Child And Family Services Reviews: States and HHS Face Challenges
in Assessing and Improving State Performance (13-MAY-04,	 
GAO-04-781T).							 
                                                                 
In 2001, the Department of Health and Human Services' (HHS)	 
Administration for Children and Families (ACF) implemented the	 
Child and Family Services Reviews (CFSR) to increase states'	 
accountability. The CFSR uses states' data profiles and statewide
assessments, as well as interviews and an on-site case review, to
measure state performance on 14 outcomes and systemic factors,	 
including child well-being and the provision of caseworker	 
training. The CFSR also requires progress on a program		 
improvement plan (PIP); otherwise ACF may apply financial	 
penalties. This testimony is based on our April 2004 report and  
addresses (1) ACF's and the states' experiences preparing for and
conducting the statewide assessments and on-site reviews; (2)	 
ACF's and the states' experiences developing, funding, and	 
implementing items in PIPs; and (3) any additional efforts that  
ACF has taken beyond the CFSR to improve state performance. For  
the April 2004 report, we surveyed all 50 states, the District of
Columbia, and Puerto Rico regarding their experiences throughout 
the CFSR process, visited 5 states to obtain first-hand 	 
information, and conducted a content analysis of all 31 available
PIPs as of January 1, 2004. We also interviewed HHS		 
officials--including those in all 10 regional offices---and key  
child welfare experts.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-781T					        
    ACCNO:   A10056						        
  TITLE:     Child And Family Services Reviews: States and HHS Face   
Challenges in Assessing and Improving State Performance 	 
     DATE:   05/13/2004 
  SUBJECT:   Child care programs				 
	     Children						 
	     Families						 
	     Performance measures				 
	     Program management 				 
	     Strategic planning 				 
	     Child welfare					 
	     Family support programs				 
	     California 					 
	     Florida						 
	     HHS Child and Family Services Reviews		 
	     System						 
                                                                 
	     New York						 
	     Oklahoma						 
	     Wyoming						 

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GAO-04-781T

United States General Accounting Office

GAO Testimony

Before the Subcommittee on Human Resources, Committee on Ways and Means,
House of Representatives

For Release on Delivery

Expected at 10:00 a.m. EDT CHILD AND FAMILY

Thursday, May 13, 2004

SERVICES REVIEWS

  States and HHS Face Challenges in Assessing and Improving State Performance

Statement of Cornelia M. Ashby, Director, Education, Workforce, and Income
Security Issues

GAO-04-781T

Highlights of GAO-04-781T, a testimony before the Subcommittee on Human
Resources, Committee on Ways and Means, House of Representative

In 2001, the Department of Health and Human Services' (HHS) Administration
for Children and Families (ACF) implemented the Child and Family Services
Reviews (CFSR) to increase states' accountability. The CFSR uses states'
data profiles and statewide assessments, as well as interviews and an
on-site case review, to measure state performance on 14 outcomes and
systemic factors, including child well-being and the provision of
caseworker training. The CFSR also requires progress on a program
improvement plan (PIP); otherwise ACF may apply financial penalties. This
testimony is based on our April 2004 report and addresses (1) ACF's and
the states' experiences preparing for and conducting the statewide
assessments and on-site reviews; (2) ACF's and the states' experiences
developing, funding, and implementing items in PIPs; and (3) any
additional efforts that ACF has taken beyond the CFSR to improve state
performance. For the April 2004 report, we surveyed all 50 states, the
District of Columbia, and Puerto Rico regarding their experiences
throughout the CFSR process, visited 5 states to obtain first-hand
information, and conducted a content analysis of all 31 available PIPs as
of January 1, 2004. We also interviewed HHS officials- including those in
all 10 regional offices-and key child welfare experts.

www.gao.gov/cgi-bin/getrpt?GAO-04-781T.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Corneila Ashby at (202)
512-8403 or [email protected].

May 2004

CHILD AND FAMILY SERVICES REVIEWS

States and HHS Face Challenges in Assessing and Improving State Performance

ACF and many state officials perceive the CFSR as a valuable process and a
substantial undertaking, but some data enhancements could improve its
reliability. ACF staff in 8 of the 10 regions considered the CFSR a
helpful tool to improve outcomes for children. Further, 26 of 36 states
responding to a relevant question in our survey commented that they
generally or completely agreed with the results of the final CFSR report,
even though none of the 41 states with final CFSR reports released through
2003 has achieved substantial conformity on all 14 outcomes and systemic
factors. Additionally, both ACF and the states have dedicated substantial
financial and staff resources to the process. Nevertheless, several state
officials and child welfare experts we interviewed questioned the accuracy
of the data used in the review process. While ACF officials contend that
stakeholder interviews and case reviews complement the data profiles, many
state officials and experts reported that additional data from the
statewide assessment could bolster the evaluation of state performance.

Program improvement planning is under way, but uncertainties have affected
the development, funding, and implementation of state PIPs. Officials from
3 of the 5 states we visited said ACF's PIP-related instructions were
unclear, and at least 9 states reported in our survey that challenges to
implementing their plans include insufficient funding, staff, and time.
While ACF has provided some guidance, ACF and state officials remain
uncertain about PIP monitoring efforts and how ACF will apply financial
penalties if states fail to achieve their stated PIP objectives.

Since 2001, ACF's focus has been almost exclusively on the CFSRs and
regional staff report limitations in providing assistance to states in
helping them to meet key federal goals. While staff from half of ACF's
regions told us they would like to provide more targeted assistance to
states, and state officials in all 5 of the states we visited said that
ACF's existing technical assistance efforts could be improved, ACF
officials acknowledged that regional staff might still be adjusting to the
new way ACF oversees child welfare programs.

