Health Center Program: Improved Oversight Needed to Ensure Grantee Compliance with Requirements

Highlights

What GAO Found

The Department of Health and Human Services’ (HHS) Health Resources and Services Administration (HRSA) relies on three main methods to oversee grantees’ compliance with the 19 key program requirements.

Annual compliance reviews. HRSA project officers review available information, including that submitted by grantees, to determine whether the grantee is in compliance with each of the 19 program requirements.

Site visits. HRSA and its consultants visit grantees to review documentation, meet with officials, and tour the health center. Some of these visits are intended to assess compliance with some or all program requirements.

Routine communications. Project officers communicate with grantees via phone and e-mail to learn about issues that may affect their compliance.

When HRSA identifies noncompliance with program requirements, it uses a process, implemented in April 2010, to address this with a grantee. This process provides a grantee with defined time frames for addressing any identified noncompliance. If a grantee is unable to correct the compliance issue by the end of the process, HRSA’s policy is to terminate the health center’s grant.

HRSA’s ability to identify grantees’ noncompliance with Health Center Program requirements is insufficient.

HRSA does not require project officers to document their basis for determining that a grantee is in compliance with a requirement. When project officers are uncertain about compliance, HRSA instructs them to consider a grantee in compliance and to note the lack of certainty in a text field of their evaluation tool. However, HRSA has no centralized mechanism to ensure this occurs. Thus, it is unclear whether project officers' decisions that a grantee is in compliance with a requirement are because there was sufficient evidence demonstrating compliance or the project officer failed to document that compliance was uncertain.

The number of compliance-related visits conducted may be limited. HRSA’s available data indicates that only 11 percent of grantees had a compliance-related site visit from January through October 2011; less than half of which had a visit that assessed compliance with all 19 program requirements.

HRSA’s project officers do not consistently identify and document grantee noncompliance. Project officers GAO interviewed had different interpretations of what constitutes compliance with some program requirements and therefore when they should cite a grantee for noncompliance.

HRSA’s process for addressing grantee noncompliance with program requirements seems to provide both the agency and grantees with a uniform structure for addressing noncompliance. However, the extent to which this process is adequately resolving grantee noncompliance or terminating grantee funding is unclear because HRSA’s experience with this process is too recent for GAO to make an overall assessment.

Why GAO Did This Study

Under the Health Center Program, HRSA provides grants to eligible health centers. HRSA is responsible for overseeing over 1,100 health center grantees to ensure their compliance with Health Center Program requirements. GAO was asked to examine HRSA’s oversight. This report (1) describes HRSA’s oversight process and (2) assesses the extent to which the process identifies and addresses noncompliance with what HRSA refers to as the 19 key program requirements. GAO reviewed and analyzed HRSA’s policies and procedures and available programwide data related to HRSA's oversight of health centers, interviewed HRSA officials, and reviewed documentation of HRSA’s oversight from 8 selected grantees that varied in their compliance experience, as well as other factors.

Recommendations

GAO recommends that, among other things, HRSA improve its documentation of compliance decisions, strengthen its ability to consistently identify and cite grantee noncompliance, and periodically assess whether its new process for addressing grantee noncompliance is working as intended. HHS concurred with all of GAOs recommendations, and stated that HRSA has already begun implementing many of them. HHS, however, did not concur with what it characterized as certain conclusions drawn from the findings. HHS based its comments on only some of the evidence. GAOs analysis of all the evidence and HRSAs planned implementation of the recommendations confirm the validity of the findings and conclusions.

