AIDS Drug Assistance Program (ADAP) Quarterly Report

The ADAP quarterly reports provide aggregate data for ADAP service 

utilization.









July 29, 2011

October 31, 2011

a

January 31, 2012

April 30, 2012

Minority AIDS Initiative Annual Plan

The primary Purpose of the Part A MAI Annual Plan is to ensure funds are 

used to link minority clients to HIV Care services. The primary purpose of 

the Part B MAI Annual Plan is to ensure funds are used to link minority 

clients into ADAP services. The plan is to include a planned timeframe for 

delivering services; a description of service goals and objectives; the racial 

and ethnic communities to be served and the number of service units to be 

provided during the reporting period.

  Part A: October 17, 2011

Part B: October 7, 2011

Mid-year Progress Report

The primary purpose of the mid-year progress report is to inform POs of 

progress made in administration of the Part B programs; to identify 

accomplishments and challenges in meeting established goals and 

objectives; and to address grantees’ need for technical assistance.

 October 31, 2011

Maintenance of Effort Expenditures Report

The maintenance of effort expenditures report is used to ensure grantees 

have maintained level expenditures for two consecutive grant years. The 

expenditures must be based on the local budget items.

 December 5, 2011

Program Terms Report

The program terms report includes a planned allocation report, budget and 

budget narrative justification, an implementation plan, the Consolidated List 

of Contractors and the Contract Review Certification.

• The allocation report serves as a monitoring tool to track and monitor 

the use of funds. It identifies categories of services that are being 

delivered, changes in the type of services being provided over time and 

trends in the amount of CARE Act funds being used to deliver these 

services.

• The budget and budget narrative justification serve as monitoring tools 

to track and monitor the use of CARE Act funds.

• The implementation plan serves as a monitoring tool to verify 

implementation of approved medical and support services for the 

current grant year. The plan should include all the services and priorities 

reflected in the allocations report. All funded services must be included 

in the implementation plan.

• The Consolidated List of Contractors serves as a list of all funded 

service providers for the current grant year.

• The Contract Review Certification requires the grantee to certify that all 

grant funded service providers for the current grant year comply with 

CARE Act program requirements, and federal grants requirements.

  December 5, 2011

Appendix I: Reporting Requirements for 

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

Part A and Part B Grantees

Page 43 GAO-12-610 Ryan White CARE Act Oversight

Reporting Requirement Part A Part B

Date Due for 

Fiscal Year 2012

Unobligated Balance Estimate and Carryover Request

The CARE Act provides that base and supplemental grant funds were 

available for obligation by the grantee for a 1-year period beginning 

on the first day of the grant year. It also requires HRSA to cancel any 

unobligated balances at the end of the grant year, recover funds that had 

been disbursed to grantees, and redistribute these funds to grantees 

in need as supplemental grants. Grantees must estimate their unobligated 

balances during the grant year and provide final amounts in their federal 

financial report. Grantees may request to carryover funds for one additional

grant year. 

  Part A: January 1, 2012

Part B: January 31, 2012

Interim Federal Financial Report

The purpose of the interim financial report is to substantiate that the grantee 

has obligated 75 percent of the awarded funds for the current grant year.

 January 3, 2012

Ryan White HIV/AIDS Program Services Report

The Ryan White HIV/AIDS program services report provides information on 

services provided by grantees and service providers to HRSA. Additionally, 

grantees and service providers use this report to provide information on 

clients, including their demographic status, services received and HIV 

clinical information.

  March 15, 2012

Part A Comprehensive Plan

The comprehensive plan is a legislative requirement that is due every 3 

years at the beginning of the grant year. The plan is to be used as a “road 

map” for the maintenance and improvement of the grantee’s system of care. 

Grantees are required to include appropriate strategies, goals and timelines.

