Residential Facilities
State and Federal Oversight Gaps May Increase Risk to Youth Well-Being Gao ID: GAO-08-696T April 24, 2008Nationwide, federal funding to states supported more than 200,000 youth in facilities seeking help for behavioral or emotional challenges in 2004. Recent federal reviews and investigations highlighted maltreatment in some facilities, resulting in hospitalizations and deaths. This testimony discusses (1) what is known about incidents that adversely affect youth well-being in residential facilities, (2) the extent that state oversight ensures youth well-being in these facilities, and (3) the factors that affect the ability of federal agencies to hold states accountable for youth well-being in residential facilities. This testimony is based on GAO's ongoing work, which included national surveys to state agencies of child welfare, health and mental health, and juvenile justice for the year 2006. GAO achieved an 85 percent response rate for each of the three surveys. The work also included site visits to four states (California, Florida, Maryland, and Utah) and discussions with the Departments of Education (Education), Justice (DOJ), and Health and Human Services (HHS). Interim work related to this testimony was completed between November 2006 and March 2008, in accordance with generally accepted government auditing standards.
Survey respondents from 49 states reported investigating complaints of youth maltreatment in residential facilities in 2006, including physical abuse, neglect, and sexual abuse, and 28 states reported deaths. There were no discernable patterns in the types of facilities involved, including whether facilities were operated by government or private entities, or located in urban or rural areas. State officials said that the number of maltreatment incidents was greater than the total reported to HHS--1,503 incidents in 2005--due to barriers in data collection and reporting, including inconsistent funding and authority. States license and monitor residential facilities, but state agencies reported oversight gaps that may place youth in some facilities at higher risk for maltreatment and death. Some types of facilities are exempt from state licensing requirements--primarily state operated juvenile justice facilities and private residential schools and academies. Licensing standards did not always address suicide prevention and other common risks. State agencies reported an inability to conduct yearly on-site visits to facilities because of fluctuating levels of staff resources dedicated by states, and infrequently sharing negative findings from their oversight results. HHS, DOJ, and Education hold states accountable for youth well-being, but federal efforts are hindered by the scope of the agencies' oversight authority and practices. Most notably, these agencies do not have the authority to hold states accountable for youth in private residential facilities unless they serve youth in state programs that receive federal funds. For facilities that were under federal purview, federal requirements did not always address the identified risks to youth--including such risks as suicide and inappropriate use of seclusion and restraint--and program requirements were inconsistent. In monitoring state compliance, federal agencies did not always include residential facilities in their oversight reviews.
GAO-08-696T, Residential Facilities: State and Federal Oversight Gaps May Increase Risk to Youth Well-Being
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Testimony:
Before the Committee on Education and Labor, House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 10:00 a.m. EDT:
Thursday, April 24, 2008:
Residential Facilities:
State and Federal Oversight Gaps May Increase Risk to Youth Well-Being:
Statement of Kay E. Brown:
Director:
Education, Workforce, and Income Security Issues:
GAO-08-696T:
GAO Highlights:
Highlights of GAO-08-696T, a report to the Committee on Education and
Labor, House of Representatives.
Why GAO Did This Study:
Nationwide, federal funding to states supported more than 200,000 youth
in facilities seeking help for behavioral or emotional challenges in
2004. Recent federal reviews and investigations highlighted
maltreatment in some facilities, resulting in hospitalizations and
deaths. This testimony discusses (1) what is known about incidents that
adversely affect youth well-being in residential facilities, (2) the
extent that state oversight ensures youth well-being in these
facilities, and (3) the factors that affect the ability of federal
agencies to hold states accountable for youth well-being in residential
facilities. This testimony is based on GAO‘s ongoing work, which
included national surveys to state agencies of child welfare, health
and mental health, and juvenile justice for the year 2006. GAO achieved
an 85 percent response rate for each of the three surveys. The work
also included site visits to four states (California, Florida,
Maryland, and Utah) and discussions with the Departments of Education
(Education), Justice (DOJ), and Health and Human Services (HHS).
Interim work related to this testimony was completed between November
2006 and March 2008, in accordance with generally accepted government
auditing standards.
What GAO Found:
Survey respondents from 49 states reported investigating complaints of
youth maltreatment in residential facilities in 2006, including
physical abuse, neglect, and sexual abuse, and 28 states reported
deaths. There were no discernible patterns in the types of facilities
involved, including whether facilities were operated by government or
private entities, or located in urban or rural areas. State officials
said that the number of maltreatment incidents was greater than the
total reported to HHS”1,503 incidents in 2005--due to barriers in data
collection and reporting, including inconsistent funding and authority.
States license and monitor residential facilities, but state agencies
reported oversight gaps that may place youth in some facilities at
higher risk for maltreatment and death. Some types of facilities are
exempt from state licensing requirements”primarily state operated
juvenile justice facilities and private residential schools and
academies. Licensing standards did not always address suicide
prevention and other common risks. State agencies reported an inability
to conduct yearly on-site visits to facilities because of fluctuating
levels of staff resources dedicated by states, and infrequently sharing
negative findings from their oversight results.