In the April 2004 report, we recommended that the Secretary of HHS ensure
that ACF uses the best available data to measure state performance. We
also recommended that the Secretary clarify PIP guidance and provide
guidance to regional officials on how to better integrate their many
oversight responsibilities. In commenting on a draft of the April 2004
report, HHS acknowledged that the CFSR is a new process that continues to
evolve, and noted several steps it has taken to address the data quality
concerns we raised in that report.

Mr. Chairman and Members of the Subcommittee:

Thank you for inviting me here today to discuss states' efforts to comply
with federal Child and Family Services Reviews (CFSR). As you are aware,
in 2001, the Department of Health and Human Services' (HHS) Administration
for Children and Families' (ACF) began implementing the CFSRs to hold
states accountable for improving child welfare outcomes. Unlike prior
federal reviews-which determined states' adherence to certain process
measures-ACF designed the CFSR as an outcomeoriented approach to assess
children's safety; their timely placement in permanent homes; and their
mental, physical, and educational well-being; and it developed certain
standards against which to measure states' success in these areas.1 ACF
also designed the reviews to assess states' performance across a range of
systemic factors, such as caseworker training and foster parent licensing.
The CFSR has multiple phases, consisting of a statewide assessment; an
on-site review, which culminates in the release of a final report; and the
development and implementation of a program improvement plan (PIP) when
states are found to be deficient. Pursuant to CFSR regulations, ACF can
withhold federal funds if states do not show adequate progress
implementing their PIPs.

My testimony today will focus on three key issues: (1) ACF's and the
states' experiences preparing for and conducting the statewide assessments
and on-site reviews; (2) ACF's and the states' experiences developing,
funding, and implementing items in their PIPs; and (3) additional efforts,
if any, that ACF has taken beyond the CFSR to help ensure that all states
meet federal goals of safety, permanency, and wellbeing for children. My
comments are based on the findings from our April

1The CFSR measures state performance on 45 performance items, which
correspond to 7 outcomes and 7 systemic factors. The outcomes relate to
children's safety, permanency, and well-being, and the systemic factors
address state agency management and responsiveness to the community. Six
national standards, as reported in the Adoption and Foster Care Analysis
and Reporting System (AFCARS) and the National Child Abuse and Neglect
Data System (NCANDS), apply to 5 of the 45 items. Three of these standards
are based on the 75th percentile of all states' performance-adoption;
stability of foster care placements; and length of time to achieve
reunification, guardianship, or permanent placement with relatives-because
a higher incidence is desirable. However, the remaining three
standards-recurrence of maltreatment, incidence of child abuse/neglect in
foster care, and foster care re-entries-are based on the 25th percentile
of state performance because lower incidence is a desired outcome for
these measures.

2004 report.2 Those findings were based on a survey of all 50 states, the
District of Columbia, and Puerto Rico regarding their experiences during
each phase of the CFSR process;3 post-survey follow up phone calls with
key states;4 and site visits to California, Florida, New York, Oklahoma,
and Wyoming to obtain first-hand information on states' experiences. We
selected these states for diversity in their location, size, program
administration, performance on the CFSR, and the timing of their review.
We also examined all 31 approved PIPs available as of January 1, 2004, and
conducted interviews with ACF's senior officials, regional staff from all
10 regions, ACF contractors, staff from all 10 national resource centers,5
and key child welfare experts. We conducted our work between May 2003 and
February 2004 in accordance with generally accepted government auditing
standards.

In summary, ACF and many state officials perceive the CFSR as a valuable
process and a substantial undertaking, but some data enhancements could
improve its reliability. ACF staff in 8 of the 10 regions considered the
CFSR a helpful tool to improve outcomes for children, and 26 of 36 states
responding to a relevant question in our survey commented that they
generally or completely agreed with the results of the final CFSR report,
even though none of the 41 states with final CFSR reports released through
2003 has achieved substantial conformity on all CFSR outcomes and systemic
factors. Additionally, both ACF and the states have dedicated substantial
financial and staff resources to the process. Nevertheless, several state
officials and child welfare experts we interviewed questioned the accuracy
of the data used in the review process and noted that

2U.S. General Accounting Office, Child and Family Services Reviews: Better
Use of Data and Improved Guidance Could Enhance HHS's Oversight of State
Performance

(GAO-04- 333, April 20, 2004).

3We achieved a 98 percent response rate from this survey; Puerto Rico was
the only nonrespondent.

4The 10 states participating in our phone follow-up surveys were Arkansas,
Iowa, Kansas, Mississippi, North Dakota, New Jersey, Pennsylvania, Rhode
Island, Utah, and West Virginia.

5ACF has established cooperative agreements with 10 national resource
centers to help states implement federal legislation intended to ensure
the safety, permanency, and wellbeing of children and families. ACF sets
the resource centers' areas of focus, and although each center has a
different area of expertise, such as organizational improvement or
information technology, all of them conduct needs assessments, sponsor
national conference calls with states, collaborate with other resource
centers and agencies, and provide on-site training and technical
assistance to states.

additional data from the statewide assessment could bolster the evaluation
of state performance. While states' PIP planning is under way,
uncertainties have affected the development, funding, and implementation
of these plans. Officials from 3 of the 5 states we visited said ACF's
PIPrelated instructions were unclear, and at least 9 of the 25 states
reporting on PIP implementation in our survey stated that insufficient
funding, staff, and time, as well as high caseloads, were among the
greatest challenges. While ACF has provided some guidance, ACF and state
officials remain uncertain about PIP monitoring efforts and how ACF will
apply financial penalties if states fail to achieve their stated PIP
objectives. Further, since 2001, ACF's focus has been almost exclusively
on the CFSRs and regional staff report limitations in providing assistance
to states in helping them to meet key federal goals. To improve its
oversight, we recommended in our April 2004 report that the Secretary of
HHS ensure that ACF use the best available data to measure state
performance, clarify PIP guidance, and help regional offices better
integrate their oversight responsibilities.

