type: other

jurisdiction: US

text: b" Report Template Version = 04-30-05_rev.15\n\n\n\n\nDepartment of Health and Human Services\n\n OFFICE OF \n\n INSPECTOR GENERAL \n\n\n\n\n\n AGENCY FOR HEALTHCARE \n\n RESEARCH AND QUALITY: \n\nMONITORING PATIENT SAFETY \n\n GRANTS\n\n\n\n\n\n Daniel R. Levinson\n\n Inspector General\n\n\n June 2006\n\n OEI-07-04-00460\n\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\n Office of Inspector General \n\n http://oig.hhs.gov\n\nThe mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452,\nas amended, is to protect the integrity of the Department of Health and Human Services\n(HHS) programs, as well as the health and welfare of beneficiaries served by those\nprograms. This statutory mission is carried out through a nationwide network of audits,\ninvestigations, and inspections conducted by the following operating components:\n\nOffice of Audit Services\nThe Office of Audit Services (OAS) provides all auditing services for HHS, either by\nconducting audits with its own audit resources or by overseeing audit work done by others.\nAudits examine the performance of HHS programs and/or its grantees and contractors\nin carrying out their respective responsibilities and are intended to provide independent\nassessments of HHS programs and operations. These assessments help reduce waste,\nabuse, and mismanagement and promote economy and efficiency throughout HHS.\n\nOffice of Evaluation and Inspections\nThe Office of Evaluation and Inspections (OEI) conducts national evaluations to provide\nHHS, Congress, and the public with timely, useful, and reliable information on\nsignificant issues. Specifically, these evaluations focus on preventing fraud, waste, or\nabuse and promoting economy, efficiency, and effectiveness in departmental programs.\nTo promote impact, the reports also present practical recommendations for improving\nprogram operations.\n\nOffice of Investigations\nThe Office of Investigations (OI) conducts criminal, civil, and administrative\ninvestigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries\nand of unjust enrichment by providers. The investigative efforts of OI lead to criminal\nconvictions, administrative sanctions, or civil monetary penalties.\n\nOffice of Counsel to the Inspector General\nThe Office of Counsel to the Inspector General (OCIG) provides general legal services to\nOIG, rendering advice and opinions on HHS programs and operations and providing all\nlegal support in OIG's internal operations. OCIG imposes program exclusions and civil\nmonetary penalties on health care providers and litigates those actions within HHS.\nOCIG also represents OIG in the global settlement of cases arising under the Civil False\nClaims Act, develops and monitors corporate integrity agreements, develops compliance\nprogram guidances, renders advisory opinions on OIG sanctions to the health care\ncommunity, and issues fraud alerts and other industry guidance.\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\n\xce\x94 E X E C U T I V E S U M M A R Y \n\n\n\n\n OBJECTIVE\n To determine whether the Agency for Healthcare Research and\n Quality\xe2\x80\x99s (AHRQ) monitoring of Financial Status Reports, performance\n reports, and the grant closeout process for patient safety grants are in\n accordance with Federal requirements.\n\n\n BACKGROUND\n Congress enacted the Healthcare Research and Quality Act of 1999\n (Public Law 106-129), which established AHRQ within the Department\n of Health and Human Services (HHS). Congress directed AHRQ to\n designate funds from its appropriation for grants to study patient safety\n in H.R. Rep. No. 106-645, at 102 (2000). For fiscal years (FY) 2001\n through 2003, AHRQ awarded 120 grants totaling $128 million to\n conduct research on improving patient safety and reducing medical\n errors. Federal regulations and departmental policies (e.g., Grant\n Policy Directives from the Office of Grants) govern HHS grants\n monitoring.\n\n To determine AHRQ\xe2\x80\x99s compliance with patient safety grant\n requirements relating to Financial Status Reports, performance reports,\n and the closeout process, the Office of Inspector General (OIG) selected\n a stratified random sample from the population of 120 patient safety\n grants that were awarded in FYs 2001, 2002, and/or 2003. The sample\n consisted of 39 grants from 2 strata. Although OIG picked a sample\n randomly, the small sample and population sizes did not allow OIG to\n make any projections about the entire population of patient safety\n grants.\n\n\n FINDINGS\n Most Financial Status Reports were not received or were late. Of the\n grants sampled, 30 percent of Financial Status Reports were not\n received and 43 percent were late, representing a combined total of\n $50.6 million in dispensed grant funds. When contacted 1 month later,\n AHRQ staff confirmed that the Financial Status Reports not found\n during the initial review of the official grant file still had not been\n received. The lack of reports received or received timely may be due to\n misinterpretation of Federal regulations addressing financial reporting\n associated with no-cost extensions, AHRQ staff not using enforcement\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS i\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nE X E C U T I V E S U M M A R Y\n\n\n tools to help to ensure timely receipt of these reports, and the lack of a\n tracking system for these reports.\n Performance reports generally complied with Federal requirements.\n At the time of OIG\xe2\x80\x99s review of the official grant files, 97 percent of the\n most recently required annual performance reports were in the file, and\n 94 percent were received timely. AHRQ staff reported that the timely\n receipt of these reports may be due to frequent interaction between\n grantees and AHRQ staff concerning the grant\xe2\x80\x99s progress, and AHRQ\xe2\x80\x99s\n use of a tracking system to record receipt of these reports.\n Federal requirements for grant closeouts were not met. Of the\n sampled grants, seven official grant files were eligible for closeout.\n Two of these grants were closed in accordance with Federal\n requirements. Three grants, however, lacked documentation of required\n closeout reports, liquidation of assets, and/or results of the final\n research. AHRQ staff did not complete the closeout process for the\n remaining two grants despite the fact that both grant files contained all\n required closeout documents.