Residential Facilities: Improved Data and Enhanced Oversight	 
Would Help Safeguard the Well-Being of Youth with Behavioral and 
Emotional Challenges (13-MAY-08, GAO-08-346).			 
                                                                 
Federal funding to states supported more than 200,000 youth in	 
residential facilities in 2004, many seeking help to address	 
behavioral or emotional challenges. However, federal		 
investigations have identified maltreatment and civil rights	 
abuses in some facilities. GAO was asked to provide national	 
information about (1) the nature of incidents that adversely	 
affect youth well-being in residential facilities, (2) how state 
licensing and monitoring requirements address youth well-being in
these facilities, and (3) what factors affect federal agencies'  
ability to hold states accountable for youth well-being in	 
residential facilities. GAO conducted national Web-based surveys 
of state child welfare, health and mental health, and juvenile	 
justice agencies and achieved an 85 percent response rate for	 
each of the three surveys. We also visited four states, 	 
interviewed program officials, and reviewed laws and		 
documentation.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-346 					        
    ACCNO:   A82103						        
  TITLE:     Residential Facilities: Improved Data and Enhanced       
Oversight Would Help Safeguard the Well-Being of Youth with	 
Behavioral and Emotional Challenges				 
     DATE:   05/13/2008 
  SUBJECT:   Accountability					 
	     Child welfare					 
	     Emotionally disturbed persons			 
	     Federal aid to states				 
	     Federal facilities 				 
	     Federal/state relations				 
	     Health and behavioral care standards		 
	     Health care facilities				 
	     Institution accreditation				 
	     Investigations by federal agencies 		 
	     Licenses						 
	     Mental care facilities				 
	     Mental health					 
	     Mental health care services			 
	     Monitoring 					 
	     Negligence 					 
	     Reporting requirements				 
	     Sexual abuse					 
	     State programs					 
	     Surveys						 
	     Youth						 

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GAO-08-346

   

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Report to the Chairman, Committee on Education and Labor, House of 
Representatives: 

United States Government Accountability Office: 
GAO: 

May 2008: 

Residential Facilities: 

Improved Data and Enhanced Oversight Would Help Safeguard the Well- 
Being of Youth with Behavioral and Emotional Challenges: 

GAO-08-346: 

GAO Highlights: 

Highlights of GAO-08-346, a report to the Chairman, Committee on 
Education and Labor, House of Representatives. 

Why GAO Did This Study: 

Federal funding to states supported more than 200,000 youth in 
residential facilities in 2004, many seeking help to address behavioral 
or emotional challenges. However, federal investigations have 
identified maltreatment and civil rights abuses in some facilities. GAO 
was asked to provide national information about (1) the nature of 
incidents that adversely affect youth well-being in residential 
facilities, (2) how state licensing and monitoring requirements address 
youth well-being in these facilities, and (3) what factors affect 
federal agenciesï¿½ ability to hold states accountable for youth well-
being in residential facilities. GAO conducted national Web-based 
surveys of state child welfare, health and mental health, and juvenile 
justice agencies and achieved an 85 percent response rate for each of 
the three surveys. We also visited four states, interviewed program 
officials, and reviewed laws and documentation. 

What GAO Found: 

Youth in some residential facilities have experienced maltreatment 
including sexual assault, physical and medical neglect, and bodily 
assault that sometimes resulted in civil rights violations, 
hospitalization, or death. Survey respondents from 28 states reported 
at least one death in residential facilities in 2006. National data 
submitted to HHS from states show that 34 states reported 1,503 
incidents of youth abuse and neglect by facility staff in 2005, but 
these data are understated due to state barriers in collecting and 
reporting facility-level information. Specific facility information 
that was reported and that could help target federal investigations was 
generally not shared with relevant agencies, such as DOJï¿½s Civil Rights 
Division, because there was no formal mechanism to share this 
information. 

All states have processes in place to license and monitor certain types 
of residential facilities, but state agencies reported several 
oversight gaps. Some government and private facilitiesï¿½particularly 
juvenile justice facilities and boarding schoolsï¿½are often exempt from 
licensing requirements by law or regulation. In addition, licensing 
standards do not always address some of the most common risks to youth 
well-being, such as suicide. State officials reported that they are 
unable to conduct annual on-site reviews at facilities, in part because 
of fluctuating levels of staff resources. Few state agencies reported 
suspending or revoking a facilityï¿½s operating license, in some cases 
due to lack of alternatives in placing the displaced youth. 

Table: Number of State Agencies Reporting That They Do Not Exempt or 
Exempt Private Residential Facilities from Licensing Requirements, 
2006: 

Facility Type: Residential schools and academies[A]; 
Not exempt, Child welfare: 19; 
Exempt, Child welfare: 18; 
Not exempt, Health and mental health: 15; 
Exempt, Health and mental health: 10; 
Not exempt, Juvenile justice: 14; 
Exempt, Juvenile justice: 14. 

Facility Type: Detention center; 
Not exempt, Child welfare: N/A; 
Exempt, Child welfare: N/A; 
Not exempt, Health and mental health: N/A; 
Exempt, Health and mental health: N/A; 
Not exempt, Juvenile justice: 14; 
Exempt, Juvenile justice: 11. 

Facility Type: Boot camp; 
Not exempt, Child welfare: 10; 
Exempt, Child welfare: 6; 
Not exempt, Health and mental health: 6; 
Exempt, Health and mental health: 2; 
Not exempt, Juvenile justice: 4; 
Exempt, Juvenile justice: 3. 

Facility Type: Wilderness camp; 
Not exempt, Child welfare: 24; 
Exempt, Child welfare: 3; 
Not exempt, Health and mental health: 16; 
Exempt, Health and mental health: 3; 
Not exempt, Juvenile justice: 13; 
Exempt, Juvenile justice: 1. 

Facility Type: Treatment facility; 
Not exempt, Child welfare: 39; 
Exempt, Child welfare: 1; 
Not exempt, Health and mental health: 35; 
Exempt, Health and mental health: 0; 
Not exempt, Juvenile justice: N/A; 
Exempt, Juvenile justice: N/A. 

Source: GAO analysis of state agencies' responses to survey. 

Note: Other agency responses included no such facility in the state, 
donï¿½t know, and no response. 