Background 	ACF's Children's Bureau administers and oversees federal
funding to states for child welfare services under Titles IV-B and IV-E of
the Social Security Act, and states and counties provide these child
welfare services, either directly or indirectly through contracts with
private agencies.6 Among other activities, ACF staff are responsible for
developing appropriate policies and procedures for states to follow to
obtain and use federal child welfare funds, reviewing states' planning
documents required by Title IV-B, conducting states' data system reviews,
assessing states' use of Title IV-E funds, and providing technical
assistance to states through all phases of the CFSR process. In addition,
ACF staff coordinate the work of the 10 resource centers to provide
additional support and assistance to the states.

Spurred by the passage of the 1997 Adoption and Safe Families Act (ASFA),
ACF launched the CFSR in 2001 to improve its existing monitoring efforts,
which had once been criticized for focusing exclusively on states'
compliance with regulations rather than on their performance over a full
range of child welfare services. The CFSR process combines a

6Title IV-B of the Social Security Act, consisting of two subparts, is the
primary source of federal funding for services to help families address
problems that lead to child abuse and neglect and to prevent the
unnecessary separation of children from their families. Funding under
Title IV-E of the Social Security Act is used primarily to pay for the
room and board of children in foster care.

statewide self-assessment, an on-site case file review that is coupled
with stakeholder interviews,7 and the development and implementation of a
2year PIP with performance benchmarks to measure progress in improving
noted deficiencies. In assessing performance through the CFSR, ACF relies,
in part, on its own data systems, known as NCANDS and AFCARS, which were
designed prior to CFSR implementation to capture, report, and analyze the
child welfare information collected by the states.8 Today, these systems
provide the national data necessary for ACF to calculate national
standards for key performance items against which all states are measured
and to determine, in part, whether or not states are in substantial
conformity on CFSR outcomes and systemic factors.9 Once ACF approves the
PIP, states are required to submit quarterly progress reports. Pursuant to
CFSR regulations, federal child welfare funds can be withheld if states do
not show adequate PIP progress, but these penalties are suspended during
the 2-year PIP implementation term.10

In preparation for the next round of CFSRs, ACF officials have formed a
Consultation Work Group of ACF staff, child welfare administrators, data
experts, and researchers who will propose recommendations on the CFSR
measures and processes. The group's resulting proposals for change, if
any, are not yet available.

7 The term stakeholder refers to two groups: (1) agency stakeholders, such
as judges or advocates, whose responsibilities are closely related to the
work of the child welfare agency and who can comment on the agency's
overall performance on outcomes and systemic factors, and (2)
case-specific stakeholders, such as parents, caseworkers, children, or
others who are interviewed to provide first-hand information that
supplements reviewers' assessment of paper or electronic case files.

8States began voluntarily reporting to NCANDS in 1990, and in 1995 started
reporting to AFCARS on the demographic characteristics of adoptive and
foster children and their parents, as well as foster children's type of
placement and permanency goals. We recently issued a report on states'
child welfare information systems and the reliability of child welfare
data. U.S. General Accounting Office, Child Welfare: Most States Are
Developing Statewide Information Systems, but the Reliability of Child
Welfare Data Could Be Improved, GAO-03-809 (Washington, D.C.: July 31,
2003).

9States achieve substantial conformity on outcomes and systemic factors
when at least 90 percent of applicable cases are substantially achieved;
stakeholder interviews confirm that state plan and other program
requirements are in place and functioning as described in the applicable
regulations or statute; and performance on items with national standards,
where applicable, meets the applicable threshold.

10The formula for calculating penalties is based in part on each state's
allocation of federal child welfare funds from Titles IV-B and IV-E and
the number of outcomes and systemic factors for which substantial
conformity has not been achieved.

  The CFSR Is a Valuable Yet Substantial Undertaking, but Data Enhancements
  Could Improve Its Reliability

ACF and many state officials perceive the CFSR as a valuable process-
highlighting many areas needing improvement-and a substantial undertaking,
but some state officials and child welfare experts told us that data
enhancements could improve its reliability. ACF staff in 8 of the 10
regions considered the CFSR a helpful tool to improve outcomes for
children. Further, 26 of the 36 states responding to a relevant question
in our survey commented that they generally or completely agreed with the
results of the final CFSR report, even though none of the 41 states with
final CFSR reports released through 2003 has achieved substantial
conformity on all 14 outcomes and systemic factors. In addition, both ACF
and the states have dedicated substantial financial and staff resources to
the process. However, several state officials and child welfare experts we
interviewed questioned the accuracy of the data used to compile state
profiles and establish the national standards. While ACF officials in the
central office contend that stakeholder interviews and case reviews
compliment the data profiles, many state officials and experts reported
that additional data from the statewide assessment could bolster the
evaluation of state performance.

The CFSR Is a Valuable Process for ACF and the States

ACF and state officials support the objectives of the review, especially
in focusing on children's outcomes and strengthening relationships with
stakeholders, and told us they perceive the process as valuable. For
example, ACF officials from 8 regional offices noted that the CFSRs were
more intensive and more comprehensive than the other types of reviews they
had conducted in the past, creating a valuable tool for regional officials
to monitor states' performance. In addition, state officials from every
state we visited told us that the CFSR process helped to improve
collaboration with community stakeholders. Furthermore, state staff from 4
of the 5 states we visited told us the CFSR led to increased public and
legislative attention to critical issues in child welfare. For example,
caseworkers in Wyoming told us that without the CFSR they doubted whether
their state agency's administration would have focused on needed reforms.
They added that the agency used the CFSR findings to request legislative
support for the hiring of additional caseworkers.

