The PRO process is just one of the many reviews that HHAs are subjected to at any given time. On a practical level, HHA should incorporate PRO criteria and GQSs into its QA program. At present, there is no mechanism in place for denial of payment for substandard care, although proposed regulations were published in the January 18, 1989 Federal Register. Medicare certification, and therefore payment, could be lost if the facility or HHA were sanctioned. The Medicare law requires PROs to coordinate their activities with other review organizations. HCFA, however, has not established procedures for providing reports from fiscal intermediaries and PROs to the state survey agencies or coordinating state surveys with PRO reviews. HHAs should have structure and process criteria in place (either manual or computerized) to identify selected records for review. This enables the agency to monitor its internal quality assurance activities so that it has confidence that the GQSs will be met when reviewed by external agencies, including the PRO. This internal monitoring will also enable the agency to document patient outcomes. This is an important aspect of the evaluation process, since the emphasis of certification and accreditation programs and site visits will be focused on patient outcomes in the 1990s.