\n\n AHRQ staff stated that the closeout of these grants was delayed due to\n a large backlog of grant files awaiting completion of the closeout\n process. Patient safety grants comprised only part of this overall\n backlog. Recently, AHRQ hired a contractor to assist in reducing this\n backlog and to assist in the collection of delinquent reports for closeout.\n AHRQ staff told OIG that the contractor\xe2\x80\x99s actions improved the\n efficiency of the closeout process and reduced the number of grants\n awaiting closeout.\n\n\n RECOMMENDATIONS\n The AHRQ practices inhibit its ability to adequately oversee and\n evaluate grantees\xe2\x80\x99 overall performance and its stewardship of Federal\n funds. While AHRQ appears to manage the receipt of performance\n reports well, other areas identified in this report reveal weaknesses that\n impact the accountability of patient safety grant funds.\n\n Therefore, OIG recommends that AHRQ:\n Require submission of interim financial information of prior year\n expenditures before future funding is authorized. The AHRQ\n methods for obtaining this information could include: semiannual\n Financial Status Reports, expansion of financial information currently\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS ii\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nE X E C U T I V E S U M M A R Y\n\n\n reported on the performance reports, or a separate process for\n accounting for financial expenditures.\n Establish a tracking system for Financial Status Reports. AHRQ staff\n reported that the system for tracking performance reports was important\n to the timely receipt of performance reports. Thus, AHRQ should use\n lessons learned from this system while implementing a similar system for\n Financial Status Reports.\n\n Require grantees with no-cost extensions to submit Financial Status\n Reports in compliance with Federal requirements. Clarification of this\n Federal requirement for AHRQ staff and grantees is needed to ensure\n compliance. Grantees with no-cost extensions must submit Financial\n Status Reports at least annually, unless they specifically request and\n receive an extension.\n Ensure that grants awaiting closeout are closed promptly. AHRQ\n should continue to take positive steps to eliminate the backlog of grants\n awaiting closeout and to ensure that future closeouts are processed timely.\n\n\n AGENCY COMMENTS\n AHRQ responded that it agrees with the findings in the report and that\n the recommendations are reasonable. AHRQ indicated that the\n recommendations reinforce ongoing improvements begun subsequent to\n the FYs that we reviewed or support already envisioned activities.\n Specifically, AHRQ indicated that it (1) can pursue the use of the\n progress report to identify the status of prior year funds, (2) has begun\n development of a tracking system for Financial Status Reports, (3) will\n develop a procedure to ensure compliance with Federal regulations\n when grantees make use of no-cost extensions, and (4) has made\n progress in dropping closeout periods from 400 days to 114 days.\n\n\n OFFICE OF INSPECTOR GENERAL RESPONSE\n OIG recognizes the positive actions AHRQ has both taken or is planning\n to meet the intent of our second and third recommendations as well as\n the agency\xe2\x80\x99s progress toward compliance with closeout deadlines, our\n fourth recommendation. In its final management decision\n memorandum, OIG requests AHRQ to provide more specific information\n on how it intends to address the first and fourth recommendations.\n Regarding the first recommendation, AHRQ indicates that it can pursue\n the use of progress reports to gather financial information on prior-year\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS iii\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nE X E C U T I V E S U M M A R Y\n\n\n funds. Committing to do so or providing another method to obtain\n interim financial status information would address this\n recommendation. As for the fourth recommendation, despite significant\n progress in reducing its backlog, AHRQ remains out of compliance with\n the 90-day requirement for grants ending in 2005. AHRQ does\n anticipate \xe2\x80\x9c. . . continued improvement as grantees realize that AHRQ\n considers submission of final reports a priority.\xe2\x80\x9d AHRQ may want to\n provide the actions it will take if grantees fail to realize the priority it\n has placed on the submission of final reports.\n\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS iv\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\n\xce\x94 T A B L E O F C O N T E N T S \n\n\n\n\n E X E C U T I V E S U M M A R Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i\n\n\n\n\n I N T R O D U C T I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1\n\n\n\n\n\n F I N D I N G S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6\n\n Most Financial Status Reports were not received or were late . . . . 6 \n\n\n Performance reports generally complied with Federal \n\n requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 \n\n\n Federal requirements for grant closeouts were not met . . . . . . . . . 9 \n\n\n\n\n\n R E C O M M E N D A T I O N S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11\n\n Agency Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 \n\n\n Office of Inspector Genereal Response . . . . . . . . . . . . . . . . . . . . . . 12 \n\n\n\n\n\n A P P E N D I X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13\n\n Agency Comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 \n\n\n\n\n\n A C K N O W L E D G M E N T S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16\n\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\n\xce\x94 I N T R O D U C T I O N \n\n\n\n\n OBJECTIVE\n To determine whether the Agency for Healthcare Research and\n Quality\xe2\x80\x99s (AHRQ) monitoring of Financial Status Reports, performance\n reports, and the grant closeout process for patient safety grants are in\n accordance with Federal requirements.