Along with the value associated with improved stakeholder relations, the
ACF officials we talked to and many state officials reported that the
process has been helpful in highlighting the outcomes and systemic
factors, as well as other key performance items that need improvement.
According to our survey, 26 of the 36 states that commented on the
findings of the final CFSR report indicated that they generally or
completely agreed with the findings, even though performance across the

states was low in certain key outcomes and performance items. For example,
not one of the 41 states with final reports released through 2003 was
found to be in substantial conformity with either the outcome measure that
assesses the permanency and stability of children's living situations or
with the outcome measure that assesses whether states had enhanced
families' capacity to provide for their children's needs. Moreover, across
all 14 outcomes and systemic factors, state performance ranged from
achieving substantial conformity on as few as 2 outcomes and systemic
factors to as many as 9.11 As figure 1 illustrates, the majority of states
were determined to be in substantial conformity with half or fewer of the
14 outcomes and systemic factors assessed.

11California and Puerto Rico were determined to be in substantial
conformity on 2 outcomes and systemic factors, while North Dakota achieved
substantial conformity on 9.

Figure 1: State Performance on the 14 CFSR Outcomes and Systemic Factors

States determined to be in substantial conformity with 4 or fewer outcomes
and systemic factors

States determined to be in substantial conformity with 5 to 7 outcomes and
systemic factors

States determined to be in substantial conformity with 8 or more outcomes
and systemic factors

States for which determinations have not yet been made

Source: GAO analysis of final reports released through December 31, 2003.

States' performance on the outcomes related to safety, permanency, and
well-being-as well as the systemic factors-is determined by their
performance on an array of items, such as establishing permanency goals,
ensuring worker visits with parents and children, and providing accessible
services to families. The CFSR showed that many states need improvement in
the same areas. For example, across all 41 states reviewed through 2003,
the 10 items most frequently rated as needing improvement included
assessing the needs and services of children, parents, and foster parents
(40 states); assessing the mental health of children (37 states); and
establishing the most appropriate permanency goal for the child (36
states).

ACF and the States Report That Reviews Have Been a Substantial Undertaking

Given the value that ACF and the states have assigned to the CFSR process,
both have spent substantial financial resources and staff time to prepare
for and implement the reviews. In fiscal years 2001-03, when most reviews
were scheduled, ACF budgeted an additional $300,000 annually for
CFSR-related travel. In fiscal year 2004, when fewer reviews were
scheduled, ACF budgeted about $225,000. To further enhance its capacity to
conduct the reviews, and to obtain additional logistical and technical
assistance, ACF spent approximately $6.6 million annually to hire
contractors. Specifically, ACF has let three contracts to assist with
CFSRrelated activities, including training reviewers to conduct the
on-site reviews, tracking final reports and PIP documents, and, as of
2002, writing the CFSR final reports. Additionally, ACF hired 22 new staff
to build central and regional office capacity and dedicated 4 full-time
staff and 2 state government staff temporarily on assignment with ACF to
assist with the CFSR process. To build a core group of staff with CFSR
expertise, ACF created the National Review Team, composed of central and
regional office staff with additional training in and experience with the
review process. In addition, to provide more technical assistance to the
states, ACF reordered the priorities of the national resource centers to
focus their efforts primarily on helping states with the review process.

Like ACF, states also spent financial resources on the review. While some
states did not track CFSR expenses-such as staff salaries, training, or
administrative costs-of the 25 states that reported such information in
our survey, the median expense to date was $60,550, although states
reported spending as little as $1,092 and as much as $1,000,000 on the
CFSR process.12 Although ACF officials told us that states can use Title
IV-E funds to pay for some of their CFSR expenses, only one state official
addressed the use of these funds in our survey, commenting that it was not
until after the on-site review occurred that the state learned these funds
could have been used to offset states' expenses. States also reported that
they dedicated staff time to prepare for the statewide assessment and to
conduct the on-site review, which sometimes had a negative impact on some
staffs' regular duties. According to our survey, 45 states reported

12These values are state-reported and reflect officials' estimates of
costs associated with all CFSR-related activities except those incurred
during PIP implementation. In reporting on their expenses, states were
instructed to include the value of training, travel, infrastructure,
technology, food, administrative supplies, and any other expenses
associated with the CFSR process. States were also asked to provide
supporting documentation for this particular question, but most states
were unable to provide documentation. Many states reported that they did
not track CFSR-related expenses. The 25 states that did provide estimates
were in different phases of the CFSR.

dedicating up to 200 full-time staff equivalents (FTE), with an average of
47 FTEs, to the statewide assessment process.13 Similarly, 42 states
responded that they dedicated between 3 and 130 FTEs, with an average of
45 FTEs, to the on-site review process. For some caseworkers, dedicating
time to the CFSR meant that they were unable or limited in their ability
to manage their typical workload. For example, Wyoming caseworkers whose
case files were selected for the on-site review told us that they needed
to be available to answer reviewers' questions all day every day during
the on-site review, which they said prevented them from conducting
necessary child abuse investigations or home visits. Child welfare-related
stakeholders-such as judges, lawyers, and foster parents-also contributed
time to the CFSR.

States and Child Welfare Experts Report That Several Data Improvements
Could Enhance CFSR Reliability

State officials in the 5 states we visited, as well as child welfare
experts, reported on several data improvements that could enhance the
reliability of CFSR findings. In particular, they highlighted inaccuracies
with the AFCARS and NCANDS data that are used for establishing the
national standards and creating the statewide data profiles, which are
then used to determine if states are in substantial conformity. These
concerns echoed the findings of a prior GAO study on the reliability of
these data sources, which found that states are concerned that the
national standards used in the CFSR are based on unreliable information
and should not be used as a basis for comparison and potential financial
penalty.14 Furthermore, many states needed to resubmit their statewide
data after finding errors in the data profiles ACF would have used to
measure compliance with the national standards.15 According to our
national survey, of the 37 states that reported on resubmitting data for
the statewide data profile, 23 needed to resubmit their statewide data at
least once, with one state needing to resubmit as many as five times to
accurately reflect revised data. Four states reported in our survey that
they did not resubmit their data profiles

13The number of FTEs participating in each phase of the CFSR is
state-reported. While states were not given specific instructions for how
to calculate FTEs, they were asked to report only on the phases of the
CFSR that they had started or completed. Therefore, states' responses
varied depending on the phase of the CFSR process they were in and the
methods they used to calculate FTEs.