Table: Aspects of Well-Being Monitored by State Agencies in Private
Residential Facilities That Served Youth and Received Government
Funding:
Monitoring Requirement: Physical plant;
Monitored for less than all residential facilities: Child welfare: 4;
Monitored for less than all residential facilities: Health and mental
health: 16;
Monitored for less than all residential facilities: Juvenile justice:
13;
Monitored for all residential facilities: Child welfare: 36;
Monitored for all residential facilities: Health and mental health: 22;
Monitored for all residential facilities: Juvenile justice: 24.
Monitoring Requirement: Staffing issues;
Monitored for less than all residential facilities: Child welfare: 5;
Monitored for less than all residential facilities: Health and mental
health: 15;
Monitored for less than all residential facilities: Juvenile justice:
13;
Monitored for all residential facilities: Child welfare: 36;
Monitored for all residential facilities: Health and mental health: 22;
Monitored for all residential facilities: Juvenile justice: 23.
Monitoring Requirement: Use of approved seclusion and restraint;
Monitored for less than all residential facilities: Child welfare: 7;
Monitored for less than all residential facilities: Health and mental
health: 13;
Monitored for less than all residential facilities: Juvenile justice:
10;
Monitored for all residential facilities: Child welfare: 33;
Monitored for all residential facilities: Health and mental health: 23;
Monitored for all residential facilities: Juvenile justice: 25.
Monitoring Requirement: Use of psychotropic medications;
Monitored for less than all residential facilities: Child welfare: 9;
Monitored for less than all residential facilities: Health and mental
health: 15;
Monitored for less than all residential facilities: Juvenile justice:
14;
Monitored for all residential facilities: Child welfare: 31;
Monitored for all residential facilities: Health and mental health: 22;
Monitored for all residential facilities: Juvenile justice: 22.
Monitoring Requirement: Presence of educational programming;
Monitored for less than all residential facilities: Child welfare: 7;
Monitored for less than all residential facilities: Health and mental
health: 18;
Monitored for less than all residential facilities: Juvenile justice:
17;
Monitored for all residential facilities: Child welfare: 31;
Monitored for all residential facilities: Health and mental health: 8;
Monitored for all residential facilities: Juvenile justice: 18.
Source: GAO analysis of state agencies' responses to survey.
Note: Other agency responses included no such facility in state, don‘t
know, and no response.
[End of table]
HHS, DOJ, and Education hold states accountable for youth well-being,
but federal efforts are hindered by the scope of the agencies‘
oversight authority and practices. Most notably, these agencies do not
have the authority to hold states accountable for youth in private
residential facilities unless they serve youth in state programs that
receive federal funds. For facilities that were under federal purview,
federal requirements did not always address the identified risks to
youth”including such risks as suicide and inappropriate use of
seclusion and restraint”and program requirements were inconsistent. In
monitoring state compliance, federal agencies did not always include
residential facilities in their oversight reviews.
What GAO Recommends:
GAO recommendations will be included in its final report upon
completion of ongoing work.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-696T]. For more
information, contact Kay E. Brown (202) 512-7215 or brownke@gao.gov.
[End of section]
Mr. Chairman and Members of the Committee:
Thank you for inviting me here today to discuss our ongoing work
reviewing how state and federal agencies protect the well-being of
youth in residential facilities who are receiving services for their
behavioral or emotional challenges. Nationwide, federal funding to
states supported more than 200,000 youth in government or private
facilities in 2004. In addition, an unknown number of youth are placed
in facilities by parents or others. These facilities include boarding
schools and academies, boot camps, and wilderness camps. Overall,
residential facilities play an important role in serving youth who
cannot be safely served in their communities while living at home, due
to risk of running away or harm to themselves or others. However,
recent federal reviews highlighted youth fatalities in residential
facilities due to neglect or maltreatment, and ongoing federal
investigations continue to document incidents of abuse and neglect in
some facilities for youth that in some cases have been severe enough to
result in hospitalization or death.
As you know, states are primarily responsible for ensuring the well-
being of youth in facilities and other settings, and do so by setting
their own standards of care certain facilities must meet to obtain and
maintain an operating license. Federal agencies also set requirements
for youth well-being that states agree to uphold in exchange for
receiving federal program funds, such as those administered by the
Department of Health and Human Services (HHS) to support state systems
of care for child welfare, mental health, and substance abuse; the
Department of Justice (DOJ), for state juvenile justice systems; and
the Department of Education (Education), for state education systems.
Further, if patterns of maltreatment are identified and found to
violate the civil rights of youth in certain facilities that are
operated or substantially sponsored by state and local governments, the
federal Civil Rights of Institutionalized Persons Act (CRIPA)
authorizes the Attorney General of the United States to conduct
investigations and bring actions against state and local governments.
However, under the current regulatory framework, federal oversight
authority does not extend to private facilities that serve only youth
placed and funded by parents or other private entities. In some states,
safeguarding youth in these facilities is the primary responsibility of
parents and facility staff.
My remarks today will focus on the following issues with regard to
youth well-being in residential facilities in terms of:
(1) what is known about the incidents that adversely affect the well-
being of youth in residential facilities;
(2) the extent that state oversight ensures the well-being of youth in
residential facilities, and;
(3) the factors that affect the ability of federal agencies to hold
states accountable for youth well-being in residential facilities.
