In response to the GAO report, CMS designed and adopted an evidence-based approach to HCBS waiver program quality. The evidence-based approach is premised on the expectation that states have first-line responsibility for program monitoring to ensure the waiver operates as it was designed (i.e., as specified in the approved waiver application) and that program participants health and welfare are safeguarded. States, on a periodic basis, must provide CMS with evidence that the program is indeed operating as specified in the approved waiver and that participants health and welfare are safeguarded. The evidence CMS requires is related to the six statutory assurances that states make to CMS as a condition of approval of a waiver. CMSs role is to review the evidence the state submits, along with other information about the waivers performance, and render a determination about the waivers compliance with the Federal assurances.