14GAO-03-809.

15ACF provides states with their statewide data about 6 months prior to
the on-site review, during which time states are allowed to make
corrections to the data and resubmit the updated data so it can be used
when determining state conformity with CFSR measures.

because they did not know they had this option or they did not have enough
time to resubmit before the review.

In addition to expressing these data concerns, child welfare experts as
well as officials in all of the states we visited commented that existing
practices that benefit children might conflict with actions needed to
attain the national standards. For example, officials in New York said
that they recently implemented an initiative to facilitate adoptions.
Because these efforts focus on the backlog of children who have been in
foster care for several years, New York officials predict that their
performance on the national standard for adoption will be lower since many
of the children in the initiative have already been in care for more than
2 years. Experts and officials from multiple states also commented that
they believe the on-site review case sample of 50 cases is too small to
provide an accurate picture of statewide performance, although ACF
officials stated that the case sampling is supplemented with additional
information.16 For example, Oklahoma officials we visited commented that
they felt the case sample size was too small, especially since they
annually assess more than 800 of their own cases-using a procedure that
models the federal CFSR-and obtain higher performance results than the
state received on its CFSR. Furthermore, because not every case in the
states' sample is applicable to each item measured in the on-site review,
we found that sometimes as few as 1 or 2 cases were being used to evaluate
states' performance on an item. For example, Wyoming had only 2 on-site
review cases applicable for the item measuring the length of time to
achieve a permanency goal of adoption, but for 1 of these cases, reviewers
determined that appropriate and timely efforts had not been taken to
achieve finalized adoptions within 24 months, resulting in the item being
assigned a rating of area needing improvement.17 While ACF officials
acknowledged the insufficiency of the

16According to our calculations-which assumed that the attribute of
interest occurred in about 50 percent of the cases-a sample size of 50
would produce percentage estimates with a 95 percent margin of error of
approximately plus or minus 14 percentage points. This level of
variability is a limitation when attempting to interpret estimates based
on this sample size.

17Because 1 of the 2 cases applicable to the adoption measure was assigned
a rating of area needing improvement, 50 percent of the cases for this
item were assigned a rating of area needing improvement. As a result, the
item was given an overall rating of area needing improvement since both
cases would have needed to be assigned a rating of strength for this item
to meet the 85 percent threshold necessary to assign an overall rating of
strength.

sample size,18 they contend that the case sampling is augmented by
stakeholder interviews for all items and applicable statewide data for the
five CFSR items with corresponding national standards, therefore providing
sufficient evidence for determining states' conformity.

All of the states we visited experienced discrepant findings between the
aggregate data from the statewide assessment and the information obtained
from the on-site review. We also found that in these 5 states, ACF had
assigned an overall rating of area needing improvement for 10 of the 11
instances in which discrepancies occurred. ACF officials acknowledged the
challenge of resolving data discrepancies, noting that such complications
can delay the release of the final report and increase or decrease the
number of items that states must address in their PIPs. While states have
the opportunity to resolve discrepancies by submitting additional
information explaining the discrepancy or by requesting an additional case
review, only 1 state to date has decided to pursue the additional case
review.19 Further, several state officials and experts also told us that
additional data from the statewide assessments-or other data sources
compiled by the states-could bolster the evaluation of states'
performance, but they found this information to be missing or
insufficiently used in the final reports. For example, child welfare
experts and state officials from California and New York-who are using
alternative data sources to AFCARS and NCANDS, such as longitudinal data
that track children's placements over time-told us that the inclusion of
this more detailed information would provide a more accurate picture of
states' performance nationwide. An HHS official told us that alternative
data are used only to assess state performance in situations in which a
state does not have NCANDS data, since states are not mandated to have
these systems.

18An ACF statistician also confirmed that the CFSR sample is too small to
generalize to the states' populations and that the three sites, from which
cases are selected, also are not representative.

19Virginia requested an additional case review to resolve a discrepancy
between the statewide data and on-site review findings for the item
measuring the state's performance on foster care re-entries. According to
an ACF regional official, the state met the national standard for this
item but the case review findings showed the state did not meet the
threshold for this measure. At the time of publication of our April 2004
report, ACF and the state were still finalizing plans to conduct the
additional case review, and until the review is completed, the state
cannot receive its final report.

  Program Improvement Planning Under Way, but Uncertainties Challenge Plan
  Development, Implementation, and Monitoring

Given their concerns with the data used in the review process, state
officials in 4 of the 5 states believed that the threshold for achieving
substantial conformity was difficult to achieve. While an ACF official
told us that different thresholds for the national standards had been
considered, ACF policy makers ultimately concluded that a threshold at the
75th percentile of the nationwide data would be used. ACF officials
recognize that they have set a high standard. However, they believe it is
attainable and supportive of their overall approach to move states to the
standard through continuous improvement.

Forty-one states are engaged in program improvement planning, but many
uncertainties, such as those related to federal guidance and monitoring
and the availability of state resources, have affected the development,
implementation, and funding of the PIPs. State PIPs include strategies
such as revising or developing policies, training caseworkers, and
engaging stakeholders, and ACF has issued regulations and guidance to help
states develop and implement their plans. Nevertheless, states reported
uncertainty about how to develop their PIPs and commented on the
challenges they faced during implementation. For example, officials from 2
of the states we visited told us that ACF had rejected their PIPs before
final approval, even though these officials said that the plans were based
on examples of approved PIPs that regional officials had provided.
Further, at least 9 of the 25 states responding to a question in our
survey on PIP implementation indicated that insufficient time, funding,
and staff, as well as high caseloads, were the greatest challenges they
faced. As states progress in PIP implementation, some ACF officials
expressed a need for more guidance on how to monitor state
accomplishments, and both ACF and state officials were uncertain about how
the estimated financial penalties would be applied if states fail to
achieve the goals described in their plans.