This testimony was developed using multiple methodologies, and was
limited to residential facilities we defined as those that require
youth--ages 12 through 17--to reside at the facility and that provide
program services[Footnote 1] for youth with behavioral and emotional
challenges. We surveyed three state agencies--child welfare, health and
mental health, and juvenile justice[Footnote 2]--about residential
facilities that were government operated, privately operated that
received government funds, and privately operated with no government
funding. To further our understanding, we visited four states--
California, Florida, Maryland, and Utah--and interviewed relevant
officials. These states were selected based on the diversity of their
state licensing and monitoring policies for residential programs,
reports of child maltreatment, and geographic location. The scope of
our work did not include the quality of services provided at
residential facilities. We also obtained data from HHS's National Child
Abuse and Neglect Data System (NCANDS); reviewed federal statutes,
regulations, and guidance; and interviewed HHS, DOJ, and Education
officials, as well as national association representatives and other
experts on residential facilities for youth. The scope of our work did
not include the quality of services provided at residential facilities.
We performed our work between November 2006 and March 2008, in
accordance with generally accepted government auditing standards.
In summary:
* Youth maltreatment and death occurred in government and private
residential facilities across the nation, according to states we
surveyed; however, data limitations hinder efforts to quantify the full
extent of the problem. State-reported data collected by HHS in 2005
showed 1,503 incidents of maltreatment by facility staff in 34 states,
including physical abuse, neglect or deprivation of necessities, and
sexual abuse. Moreover, 28 states responding to our survey reported at
least one death in residential facilities in 2006, with accidents and
suicides among the most common types of fatalities. These reported
data, however, did not capture information from all facilities. Many
states lack authority under state law to collect data on exclusively
private facilities, and data that states did report were often
incomplete. As a result, the number of adverse incidents was likely
more numerous and widespread than reported.
* All states have processes in place to license and monitor certain
residential facilities, but states reported oversight gaps that may
place youth in some facilities at higher risk for maltreatment and
death. Most notably, state agencies exempted some types of government
and private facilities from licensing requirements altogether,
primarily juvenile justice facilities and private schools and
academies. In addition, licensing standards do not always address
suicide and other common risks to youth well-being. Although monitoring
is key to ensuring facility compliance with standards, agencies in
states we visited reported an inability to conduct yearly on-site
reviews of conditions at each facility, because of fluctuating levels
of staff resources committed by the state. Similarly, although
information sharing can strengthen oversight for facilities shared by
multiple agencies, many state agencies reported that they did not
routinely share information with other state agencies about negative
findings or when facility licenses were suspended or revoked.
* HHS, DOJ, and Education all have processes to hold states accountable
for the well-being of youth, but federal efforts are hindered by the
scope of the agencies' oversight authority and monitoring practices.
Most notably, these agencies do not have the authority to hold states
accountable for youth well-being in private residential facilities
unless they serve youth in state programs that receive federal funds.
For facilities under federal purview, federal requirements did not
always address the primary risks to youth well-being, such as suicide,
and requirements were inconsistent among programs. In monitoring state
compliance, federal agencies did not always include residential
facilities in their oversight reviews.
Youth Maltreatment Occurred in Facilities Across the Nation, but Data
Are Limited and Not Used to Target Federal Civil Rights Investigations:
Nearly all states (49) responding to our survey reported investigating
complaints of youth maltreatment in residential facilities in 2006,
including facilities operated by government as well as private
entities, and located in both urban or rural areas. The types of
maltreatment reported by states included physical abuse, neglect or
deprivation of necessities, and sexual abuse that sometimes resulted in
hospitalization or death. State reported data to NCANDS from 2005
showed that 34 states reported 1,503 incidents of youth maltreatment by
facility staff. Of these incidents, neglect or deprivation of
necessities was the most frequent cause of youth maltreatment, followed
by physical abuse, as shown in figure 1.
Figure 1: Percentage of State-Reported Incidents of Youth Maltreatment
by Residential Facility Staff, Fiscal Year 2005:
[See PDF for image]
This figure is a horizontal bar graph depicting the following data:
Percentage of State-Reported Incidents of Youth Maltreatment by
Residential Facility Staff, Fiscal Year 2005:
Physical abuse: 24%;
Neglect or deprivation of necessities: 44%;
Sexual abuse: 9%;
Other[A]: 23%.
[A] "Other" incidents of youth maltreatment states reported to NCANDS
include medical neglect and psychological or emotional maltreatment.
[End of figure]
Of the states we surveyed, 28 reported that at least one youth had died
in a residential facility in 2006. These deaths were primarily due to
accidents and suicide, but also due to homicide and application of
seclusion and restraint (see fig. 2).
Figure 2: Number of States That Reported Specific Causes of Youth
Fatalities in Residential Facilities, 2006:
[See PDF for image]
This figure is a horizontal bar graph depicting the following data:
Number of States That Reported Specific Causes of Youth Fatalities in
Residential Facilities, 2006:
Accidental causes: 16 states;
Suicide: 9 states;
Other causes (specify): 9 states;
Homicide: 3 states;
Medically related accident: 3 states;
Application of seclusion or restraint techniques: 2 states;
Did not know: 4 states.
Source: GAO analysis of state agency responses to survey.
Notes:
The survey question was as follows: Of the total youth deaths that you
reported, how many died from each of the following causes: (a) suicide,
(b) homicide, (c) application of seclusion and restraint techniques,
(d) medically related accident, (e) accident that occurred while in a
runaway or absence without leave status, (f) other accidental cause,
and (g) other causes?
