Testimony 

Before the Subcommittee on Human 

Resources, Committee on Ways and 

Means, House of Representatives

United States General Accounting Office 

GAO

For Release on Delivery 

Expected at 10:00 a.m. EDT 

Thursday, May 13, 2004 CHILD AND FAMILY 

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 
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 ashbyc@gao.gov. 

Highlights of GAO-04-781T, a testimony 

before the Subcommittee on Human 

Resources, Committee on Ways and 

Means, House of Representative 

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. 

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. 
Page 1 GAO-04-781T Child and Family 

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 

 1

The 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. 
Page 2 GAO-04-781T Child and Family 

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 

 2

U.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). 

3

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

4

The 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. 

5

ACF 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. 
Page 3 GAO-04-781T Child and Family 

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. 

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 

 6

Title 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. 

Background 
Page 4 GAO-04-781T Child and Family 

statewide self-assessment, an on-site case file review that is coupled with 

stakeholder interviews,7

 and the development and implementation of a 2-

year 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. 

8

States 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). 

9

States 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. 
Page 5 GAO-04-781T Child and Family 

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. 

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 

The CFSR Is a 

Valuable Yet 

Substantial 

Undertaking, but Data 

Enhancements Could 

Improve Its Reliability 

The CFSR Is a Valuable 

Process for ACF and the 

States 
Page 6 GAO-04-781T Child and Family 

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. 
Page 7 GAO-04-781T Child and Family 

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

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). 

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

States for which determinations have not yet been made

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

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

WA

OR

CA

NV UT

ID

MT

WY

CO

NM

TX

AK

HI

OK

KS

NE

SD

ND

MN

IA

MO

AR

LA

MS AL GA

FL

SC

NC

WV VA

KY

TN

IL IN OH

MI

WI NY

PA

ME

AZ

VT

NH

MA

RI

CT

DC

NJ

DE

MD

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

PR
Page 8 GAO-04-781T Child and Family 

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 IVE 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. 

ACF and the States Report 

That Reviews Have Been a 

Substantial Undertaking 
Page 9 GAO-04-781T Child and Family 

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. 

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. 

States and Child Welfare 

Experts Report That 

Several Data 

Improvements Could 

Enhance CFSR Reliability 
Page 10 GAO-04-781T Child and Family 

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. 
Page 11 GAO-04-781T Child and Family 

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. 
Page 12 GAO-04-781T Child and Family 

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 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. 

Program 

Improvement 

Planning Under Way, 

but Uncertainties 

Challenge Plan 

Development, 

Implementation, and 

Monitoring 

State Plans Include a 

Variety of Strategies to 

Address Identified 

Weaknesses 
Page 13 GAO-04-781T Child and Family 

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. 
Page 14 GAO-04-781T Child and Family 

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

PIP strategy category Description (number of states that included the strategy in their PIP) 

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. 
Page 15 GAO-04-781T Child and Family 

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. 

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 

Insufficient Guidance 

Hampered State Planning 

Efforts, but ACF Has 

Taken Steps to Clarify 

Expectations and Improve 

Technical Assistance 
Page 16 GAO-04-781T Child and Family 

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. 
Page 17 GAO-04-781T Child and Family 

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 

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. 

State and Federal 

Uncertainties Cloud PIP 

Implementation and 

Monitoring 

9

11

Number of states reporting how much challenges affected PIP implementation

0

5

10

15

20

25

Very great or great extent

Moderate, some or little extent

Insufficient

time

Insufficient

funding

Insufficient

staff

9

13

13

8

11

12

Source: GAO survey.

High

 caseloads
Page 18 GAO-04-781T Child and Family 

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 
Page 19 GAO-04-781T Child and Family 

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 
Page 20 GAO-04-781T Child and Family 

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 nonCFSR 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. 
Page 21 GAO-04-781T Child and Family 

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 

Concluding 

Observations 
Page 22 GAO-04-781T Child and Family 

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. 
Page 23 GAO-04-781T Child and Family 

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. 

Appendix I: GAO Contacts Acknowledgments

GAO Contacts 
Page 24 GAO-04-781T Child and Family 

D.C. Family Court: Operations and Case Management Have Improved, 

but Critical Issues Remain. GAO-04-685T. Washington, D.C.: 

April 23, 2004. 

Child and Family Services Reviews: Better Use of Data and Improved 

Guidance Could Enhance HHS’s Oversight of State Performance. GAO04-333 Washington, D.C.: April 20, 2004. 

Child Welfare: Improved Federal Oversight Could Assist States in 

Overcoming Key Challenges. GAO-04-418T. Washington, D.C.: 

January 28, 2004. 

D.C. Family Court: Progress Has Been Made in Implementing Its 

Transition. GAO-04-234. Washington, D.C.: January 6, 2004. 

Child Welfare: States Face Challenges in Developing Information 

Systems and Reporting Reliable Child Welfare Data. GAO-04-267T. 

Washington, D.C.: November 19, 2003. 

Child Welfare: Enhanced Federal Oversight of Title IV-B Could Provide 

States Additional Information to Improve Services. GAO-03-956. 

Washington, D.C.: September 12, 2003. 

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. 

D.C. Child and Family Services: Key Issues Affecting the Management of 

Its Foster Care Cases. GAO-03-758T. Washington, D.C.: May 16, 2003. 

Child Welfare and Juvenile Justice: Federal Agencies Could Play a 

Stronger Role in Helping States Reduce the Number of Children Placed 

Solely to Obtain Mental Health Services. GAO-03-397. Washington, D.C.: 

April 21, 2003. 

Foster Care: States Focusing on Finding Permanent Homes for Children, 

but Long-Standing Barriers Remain. GAO-03-626T. Washington, D.C.: 

April 8, 2003. 

Child Welfare: HHS Could Play a Greater Role in Helping Child Welfare 

Agencies Recruit and Retain Staff. GAO-03-357. Washington, D.C.: 

March 31, 2003. 

Related GAO Products 
Page 25 GAO-04-781T Child and Family 

Foster Care: Recent Legislation Helps States Focus on Finding 

Permanent Homes for Children, but Long-Standing Barriers Remain. 

GAO-02-585. Washington, D.C.: June 28, 2002. 

District of Columbia Child Welfare: Long-Term Challenges to Ensuring 

Children’s Well- Being. GAO-01-191. Washington, D.C.: December 29, 2000. 

Child Welfare: New Financing and Service Strategies Hold Promise, but 

Effects Unknown. GAO/T-HEHS-00-158. Washington, D.C.: July 20, 2000. 

Foster Care: States’ Early Experiences Implementing the Adoption and 

Safe Families Act. GAO/HEHS-00-1. Washington, D.C.: December 22, 1999. 

Foster Care: HHS Could Better Facilitate the Interjurisdictional 

Adoption Process. GAO/HEHS-00-12. Washington, D.C.: 

November 19, 1999. 

Foster Care: Effectiveness of Independent Living Services Unknown. 

GAO/HEHS-00-13. Washington, D.C.: November 10, 1999. 

Foster Care: Kinship Care Quality and Permanency Issues. GAO/HEHS99-32. Washington, D.C.: May 6, 1999. 

Juvenile Courts: Reforms Aim to Better Serve Maltreated 

Children. GAO/HEHS-99-13. Washington, D.C.: January 11, 1999. 

Child Welfare: Early Experiences Implementing a Managed Care 

Approach. GAO/HEHS-99-8. Washington, D.C.: October 21, 1998. 

Foster Care: Agencies Face Challenges Securing Stable Homes for 

Children of Substance Abusers. GAO/HEHS-98-182. Washington, D.C.: 

September 30, 1998. 

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