State Plans Include a Variety of Strategies to Address Identified
Weaknesses

State plans include a variety of strategies to address weaknesses
identified in the CFSR review process. However, because most states had
not completed PIP implementation by the time of our analysis, the extent
to which states have improved outcomes for children has not been
determined.20 While state PIPs varied in their detail, design, and scope,

20As we reported in our April 2004 report, only Delaware and North
Carolina had completed the 2-year term of their PIPs, and ACF was still
analyzing the states' progress and had not determined if there has been
overall improvement or if ACF will apply financial penalties.

according to our analysis of 31 available PIPs, these state plans have
focused to some extent on revising or developing policies; reviewing and
reporting on agency performance; improving information systems; and
engaging stakeholders such as courts, advocates, foster parents, private
providers, or sister agencies in the public sector.21 Table 1 shows the
number of states that included each of the six categories and
subcategories of strategies we developed for the purposes of this study.

21Although 41 states were developing or implementing PIPs when our April
2004 report was published, we reviewed the 31 available PIPs that ACF had
approved as of January 1, 2004.

Table 1: Number of States Including Each of the PIP Strategy Categories
Used in This Study

Policies and procedures Review, modify, or develop/implement any policy,
procedure or case practice standard (31)

Enhance foster home/parent licensing standards (7)

Develop child and family assessment tools, such as protocols for
risk/safety determinations (28)

Identify and adopt any promising practices (19)

Data collection and analysis 	Review and report on agency performance
through self-assessments or internal audits/review (31)

Apply federal CFSR or similar process for internal statewide case reviews
(16)

Improve information and data collection systems (31)

Staff supports 	Train and develop caseworkers (through dissemination and
training on policy or through revisions to overall curriculum) (30)

Assess and monitor staff responsibilities, skills, or performance (24)

Recruit additional staff/retain staff (14)

Lower caseloads (11)

Increase caseworker pay (1) Foster parent supports/services and resources
for children and families Train and develop foster families'/providers'
skills and capacities (27)

Recruit and retain foster families (22)

Increase involvement of foster or birth families in case (18)

Expand service array for children and families (includes developing or
enhancing transportation systems to transport siblings and parents for
visits, creating one-stop centers for assistance, modifying visitation
services, and providing any additional support services) (27)

Engage stakeholders such as courts, advocates, foster homes, private
providers, or sister agencies in public sector, e.g., mental health (can
include consultation, training, or formal partnering to improve services
or placements) (31)

Create or improve monitoring of contracts with private providers to
enhance service delivery (includes development of performance based or
outcome-based contracts or other evaluations of provider performance) (25)

State legislative supports State request for legislative action to support
any of the above strategies (20)

Federal technical assistance 	State request technical assistance from ACF
or any resource center to support any of the above strategies (27)

                             Source: GAO analysis.

Our analysis also showed that many states approached PIP development by
building on state initiatives in place prior to the on-site review. Of the
42 surveyed states reporting in our survey on this topic, 30 said that
their state identified strategies for the PIP by examining ongoing state
initiatives. For example, local officials in New York City and state
officials in California told us that state reform efforts-borne in part
from legal settlements-have become the foundation for the PIP. State
officials in California informed us that reform efforts initiated prior to
the CFSR, such as implementing a new system for receiving and
investigating reports of abuse and neglect and developing more early
intervention programs, became integral elements in the PIP.

Insufficient Guidance Hampered State Planning Efforts, but ACF Has Taken
Steps to Clarify Expectations and Improve Technical Assistance

ACF has provided states with regulations and guidance to facilitate PIP
development, but some states believe the requirements have been unclear.
For example, several states commented in our survey that multiple aspects
of the PIP approval process were unclear, such as how much detail and
specificity the agency expects the plan to include; what type of feedback
states could expect to receive; when states could expect to receive such
feedback; and whether a specific format was required. Officials in the
states we visited echoed survey respondents' concerns with officials from
3 of the 5 states informing us that ACF had given states different
instructions regarding acceptable PIP format and content. For example,
California and Florida officials told us that their program improvement
plans had been rejected prior to final approval, even though they were
based on examples of approved plans that regional officials had provided.
In addition, California officials told us that they did not originally
know how much detail the regional office expected in the PIP and believed
that the level of detail the regional office staff ultimately required was
too high. Specifically, officials in California said that the version of
their plan that the region accepted included 2,932 action steps-a number
these officials believe is too high given their state's limited resources
and the 2-year time frame to implement the PIP.

ACF officials have undertaken several steps to clarify their expectations
for states and to improve technical assistance. For example, in 2002, 2
years after ACF released the CFSR regulations and a procedures manual, ACF
offered states additional guidance and provided a matrix format to help
state officials prepare their plans. ACF officials told us the agency
sends a team of staff from ACF and resource centers to the state to
provide intensive on-site technical assistance, when it determines that a
state is slow in developing its PIP. Further, ACF has sent resource center
staff to states to provide training almost immediately after the
completion

of the on-site review to encourage state officials to begin PIP
development before the final report is released. Our survey results
indicate that increasing numbers of states are developing their PIPs early
in the CFSR process, which may reflect ACF's emphasis on PIP development.
According to our analysis, of the 18 states reviewed in 2001, only 2
started developing their PIPs before or during the statewide assessment
phase. Among states reviewed in 2003, this share increased to 5 of 9.