Other causes of youth fatalities in residential facilities include
natural causes, choking, and internal bleeding.
[End of figure]
Overall, officials from the states we visited said that the number of
maltreatment incidents and deaths was greater than reported due to
barriers in collecting and maintaining data. When available,
comprehensive reporting of incident data can be used by state and
federal agencies to assess the extent of maltreatment in residential
facilities, inform risk assessments, target oversight resources, and
develop policies to address trends. However, the lack of authority
under state law hinders many states from collecting data on certain
facilities--such as exclusively private facilities--and expanding
oversight to cover them. In addition, states that have such authority
reported difficulties sustaining data collection in times of budget
shortages. National data in NCANDS for 2005--derived from state
reports--suffers from these same limitations, as well as others. First,
some states did not report data for residential facilities to NCANDS,
[Footnote 3] so the data may understate the number of maltreatments and
fatalities. Second, many states (37) did not consistently identify
whether the individual maltreating youth was facility staff, a parent,
or other individual. Last, NCANDS only tracked fatalities resulting
from maltreatment, not suicide or accidents that may be an indicator of
neglect or other problem that needs resolution.
In the states we visited, youth maltreatment in facilities was
attributed to several factors--such as a lack of experienced staff,
insufficient staff training, or lack of appropriate supervision--
particularly in smaller facilities. For example, county officials in
one state told us that adverse incidents were most likely to occur in
contractor operated six-bed group homes--frequently used by state
probation and child welfare agencies--where the state reimbursement
rate is generally not high enough to hire skilled personnel and provide
staff with ongoing training, support, and oversight.
However, while in most facilities youth maltreatment may occur
infrequently as a result of isolated circumstances, investigations of
government and private facilities serving youth conducted under DOJ's
Civil Rights Division (Division) have found a pattern or practice of
civil rights violations in some facilities, including physical and
sexual abuse, medical neglect, and inadequate education. At the end of
fiscal year 2006, the latest year for which data were available,
federal investigators reported active cases involving over 175
facilities in 34 states.[Footnote 4] Annual reports from DOJ over the
past several years have documented their findings of youth maltreatment
in certain juvenile justice or mental health facilities:
Physical and sexual abuse occurred without management intervention: In
one facility, staff hit youth and slammed them to the ground. Staff hog-
tied and shackled youth to poles in public places, and girls were
forced to eat their own vomit if they threw up while exercising in the
hot sun. Staff routinely broke and wired shut the jaws of youth who
showed disrespect in another facility. In some facilities, staff
engaged in sexual acts with boys. Youth-on-youth violence occurred on
an almost daily basis in some facilities, at times resulting in
injuries that required hospitalization. Youth were sexually assaulted
and threatened with sexual assault by other youth in some facilities,
all without effective intervention from management.
Severe neglect resulted in poor education, suffering, and death: In a 1-
year period at one facility, three boys committed suicide. In one
suicide, staff lacked the appropriate tool to cut the noose from a
victim's neck and also did not have oxygen in the tank they brought to
help resuscitate him. The dental clinic at one facility was full of
mouse droppings, dead roaches, and cobwebs; medications in the cabinet
had expired over 10 years ago. In a state-operated mental health
facility used by adolescents, older psychotropic medications, with
serious side effects, were administered to sedate patients. One
adolescent received 22 such psychotropic sedatives over a 2-month
period. In another facility, youth were not provided with special
education services as required by federal law.
The Special Litigation Section of DOJ's Civil Rights Division receives
more credible allegations of violations of youth rights than it can
investigate. During fiscal year 2006 alone, the Division received
approximately 5,000 citizen letters; hundreds of telephone complaints,
and 135 inquiries from Congress and the White House. Division officials
stated that with additional sources of information, they could better
target their scarce investigative resources. Officials said that
receiving more detailed information from NCANDS on the incidents of
maltreatment and death occurring in specific facilities would be
helpful, as would the results of federal agency monitoring reviews of
states that highlight findings related to residential facilities.
Except in one instance,[Footnote 5] officials said that no federal
agencies--including HHS, Education, and DOJ's Office of Juvenile
Justice and Delinquency Prevention (OJJDP)--were coordinating with the
Division to provide pertinent oversight results.
Gaps in State Oversight of Residential Facilities May Place Well-being
of Some Youth at Risk:
All states have processes in place to license and monitor certain
residential facilities, but our survey identified several gaps that
allow some of the common causes of youth maltreatment and death to go
unaddressed. These gaps include the fact that some types of government
and private facilities are exempt from licensing requirements,
licensing standards do not always address the primary causes of youth
maltreatment and death, and state agencies inconsistently monitor and
enforce facility compliance and share their monitoring results.
Certain Facilities Are Exempt from State Licensing Requirements:
Licensing all facilities in a state--government or private facilities-
-can help ensure that residential facilities meet relevant state
standards. Among state-operated facilities, however, more than half
(28) of juvenile justice agencies reported exempting facilities from
licensing.[Footnote 6] In addition, many state agencies reported that
certain types of private facilities were also exempt from licensing,
regardless of whether they received some government funding or were
exclusively private. Private residential schools and academies--a
category that includes boarding schools and training or reform schools-
-were exempted more often from licensing than other types of private
facilities, according to survey respondents. Conversely, treatment
facilities were the type most commonly required to have a license.