Recommendations for Executive Action

Agency Affected	Recommendation	Status
Health Resources and Services Administration	To improve HRSA's ability to identify and address noncompliance with Health Center Program requirements, the Administrator of HRSA should develop and implement a mechanism for recording, tracking, and following-up on instances when project officers are unable to determine compliance during the annual compliance review process.	Closed – Implemented In response to our recommendation, HRSA enhanced its annual compliance assessment tool by providing project officers with the option to conclude that they need additional information in order to determine whether a grantee is in compliance with a health center program requirement. As part of this enhancement, HRSA issued revised procedures and guidance for project officers; which provided instructions on reaching such conclusions about grantee compliance, and for tracking and following up on these cases.
Health Resources and Services Administration	To improve HRSA's ability to identify and address noncompliance with Health Center Program requirements, the Administrator of HRSA should require that when completing annual compliance reviews, project officers clearly document their basis for determining that grantees are in compliance with program requirements.	Closed – Implemented In response to our recommendation, HRSA revised its annual compliance assessment procedures so that project officers must indicate their basis for determining a grantee is in compliance with a health center program requirement. As part of these procedures, HRSA requires that project officers enter comments in the compliance assessment system to document which information they used to determine that grantees are in compliance. Further, under the revised procedures, HRSA instituted business rules which prevent project officers from completing their compliance review without providing such information.
Health Resources and Services Administration	To improve HRSA's ability to identify and address noncompliance with Health Center Program requirements, the Administrator of HRSA should clarify agency guidance and provide training, as needed, to better ensure that project officers are accurately and consistently assessing grantees' compliance with program requirements.	Closed – Implemented In response to our recommendation, in late 2013, HRSA determined that a detailed resource on all program requirements would be the most effective and beneficial way to address the recommendation and improve program guidance overall. In 2016, HRSA issued a draft Health Center Program Compliance Manual for public comment; and in August 2017, HRSA published the final Health Center Program Compliance Manual. The manual outlines program requirements and expectations for monitoring and compliance, and according to HRSA, serves as the foundation for compliance assessments at the time of health center grantees are competing for continued grant funding (referred to as Service Area Competitions) and during Operational Site Visits, which are used to assess existing health center's compliance with program requirements. Along with manual, HRSA prepared and disseminated frequently asked questions for both HRSA compliance staff and external stakeholders; which will be used to support and facilitate a successful implementation of the Health Center Program Compliance Manual. In addition, HRSA conducted internal briefings/trainings for project officers, and plans to provide ongoing support through informal trainings over the next several months.
Health Resources and Services Administration	To improve HRSA's ability to identify and address noncompliance with Health Center Program requirements, the Administrator of HRSA should ensure that site visit data contained in HRSA's electronic system are complete, reliable, and accurate to better target the use of available resources and to help ensure that all grantees have compliance-related site visits at regular and timely intervals.	Closed – Implemented In response to our recommendation, HRSA developed new tools to ensure the reliability of data contained in its site visit data system. Specifically, it modified the site visit electronic data system by developing enhanced edit checks to eliminate duplicate site visit records, and developed new procedures which allow for editing and updating incorrect information. Additionally, HRSA established a policy that all health center program grantees will receive an operational site visit to assess compliance with all requirements at least once per project period or every three years.
Health Resources and Services Administration	To improve HRSA's ability to identify and address noncompliance with Health Center Program requirements, the Administrator of HRSA should develop and implement procedures to ensure that instances of noncompliance with program requirements consistently result in the placement of a condition on a health center's grant.	Closed – Implemented In response to our recommendation, HRSA developed new procedures to ensure that project officers consistently place conditions when they identify grantees that are not in compliance with program requirements. Specifically, HRSA developed and updated its standard operating procedures for placing conditions on grantees which requires project officers to issue conditions when they identify instances of grantee non-compliance outside of the annual compliance assessment process. Further, HRSA updated its site visit procedures to require that supervisors review all site visit reports before they are finalized and established a clear timeline for issuing conditions based on site visit findings.
Health Resources and Services Administration	To improve HRSA's ability to identify and address noncompliance with Health Center Program requirements, the Administrator of HRSA should periodically assess whether its new progressive action process for addressing grantee noncompliance, including the time frames allotted for grantees to respond, is working as intended and make any needed improvements to the process.	Closed – Implemented In response to our recommendation, HRSA indicated they plan to annually review the progressive action process, and make improvements as appropriate, to ensure ensure grantees address compliance issues in a timely manner. They indicated that managers review reports which outline the status of open issues of noncompliance, and specifically reports which highlight noncompliance issues grantees have repeatedly failed to adequately address. According to HRSA, reviews conducted to date indicate the progressive action process is working effectively. Additionally, HRSA now makes information about health center grantees' compliance status available to the public; compliance information is now included on a health center's profile on HRSA's website. In addition, in June 2014, HRSA updated its guidance regarding the progressive action process via a Program Assistance Letter issued to grantees. This letter clarifies when and how HRSA will take enforcement actions in cases where grantees materially fail to comply with the terms and conditions of their grant award, as well as when and how compliance status with program requirements and past performance is taken into consideration when making award decisions to current grantees. For example, the guidance notes instances where HRSA may require grantees to implement corrective action within a more immediate timeframe than provided under the progressive action process; failure to achieve compliance within this abbreviated timeframe will result in enforcement actions such as the cancellation of the grant award.