[A] Residential schools and academies includes both government and 
private facilities. 

[End of table] 

HHS, DOJ, and Education hold states accountable for youth well-being 
under federal grant programs, but their authority is limited and 
monitoring practices are inconsistent. These agencies do not have the 
legal authority to hold states accountable for youth well-being in 
private residential facilities unless they serve youth under programs 
that receive federal funds. Agency officials also said they lack 
authority to require suicide prevention, and other requirements were 
inconsistent across programs. Agencies did not always include 
facilities in their state oversight reviews, and were inconsistent in 
addressing state noncompliance. 

What GAO Recommends: 

GAO recommends that the Secretary of Health and Human Services (HHS) 
work to address state barriers in reporting maltreatment data for 
residential facilities, that the Attorney General work with federal 
agencies to access information for targeting civil rights 
investigations, and that the Attorney General and the Secretaries of 
HHS and Education work to enhance their state oversight efforts. GAO 
also discusses the implications of options that states, federal 
agencies, and Congress may use to safeguard and improve the civil 
rights and well-being of youth in residential facilities. While HHS and 
the Department of Justice (DOJ) generally agreed with our 
recommendations and suggested further action that could be taken, 
Education did not directly respond to the recommendations in its 
comments. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-346]. To view the 
e-supplement online, click on [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-08-631SP]. For more information, contact Kay Brown, 
(202) 512-7215 or [email protected]. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

Fatalities and Maltreatment Occurred in Government and Private 
Facilities, but State and National Data Do Not Fully Capture the Extent 
and Nature of the Problem: 

State Licensing and Monitoring Exclude Some Facilities and Do Not 
Address All Risks to Youth Well-Being: 

Federal Agencies Challenged to Address Weaknesses in State Oversight of 
Residential Facilities: 

Options for Taking Action to Promote Youth Well-Being in Residential 
Facilities: 

Conclusion: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Circumstances Surrounding State-Reported Suicides in 
Residential Facilities for Youth, 2006: 

Appendix III: State-Reported Incidents of Staff Maltreatment of Youth 
in Residential Facilities, Fiscal Year 2005: 

Appendix IV: Licensing Status for Selected Residential Facilities: 

Appendix V: State Agency Accreditation Requirements for Residential 
Facilities for Youth: 

Appendix VI: Selected State Licensing Standards for Residential 
Facilities for Youth: 

Appendix VII: Selected State Monitoring Requirements for Residential 
Facilities for Youth: 

Appendix VIII: State Agency Actions Taken within the Last 3 Years 
against Government and Private Residential Facilities: 

Appendix IX: Comments from the Department of Education: 

Appendix X: Comments from the Department of Health and Human Services: 

Appendix XI: Comments from the Department of Justice: 

Appendix XII: GAO Contacts and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: Selected Federal Funds That Can Be Used to Support Youth in 
Residential Facilities, by Federal Agency and Subagency: 

Table 2: Estimated Number of Youth in Residential Settings per Latest 
Available Agency Data: 

Table 3: State Child Welfare Agencies Reporting the Greatest Number of 
Youth Placed in Out-of-State Residential Facilities: 

Table 4: State Child Welfare Agencies Reporting the Greatest Number of 
Youth Received from Other States for Placement in Residential 
Facilities: 

Table 5: Federal Program Requirements for States That Address Certain 
Risks to Youth Well-Being in Residential Facilities: 

Table 6: Status of State Agency Responses to GAO Survey on Residential 
Facilities for Youth: 

Table 7: States Reporting Youth Suicides by Type of Facility, 
Authorization for Providing Services, and Related Investigatory 
Findings, 2006: 

Table 8: State-Reported Incidents of Staff Maltreatment of Youth in 
Residential Facilities, Fiscal Year 2005: 

Table 9: Licensing Status for Selected State-Operated Residential 
Facilities: 

Table 10: State Agencies Reporting the Licensing Status for State- 
Operated Residential Facilities That Serve Youth: 

Table 11: Licensing Status for Selected Residential Facilities That 
Receive Government Funds: 

Table 12: State Child Welfare Agencies Reporting the Licensing Status 
for Selected Private Residential Facilities That Serve Youth and 
Receive Government Funding: 

Table 13: State Health and Mental Health Agencies Reporting the 
Licensing Status for Selected Private Residential Facilities That Serve 
Youth and Receive Government Funding: 

Table 14: State Juvenile Justice Agencies Reporting the Licensing 
Status for Selected Private Residential Facilities That Serve Youth and 
Receive Government Funding: 

Table 15: Licensing Status for Selected Exclusively Private Residential 
Facilities: 

Table 16: State Child Welfare Agencies Reporting the Licensing 
Requirements for Selected Exclusively Private Residential Facilities 
That Serve Youth and Receive No Government Funding: 

Table 17: State Health and Mental Health Agencies Reporting the 
Licensing Requirements for Selected Exclusively Private Residential 
Facilities That Serve Youth and Receive No Government Funding: 

Table 18: State Juvenile Justice Agencies Reporting the Licensing 
Status for Selected Exclusively Private Residential Facilities That 
Serve Youth and Receive No Government Funding: 

Table 19: Number of States that Require at Least Some of the 
Residential Facilities That They License or Certify to Have Independent 
Accreditation: 

Table 20: Number of State Agencies Reporting That They Require Licensed 
Government-Operated and Private Residential Facilities to Meet Certain 
Standards, 2006: 

Table 21: Number of State Agencies Reporting That They Monitored, for 
All or Less Than All, Selected Issues at Residential Facilities for 
Youth, 2006: 

Table 22: Number of State Agencies Taking Actions against Government 
and Private Residential Facilities within the Last 3 Years: 

Figures: 

Figure 1: States That Reported at Least One Fatality in Residential 
Facilities, 2006: 

Figure 2: Number of State-Reported Fatalities by Type of Residential 
Facility and Agency, 2006: 

Figure 3: Number of States That Reported Specific Causes of Youth 
Fatalities in Residential Facilities, 2006: 

Figure 4: Percentage of State-Reported Incidents of Youth Maltreatment 
by Residential Facility Staff, Fiscal Year 2005: 

Figure 5: State Agencies Reporting the Licensing Status of State- 
Operated Residential Facilities That Serve Youth: 