Agencies in six states reported they exempted faith-based facilities
from licensure.[Footnote 7] In addition, many agencies reported not
knowing the licensing status of certain types of private facilities or
reported that they did not have certain types of facilities in their
state.[Footnote 8] Some states are considering laws that would expand
their licensing authority for private facilities.
One reason that private residential facilities may be exempt from
licensing requirements is that state agencies do not have the necessary
statutory or regulatory authority. Regarding residential schools and
academies, for example, all agencies in 15 of the 33 states that
responded to all three agency surveys reported that they did not have
either the authority or the regulatory responsibility to license these
facilities.[Footnote 9]
The lack of licensing for all facilities serving youth has several
consequences, in that there are no commonly accepted definitions of
facility types. Within individual states, facility operators may bypass
state licensing requirements by self-identifying their business as a
type that is exempt from state licensing. In Texas, for example, a
residential program self-identified as a private boarding school is not
regulated by the state licensing agency, but the same facility would
require a license if it self-identified as a residential treatment
center or therapeutic camp. Inconsistent licensing practices across
states can have implications as well. For example, a 2007 directory
showed that Utah, which only recently implemented licensing
requirements covering wilderness camps, was home to over 25 percent of
registered wilderness programs in the United States.
Facility licensing is also important because parents and others
considering placing youth in private facilities at their own expense do
not always have the information they need to screen facilities and make
an informed decision. In our testimony on private facilities last
October,[Footnote 10] we described cases in which program leaders told
parents their programs could provide services that they were not
qualified to offer, claimed to have credentials in therapy or medicine
that they did not have, and led parents to trust them with youth who
had serious mental disabilities. One national association for programs
serving youth with behavioral and emotional difficulties testified
before Congress that state licensing was important because the field
does not currently have the capacity to certify facility integrity.
Some states are considering laws that would expand their licensing
authority for private facilities, while some use other methods to
provide protections for youth. For example, Florida, among other
states, includes requirements addressing youth well-being in contracts
facilities must sign to serve youth under state care. Florida officials
estimated that 85 percent of residential facilities in the state's
juvenile justice system are private facilities under contract with the
state. The agency uses the contract provisions to help ensure that
facilities provide youth with needed services in compliance with agency
regulations as well as state statutes.
Accreditation is another method used by some states in lieu of, or to
augment, state licensing requirements. For example, Ohio and Wyoming
require specific health-related facilities to obtain accreditation
instead of licensure as a condition to serving youth under state care.
Of the states responding to our survey, a greater number of health and
mental health agencies reported requiring facilities to be accredited
by private organizations, due in part to conditions of participation
for certain federal programs.[Footnote 11] The accreditation process
may require providers to meet higher standards than those required by
state licensing bodies; however, accreditation does not necessarily
ensure the safety and well-being of youth. Officials from an
accrediting organization told us that they do not always inform the
state if a facility's accreditation status has been suspended or
limited. In general, fewer states reported requiring accreditation than
not across the three agencies we surveyed.
State Licensing Standards Do Not Address Some Primary Risks to Youth
Well-being:
Our survey results showed that the licensing standards that states have
in place for certain government and private residential facilities
address many, but not all, of the most common risks to youth well-being
that states had identified in our survey. The extent that state
licensing standards cover the various aspects of youth well-being is
important to safeguard youth from harm. Almost all states reported that
when they required licensing, they required facilities to meet
standards related to the safety of the physical plant, proper use of
seclusion and restraint techniques, reporting of adverse incidents, and
qualification requirements and background checks for staff.[Footnote
12] These standards can help reduce the risk of harm due to accidental
causes and staff maltreatment. However, other requirements addressing
risks to youth are less often included as a part of licensing. For
example, while states reported that almost all juvenile justice
facilities are required to have written suicide prevention plans, about
a third of state child welfare and health and mental health agencies
reported that they do not have similar requirements for government
facilities. In addition, most of the agencies in our survey did not
require private facilities to have written suicide prevention plans.
State Practices Inconsistent in Monitoring and Enforcing Facility
Compliance:
State agencies reported monitoring youth well-being in residential
facilities, but survey results showed that certain aspects of youth
well-being were not included in all monitoring activities, as shown in
figure 3. Periodic on-site reviews to monitor and enforce facility
compliance help ensure that licensing standards are taken seriously and
that risks to youth well-being are quickly addressed. Among six
different aspects of youth well-being we asked about in our survey, the
quality of educational programming and the use of psychotropic
medications were most likely to be reviewed at only some or none of the
facilities monitored by child welfare, health and mental health, and
juvenile justice agencies. Conversely, staffing issues were most often
included in all monitoring reviews of government and private
facilities.
Figure 3: Fig. 3: Aspects of Well-Being Monitored by State Agencies in
Private Residential Facilities That Served Youth and Received
Government Funding:
[See PDF for image]
This figure is a horizontal bar graph depicting the following data:
Monitoring Requirement: Physical plant;
Monitored for less than all residential facilities: Child welfare: 4;
Monitored for less than all residential facilities: Health and mental
health: 16;
Monitored for less than all residential facilities: Juvenile justice:
13;
Monitored for all residential facilities: Child welfare: 36;
Monitored for all residential facilities: Health and mental health: 22;
Monitored for all residential facilities: Juvenile justice: 24.