Evidence suggests that lengthy time frames for PIP approval have not
necessarily delayed PIP implementation, and ACF has made efforts to reduce
the time the agency takes to approve states' PIPs. For example, officials
in 3 of the 5 states we visited told us they began implementing new action
steps before ACF officially approved their plans because many of the
actions in their PIPs were already under way. In addition, according to
our survey, of the 28 states reporting on this topic, 24 reported that
they had started implementing their PIP before ACF approved it. Further,
our analysis shows that the length of time between the PIP due date, which
statute sets at 90 days after the release of the final CFSR report, and
final ACF PIP approval has ranged considerably-from 45 to 349 business
days. For almost half of the plans, ACF's approval occurred 91 to 179
business days after the PIP was due. Our analysis indicated that ACF has
recently reduced the time lapse by 46 business days. This shorter time
lapse for PIP approval may be due, in part, to the ACF's emphasis on PIP
development. According to one official, ACF has directed states to
concentrate on submitting a plan that can be quickly approved. Another ACF
official added that because of ACF's assistance with PIP development,
states are now submitting higher-quality PIPs that require fewer
revisions.

State and Federal Uncertainties Cloud PIP Implementation and Monitoring

Program improvement planning has been ongoing, but uncertainties have made
it difficult for states to implement their plans and ACF to monitor state
performance. Such uncertainties include not knowing whether state
resources are adequate to implement the plans and how best to monitor
state reforms. In answering a survey question about PIP implementation
challenges, a number of states identified insufficient funding, staff, and
time-as well as high caseloads-as their greatest obstacles. Figure 2
depicts these results.

Figure 2: Most Common Challenges Affecting States' PIP Implementation

Number of states reporting how much challenges affected PIP implementation

                                       25

                                       20

                                       15

                                      10 5

                                       0

e

        InsufficientfundingInsufficientstaffInsufficienttimHighcaseloads

Very great or great extent

Moderate, some or little extent

Source: GAO survey.

Note: This is based on responses from 25 states. The results reported in
the figure are a sum of the states reporting that the issue was a
challenge to PIP implementation to a very great extent, great extent,
moderate extent, or some/little extent. States not included answered no
extent, no basis to judge, or not applicable.

One official from Pennsylvania commented that because of the state's
budget shortfall, no additional funds were available for the state to
implement its improvement plan, so most counties must improve outcomes
with little or no additional resources. A Massachusetts official reported
that fiscal problems in his state likely would lead the state to lay off
attorneys and caseworkers and to cut funding for family support programs.
While state officials acknowledged that they do not have specific
estimates of PIP implementation expenses because they have not tracked
this information in their state financial systems, many states indicated
that to cope with financial difficulties, they had to be creative and use
resources more efficiently to fund PIP strategies. Of the 26 states
responding to a question in our survey on PIP financing, 12 said that they
were financing the PIP strategies by redistributing current funding, and 7
said that they were using no-cost methods. In an example of the latter,
Oklahoma officials reported pursuing in-kind donations from a greeting
card company so that they could send thank-you notes to foster parents,
believing this could increase foster parent retention and engagement.
Aside from funding challenges, states also reported that PIP
implementation has been affected by staff workloads, but these comments
were mixed. In Wyoming, for example, caseworkers told us that their high
caseloads would prevent them from implementing many of the positive action
steps included in their improvement plan. In contrast, Oklahoma
caseworkers told us that the improvement plan priorities in their state-
such as finding permanent homes for children-have helped them become more
motivated, more organized, and more effective with time management.

ACF officials expressed uncertainty about how best to monitor states'
progress and apply estimated financial penalties when progress was slow or
absent, and 3 of the 5 states we visited reported frustration with the
limited guidance ACF had provided on the PIPs quarterly reporting process.
For example, 4 regional offices told us that they did not have enough
guidance on or experience with evaluating state quarterly reports. Some
regional offices told us they require states to submit evidence of each
PIP action step's completion, such as training curricula or revised
policies, but one ACF official acknowledged that this is not yet standard
procedure, although the agency is considering efforts to make the
quarterly report submission procedures more uniform. Moreover, ACF staff
from 1 region told us that because PIP monitoring varies by region, they
were concerned about enforcing penalties. Shortly before California's
quarterly report was due, state officials told us they still did not know
how much detail to provide; how to demonstrate whether they had completed
certain activities; or what would happen if they did not

reach the level of improvement specified in the plan. Based on data from
the states that have been reviewed to date, the estimated financial
penalties range from a total of $91,492 for North Dakota to $18,244,430
for California, but the impact of these potential penalties remains
unclear. While ACF staff from most regional offices told us that potential
financial penalties are not the driving force behind state reform efforts,
some contend that the estimated penalties affect how aggressively states
pursue reform in their PIPs. For example, regional office staff noted that
1 state's separate strategic plan included more aggressive action steps
than those in its PIP because the state did not want to be liable for
penalties if it did not meet its benchmarks for improvement. State
officials also had mixed responses as to how the financial penalties would
affect PIP implementation. An official in Wyoming said that incurring the
penalties was equivalent to shutting down social service operations in 1
local office for a month, while other officials in the same state thought
it would cost more to implement PIP strategies than it would to incur
financial penalties if benchmarks were unmet. Nevertheless, these
officials also said that while penalties are a consideration, they have
used the CFSR as an opportunity to provide better services. One official
in another state agreed that it would cost more to implement the PIP than
to face financial penalties, but this official was emphatic in the state's
commitment to program improvement.

To implement the CFSRs, ACF has focused its activities almost entirely on
the CFSR review process, and regional staff report limitations in
providing assistance to states in helping them to meet key federal goals.
ACF officials told us the CFSR has become the agency's primary mechanism
for monitoring states and facilitating program improvement, but they
acknowledged that regional office staff might not have realized the full
utility of the CFSR as a tool to integrate all existing training and
technical assistance efforts. Further, according to ACF officials,
meetings to discuss a new system of training and technical assistance are
ongoing, though recommendations were not available at the time of
publication of our April 2004 report. Levels of resource center funding,
the scope and objectives of the resource centers' work, and the
contractors who operate the resource centers are all subject to change
before the current cooperative agreements expire at the close of fiscal
year 2004.