Figure 6: Number of State Agencies Reporting That They Do Not Exempt or 
Exempt Private Residential Facilities Receiving Government Funds from 
Licensing Requirements, 2006: 

Figure 7: Aspects of Well-Being Monitored by State Agencies in Private 
Residential Facilities That Served Youth and Received Government 
Funding: 

Figure 8: State Agency Actions Taken within the Last 3 Years against 
Government Residential Facilities: 

Figure 9: Number of State Agencies Reporting That They Did Not 
Routinely Share Oversight Information Regarding Certain Residential 
Facilities: 

Abbreviations: 

AWOL: Absent Without Leave: 

CAPTA: Child Abuse Prevention and Treatment Act: 

CARF: Commission on Accreditation Rehabilitation Facilities: 

CMS: Centers for Medicare & Medicaid Services: 

COA: Council on Accreditation: 

CRIPA: Civil Rights of Institutionalized Persons Act: 

DOJ: Department of Justice: 

HHS: Department of Health and Human Services: 

JC: The Joint Commission: 

NCANDS: National Child Abuse and Neglect Data System: 

OJJDP: Office of Juvenile Justice and Delinquency Prevention: 

Education: Department of Education: 

[End of section] 

United States Government Accountability Office:
Washington, DC 20548: 

May 13, 2008: 

The Honorable George Miller: 
Chairman: 
Committee on Education and Labor: 
House of Representatives: 

Dear Mr. Chairman: 

Since the 1990s, government and private entities have established 
hundreds of residential facilities--including boarding schools and 
academies, boot camps, and wilderness camps--to serve youth with 
behavioral and emotional challenges. Nationwide, federal funding to 
states supported more than 200,000 youth in facilities in 2004, and an 
unknown number of youth were placed in facilities by parents or others. 
These facilities can provide youth who cannot be served in their 
communities with a less restrictive alternative to hospitalization or 
incarceration. However, annual investigations by the Civil Rights 
Division within the Department of Justice, have detailed incidents of 
abuse and neglect, which in some cases have been severe enough to 
result in hospitalization or death. 

States are primarily responsible for ensuring the well-being of youth 
in facilities and other settings, and states vary in how they license 
and monitor facilities in accordance with individual state standards of 
care. In addition, in return for receiving funds under various federal 
grant programs, state agencies agree to comply with federal program 
requirements, including those related to youth well-being. These 
programs generally fall under the purview of three federal agencies: 
The Department of Health and Human Services (HHS) provides funds to 
states for child welfare, mental health, and substance abuse; the 
Department of Justice (DOJ), for serving delinquent youth; and the 
Department of Education (Education), for educating youth. These 
agencies have authority to hold states accountable for state-operated 
or private facilities that serve youth under federally funded state 
programs. However, the federal government does not have oversight 
authority for other private facilities that serve only youth placed and 
funded by parents or other private entities. In this report we refer to 
facilities that receive no government funding as exclusively private 
facilities. 

In an October 2007 testimony on residential treatment programs for 
troubled youth we looked specifically at abuse and neglect of youth in 
certain types of private facilities.[Footnote 1] This report provides 
national information about (1) the nature of the incidents that 
adversely affect the well-being of youth in government and private 
residential facilities, (2) how state licensing and monitoring 
requirements address the well-being of youth in residential facilities, 
and (3) what factors affect federal agencies' ability to hold states 
accountable for youth well-being in residential facilities. We are also 
providing information on options that states, federal agencies, and 
Congress may use to better promote youth well-being in residential 
facilities. 

For purposes of this study, we defined residential facilities as those 
that require youth--ages 12 through 17--to reside at the facility and 
that provide program services for youth with behavioral and emotional 
challenges.[Footnote 2] There are no uniform definitions for the types 
of residential facilities, and we worked with states to identify 
definitions that would be commonly understood, including boarding 
schools and academies, training and reform schools, wilderness camps, 
ranches, and treatment centers. We surveyed state child welfare, health 
and mental health, and juvenile justice directors in the 50 states, the 
District of Columbia, and Puerto Rico to determine how states oversee 
child well-being[Footnote 3] in residential facilities. [Footnote 4] We 
received at least one completed survey from each state except Puerto 
Rico, completed surveys from all 3 agencies in 33 states, and completed 
surveys from a total of 44 child welfare agencies, 45 health and mental 
health agencies, and 44 juvenile justice agencies. In the surveys, we 
asked about residential facilities that were government operated; 
privately operated that received any government funds; [Footnote 5] and 
privately operated with no government funding. This report does not 
contain all of the results from the survey. The survey and a more 
complete tabulation of the results can be viewed by accessing the 
following link: [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-
631SP]. To further our understanding, we visited 4 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. We also obtained state-reported 
data that HHS collects and maintains in its National Child Abuse and 
Neglect Data System (NCANDS). We reviewed federal statutes, 
regulations, and guidance concerning the roles and responsibilities of 
selected agencies, and interviewed HHS, DOJ, and Education officials, 
as well as national association representatives and other experts on 
residential facilities for youth. We analyzed reports, studies, 
evaluations, and other documents regarding state licensing and 
monitoring of residential facilities for youth, but the scope of our 
work did not include the quality of services provided at residential 
facilities. See appendix I for more information on our scope and 
methodology. We performed our work between November 2006 and April 
2008, in accordance with generally accepted government auditing 
standards. 

Results in Brief: 

Youth in some government and private residential facilities have 
experienced maltreatment including physical abuse, neglect or 
deprivation of necessities, and sexual abuse that sometimes resulted in 
death or hospitalization, but data limitations hinder efforts to 
quantify the problem. Survey respondents from 28 states reported at 
least one death in a residential facility in 2006, often in accidents 
or suicides that, in some cases, may have been attributable to a lack 
of supervision or neglect by staff. In terms of youth maltreatment, 
NCANDS data show that 34 states reported 1,503 incidents of youth abuse 
and neglect by facility staff in 2005, but these data are 
underreported. Many state agencies we surveyed reported having 
information gaps, in part due to barriers in collecting facility 
specific information on deaths and maltreatment for all or some 
facilities. Facility-specific information for facilities that states 
did report to NCANDS was not shared with agencies, such as the DOJ 
Civil Rights Division, that may use such information to prioritize 
civil rights investigations at the federal level. DOJ annual reports 
convey the severity of maltreatment and civil rights violations 
uncovered by investigations in both government and private facilities 
receiving government funds across the nation. 