Monitoring Requirement: Staffing issues;
Monitored for less than all residential facilities: Child welfare: 5;
Monitored for less than all residential facilities: Health and mental
health: 15;
Monitored for less than all residential facilities: Juvenile justice:
13;
Monitored for all residential facilities: Child welfare: 36;
Monitored for all residential facilities: Health and mental health: 22;
Monitored for all residential facilities: Juvenile justice: 23.
Monitoring Requirement: Use of approved seclusion and restraint;
Monitored for less than all residential facilities: Child welfare: 7;
Monitored for less than all residential facilities: Health and mental
health: 13;
Monitored for less than all residential facilities: Juvenile justice:
10;
Monitored for all residential facilities: Child welfare: 33;
Monitored for all residential facilities: Health and mental health: 23;
Monitored for all residential facilities: Juvenile justice: 25.
Monitoring Requirement: Use of psychotropic medications;
Monitored for less than all residential facilities: Child welfare: 9;
Monitored for less than all residential facilities: Health and mental
health: 15;
Monitored for less than all residential facilities: Juvenile justice:
14;
Monitored for all residential facilities: Child welfare: 31;
Monitored for all residential facilities: Health and mental health: 22;
Monitored for all residential facilities: Juvenile justice: 22.
Monitoring Requirement: Presence of educational programming;
Monitored for less than all residential facilities: Child welfare: 7;
Monitored for less than all residential facilities: Health and mental
health: 18;
Monitored for less than all residential facilities: Juvenile justice:
17;
Monitored for all residential facilities: Child welfare: 31;
Monitored for all residential facilities: Health and mental health: 8;
Monitored for all residential facilities: Juvenile justice: 18.
Source: GAO analysis of state agencies' responses to survey.
Note: The survey question was as follows: In 2006, did your agency
routinely monitor or follow-up, or authorize for monitoring or follow-
up, any of the following issues--in the absence of a complaint--at
private residential facilities that received government funding
providing targeted services for youth? Response options for this
question were: (a) yes, monitored for all; (b) yes, monitored for some;
(c) no, did not monitor; (d) no such facility in the state; (e) don't
know; (f) no response.
[End of figure]
In addition, three of the four states we visited reported that they
were unable to meet their goals for conducting annual monitoring visits
at residential facilities due to a lack of resources. States reported
that visiting facilities was necessary at least once a year, if not
more often, to ensure that conditions for youth had not changed due to
changes in personnel, ownership, or funding. However, the number of
facilities visited each year depended on the fluctuating levels of
resources committed by the state. In Maryland, agency officials said
that state resources were redirected, as necessary, to meet state goals
for monitoring residential facilities for youth. In Florida and Utah,
however, agency officials said that imbalances between the current
workload and staff resources constrained the state's capacity to
conduct efficient, effective, and timely monitoring of residential
facilities. A facility operator in California said that on-site
monitoring had been as infrequent as once every 5 years.
State agencies reported taking actions against facilities with
identified problems in the last 3 years, but few reported suspending or
revoking a facility's operating license. Options used included
increased monitoring or requiring corrective action plans. Maryland
state officials said that they may be less likely to close facilities
when they fall below state standards if there is a shortage of
facilities in the state and closing the facility would limit the
state's ability to serve the youth who would be displaced by a closing.
In addition, these officials noted that shutting down a facility is
extremely disruptive to the youth who are placed there.
State Agencies Reported a Lack of Coordination to Share Oversight
Results:
Many state agencies reported that they did not routinely share
information with others regarding negative findings from their
monitoring reviews. State agency coordination to share monitoring
results can strengthen oversight in situations where facilities are
used by multiple agencies and can help ensure that youth are not placed
in facilities that another agency has already identified as having
problems. However, one or more state agencies reported that they did
not routinely share reports of adverse incidents (17) or when facility
licenses had been suspended or revoked (12).
Improving coordination among agencies across states is also important
because almost all states reported in our survey that they placed some
youth in out-of-state residential facilities. For example, child
welfare agencies in the top 5 states reported placing over 3,500 youth
in at least 26 states. Out-of-state placement can be difficult to
manage, but may be used when the demand for services exceeds the
state's capacity, particularly for cases requiring highly specialized
services--such as therapeutic treatment for youth who committed arson,
or who were involved in gangs. State agencies or parents may also place
youth in other states where family members reside. Interstate
coordination is important is to ensure that agencies sending youth for
placement in other states are able to screen out facilities that have
had negative findings uncovered during monitoring reviews or have
outstanding allegations of maltreatment. Information sharing about
adverse conditions in facilities may be particularly important in cases
where state licenses cannot serve to help in making appropriate
placement decisions. Four of the top five states that received the
greatest number of out-of-state placements--according to child welfare
agencies we surveyed--exempted one or more types of facilities from
state licensing requirements.
Federal Agencies Challenged to Address Weaknesses in State Oversight of
Residential Facilities:
HHS, DOJ, and Education hold states accountable for youth well-being in
certain residential facilities, but their scope of authority is
limited, and gaps in agency oversight practices result in inconsistent
protections for youth. Most notably, these agencies can hold states
accountable for conditions in facilities that serve youth through
programs supported by federal funds[Footnote 13]--whether government or
private--but cannot hold states accountable for conditions in
facilities that are exclusively private. When federal agencies do have
oversight authority under certain federal programs, however, they do
not always hold states accountable for addressing some of the primary
risks to youth well-being. For example, in comparing requirements
across HHS, DOJ, and Education, only HHS reported requiring states to
address abuse and neglect prevention under certain federal programs.