\n\n\n BACKGROUND\n The Department of Health and Human Services (HHS) funds almost\n one-quarter of all Federal outlays and administers more grant dollars\n than all other Federal agencies combined.1 The Office of Inspector\n General (OIG) identified grants management as one of the top\n management challenges for HHS. The OIG\xe2\x80\x99s mission is to ensure that\n Federal funds are used appropriately to maximize their intended\n purpose and that fraud, waste, and abuse, if present, are identified and\n eliminated.2\n Congress enacted the Healthcare Research and Quality Act of 1999\n (Public Law 106-129), which established AHRQ within HHS. Congress\n directed AHRQ to designate funds from its appropriation for grants to\n study patient safety.3 For fiscal years (FY) 2001 through 2003, AHRQ\n awarded 120 patient safety grants totaling $128 million to conduct\n research on improving patient safety and reducing medical errors.4\n Monitoring Requirements\n Federal regulations and departmental policies (e.g., Grant Policy\n Directives (GPD) issued by the Office of Grants) govern HHS grants\n monitoring.5 AHRQ is required to collect and assess grantees\xe2\x80\x99 Financial\n Status Reports (Standard Forms 269 or 269A) and performance reports\n\n 1 \xe2\x80\x9cHHS: What We Do.\xe2\x80\x9d Available online at http://www.hhs.gov/about/whatwedo.html/.\n\n Accessed April 25, 2006.\n 2 \xe2\x80\x9cFY 2005 Performance and Accountability Report,\xe2\x80\x9d Appendix A. Available online at\n http://www.hhs.gov/of/library/par05/pdfmenu/. Accessed April 25, 2006.\n 3 H.R. Rep. No. 106-645, at 102 (2000).\n\n 4 AHRQ\xe2\x80\x99s Grants Management Officer furnished OIG an FY 2001-FY 2003 Summary of\n Patient Safety Grants in November 2004. This summary, which listed all patient safety\n grants, was used to select the sample.\n 5 See 45 CFR Part 74 (regulations establishing, in part, grant monitoring and reporting\n requirements for HHS grants to universities, nonprofit organizations, and hospitals); and\n the GPD Parts 3.01-3.07 (guidance to HHS offices on grants management issues, including\n requirements for postaward monitoring and reporting).\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 1\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nI N T R O D U C T I O N\n\n\n (both interim and final), and ensure that the grant closeout process has\n been completed. AHRQ may implement enforcement provisions, where\n appropriate, for grantees that do not comply with Federal regulations\n and/or departmental policies.6\n Financial Monitoring. AHRQ staff use Financial Status Reports to\n monitor grantees\xe2\x80\x99 use of Federal funds. These reports must document\n the financial aspects of the grant including unobligated balances, assets,\n and outlays. A grantee\xe2\x80\x99s business office normally completes and\n submits the Financial Status Report to AHRQ.\n\n Grantees must submit the Financial Status Report at least annually,\n although AHRQ can require more frequent reporting, as it deems\n necessary.7 Financial Status Reports submitted annually must be\n received no later than 90 calendar days after each specified reporting\n period; however, AHRQ may approve a request from the grantee for an\n extension of the due date.8 Departmental policy requires AHRQ to take\n timely action to advise grantees of noncompliance, including late\n submission of a Financial Status Report, and to take appropriate\n enforcement actions.9\n Performance Monitoring. The performance report contains information\n regarding the accomplishments of the grant. The performance report\n must generally include a narrative discussion of the grantee\xe2\x80\x99s progress\n toward achieving the grant\xe2\x80\x99s goals and objectives. 10 The Principal\n Investigator, generally a grantee employee, has primary responsibility\n for ensuring compliance with all grant requirements, including\n completion of the performance report.\n Grantees must submit the performance report at least annually,\n although AHRQ can require more frequent reporting, as it deems\n necessary. Performance reports submitted annually must be received\n no later than 90 calendar days after the end of the specified reporting\n\n\n\n\n 6 45 CFR \xc2\xa7 74.62(a). \n\n\n 7 45 CFR \xc2\xa7 74.52(a)(1)(iii). \n\n\n 8 45 CFR \xc2\xa7 74.52(a)(1)(iv). If quarterly or semiannual reporting periods are used, the \n\n reports are due no later than 30 days after each reporting period.\n 9 GPD Part 3.07.B.5.\n\n 10 45 CFR \xc2\xa7 74.51(d).\n\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 2\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nI N T R O D U C T I O N\n\n\n period.11 AHRQ has the responsibility to initiate appropriate follow-up\n action, as necessary, on delinquent reports.12\n Grant Closeout Procedures. AHRQ must ensure through its grant\n closeout procedures that the grantee has completed and submitted all\n work outlined in the terms and conditions of the grant. Unless AHRQ\n authorizes an extension, the grantee is required to liquidate all\n obligations incurred no later than 90 calendar days after the funding\n period or the date of completion of the award.13 Further, Federal\n regulations require that a grantee must submit a final Financial Status\n Report, a final performance report, and all other reports specified in the\n terms and conditions of the grant no later than 90 calendar days after\n the date of completion of the award.14 The grantee can request\n extension of the final performance report and/or the final Financial\n Status Report that is due as part of the grant closeout process.15\n Federal regulations do not specify the type of notification (written or\n verbal) that grantees must make when requesting an extension to\n closeout their grant.\n\n The final performance report indicates accomplishments under the\n project and whether the research objectives were met or gives an\n explanation of why they were not. Once accepted by the Project Officer,\n an AHRQ employee, results from the final performance report are then\n made available to the public. The Financial Status Report also must be\n reconciled. The Grants Management Officer remains responsible for the\n closeout of the grant until all requirements of the terms and conditions\n are fulfilled, all reports have been received and accepted, and the\n account is closed.16\n\n\n\n\n 11 45 CFR \xc2\xa7 74.51(b). Alternatively, AHRQ may establish a due date based on the\n\n anniversary dates of multiple year awards. If quarterly or semiannual reporting periods\n are used, the reports are due no later than 30 days after each reporting period.