All states have processes in place to license and monitor certain types 
of residential facilities, but state agencies reported several gaps in 
coverage that may place some youth at higher risk for maltreatment and 
death. First, some government-operated and private facilities--such as 
juvenile justice facilities and residential schools and academies--are 
often exempt from licensing requirements altogether by law or 
regulation. Additionally, licensing requirements do not always address 
suicide and other common risks to youth well-being, and requirements 
that do exist may be inconsistently applied across different types of 
agencies and facilities. For example, almost all state juvenile justice 
agencies we surveyed required facilities to have written suicide 
prevention plans, compared to about two-thirds of state child welfare 
and health and mental health agencies. State agencies also reported 
gaps in their monitoring processes for residential facilities. Some 
state agencies reported that monitoring did not occur at some 
facilities or reported that certain aspects of youth well-being, such 
as the quality of education programming and the use of psychotropic 
medications, were not included in their monitoring reviews. State 
officials also reported that they are unable to conduct yearly on-site 
reviews at facilities they monitor, because of fluctuating levels of 
staff resources committed by the state. Few state agencies reported 
taking action to suspend or revoke a facility's operating license, in 
some cases because the state had no alternatives for serving the youth 
who would have been displaced. Finally, interagency coordination to 
ensure that facilities are providing an appropriate education, or other 
specialized services, is often lacking. Several officials also noted 
the importance of increasing coordination to share monitoring results 
as agencies may place youth in common facilities within and across 
state lines. 

HHS, DOJ, and Education all have oversight processes to hold states 
accountable for the well-being of youth under the grant programs they 
administer, but the scope of the agencies' oversight authority and 
different monitoring practices hinder their efforts. Most notably, 
these agencies do not have the legal 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, agency officials said that they 
do not have authority to modify youth well-being requirements 
established in law, and such requirements vary by federal agency and 
program. For example, in comparing requirements across relevant HHS, 
DOJ, and Education programs, only HHS had requirements for states to 
address abuse and neglect prevention. Requirements were inconsistent 
even among programs within the same agency. HHS, for example, had 
requirements for states to address suicide prevention under Medicaid 
programs, but not under child welfare programs or programs for 
substance abuse and mental health. In monitoring state compliance with 
federal program requirements, agencies did not always include 
residential facilities in their oversight reviews. While on-site 
reviews conducted by DOJ specifically included these facilities, HHS 
reviews of states' child welfare systems targeted individual children, 
and did not necessarily include those in residential facilities. 
Federal agencies were also inconsistent in how they addressed state 
noncompliance with federal program requirements. In fiscal year 2007, 
for example, DOJ assessed financial penalties against 8 states and 
Puerto Rico, while other federal agencies reported that they did not 
assess penalties against noncompliant states. 

Weaknesses in the current federal-state regulatory structure have 
failed to safeguard the civil rights and well-being of some of the 
nation's most vulnerable youth, and we discuss the implications of some 
options for action that states, federal agencies, and Congress may 
consider in any restructuring effort. In addition, we remain concerned 
about the gaps in reported data that have persisted over a decade since 
the reporting requirement has been in place. We are also making 
recommendations for action that federal agencies can implement now 
under the existing regulatory structure, including that the Secretary 
of Health and Human Services explore options to address state barriers 
in reporting maltreatment data for residential facilities; the Attorney 
General work with other federal agencies to access information that 
could help target civil rights investigations; and HHS, DOJ, and 
Education work to enhance their oversight of state accountability for 
youth well-being in residential facilities. HHS and DOJ either 
generally agreed, or did not disagree, with each of our 
recommendations. They also suggested further action that could be taken 
to address the report findings related to oversight for residential 
facilities. Education did not directly respond to the report 
recommendations but rather discussed its role and responsibilities for 
oversight of certain programs. 

Background: 

In the continuum of care for youth with behavioral and emotional 
challenges, residential facilities can provide an alternative to 
hospitalization or incarceration for youth who cannot live at home and 
receive services in their communities.[Footnote 6] Youth in these 
facilities range from young children through those who are 
transitioning to adulthood. These youth can exhibit a wide range of 
challenging behaviors, including antisocial or suicidal behaviors, 
substance abuse, and delinquency. 

The array of residential facilities reflects the diversity of the 
population they serve. There are no uniform definitions of residential 
facilities, and for those facilities treating children with mental 
illness, states reported at least 71 different facility types, 
according to a 2006 HHS report.[Footnote 7] Facilities can provide a 
range of services, such as those for youth suffering from substance 
abuse or severe emotional disorders, either on-site or through links 
with community programs, including educational, medical, psychiatric, 
and clinical/mental health services. A wide range of government or 
private entities, including faith-based organizations, can operate 
these facilities. The cost to support youth in a residential setting 
can amount to thousands of dollars per month at some residential 
facilities. 

Youth Maltreatment Data: 

HHS maintains and disseminates state-reported child abuse and neglect 
data in NCANDS to fulfill requirements in the Child Abuse Prevention 
and Treatment Act (CAPTA). Enacted in 1974, CAPTA established a focal 
point in the federal government to identify and address issues of child 
abuse and neglect in all settings, including residential facilities, 
and support effective methods of prevention and treatment.[Footnote 8] 
Under CAPTA, all states receiving funds from the state grant program 
are required to work with HHS to provide--to the maximum extent 
practicable--specific data on child maltreatment, including the number 
of children reported to have been abused or neglected and the number of 
deaths resulting from abuse and neglect. [Footnote 9] 

In addition, CAPTA requires that states receiving grants have laws or 
programs in effect for the investigation of child abuse and 
neglect.[Footnote 10] The law also requires states receiving grants to 
establish citizen review panels to review state and local child 
protection activities, which may include child fatality review 
committees established by states to review child fatalities for 
evidence of maltreatment, and to forward such cases for prosecution. 