 May 21, 2012

Statewide Coordinated Statement of Need (SCSN)

The SCSN is a written statement of need developed through a locally 

chosen collaborative process with other CARE Act grant parts. The purpose 

of the SCSN is to provide a collaborative mechanism to identify and address 

significant HIV care issues related to the needs of people living with 

HIV/AIDS, and to maximize coordination, integration, and effective linkages 

across the CARE Act parts. The SCSN process should consider all CARE 

Act resources within the state, including the amount of funds, as well as the 

services these funds are support. 

 June 1, 2012

Final Expenditure Table, including MAI expenditures

This expenditure table serves as a monitoring tool to identify the use of 

funds at the end of the grant period. It identifies service categories that have 

been delivered, the use of carry-over funds and identifies trends in the 

amount of CARE Act funds being used to deliver these services.

  Part A: June 28, 2012

Part B: September 28, 2012

Federal Financial Report

The Federal Financial Report outlines the grantee’s outlays, unliquidated 

obligations, total federal share and final unobligated balance.

  Part A:July 30, 2012

Part B: July 30, 2012

Annual Progress Report

The Annual Progress Report is to inform POs of the progress made in the 

administration of Ryan White programs; to identify accomplishments and 

challenges in meeting established goals and objectives; and to address 

grantees’ need for technical assistance.

  Part A: June 28, 2012

Part B: September 28, 2012
Appendix I: Reporting Requirements for 

Part A and Part B Grantees

Page 44 GAO-12-610 Ryan White CARE Act Oversight

Reporting Requirement Part A Part B

Date Due for 

Fiscal Year 2012

Report on Expenditures for Women, Infants, Children and Youth

The report on expenditures for Women, Infants, Children and Youth is a 

legislative requirement used to determine that a grantee allocates resources 

for women, infants, children and youth at no less than the percentage 

constituted by the ratio of the population of women, infants, children and 

youth with HIV/AIDS to the general populations with HIV/AIDS.

  Part A: July 28, 2012

Part B: September 28, 2012

Minority AIDS Initiative Annual Report

Part A and B grantees receiving MAI funds must submit two components of 

the MAI Report annually: (1) the MAI Annual Plan for the use of these funds, 

and (2) the year-end MAI Annual Report documenting program outcomes. 

Each MAI Report has two parts: (1) Web forms for standardized quantitative 

and qualitative information and (2) an accompanying narrative providing 

background information to explain the data submitted and a summary of 

program accomplishments, challenges, and lessons. 

  Part A: January 31, 2013

Part B: September 28, 2012

b

Source: HRSA.

Note: The federal 2012 fiscal year was from October 1, 2011, through September 30, 2012. HRSA 

uses the federal fiscal year to determine when grantee reports are due. However, CARE Act grants 

have their own grant years. The grant year for Part A is from March 1 through February 28. The 

Part B grant year is from April 1 through March 31.

a

The July 29, 2011, AIDS Drug Assistance Program (ADAP) Quarterly Report is due in federal fiscal 

year 2011.

b

The Minority AIDS Initiative Annual Report for Part A grantees is due on January 31, 2012, which is 

in federal fiscal year 2013.
Appendix II: HRSA Site Visits of Part A and 

Part B Grantees

Page 45 GAO-12-610 Ryan White CARE Act Oversight

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

2011 Grant 

award

(dollars)