\n 12 45 CFR \xc2\xa7 74.62(a) and GPD Part 1.04D.1.i.\n\n 13 45 CFR \xc2\xa7 74.71(b).\n\n 14 45 CFR \xc2\xa7 74.71(a).\n\n 15 45 CFR \xc2\xa7 74.71(a). AHRQ may approve extensions of closeout reports when the grantee\n\n requests such an extension.\n 16 45 CFR \xc2\xa7 74.71 and GPD Part 1.04D.1.i.\n\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 3\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nI N T R O D U C T I O N\n\n\n No-Cost Extensions\n A no-cost extension is a written notice by the grantee to AHRQ to\n initiate an extension of the period of the grant award.17 Such\n extensions do not modify or eliminate Federal reporting requirements\n for Financial Status Reports or performance reports. If a grantee wants\n an extension for the Financial Status Report, the grantee must make a\n specific request to AHRQ, and AHRQ must approve the request.18\n\n\n METHODOLOGY\n OIG selected a stratified random sample from the population of\n 120 patient safety grants that received funding in FYs 2001, 2002,\n and/or 2003. The sample consisted of 39 grants from 2 strata.\n\n The first stratum consisted of 12 grants that received patient safety\n grant funding in FYs 2001, 2002, and/or 2003 and that AHRQ identified\n as being complex or requiring additional administrative efforts.19\n The second stratum consisted of the remaining 108 grants that received\n patient safety grant funding in FYs 2001, 2002, and/or 2003. Grants\n were sorted in descending order by the total grant dollars received in\n the 3 FYs. To obtain a sample with varying amounts of total grant\n dollars received, 27 grants were selected by a systematic process in\n which OIG chose every fourth grant in the list. Although OIG picked a\n sample randomly, due to the small sample and population sizes, this\n sample was not designed to make any projections about the entire\n population of patient safety grants.\n Grant File Review\n OIG developed a checklist based on Federal requirements to review\n AHRQ\xe2\x80\x99s official grant files for the 39 sampled grants. This file review\n determined whether Financial Status Reports, performance reports, and\n grant closeouts complied with Federal regulations and departmental\n\n\n\n\n 17 45 CFR \xc2\xa7 74.25(d)(2).\n\n 18 45 CFR \xc2\xa7 74.52(a)(1)(iv).\n\n 19 AHRQ defined complex grants as those with (a) projects involving carryover of funds in\n multiple years, (b) supplemental awards issued during the project, and (c) multiple\n subcontractors. AHRQ defined grants requiring additional administrative efforts as\n those (a) with habitually large unobligated balances and (b) that repeatedly requested\n carryover funds for the next awarding period.\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 4\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nI N T R O D U C T I O N\n\n\n policies.20 Specifically, OIG determined whether Financial Status\n Reports were complete and timely, and whether these reports\n documented the status of funds. Further, OIG determined whether\n performance reports were complete and timely, and documented\n (1) accomplishments of the grant goals, (2) objectives of research\n findings, (3) circumstances when grant goals were not met, and\n (4) developments that had a significant impact on the award-supported\n activities.\n\n OIG reviewed file documentation for seven of the sampled grants\n identified by AHRQ as eligible for closeout to assess whether AHRQ had\n taken appropriate administrative actions to closeout official grant files.\n Where applicable, OIG looked for evidence of AHRQ\xe2\x80\x99s enforcement\n actions for grantees not in compliance with Federal regulations and\n departmental policies.\n Interviews\n Upon completion of the review of the official grant files, OIG used a\n structured survey to request additional information from AHRQ staff\n (i.e., Project Officers, Grants Management Specialists, and the Grants\n Management Officer) about the processes used to monitor these grants.\n OIG interviewed 17 of 19 Project Officers, 21 the 7 Grants Management\n Specialists, and the Grants Management Officer who were involved in\n monitoring the sampled patient safety grants. In addition, when the\n official grant file did not contain the required documentation, OIG\n contacted the responsible AHRQ staff to (1) verify that the\n documentation had not been misfiled, (2) determine if documentation\n was received after OIG\xe2\x80\x99s data collection occurred, and (3) identify and\n clarify the enforcement actions, if any, AHRQ took to obtain delinquent\n reports.\n Standards\n This study was conducted in accordance with the \xe2\x80\x9cQuality Standards for\n Inspections\xe2\x80\x9d issued by the President\xe2\x80\x99s Council on Integrity and\n Efficiency and the Executive Council on Integrity and Efficiency.\n\n\n\n\n 20 OIG used criteria contained in 45 CFR \xc2\xa7\xc2\xa7 74.51, 74.52, and 74.71 to establish whether\n AHRQ appropriately closed the official grant file.\n 21 One Project Officer was unavailable due to a lengthy illness. The other Project Officer\n had left AHRQ\xe2\x80\x99s employment prior to the start of this study.\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 5\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\n\xce\x94 F I N D I N G S \n\n\n\n All of the grants in the sample used\n Most Financial Status Reports were not\n annual reporting periods, and\n received or were late\n 45 CFR \xc2\xa7 74.52(a)(1)(iv) requires\n grantees to submit completed Financial Status Reports no later than\n 90 calendar days after the end of each annual reporting period.\n\n The Financial Status Report is necessary for monitoring grantees\xe2\x80\x99\n financial obligations as they relate to the terms and conditions of the\n grants. AHRQ staff use this report to assess expenditures that were\n charged against the grants and to determine if grantees have obligated\n these funds. This report is also useful in measuring how grantees are\n expending funds and whether such spending is in the amount and at the\n pace anticipated for the projects.