State Oversight Processes: 

States have systems in place to license a wide range of businesses, and 
have general licensing requirements that include obtaining permits for 
land use, meeting building and safety codes, and establishing a basis 
for taxation. Beyond these general licensing requirements, states may 
have additional requirements that are specific to a category of 
business declared by the owner, such as a residential facility, or more 
specific types of businesses within this category, such as a boarding 
school or wilderness camp. Some states have centralized all licensing 
and monitoring of facilities serving youth within a single agency, 
while other states have decentralized these functions among three or 
more different agencies, including state child welfare, mental health, 
and juvenile justice agencies. In addition, other agencies may provide 
oversight, such as the local fire and health departments, and the 
agency that places youth in the facility. State education agencies may 
also provide oversight for a facility's educational programs. Oversight 
activities typically include licensing or certifying government or 
privately operated facilities, investigating complaints, and monitoring 
facility compliance with state or local standards, but there are no 
minimum standards commonly used by licensing agencies. 

States may also require residential facilities to seek accreditation in 
addition to obtaining a license to operate in their state. Accrediting 
agencies are private, peer-based, member-funded agencies designed to 
encourage and promote high-quality care. Accreditation is typically 
obtained by a self-initiated application and guided self-evaluation, 
followed by an on-site visit by a voluntary committee associated with 
the accrediting agency.[Footnote 11] Some of the benefits to 
accreditation that states provide include strengthening confidence in 
the quality of care, fulfilling regulatory requirements in some states, 
and improving risk management and risk reduction. 

Federal Oversight of Programs That Support Residential Facilities: 

Three federal agencies--HHS, DOJ, and Education--administer federal 
programs that states may use to support youth with community-based 
services while living at home or, when needed, in residential 
facilities or other settings. This support is provided primarily 
through certain subagencies, as shown in table 1. 

Table 1: Selected Federal Funds That Can Be Used to Support Youth in 
Residential Facilities, by Federal Agency and Subagency: 

Agency and Subagency: HHS: Administration for Children and Families; 
Program authority and fiscal year 2007 funding: Title IV-B of the 
Social Security Act-$287 million; 
Purpose: Support for state child welfare system. 

Agency and Subagency: HHS: Administration for Children and Families;
Program authority and fiscal year 2007 funding: Title IV-E of the 
Social Security Act-$6.9 billion; 
Purpose: Support for state child welfare system. 

Agency and Subagency: HHS: Substance Abuse and Mental Health Services 
Administration; 
Program authority and fiscal year 2007 funding: Block Grants for 
Prevention and Treatment of Substance Abuse-$1.8 billion; 
Purpose: Support for state substance abuse prevention and treatment 
systems. 

Agency and Subagency: HHS: Substance Abuse and Mental Health Services 
Administration; 
Program authority and fiscal year 2007 funding: Block Grants for 
Community Mental Health Services-$428 million; 
Purpose: Support for state mental health systems. 

Agency and Subagency: HHS: Center for Medicare and Medicaid Services; 
Program authority and fiscal year 2007 funding: Title XIX of the Social 
Security Act-$189.1 billion; 
Purpose: Support for medical assistance for low-income persons. 

Agency and Subagency: DOJ: Office of Juvenile Justice and Delinquency 
Prevention; 
Program authority and fiscal year 2007 funding: Juvenile Justice 
Delinquency Prevention Act-$320 million; 
Purpose: Support for state juvenile justice system. 

Agency and Subagency: Education: Office of Special Education and 
Rehabilitative Services; 
Program authority and fiscal year 2007 funding: Individuals with 
Disabilities Education Act-$11.8 billion; 
Purpose: Support for state special education systems. 

Agency and Subagency: Education: Office of Elementary and Secondary 
Education; 
Program authority and fiscal year 2007 funding: Elementary and 
Secondary Education Act as Amended by the No Child Left Behind Act of 
2001-$14.7 billion; 
Purpose: Support for state education systems. 

Source: GAO analysis of federal budget documents. 

[End of table] 

In 2004, HHS and DOJ reported that states served more than 200,000 
youth in residential settings under certain federal programs for child 
welfare, mental health, and juvenile justice as shown in table 2. 

Table 2: Estimated Number of Youth in Residential Settings per Latest 
Available Agency Data: 

Placement: Number of youth; 
State agency: Child welfare: 107,000; 
State agency: Mental health[A]: 11,000; 
State agency: Juvenile justice: 93,000. 

Source: Child welfare data: Child Welfare League of America: National 
Data Analysis System, Number of Children in Out-of-Home Care, by 
Placement Setting 2004. 

Notes: Mental health data: Office of Applied Studies, Substance Abuse 
and Mental Health Services Administration, National Survey of Substance 
Abuse Treatment Services, March 31, 2006. 

Juvenile justice data: Office of Juvenile Justice and Delinquency 
Protection: Census of Juveniles in Residential Placement, 2006. 

[A] According to HHS's Substance Abuse and Mental Health Services 
Administration officials, the approximately 11,000 youth include those 
receiving treatment at public and private facilities as of March 31, 
2006, most with a primary focus of substance abuse treatment and many 
fewer with a mental health focus. 

[End of table] 

To receive federal funds under these programs, states generally develop 
and submit to the relevant agency a multiyear plan that addresses 
federal program requirements.[Footnote 12] The relevant federal agency 
reviews and approves state plans, along with any annual performance 
reports that states submit describing progress in meeting goals. 
Federal agencies also audit states' use of grant funds via reviews of 
state records and site visits in the settings where youth reside, such 
as residential facilities. States that fail to meet the required 
standards may face the withholding of federal funds. 

Federal Investigations of Civil Rights Abuses in Residential 
Facilities: 

The Civil Rights of Institutionalized Persons Act (CRIPA), enacted in 
1980, authorizes the Attorney General of the United States to conduct 
investigations and bring actions against state and local governments 
relating to conditions of confinement in institutions that are owned, 
operated, or managed by or provide services on behalf of, state or 
local governments.[Footnote 13] Institutions covered by CRIPA include 
youth residential facilities. 

CRIPA is implemented by the Special Litigation Section within DOJ's 
Civil Rights Division. Under CRIPA, the Special Litigation Section 
investigates covered facilities to determine whether there is a pattern 
or practice of violations of residents' federal rights. According to 
DOJ, to date, the Special Litigation Section has been successful in 
resolving the majority of CRIPA investigations that have uncovered 
unlawful conditions by obtaining voluntary correction or a judicially 
enforceable settlement designed to improve conditions. 