ACF officials told us that the learning opportunities in the Children's
Bureau are intentionally targeted at the CFSR, but staff in 3 regions told
us that this training should cover a wider range of subjects-including
topics outside of the CFSR process-so that regional officials could better
meet

  ACF's Focus Rests Almost Exclusively on Implementing the CFSR

states' needs. All 18 of the courses that ACF has provided to its staff
since 2001 have focused on such topics as writing final CFSR reports and
using data for program improvement, and while ACF officials in the central
office said that the course selection reflects both the agency's
prioritization of the CFSR process and staff needs, our interviews with
regional staff suggest that some of them wish to obtain additional
non-CFSR training. In addition, although ACF organizes biennial
conferences for state and federal child welfare officials, staff from 5
regions told us that they wanted more substantive interaction with their
ACF colleagues, such as networking at conferences, to increase their
overall child welfare expertise. Further, staff from 6 of the 10 regions
told us that their participation in conferences is limited because of
funding constraints.

ACF staff in all 10 regions provide ongoing assistance or ad hoc
counseling to states, either through phone, e-mail, or on-site support,
but staff from 6 regions told us they would like to conduct site visits
with states more regularly to improve their relationships with state
officials and provide more targeted assistance. Further, staff in 4
regions felt their travel funds were constrained and explained that they
try to stretch their travel dollars by addressing states' non-CFSR needs,
such as court improvements, during CFSR-related visits. While an ACF
senior official from the central office confirmed that CFSR-related travel
constituted 60 percent of its 2002 child welfare-monitoring budget, this
official added that CFSR spending represents an infusion of funding rather
than a reprioritization of existing dollars, and stated that regional
administrators have discretion over how the funds are allocated within
their regions. In addition, the same official stated that he knew of no
instance in which a region requested more money for travel than it
received.

Concerns from state officials in all 5 of the states we visited echoed
those of regional office staff and confirmed the need for improvements to
the overall training and technical assistance structure. For example,
state officials in New York and Wyoming commented that ACF staff from
their respective regional offices did not have sufficient time to spend
with them on CFSR matters because regional staff were simultaneously
occupied conducting reviews in other states. However, our survey results
revealed that states reviewed in 2003 had much higher levels of
satisfaction with regional office assistance than those states reviewed in
2001, which suggests improvements to regional office training and
technical assistance as the process evolved.

Concluding Observations

ACF and the states have devoted considerable resources to the CFSR
process, but to date, no state has passed the threshold for substantial
conformity on all CFSR measures, and concerns remain regarding the
validity of some data sources and the limited use of all available
information to determine substantial conformity. The majority of states
surveyed agreed that CFSR results are similar to their own evaluation of
areas needing improvement. However, without using more reliable data- and
in some cases, additional data from state self-assessments-to determine
substantial conformity, ACF may be over-or under-estimating the extent to
which states are actually meeting the needs of the children and families
in their care. These over-or under-estimates can, in turn, affect the
scope and content of the PIPs that states must develop in response.

In addition, the PIP development, approval, and monitoring processes
remain unclear to some, potentially reducing states' credibility with
their stakeholders and straining the federal/state partnership. Similarly,
regional officials are unclear as to how they can accomplish their various
training and technical assistance responsibilities, including the CFSR.
Without clear guidance on how to systematically prepare and monitor
PIP-related documents, and how regional officials can integrate their many
oversight responsibilities, ACF has left state officials unsure of how
their progress over time will be judged and potentially complicated its
own monitoring efforts.

To ensure that ACF uses the best available data in measuring state
performance, we recommended in our April 2004 report that the Secretary of
HHS expand the use of additional data states may provide in their
statewide assessments and consider alternative data sources when
available, such as longitudinal data that track children's placements over
time, before making final CFSR determinations. In addition, to ensure that
ACF regional offices and states fully understand the PIP development,
approval, and monitoring processes, and that regional offices fully
understand ACF's prioritization of the CFSR as the primary mechanism for
child welfare oversight, we recommended that the Secretary of HHS issue
clarifying guidance on the PIP process and evaluate states' and regional
offices' adherence to this instruction and provide guidance to regional
offices explaining how to better integrate the many training and technical
assistance activities for which they are responsible, such as
participation in state planning meetings and the provision of counsel to
states on various topics, with their new CFSR responsibilities. In
response to the first recommendation, HHS acknowledged that the CFSR is a
new process that continues to evolve, and also noted several steps it has
taken to

address the data quality concerns we raise in our report. We believe that
our findings from the April 2004 report, as well as a previous report on
child welfare data and states' information systems, fully address HHS's
initial actions, as well as the substantial resources the agency has
already dedicated to the review process. However, to improve its oversight
of state performance, our recommendation was meant to encourage HHS to
take additional actions to improve its use of data in conducting these
reviews. In response to the second recommendation, HHS said that it has
continued to provide technical assistance and training to states and
regional offices, when appropriate. HHS noted that it is committed to
continually assessing and addressing training and technical assistance
needs. In this context, our recommendation was intended to encourage HHS
to enhance existing training efforts and focus both on state and on
regional officials' understanding of how to incorporate the CFSR process
into their overall improvement and oversight efforts.

Mr. Chairman, this concludes my prepared statement. I would be pleased to
respond to any questions that you or other members of the subcommittee may
have.

Appendix I: GAO Contacts Acknowledgments

GAO Contacts 	For further contacts regarding this testimony, please call
Cornelia M. Ashby at (202) 512-8403. Individuals making key contributions
to this testimony include Diana Pietrowiak and Joy Gambino.

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