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. 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. 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, (4) ADAP supplemental grants, (5) MAI grants, and (6) supplemental grants for states with “emerging communities”. Part A and Part B grantees apply for funding annually. 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. 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. 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 Because the us in August 2011 and updated in December 2011.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 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. 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, 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. 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; 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; 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.