\n Thirty percent of the Financial Status Reports were not received\n Of the 90 Financial Status Reports in the sample population that were\n required to be in the official grant file for FY 2001 through FY 2003, 22\n OIG identified\n Table 1: Financial Status Reports Not in File\n and Associated Dollars 27 instances in\n Year Not in File Dollars which these\n FY 2001 0 $0 reports were not in\n FY 2002 2 $2,255,454 the file. When OIG\n FY 2003 25 $19,299,625 made a follow-up\n Total 27 $21,555,079 request 1 month\n Source: Office of Inspector General analysis of official grant files, 2005. later, AHRQ staff\n confirmed that these reports still had not been received. These grants\n represented $21.5 million in awards that lacked a formal accounting\n and review of the grantees\xe2\x80\x99 financial expenditures (Table 1). The two\n grants that lacked Financial Status Reports in FY 2002 also lacked\n these reports for FY 2003. As a result, there is no evidence that AHRQ\n reviewed Financial Status Reports for these grants during that 2-year\n period.\n\n\n\n\n 22 Not all grants spanned the period of OIG review, FY 2001 through FY 2003. Some\n grants were only 1-year or 2-year grants.\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 6\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nF I N D I N G S\n\n\n OIG found that for the 12 grants that AHRQ identified as either being\n complex or requiring additional administrative efforts:23\n o in FY 2001, all Financial Status Reports were in the file;\n\n o in FY 2002, 2 Financial Status Reports were not received; and\n\n o in FY 2003, 9 Financial Status Reports were not received.\n\n Despite AHRQ\xe2\x80\x99s acknowledgment that these grants were complex or\n required additional administrative efforts, the Financial Status Reports\n for these grants comprised 11 of the 27 reports that were not received.\n Additionally, 43 percent of Financial Status Reports were not timely\n OIG identified 39 instances over the 3-year period in which Financial\n Status Reports were not received timely. These grants represented\n $29 million in awards that AHRQ reviewed later than it would have,\n provided the grantee had submitted the Financial Status Report as\n Federal regulations require (Table 2).\n\n Table 2: Late Financial Status Reports\n\n Financial Status Report - Days Past Due and Associated Dollars\n Year 1-30 31-60 61-90 91-180 181-365 >365 Total Dollars\n FY 2001 2 3 0 1 7 2 15 $14,232,043\n FY 2002 2 3 0 6 6 2 19 $12,298,535\n FY 2003 1 2 0 1 1 0 5 $2,562,138\n Total 5 8 0 8 14 4 39 $29,092,716\n Source: Office of Inspector General analysis of official grant files, 2005.\n\n\n The combined dollars for reports that were not received or were late\n over the 3-year review period totaled $50.6 million.24 AHRQ\xe2\x80\x99s Grants\n Management Officer stated that AHRQ currently lacks a system to\n track the receipt of Financial Status Reports.\n\n\n\n\n 23 Due to a late start date for one grant and a 1-year suspension for another grant,\n 11 grants had Financial Status Reports due in FY 2001 and FY 2002, while all 12 grants\n had Financial Status Repots due in FY 2003.\n 24 Of the 90 Financial Status Reports OIG expected to find in the review, OIG found that\n 24 were received timely, 27 were not received, and 39 were received late. Of the reports\n reviewed, all were complete and notations contained within the official grant file\n indicated that AHRQ staff reviewed the Financial Status Reports and compared the\n expenditures listed against the funding approved for the grant.\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 7\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nF I N D I N G \nS\n\n\n Misinterpretation of no-cost extensions may contribute to late Financial\n Status Reports\n Twenty of the twenty-five Financial Status Reports not received for\n FY 2003 involved grants with no-cost extensions. AHRQ staff informed\n OIG of their belief that a no-cost extension also extended the due date\n for the Financial Status Report. While regulations in\n 45 CFR \xc2\xa7 74.25(d)(2) allow grantees to initiate a no-cost extension up to\n 12 months prior to the expiration date of the award, grantees must\n continue to comply with the reporting requirements specified in\n 45 CFR \xc2\xa7 74.52(a)(1), unless they also request an extension of the\n Financial Status Report. OIG found no evidence of such requests\n during the review.\n Grants Management Specialists offered additional explanations for late\n reports\n Several Grants Management Specialists with whom OIG spoke noted\n that grantees might be confused about AHRQ\xe2\x80\x99s reporting requirements.\n This confusion may be due to their involvement with other HHS\n awarding agencies that conduct similar research grants, but have\n different reporting procedures. For example, many of these agencies\n use electronic systems to collect Financial Status Reports, whereas\n AHRQ requires a paper format. As a result, grantees may be uncertain\n about the reporting process used for a particular grant. One specialist\n stated that there is often a lack of communication between the Principal\n Investigator and business office on how the reports are to be submitted.\n AHRQ\xe2\x80\x99s reporting requirements specify that the terms and conditions of\n the grant may go to the Principal Investigator; however, two specialists\n told OIG that reporting requirements are not always shared with the\n grantee\xe2\x80\x99s business office, which is normally responsible for completing\n and submitting the Financial Status Report.\n Enforcement tools were not used to ensure timely receipt of Financial Status\n Reports\n AHRQ staff informed OIG that they have used enforcement actions for\n grantees that did not submit their Financial Status Reports, but to little\n effect. However, for the grant files OIG reviewed, AHRQ did not use the\n authorities provided in Federal regulation and departmental policies\n (e.g., disallowance of funds) to obtain the delinquent Financial Status\n Reports.25 Only 2 of the 27 official grant files without Financial Status\n\n\n 25 45 CFR \xc2\xa7 74.62(a) and GPD Part 3.06.B.4.d.\n\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 8\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nF I N D I N G S\n\n\n Reports contained documentation of AHRQ\xe2\x80\x99s requests for the reports\n (e.g., electronic mail or telephone calls), which are not enforcement\n actions.