This report is about the Department of Children and Families' systems and controls to ensure service provision quality in the developmental services Home-and Community-Based Services Medicaid waiver.

• To improve its responsiveness to changing client needs, the Department of Children and Families is developing initiatives giving clients and their families more control over how to use the money allocated for their services. While many clients may want to participate in these initiatives, many may be unable to do so.
• The department is monitoring the quality of services provided by service coordinators. However, it has not yet implemented an effective system to monitor the quality of services from other providers.
• Home and community-based services is a cost-effective alternative to institutional placement, but some clients receive community services when they could be more cost-effectively served in institutions while others receive care in institutions when they could be more cost-effectively served in communities. While Medicaid requirements limit the department's ability to divert clients from more costly institutional settings to less costly community settings, the department could do more to control institutional costs. Serving clients in the most cost-effective setting could have provided another $21.5 million for additional services to clients.