(See table 1.)
Table 1: Federal Program Requirements for States that Address Certain
Risks to Youth Well-being in Residential Facilities:
Agency and program area: HHS: Child welfare;
Abuse and neglect prevention: Yes;
Suicide prevention: No;
Use of seclusion and restraint: No;
Education quality: Yes.
Agency and program area: HHS: Medicaid;
Abuse and neglect prevention: Yes;
Suicide prevention: Yes;
Use of seclusion and restraint: Yes[A];
Education quality: No.
Agency and program area: HHS: Substance abuse and mental health;
Abuse and neglect prevention: Yes;
Suicide prevention: No;
Use of seclusion and restraint: No;
Education quality: No.
Agency and program area: DOJ: Juvenile justice and delinquency
prevention;
Abuse and neglect prevention: No;
Suicide prevention: No;
Use of seclusion and restraint: No;
Education quality: No.
Agency and program area: Education: Elementary and secondary education;
Abuse and neglect prevention: No;
Suicide prevention: No;
Use of seclusion and restraint: No;
Education quality: Yes[B].
Agency and program area: Education: Special education and
rehabilitative services;
Abuse and neglect prevention: No;
Suicide prevention: No;
Use of seclusion and restraint: No;
Education quality: Yes[B].
Source: Analysis of HHS, DOJ, and Education documents.
[A] Applies only to psychiatric residential treatment facilities.
[B] Applies only to public agencies and children placed by public
agencies in private facilities.
[End of table]
Federal program requirements are limited even for risks such as
suicide, a problem documented by several federal agencies. For example,
the Centers for Disease Control and Prevention (CDC)--which is part of
HHS--have identified suicide as the third leading cause of death in
2004 among all U.S. youth,[Footnote 14] and suicide was one of the
leading causes of death among youth in residential facilities, as
reported by states in this study. In addition, a study commissioned by
DOJ recommends increased mental health screening for suicide prevention
among incarcerated youth.[Footnote 15] DOJ officials we spoke with
generally agreed with the need to focus on suicide prevention in
residential facilities, and suggested that additional federal
requirements in this area would be helpful. DOJ and HHS have Web sites
that list resources states can use for this purpose, but HHS officials
said that states are more responsive to a requirement or more specific
agency guidance.
Similarly, federal programs also do not generally require that states
ensure the proper use of seclusion and restraint practices, which have
come under intense scrutiny in recent years. Researchers and clinicians
have chronicled the inherent physical and psychological risks in each
use of these types of interventions---including death, disabling
physical injuries, and significant trauma. Currently, federal seclusion
and restraint requirements cover youth placed in psychiatric
residential treatment facilities that receive Medicaid payments.
However, requirements do not extend to other types of facilities, and
federal officials told us that these techniques continue to be used in
ways that sometimes cause injury and death. HHS is preparing a draft
notice of proposed rulemaking concerning the use of seclusion and
restraint in non-medical community-based children's facilities.
[Footnote 16]
Federal agencies have several means of oversight for youth well-being,
but perhaps one of the most rigorous is unannounced site visits to the
youth's place of residence. According to the federal and state
officials we spoke with, only an on-site visit to the facility can
reveal whether services in the administrative reports are provided
under conditions that ensure youth well-being. For example, DOJ
officials observed that students in one of the facilities they visited
received their educational instruction while in cages, and reported
that it would have been difficult to detect this practice in an
administrative review.
Among the federal agencies we reviewed, all included visits to states
to ensure compliance with federal requirements, but agencies did not
always include visits to residential facilities. DOJ officials target
juvenile justice facilities, such as correctional facilities and
detention centers, during on-site reviews, but HHS officials do not
necessarily include residential facilities in their oversight reviews
of state child welfare systems. HHS selects a sample of child case
files for site visits, and because most children are in foster home
settings, residential facilities are usually not included.
Similarly, while federal programs contain provisions agencies can use
to enforce state compliance with federal requirements, these provisions
vary in their rigor and use, and only DOJ has levied financial
penalties.[Footnote 17] To date, HHS and Education have required state
corrective action plans as a method of enforcement, but officials said
that they may also assess financial penalties in the future.
Concluding Remarks:
As the results of our work show, protecting youth in residential
facilities--many of whom are troubled and vulnerable to harm from
themselves or from others--requires particular vigilance on the part of
parents and responsible government agencies. However, abuse, neglect,
and civil rights violations documented in all types of residential
facilities--government and private, licensed and unlicensed--show that
the current federal-state oversight structure is inadequate to protect
youth from maltreatment. Comprehensive results of our work will be
included in a report to be released next month. This report will
provide some options for action that states, federal agencies, and
Congress may consider in any restructuring effort. We anticipate our
report will also include recommendations for action that federal
agencies can implement now under the existing regulatory structure.
Mr. Chairman, this completes my prepared statement. I would be happy to
respond to any questions you or other Members of the committee may
have.
GAO Contacts and Acknowledgments:
For further information regarding this testimony, please contact me at
(202) 512-7215. Individuals making key contributions to this testimony
include Lacinda Ayers, Carolyn Boyce, Doreen Feldman, Art Merriam, Jim
Rebbe, and Mark Ward.