\n\n\n Performance reports generally complied with At the time of OIG\xe2\x80\x99s review of\n the official grant files,\n Federal requiremen\n requirementts\n s\n 97 percent of the most recently\n required annual performance reports were in the file, and 94 percent\n were received timely, including all 12 grants that AHRQ identified as\n either being complex or requiring additional administrative efforts.\n OIG found that all but one of these performance reports documented the\n accomplishments of the grant\xe2\x80\x99s goals, objectives, research findings, and\n the reasons particular goals (if any) were not met.\n\n AHRQ attributed the timely receipt of performance reports to the\n professional relationship between Project Officers and Principal\n Investigators, involving frequent communication to monitor the overall\n progress of the grant. AHRQ staff stated that during these\n communications, the Principal Investigator is informed or reminded\n that performance reports must be received before authorization of the\n next year\xe2\x80\x99s funding. In addition, AHRQ has in place a system to track\n the receipt of these reports, which also contributes to the successful\n timely receipt of these reports.\n\n\n Federal requirements for grant closeouts Grantees must submit all\n required reports within\n were not met\n 90 calendar days after\n completion of the grant pursuant to Federal regulation\n 45 CFR \xc2\xa7 74.71(a). Seven of the thirty-nine sampled grants were\n eligible for closeout. Two of the seven grants were closed in accordance\n with Federal requirements. Three grants lacked documentation of\n required closeout reports, liquidation of assets, and/or results of the\n final research. The remaining two grant files contained all required\n grant closeout documents; however, AHRQ staff had not completed the\n closeout process.\n\n AHRQ staff stated that the closeout of these grants was delayed due to\n a large backlog of grant files awaiting completion of the closeout\n process. Patient safety grants comprised only part of this overall\n backlog. Recently, AHRQ hired a contractor to assist in reducing this\n backlog and to assist in the collection of delinquent reports for closeout.\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 9\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nF I N D I N G S\n\n\n AHRQ staff told OIG that the contractor\xe2\x80\x99s actions improved the\n efficiency of the closeout process and reduced the number of grants\n awaiting closeout. The lack of timely closeout inhibits AHRQ\xe2\x80\x99s ability to\n provide prompt payments to grantees for allowable reimbursable costs\n and to ensure grantees promptly refund any balances of unobligated\n funds that have been advanced or paid, as Federal regulations require.26\n Available enforcement actions are not always used\n For the grants reviewed, AHRQ staff stated they did not always use\n available enforcement actions to achieve grantee compliance with\n Federal and departmental closeout requirements. Many of the\n enforcement tools (e.g., disallowance of funds) identified in the terms\n and conditions of awards and in Federal regulation are ineffective at the\n closeout stage of the grant because all grant payments have been made.\n\n\n\n\n 26 45 CFR \xc2\xa7 74.71.\n\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 10\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nE X E C U T I V E S U M M A R Y\n\xce\x94 R E C O M M E N D A T I O N S \n\n\n\n RECOMMENDATIONS\n The AHRQ practices inhibit its ability to adequately oversee and\n evaluate grantees\xe2\x80\x99 overall performance and its stewardship of Federal\n funds. While AHRQ appears to manage the receipt of performance\n reports well, other areas identified in this report reveal weaknesses that\n impact the accountability of patient safety grant funds.\n\n Therefore, OIG recommends that AHRQ:\n Require submission of interim financial information of prior year\n expenditures before future funding is authorized. The AHRQ\n methods for obtaining this information could include: semiannual\n Financial Status Reports, expansion of financial information currently\n reported on the performance reports, or a separate process for\n accounting for financial expenditures.\n Establish a tracking system for Financial Status Reports. AHRQ staff\n reported that the system for tracking performance reports was important\n to the timely receipt of performance reports. Thus, AHRQ should use\n lessons learned from this system while implementing a similar system for\n Financial Status Reports.\n\n Require grantees with no-cost extensions to submit Financial Status\n Reports in compliance with Federal requirements. Clarification of this\n Federal requirement for AHRQ staff and grantees is needed to ensure\n compliance. Grantees with no-cost extensions must submit Financial\n Status Reports at least annually, unless they specifically request and\n receive an extension.\n Ensure that grants awaiting closeout are closed promptly. AHRQ\n should continue to take positive steps to eliminate the backlog of grants\n awaiting closeout and to ensure that future closeouts are processed timely.\n\n\n AGENCY COMMENTS\n AHRQ responded that it agrees with the findings in the report and that\n the recommendations are reasonable. AHRQ indicated that the\n recommendations reinforce ongoing improvements begun subsequent to\n the FYs that we reviewed or support already envisioned activities.\n Specifically, AHRQ indicated that it (1) can pursue the use of the\n progress report to identify the status of prior year funds, (2) has begun\n development of a tracking system for Financial Status Reports, (3) will\n develop a procedure to ensure compliance with Federal regulations\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 11\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nR E C O M M E N D A T I O N S\n\n\n when grantees make use of no-cost extensions, and (4) has made\n progress in dropping closeout periods from 400 days to 114 days. The\n complete text of AHRQ comments can be found in the Appendix.