Fatalities and Maltreatment Occurred in Government and Private 
Facilities, but State and National Data Do Not Fully Capture the Extent 
and Nature of the Problem: 

States we surveyed reported fatalities as well as incidents of physical 
abuse, sexual abuse, and neglect of youth in both government and 
private facilities in 2006, but data limitations hinder efforts to 
quantify the problem. Accidents and suicides--often attributable to a 
lack of supervision by staff--were among the most common types of youth 
fatalities, according to surveyed states; while in the four states we 
visited, the most common causes of youth maltreatment were abusive 
staff and lack of appropriate supervision. Many states had inconsistent 
or incomplete data on adverse incidents--especially from exclusively 
private facilities. National data, derived from state reports, suffer 
from these same limitations, leaving states with little opportunity to 
identify the extent of the problem and find solutions. State-reported 
information also fails to convey the severity of civil rights 
violations uncovered in some facilities each year--that show extreme 
cases of sexual assault, medical neglect, and bodily assault requiring 
hospitalization. 

Youth Fatalities Occurred in Government and Private Facilities across 
the Nation, with Accidents and Suicide among the Primary Causes: 

Youth fatalities occurred in both government and private residential 
facilities, in states across the nation. Of the states we surveyed, 28 
reported that at least one youth had died in this setting in 2006, as 
shown in figure 1.[Footnote 14] 

Figure 1: States That Reported at Least One Fatality in Residential 
Facilities, 2006: 

[See PDF for image] 

This figure is a map of the United States depicting states that 
reported at least one fatality in residential facilities, 2006. Those 
states are: 

Alabama; 
Alaska; 
Arizona; 
California; 
Colorado; 
Delaware; 
District of Columbia; 
Florida; 
Georgia; 
Hawaii; 
Indiana; 
Iowa; 
Louisiana; 
Massachusetts; 
Maryland; 
Mississippi; 
Nebraska; 
New Jersey; 
North Carolina; 
North Dakota; 
Ohio; 
Pennsylvania; 
Rhode Island; 
Tennessee; 
Texas; 
Virginia; 
Wisconsin; 
Wyoming. 

Source: GAO analysis of state agency responses to survey; map, Map 
Resources. 

Note: The survey question was as follows: In 2006, how many youth aged 
12-17 died in each of the following categories of residential 
facilities providing targeted services in your state? Include youth who 
died at the facility as well as youth in AWOL status or others who died 
or were pronounced dead outside the facility: (a) total deaths in 2006, 
(b) deaths of youth under the care and supervision of your agency at 
government-operated facilities, (c) deaths of youth under the care and 
supervision of your agency at private facilities that receive any 
government funds, (d) deaths of youth under parental or non-government 
custodial care at private facilities that receive any government funds, 
and (e) deaths of youth under parental or nongovernment custodial care 
at private facilities that do not receive government funds (including 
faith-based facilities). 

[End of figure] 

Child welfare agencies reported more deaths in residential facilities 
than other agencies, and nearly three times as many states reported 
deaths in private facilities that received government funds than in 
government-operated facilities (see fig. 2). However, this may bear 
little or no relation to the relative risk of death in either facility 
type due to differences in the proportion and risk factors of youth 
served, among other factors. While no state we surveyed reported 
fatalities in exclusively private facilities, one or more agencies in 
45 states reported that they did not have data for these types of 
facilities. 

Figure 2: Number of State-Reported Fatalities by Type of Residential 
Facility and Agency, 2006: 

[See PDF for image] 

This figure is a stacked horizontal bar graph depicting the following 
data: 

State agency: Child welfare; 
Fatalities, Government facilities: 4; 
Fatalities, Private facility that received government funds: 28; 
Fatalities, not categorized by facility type: 10; 
Total: 42. 

State agency: Health and mental health; 
Fatalities, Government facilities: 3; 
Fatalities, Private facility that received government funds: 13; 
Fatalities, not categorized by facility type: 0; 
Total: 16. 

State agency: Juvenile justice; 
Fatalities, Government facilities: 3; 
Fatalities, Private facility that received government funds: 8; 
Fatalities, not categorized by facility type: 0; 
Total: 11. 

Source: GAO analysis of state responses to surveys. 

[End of figure] 

In our survey, deaths in the 28 states were most often attributed to 
accidental causes (see fig. 3), but sometimes accidental deaths, if 
investigated, are attributable to abuse or neglect. In Florida, for 
example, juvenile justice officials said that a youth death in a county-
operated boot camp was first classified as an accident, but after 
investigation by a child fatality review committee, was reclassified as 
a death caused by maltreatment and referred for prosecution. 

Figure 3: 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: 

Causes of youth fatalities: 
Accidental causes: 16 states; 
Suicide: 9 states; 
Other cause (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 responses to surveys. 

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 AWOL 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] 

Suicide was among the most common causes of fatalities in residential 
facilities reported by states we surveyed, and can be related in some 
instances to inadequate staff supervision and services. In Alaska, for 
example, a youth participating in a sex offender program hanged himself 
at night while residing in a private facility contracting with the 
state. After the state agency and the local law enforcement agency 
investigated, the facility corrected substandard practices in staffing, 
supervision, and clinical services. In Wisconsin, after three youth 
hanged themselves in private residential facilities under contract with 
a state agency, the state increased staff training and monitoring of 
residents and sponsored statewide suicide awareness and prevention 
training for those who work with youth in residential settings. See 
appendix II for more information on the results of suicide 
investigations in the states we surveyed. 

Youth Maltreatment Was Primarily Related to Inexperienced Staff, Lack 
of Supervision, or Insufficient Training: 

States responding to our survey reported that they investigated 
complaints of physical abuse, sexual abuse, or neglect in both 
government and private facilities (49 states), including those that are 
exclusively private (37 states). Similarly, NCANDS data from 2005 
showed that 34 states reported incidents of youth abuse and neglect in 
residential facilities. Of the 1,503 reported incidents, neglect was 
the most frequent cause of youth maltreatment, followed by physical 
abuse. (See fig. 4 and app. III.) 