[End of testimony]
Footnotes:
[1] Our review included facilities that provided one or more of the
following types of programs: juvenile justice, youth offender, juvenile
delinquency, and incorrigibility programs; treatment programs for youth
with behavioral, emotional, mental health, and substance abuse issues;
homes for pregnant teens; schools for discipline or character
education; and therapeutic group homes, such as a home that specializes
in supporting and treating youth with severe emotional disorders.
[2] In this report, we use the term states to refer collectively to the
50 states plus the District of Columbia and Puerto Rico. We did not
survey state education agencies because they generally do not license
residential facilities for youth.
[3] In fiscal year 2005, 10 states did not submit reports showing the
number of fatalities in residential facilities, 2 states did not submit
a report, 7 states did not track facility incident data in a format
that could be shared with NCANDS, and 1 state involved in litigation
did not report facility data.
[4] For additional information see U.S. Department of Justice
Department of Justice Activities Under the Civil Rights for
Institutionalized Persons Act, Fiscal Year 2006, U.S. Department of
Justice (Washington, D.C.: 2007).
[5] According to DOJ officials, the Civil Rights Division has been
granted access to HHS's Centers for Medicare and Medicaid Services
(CMS) database that contains the annual survey results for CMS
oversight of residential facilities.
[6] The survey question was as follows: Which, if any, of the following
types of government operated facilities providing residential targeted
(child welfare, health mental health, juvenile justice) services for
youth are currently exempt from licensing or monitoring in your state
by statute or state regulations--state operated facilities? Response
options were (a) exempt from licensing by our agency, (b) exempt from
routine monitoring by our agency, (c) exempt from both, (d) not exempt
from either, (e) no such facility in state, (f) don't know, and (g) no
response.
[7] These six states are Arizona, Arkansas, Iowa, Maine, Missouri, and
South Carolina. In addition, licensing officials we interviewed in
Florida stated that faith-based facilities had the option of being
licensed by the state or by a faith-based licensing authority. The
survey question was as follows: Which, if any, of the following types
of private facilities providing residential targeted services for youth
are currently exempt from licensing or routine monitoring in your state
by statute or state regulation: Faith-based facilities? (a) exempt from
licensure by our agency, (b) exempt from routine monitoring by our
agency, (c) exempt from both, (d) not exempt from either, (e) no such
facility in state, (f) don't know, and (g) no response.
[8] Across agencies, states most often responded that they did not have
private boot camps, ranches, and wilderness camps. Among state juvenile
justice agencies, for example, 25 reported having no private boot camps
in their state that received government funding, 22 reported having no
ranches, and 17 reported having no wilderness camps. Somewhat fewer
states reported not having exclusively private boot camps (19), ranches
(17), and wilderness camps (14).
[9] Two of the 15 states--Massachusetts and Utah--have a central agency
that is responsible for licensing residential facilities. While we did
not receive all three surveys from Texas, it also exempts residential
schools and academies from licensing.
[10] GAO, Residential Treatment Programs: Concerns regarding Abuse and
Death in Certain Programs for Troubled Youth [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-08-146T] (Washington, D.C.:
October 10, 2007)
[11] For example, HHS's Medicaid program, a federal-state health
insurance program for low-income and other specific populations,
requires that providers of certain health or mental health services
obtain accreditation from an approved accrediting organization to
certify that the facility meets standards for safety, quality of care,
treatment, and services.
[12] Note: the survey question was as follows: When your agency
develops or opens a government-operated residential facility that
provides targeted services to youth, is the facility required to meet
state standards in any of the following areas? (a) pass inspection of
physical plant, (b) provide evidence of safe child care practices, (c)
have written procedures for reporting physical or sexual abuse or
neglect of youth, (d) meet all staff qualifications requirements,
including training, (e) perform staff background checks, (f) meet
specified staff-to-child ratios (g) provide evidence of appropriate
educational programming, (h) have procedures in place for use of
approved seclusion and restraint techniques, and (i) have written
suicide prevention plans. A similar question was asked for private
facilities.
[13] This derives from Congress' powers under Article I, Section 8 of
the U.S. Constitution and provisions of federal law establishing
conditions for state grants. Congress, as part of its spending power,
can attach conditions to states' receipt of federal funds.
[14] For additional information, see Department of Health and Human
Services' Centers for Disease Control Morbidity and Mortality Weekly
Report on Suicide Trends Among Youths and Young Adults, aged 10-24
years--United States, 1990--2004.
[15] National Center on Institutions and Alternatives. Juvenile Suicide
in Confinement: A National Survey. February 2004.
[16] This draft notice has been submitted for departmental review and
clearance. This rule is being promulgated in response to the Children's
Health Act of 2000 (Pub. L. No. 106-310, tit. XXXII, §3208) (amending
Title V of the Public Health Service Act)), which requires that public
or private non-medical, community-based facilities for children
receiving support in any form from any program supported, in whole or
part, with funds appropriated under the Children's Health Act, shall
protect and promote the rights of each resident of a facility,
including the right to be free from any restraint or involuntary
seclusion imposed for purposes of discipline or convenience. The
statute requires HHS to define in regulation the types of facilities
covered by this provision's requirements.
[17] Federal funding was reduced by $1,552,200 among 8 states and
territories in 2007.
[End of section]
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