\n\n\n OFFICE OF INSPECTOR GENERAL RESPONSE\n OIG recognizes the positive actions AHRQ has both taken or is planning\n to meet the intent of our second and third recommendations as well as\n the agency\xe2\x80\x99s progress toward compliance with closeout deadlines, our\n fourth recommendation. In its final management decision\n memorandum, OIG requests AHRQ to provide more specific information\n on how it intends to address the first and fourth recommendations.\n Regarding the first recommendation, AHRQ indicates that it can pursue\n the use of progress reports to gather financial information on prior-year\n funds. Committing to do so or providing another method to obtain\n interim financial status information would address this\n recommendation. As for the fourth recommendation, despite significant\n progress in reducing its backlog AHRQ remains out of compliance with\n the 90-day requirement for grants ending in 2005. AHRQ does\n anticipate \xe2\x80\x9c. . . continued improvement as grantees realize that AHRQ\n considers submission of final reports a priority.\xe2\x80\x9d AHRQ may want to\n provide the actions it will take if grantees fail to realize the priority it\n has placed on the submission of final reports.\n\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 12\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\n\xce\x94 A P P E N D I X \n\n\n Agency for Healthcare Research and Quality Comments\n\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 13\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nA P P E N D I X \n\n\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 14\n\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\nA P P E N D I X \n\n\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 15\n\n\x0c Report Template Version = 04-30-05_rev.15\n\n\n\n\n\xce\x94 A C K N O W L E D G M E N T S \n\n\n\n This report was prepared under the direction of Brian T. Pattison,\n Regional Inspector General for Evaluation and Inspections in the\n Kansas City regional office, and Gina C. Maree, Deputy Regional\n Inspector General. Other principal Office of Evaluation and Inspections\n staff who contributed include:\n\n Perry A. Seaton, Team Leader\n Zula Crutchfield, Project Leader\n\n Dennis Tharp, Program Analyst\n\n Brian T. Whitley, Program Analyst\n\n Alan Levine, Program Specialist\n\n Elise Stein, Director, Public Health and Human Services\n\n\n\n Technical Assistance\n\n Barbara Tedesco, Mathematical Statistician\n\n\n\n\n OEI-07-04-00460 AGENCY FOR HEALTHCARE RESEARCH AND QUALITY: MONITORING PATIENT SAFETY GRANTS\n 16\n\x0c"


type: caselaw

text:
 195 Md. 600 (1950)
 74 A.2d 22
 WRIGHT
 v.
 CROWN CORK & SEAL CO.
 [No. 192, October Term, 1949.]
 Court of Appeals of Maryland.
 Decided June 9, 1950.
 The cause was argued before MARBURY, C.J., and DELAPLAINE, COLLINS, GRASON, HENDERSON and MARKELL, JJ.
 Marshall A. Levin, with whom were Levin & Levin on the brief, for appellant.
 J. Sarsfield Sweeny, with whom were Hershey, Donaldson, Williams & Stanley on the brief, for appellee.
 GRASON, J., delivered the opinion of the Court.
 This is a workmen's compensation case. The sole and only issue is: did the workman file his claim for compensation within the time for him to do so, as prescribed by law? Neither fraud nor estoppel is involved. The State Industrial Accident Commission denied the claim and refused compensation, because the claim was not filed "within one year after the beginning of his disability". (Supp. Code 1947, art. 101, sec. 38.) From its order the claimant appealed to the Baltimore City Court. The case was tried in that court before a jury. There was only one issue submitted to the jury: "Did the *602 above Claimant file his claim within the time allowed by law?" Testimony was taken and the case submitted to the jury. It answered the issue "yes", thus overruling the Commission. The judge granted a motion for judgment non obstante veredicto, reversed the finding of the jury, answered the issue "no", and entered a judgment for the employer for costs. The claimant appealed.
 Edwin J. Wright, (claimant and appellant) was employed by the Crown Cork and Seal Company (defendant and appellee). The accident happened on September 13, 1947. Prior thereto Wright had been employed continuously by the Company for over three years as an "industrial engineer, laying out the new building". At the time of the accident, he said: "I was in the process of laying out the new building. I was down on the haunches, on the floor, and the place I had to mark for the men to come and drill holes in the floor, I had to be behind some big cases, about nine feet high and five feet in width, and two cases like that, I was told after awhile, weigh about nine hundred pounds. * * * A lift truck came the other side of the cases, tried to get under the cases, tried to lift them up, and pushed them over on me. Well, nine hundred pounds is a lot of weight to have on your back and it was crushing me." He stated he fell on the floor, was picked up and taken to the "first aid", and Dr. Pillsbury came in and examined him. He returned to work that day and continued to do the same work for the Company until it closed down on September 24, 1948.
 The claim for compensation was not filed by Wright until October 28, 1948, that is, one year and 45 days from the date of the accident. He says he was injured in "the knees and the back"; that his "shoulders ached for about four months after the accident"; that the boxes hit his "head, back and the whole back of my body". There was a column that the boxes hit, that broke the force of the blow he received. His "knees ache continually". "Q. Did you, yourself, fully perform your tasks physically afterwards, as you did before? A. *603 Not after about four months after the accident. * * * Q. What was the condition of your knees after this accident and what symptoms did you notice, if any? A. Approximately four months after the accident, I noticed I had locking of the knees; every time I crossed my legs, my knees would lock. I'd have to unlock the knee and put the leg down on the floor." The doctor examined him and told him "there was a mouse in the knees". He said for three months after the accident "I ached all over, I didn't feel as strong as I was before. * * * Q. What were your symptoms September 13, 1947? A. From the accident on, September 13, 1947, I ached all over, I was weaker than I was before. * * * Approximately three to four months after that, when my knees began to lock." They "never locked before that time".