Estimated 

living 

HIV/AIDS 

cases

Number of 

HRSA site 

visits, 2008 a

Number of 

HRSA site 

visits, 2009

Number of 

HRSA site 

visits, 2010

Number of 

HRSA site 

visits, 2011

Total 

number 

of HRSA 

site visits, 

2008 – 2011

Atlanta, GA $21,468,517 22,794 0 0 0 1 1 

Austin, TX 4,400,041 4,483 0 0 0 0 0 

Baltimore, MD 19,867,958 21,834 1 0 0 1 2 

Baton Rouge, LA 3,699,040 4,152 0 0 0 0 0 

Bergen-Passaic, NJ 4,044,886 4,296 0 0 1 0 1

Boston, MA 13,769,366 14,992 0 0 0 0 0 

Caguas, P.R. 1,524,285 b 1,310 0 2 3 1 6

Charlotte-Gastonia, NC-SC 

c

5,748,542 5,859 0 0 0 0 0 

Chicago, IL 25,986,577 27,451 0 1 1 0 2 

Cleveland, OH 3,997,596 4,252 0 0 2 0 2 

Dallas, TX 14,570,875 16,288 1 1 0 0 2

Denver, CO 7,826,960 8,452 0 0 0 0 0 

Detroit, MI 8,924,079 9,341 1 1 1 0 3 

Dutchess County, NY 1,347,313 b 1,292 0 0 0 1 1 

Fort Lauderdale, FL 15,005,889 16,513 0 0 0 0 0 

Fort Worth, TX 3,864,078 4,082 0 0 0 0 0 

Hartford, CT 4,249,488 3,635 0 0 0 1 1

Houston, TX 19,735,854 20,934 0 0 0 0 0 

Indianapolis, IN 3,908,947 4,124 0 1 0 0 1 

Jacksonville, FL 5,805,921 5,860 0 0 0 0 0 

Jersey City, NJ 5,074,144 5,089 0 0 1 0 1 

Kansas City, MO 4,288,671 4,567 0 0 0 0 0 

Las Vegas, NV 5,491,345 6,017 0 0 0 0 0

Los Angeles, CA 40,064,159 43,264 1 0 0 0 1 

Memphis, TN 6,534,155 6,911 2 1 0 0 3 

Miami, FL 25,053,334 25,855 1 0 0 0 1 

Middlesex-Somerset-Hunterdon, 

NJ 2,503,584 2,831 0 3 0 0 3 

Minneapolis-St. Paul, MN 5,608,011 5,722 0 0 0 0 0 

Nashville, TN 4,677,970 4,765 0 0 1 0 1 

Nassau-Suffolk, NY 6,441,136 6,030 0 0 0 0 0 

New Haven, CT 6,956,397 6,137 0 0 0 0 0

New Orleans, LA 7,370,711 7,866 0 0 1 0 1 

Appendix II: HRSA Site Visits of Part A and 

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

Part B Grantees

Page 46 GAO-12-610 Ryan White CARE Act Oversight

2011 Grant 

award

(dollars)