Figure 4: 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: 

Type of maltreatment: Physical abuse; 
Percentage of state reported incidents: 24%; 

Type of maltreatment: Neglect or deprivation of necessities; 
Percentage of state reported incidents: 44%; 

Type of maltreatment: Sexual abuse; 
Percentage of state reported incidents: 9%; 

Type of maltreatment: Other[A]; 
Percentage of state reported incidents: 23%. 

Source: NCANDS. 

[A] "Other" incidents of youth maltreatment states reported to NCANDS 
include medical neglect and psychological or emotional maltreatment. 

[End of figure] 

In the states we visited, abuse and neglect of youth in residential 
facilities was often associated with staff resource concerns--such as a 
lack of experienced staff, insufficient training, or lack of 
appropriate supervision--particularly in smaller facilities. In 
California, for example, county officials 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. 

Another cause of youth maltreatment may be attributable to the improper 
application of seclusion and restraint, according to state officials. 
State officials in Florida said that improper application of seclusion 
and restraint techniques may result in staff restraining youth for too 
long, or with too much force, causing injury or death. 

Data Limitations Preclude Identifying the Extent of the Maltreatment or 
Finding Solutions: 

State and federal information systems for tracking and reporting 
incidents of maltreatment have limitations in helping state and federal 
agencies monitor the well-being of youth in residential facilities and 
address outstanding problems. 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, although states responding to our survey 
reported that the ability to collect and maintain data on all 
facilities in the state was a high priority, state officials we 
interviewed reported barriers in addressing these activities: First, 
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; second, states that 
have such authority reported difficulties sustaining data collection in 
times of budget shortages. As a result, state officials said that the 
number of adverse incidents was likely more widespread and numerous 
than reported. 

NCANDS, which is derived from state reports, suffers from these same 
limitations, as well as others. First, some states do not report data 
for residential facilities to NCANDS,[Footnote 15] so it may understate 
the number of fatalities and maltreatments. Second, many states do not 
consistently identify whether the individual maltreating youth was 
facility staff, a parent, or other individual.[Footnote 16] Finally, 
NCANDS only tracks fatalities resulting from maltreatment, not suicide 
or accidents that may be an indicator of neglect or another problem 
that needs resolution. Cognizant HHS officials said that its NCANDS 
contractor routinely works with states to improve data quality, but 
cannot enforce state participation as data reporting is voluntary under 
the law. 

HHS highlighted the need to improve the quality of data reported by 
states in a 2005 report to Congress,[Footnote 17] noting that national 
collection of data on child fatalities is complicated by the many steps 
that are needed to establish the cause of death. The report stated that 
while state child fatality review committees can investigate and help 
classify deaths correctly, they are not implemented in every community, 
nor do they have the resources to review each suspicious death of a 
child or adolescent. In this report, HHS suggested that Congress fund 
research on ways to improve national reporting of youth fatality data, 
including procedures for investigating and documenting the cause of 
fatalities. 

Federal Investigations Highlight the Severity of Civil Rights 
Violations Occurring in Some Residential Facilities: 

In most facilities, youth maltreatment may occur infrequently as a 
result of isolated circumstances, but over the years, DOJ 
investigations of facilities serving youth have found a pattern or 
practice of civil rights violations, including physical and sexual 
abuse, medical neglect, and inadequate education in some government and 
private facilities receiving government funds. At the end of fiscal 
year 2006, the latest year for which data were available, DOJ's Civil 
Rights Division reported active cases involving over 175 facilities and 
34 states.[Footnote 18] Annual reports from the division 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 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. 

DOJ's Civil Rights Division reports that it receives more credible 
allegations of violations of youth rights than it can investigate. 
During fiscal year 2006 alone, the division reported receiving 
approximately 5,000 citizen letters, hundreds of telephone complaints, 
and 135 inquiries from Congress and the White House. In the 26 years 
CRIPA had been in effect, through September 2006, the division 
investigated conditions in 433 facilities. Division officials said that 
they also receive many allegations of civil rights violations in 
exclusively private facilities, such as private boarding schools. 

DOJ Civil Rights Division officials stated they rely on advocacy groups 
and media stories to identify investigations, but with additional 
sources of information, they could better target their scarce 
investigative resources. Division officials said that they were unaware 
that NCANDS tracked state-reported maltreatment data, and that 
obtaining case-level NCANDS information on the incidents of 
maltreatment and death occurring in specific facilities would be 
helpful. Division officials said that the results of federal agency 
monitoring reviews of states that highlight findings related to 
residential facilities would also be useful, but that there was no 
formal mechanism to share oversight findings for residential facilities 
under the purview of multiple federal programs. Except in one 
instance,[Footnote 19] officials said that no federal agencies-- 
including HHS, Education, and DOJ's Office of Juvenile Justice and 
Delinquency Prevention--were coordinating with DOJ's Civil Rights 
Division to provide pertinent oversight results. 

State Licensing and Monitoring Exclude Some Facilities and Do Not 
Address All Risks to Youth Well-Being: 

All states have processes in place to license and monitor certain types 
of residential facilities, but our survey identified several gaps that 
exempt certain types of facilities from oversight and allow some of the 
common causes of youth death and maltreatment to go unaddressed. These 
gaps include the fact that some types of government-operated and 
private facilities are exempt from licensing requirements, licensing 
requirements do not always address the primary causes of youth death 
and maltreatment, and state agencies inconsistently monitor facilities 
and share their monitoring results. Increasing coordination and 
information sharing among state agencies--both within and across 
states--was a high-priority activity states identified to improve the 
oversight of youth well-being in residential facilities. 

Juvenile Justice Facilities and Residential Schools and Academies Are 
Often Excluded from Agency Licensing Requirements: 

All states reported licensing certain types of residential facilities 
for youth, but their responses to our survey also showed gaps in 
licensing coverage (see app. IV). Licensing all facilities, public or 
private, can help ensure that residential facilities meet the relevant 
standards for protecting youth well-being. Among state-operated 
facilities, juvenile justice agencies were more likely to exempt 
facilities from licensing than child welfare and mental health agencies 
(see fig. 5). The juvenile justice officials we interviewed said that 
this was because some state statutes do not require state-operated 
juvenile facilities to have a license in order to operate. 