 On cross examination Wright testified: From the date of the accident, approximately three times a week, heat treatments were applied, for "approximately three to four months". "Q. To what parts of your body? A. To the knees particularly." He admitted he testified before the Commission: That he was taken to the "first aid" after he was injured, and examined by Dr. Pillsbury, and heat treatment was administered; both knees were bandaged; that the locking of his knees occurred within a week after the accident, and that was when Dr. Pillsbury told him there was a mouse in there. "Q. Do you remember your knees actually locking when Dr. Pillsbury was there? A. I don't remember. Q. If you did not have this locking, Mr. Wright, what symptoms did you have in your knees, from September 13, 1947, to October 15, 1947? A. I remember one time trying to dance and they'd swell after that. Q. That was between * * * September 13 to October 15, 1947, and your answer is that at one time you tried to dance and they began to swell? A. That's right." And he said that his knees continued to swell if "I exerted myself in any way."
 In his claim filed with the Commission, Wright gave the following description of the accident: "While zoning *604 aisles in building, in crouching position, two crates of materials weighing about 900 lbs. came down on me."
 Dr. Pillsbury testified that he first saw the claimant on September 15, 1947, at the plant, and that claimant then told him that a high-lift pushed several boxes against him "injuring his shoulders and back". On the 17th of September, 1947, he was X-rayed for "the shoulder, which included the scapula and the clavicle, and showed no evidence of any bone injury. He was continued to be seen off and on at the plant, and during September, the last record I have, was September 22nd, October 15th, October 20th  that is in 1947  then again on the 19th of October, 1948. On October 15, 1947 * * * he (claimant) returned to the plant * * * and stated that since he caught the load on his shoulder he sustained some injury to his right knee and at the time did not pay much attention to the right knee." He said to the doctor that that condition had gotten worse, and on several occasions it had locked on him. He said to the doctor: "`The latest occurrence of locking was today in the first aid room.' That was under date of 10-15-47." There was a definite clicking sensation in the knee, which the doctor referred to as a "mouse-body". X-ray was taken and "showed no radiable bone injury about the knees". The doctor saw claimant on October 20, 1947, and did not see him again until the 19th of October, 1948. As to his condition at that time, the doctor testified: "I do not feel that any of the complaints which he has could be attributable to the injury of September 13, 1947." The claimant and Dr. Pillsbury were the only witnesses.
 This uncontradicted evidence shows that the claimant was injured on September 13, 1947, while in the course of his employment with the Company. Boxes containing materials weighing 900 pounds fell and struck him (some evidently partly rested on him) and he was pinned to the floor, and the blow nearly crushed him. He was released by workmen and taken to the "first aid" at the plant, and received treatment, but returned to his *605 work that day and continued in his work until the plant closed down. He complained of pains in the region of his shoulders and back, and ached all over his body, and was weak. X-ray was taken of his shoulders and back. It is uncontradicted that X-ray was taken of his knees. He received heat treatment and massage to his back, and other parts of his body, two or three time a week for three months after the accident, for pains caused by the accident; he was treated under the direction of Dr. Pillsbury, who saw and examined him at least five times after the accident, at intervals between September 15, 1947 and October 20, 1947. Examinations were made, X-rays were taken on or before October 20, 1947, and the heat treatment continued for three months.
 Although claimant testified that the trouble with his knees did not begin until his pain localized, about three months after the accident, and he then knew his injury was serious, it was testified to by Dr. Pillsbury that claimant told him, on one occasion he visited the doctor, that his knees locked that day while he was in the first aid room. When asked on cross examination if this was true, he said: "I don't remember." He testified that between September 13, 1947, and October 15, 1947, he tried to dance and they (his knees) "began to swell".
 The question is: Did he know, or should have known, that he suffered a disability from the accident within 45 days from September 13, 1947? He states that he thought that his injury was trivial and would pass away, until it localized about three months after the accident, and it was at that time he first knew he suffered a disability caused by the accident. In other words, his contention is that for three months following the accident his injury was latent, but after that time it was patent.
 In Griffin v. Rustless Iron & Steel Co., 187 Md. 524, 540, 51 A.2d 280, 288, it is said: "We think, however, that the wording of the Maryland statute indicates that the period of limitation begins to run from the time when disability becomes, or should become, reasonably *606 apparent. And we hold that this does not mean the particular class of disability for which compensation is asked, but any disability (except that of a trivial nature) which arises from an accident and which eventually ripens into the class of disability for which compensation is claimed." Dunstan v. Bethlehem Steel Co., 187 Md. 571, 51 A.2d 288; Bethlehem-Sparrows Pt. Shipyard, Inc. v. Glass, 188 Md. 501, 53 A.2d 405; Champness v. Glenn L. Martin Co., 193 Md. 188, 66 A.2d 396.
 We think it plain, from the undisputed evidence in this case, that the claimant suffered a disability at the time of the accident. While he lost no time from work, the evidence discloses that the injury he suffered was not slight and inconsequential, and that his condition at that time, and certainly within 45 days from the date of the accident, was apparent to him. His injury does not fall in that class where a claimant suffers a slight injury, goes to a doctor who tells him that his injury is slight, and continues his work, in the meantime employing home remedies, but, nevertheless, the accident occasioned a sleeping or latent injury which afterwards becomes active and results in a serious condition to the claimant. In such a case the injury is latent and does not become apparent until the sleeping injury flares up and the claimant's condition becomes known, or should have become known to him. In such a case the one year period within which a claim must be filed by the workman, with the Commission, is tolled until the latent injury caused by the accident becomes apparent. The case of Baltimore Steel Co. v. Burch, 187 Md. 209, 49 A.2d 542, was such a case, and that case is strongly relied on by the claimant. Its facts are entirely different from the case at bar. In that case the injury was latent, and in this case the injury was apparent at the time of the accident, and certainly was known, or should have been known within 45 days from the date of the accident. If he had filed his claim within one year from that time, it would have been within the one year period *607 required by the statute. We conclude that the action of the learned judge below was correct and the judgment will be affirmed.
 Judgment affirmed, with costs.