Estimated 

living 

HIV/AIDS 

cases

Number of 

HRSA site 

visits, 2008 a

Number of 

HRSA site 

visits, 2009

Number of 

HRSA site 

visits, 2010

Number of 

HRSA site 

visits, 2011

Total 

number 

of HRSA 

site visits, 

2008 – 2011

New York, NY 120,859,664 104,932 0 0 0 1 1

Newark, NJ 13,917,826 13,508 0 1 0 0 1 

Norfolk, VA 5,986,127 6,179 1 0 0 0 1 

Oakland, CA 6,789,146 7,576 0 1 0 0 1 

Orange County, CA 5,968,395 6,572 1 0 0 0 1 

Orlando, FL 8,313,970 9,791 0 0 1 0 1 

Philadelphia, PA 24,102,413 25,047 0 0 0 0 0

Phoenix, AZ 8,257,524 9,073 1 0 0 0 1 

Ponce, P.R. 1,842,886 1,929 1 3 3 0 7

Portland, OR

c

3,742,527 4,210 0 0 1 0 1 

Riverside-San Bernardino, CA 7,356,532 8,742 1 0 0 0 1 

Sacramento, CA 2,654,867 3,119 1 0 0 0 1 

Saint Louis, MO 6,528,396 6,562 0 1 0 0 1

San Antonio, TX 4,413,440 4,657 0 0 0 0 0 

San Diego, CA 11,765,451 12,844 0 0 1 0 1 

San Francisco, CA 25,608,437 18,463 0 0 0 0 0 

San Jose, CA 2,844,809 3,321 0 0 0 0 0 

San Juan, P.R. 15,049,530 11,291 3 2 3 1 9

Santa Rosa, CA

c

1,169,014 b 1,330 0 1 0 1 2

Seattle, WA 6,870,026 7,373 0 0 0 0 0 

Tampa-St. Petersburg, FL 9,370,009 10,367 0 0 0 0 0 

Vineland-Millville-Bridgeton, NJ 897,630 b 852 0 0 0 0 0 

Washington, DC 31,006,866 34,715 0 1 0 0 1 

West Palm Beach, FL 8,684,130 7,949 0 0 0 0 0 

Source: GAO analysis of HRSA data.

a

Estimated living HIV/AIDS cases as of December 31, 2009. These case counts were used to 

calculate the 2011 grant award.

b

Caguas, P.R., Dutchess County, NY, Santa Rosa, CA, and Vineland-Millville-Bridgeton, NJ lost their 

classification as TGAs before the 2011 grant year, which began March 1, 2011, so the award amount 

is from grant year 2010 and the estimated living HIV/AIDS cases are as of December 31, 2008.

c

HRSA officials explained that when HRSA staff made trips to Puerto Rico that included stops at one 

or multiple Part A grantees and/or the Part B grantee. For example, a March 2009 trip to Puerto Rico 

included a site visit to the Part B grantee, to the San Juan Part A grantee, and to the Caguas Part A 

grantee. From 2008 through 2011, HRSA made 12 separate trips to Puerto Rico.
Appendix II: HRSA Site Visits of Part A and 

Part B Grantees

Page 47 GAO-12-610 Ryan White CARE Act Oversight

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

2011 Grant 

award

(dollars)

Estimated 

living 

HIV/AIDS 

cases

Number of 

HRSA site 

visits, 2008 a

Number of 

HRSA site 

visits, 2009

Number of 

HRSA site 

visits, 2010

Number of 

HRSA site 

visits, 2011

Total 

number of 

HRSA 

site visits, 

2008 – 2011

Alabama $18,809,782 10,941 0 0 0 0 0 

Alaska 1,134,180 658 0 0 0 0 0 

American Samoa 50,000 2 0 0 0 0 0 

Arizona 15,534,483 12,068 0 1 0 0 1 

Arkansas 8,373,354 4,992 0 1 0 0 1 

California 148,168,287 117,869 0 0 0 0 0 

Colorado 14,202,569 10,972 0 0 0 0 0 

Connecticut 14,571,752 11,068 0 0 0 0 0 

Delaware 5,790,675 3,087 1 0 0 0 1 

District of Columbia 21,101,829 17,250 0 1 0 0 1 

Federated States of Micronesia 50,000 6 0 0 0 0 0 

Florida 126,286,273 97,463 1 0 0 1 2 

Georgia 45,331,646 34,733 0 0 0 1 1 

Guam 286,530 97 0 0 0 0 0 

Hawaii 3,583,940 2,228 0 0 0 0 0 

Idaho 1,315,589 780 0 0 0 0 0 

Illinois 41,738,721 32,322 0 1 0 0 1 

Indiana 11,811,918 8,689 0 1 0 0 1 

Iowa 2,933,874 1,759 1 0 0 0 1 

Kansas 3,656,596 2,825 0 0 0 0 0 

Kentucky 8,304,138 4,777 0 0 0 1 1 

Louisiana 23,144,643 17,644 0 0 1 1 2 

Maine 1,733,995 1,084 0 0 1 1 2 

Marshall Islands 50,000 1 0 0 0 0 0 

Maryland 40,187,548 34,379 0 0 0 0 0 

Massachusetts 20,457,176 16,929 0 0 0 1 1 

Michigan 17,823,185 14,216 0 1 0 0 1 

Minnesota 7,711,593 6,488 0 1 0 0 1 

Mississippi 12,080,715 8,334 0 0 1 0 1 

Missouri 14,157,823 11,584 0 0 0 0 0 

Montana 856,281 374 0 1 0 0 1 

Northern Mariana Islands 50,000 10 0 0 0 0 0 
Appendix II: HRSA Site Visits of Part A and 

Part B Grantees

Page 48 GAO-12-610 Ryan White CARE Act Oversight

2011 Grant 

award

(dollars)

Estimated 

living 

HIV/AIDS 

cases

Number of 

HRSA site 

visits, 2008 a

Number of 

HRSA site 

visits, 2009

Number of 

HRSA site 

visits, 2010

Number of 

HRSA site 

visits, 2011

Total 

number of 

HRSA 

site visits, 

2008 – 2011

Nebraska 2,728,244 1,609 0 0 0 0 0 

Nevada 8,462,067 7,024 0 0 0 0 0 

New Hampshire 1,507,461 1,139 0 0 1 0 1 

New Jersey 46,624,149 35,467 0 1 0 0 1 

New Mexico 4,019,762 2,487 1 0 0 0 1 

New York 162,437,735 130,091 0 1 0 0 1 

North Carolina 34,992,574 24,308 0 0 0 0 0 

North Dakota 378,141 187 0 0 0 0 0 

Ohio 24,817,612 16,997 0 0 0 0 0 

Oklahoma 8,431,948 4,840 0 1 0 0 1 

Oregon 6,664,158 5,163 0 0 0 0 0 

Pennsylvania 43,068,009 33,661 0 3 0 0 3 

Puerto Rico 31,376,731 18,172 3 3 2 0 10

Republic of Palau

b

50,000 3 0 0 0 0 0 

Rhode Island 3,962,190 2,555 0 0 2 0 2 

South Carolina 25,815,827 14,746 0 0 0 2 2 

South Dakota 883,908 403 0 0 0 0 0 

Tennessee 20,350,806 15,578 0 0 1 1 2 

Texas 85,169,848 66,002 0 0 0 0 0 

Utah 3,775,386 2,336 0 0 0 0 0 

Vermont 893,492 403 0 0 0 1 1 

Virgin Islands 1,161,007 568 1 3 2 0 6 

Virginia 27,770,365 20,574 1 0 0 0 1 

Washington 13,896,285 10,734 0 0 0 0 0 

West Virginia 2,535,511 1,514 0 0 0 0 0 

Wisconsin 8,910,774 5,131 0 0 0 0 0 

Wyoming 728,630 240 0 0 0 0 0 

Source: GAO analysis of HRSA data.

a

Estimated living HIV/AIDS cases as of December 31, 2009. These case counts were used to 

calculate the 2011 grant award.

b

HRSA officials explained that HRSA staff made to Puerto Rico included stops at one or multiple 

Part A grantees and/or the Part B grantee. For example, a March 2009 trip to Puerto Rico included a 

site visit to the Part B grantee, to the San Juan Part A grantee, and to the Caguas Part A grantee. 

From 2008 through 2011, HRSA made 12 separate trips to Puerto Rico.
Appendix III: Comments from the Department 

of Health and Human Services

Page 49 GAO-12-610 Ryan White CARE Act Oversight

Appendix III: Comments from the 

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

of Health and Human Services

Page 50 GAO-12-610 Ryan White CARE Act Oversight
Appendix III: Comments from the Department 

of Health and Human Services

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of Health and Human Services

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of Health and Human Services

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of Health and Human Services

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of Health and Human Services

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of Health and Human Services

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Appendix IV: GAO Contact and Staff 

Acknowledgments

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Marcia Crosse, (202) 512-7114 or crossem@gao.gov

In addition to the contact named above, key contributors to this report 

were Tom Conahan, Assistant Director; Romonda Bumpus; Cathleen 

Hamann; Kathryn Richter; Sara Rudow; and Jennifer Whitworth.

Appendix IV: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Acknowledgments 

(290915)
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