Figure 5: State Agencies Reporting the Licensing Status of State- 
Operated Residential Facilities That Serve Youth: 

[See PDF for image] 

This figure is a vertical bar graph depicting the following data: 

Type of facility: Child welfare; 
Number of state agencies, not exempt: 13; 
Number of state agencies, exempt: 7. 

Type of facility: Health and mental health; 
Number of state agencies, not exempt: 23; 
Number of state agencies, exempt: 6. 

Type of facility: Juvenile justice; 
Number of state agencies, not exempt: 13; 
Number of state agencies, exempt: 28. 

Source: GAO analysis of state agenciesï¿½ responses to survey. 

Note: 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 regulation--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, 
(g) no response. 

[End of figure] 

Many state agencies also reported that certain types of private 
facilities were exempt from licensing, regardless of whether they 
received some government funding or were exclusively private (see fig. 
6). 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 
20] However, 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. Across agencies, states 
most often responded that they did not have private boot camps, 
ranches, and wilderness camps.[Footnote 21] 

Figure 6: Number of State Agencies Reporting That They Do Not Exempt or 
Exempt Private Residential Facilities Receiving Government Funds from 
Licensing Requirements, 2006: 

[See PDF for image] 

This figure is a combined horizontal bar graph depicting the following 
data: 

Facility Type: Residential schools and academies[A]; 
Not exempt, Child welfare: 19; 
Exempt, Child welfare: 18; 
Not exempt, Health and mental health: 15; 
Exempt, Health and mental health: 10; 
Not exempt, Juvenile justice: 14; 
Exempt, Juvenile justice: 14. 

Facility Type: Detention center; 
Not exempt, Child welfare: N/A; 
Exempt, Child welfare: N/A; 
Not exempt, Health and mental health: N/A; 
Exempt, Health and mental health: N/A; 
Not exempt, Juvenile justice: 14; 
Exempt, Juvenile justice: 11. 

Facility Type: Boot camp; 
Not exempt, Child welfare: 10; 
Exempt, Child welfare: 6; 
Not exempt, Health and mental health: 6; 
Exempt, Health and mental health: 2; 
Not exempt, Juvenile justice: 4; 
Exempt, Juvenile justice: 3. 

Facility Type: Wilderness camp; 
Not exempt, Child welfare: 24; 
Exempt, Child welfare: 3; 
Not exempt, Health and mental health: 16; 
Exempt, Health and mental health: 3; 
Not exempt, Juvenile justice: 13; 
Exempt, Juvenile justice: 1. 

Facility Type: Treatment facility; 
Not exempt, Child welfare: 39; 
Exempt, Child welfare: 1; 
Not exempt, Health and mental health: 35; 
Exempt, Health and mental health: 0; 
Not exempt, Juvenile justice: N/A; 
Exempt, Juvenile justice: N/A. 

Source: GAO analysis of state agencies' responses to survey. 

Notes: The total number of agency responses for a specific facility 
type does not include instances in which agencies reported that there 
was no such facility in the state, they did not know, or that they did 
not respond. 

The survey question was as follows: Which, if any of the following 
types of residences that provide targeted services for youth are 
currently exempt from licensing or routine monitoring in your state by 
statute or state regulations? The response options were (a) exempt from 
licensure, (b) exempt from monitoring, (c) exempt from both, (d) not 
exempt from either, (e) no such residence in the state, (f) don't know, 
and (g) no response. 

[A] Responses for this type include all private facilities, not just 
those receiving government funding. 

[End of figure] 

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 22] 

The lack of licensing for all facilities serving youth has several 
consequences. 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 treatment program self-identified as a private boarding 
school is not regulated by the state licensing agency, but the same 
facility would be required to obtain 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, 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. 

Certain states have taken different approaches to improve oversight of 
residential facilities. Some states are considering laws that would 
expand their licensing authority for private facilities, while other 
states use alternative methods to provide protections for youth. For 
example, some state agencies include 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. Florida's juvenile justice 
system 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 compared to other agencies reported requiring 
facilities to be accredited by private organizations, due in part to 
conditions of participation for certain federal programs.[Footnote 23] 
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; such information sharing is dependent on how 
well state agencies coordinate with them. In general, fewer states 
reported requiring accreditation than not across the three agencies we 
surveyed, as shown in appendix V. 

State Licensing Standards Do Not Consistently Address Suicide and Other 
Identified Risks to Youth Well-Being: 

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. Standards based on sound research can help ensure that youth 
receive minimum standards of care that address risks to well-being 
across facility types. 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 24] 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. (See app. VI.) 

Monitoring May Not Be Comprehensive or Frequent Enough to Protect All 
Aspects of Youth Well-Being: 

State agencies reported monitoring youth well-being in residential 
facilities, but certain aspects of youth well-being were not included 
in all monitoring activities. Among six different aspects of youth well-
being we asked about in our survey, the quality of educational 
programming and 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. (See fig. 7 for results 
pertaining to private facilities that receive government funds, and 
app. VII for results pertaining to state-operated facilities, private 
facilities that received government funds, and exclusively private 
facilities.) 

Figure 7: 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 combined horizontal bar graph depicting the following 
data: 

Monitoring Requirement: Physical plant; 
Child welfare, monitored for less than all facilities: 4 states; 
Child welfare, monitored for all facilities: 35 states; 
Health and mental health, monitored for less than all facilities: 16 
states; 
Health and mental health, monitored for all facilities: 22 states; 
Juvenile justice, monitored for less than all facilities: 13 states; 
Juvenile justice, monitored for all facilities: 24 states. 

Monitoring Requirement: Staffing issues; 
Child welfare, monitored for less than all facilities: 5 states; 
Child welfare, monitored for all facilities: 35 states; 
Health and mental health, monitored for less than all facilities: 15 
states; 
Health and mental health, monitored for all facilities: 22 states; 
Juvenile justice, monitored for less than all facilities: 13 states; 
Juvenile justice, monitored for all facilities: 23 states. 

Monitoring Requirement: Use of approved seclusion and restraint; 
Child welfare, monitored for less than all facilities: 7 states; 
Child welfare, monitored for all facilities: 32 states; 
Health and mental health, monitored for less than all facilities: 13 
states; 
Health and mental health, monitored for all facilities: 23 states; 
Juvenile justice, monitored for less than all facilities: 10; states; 
Juvenile justice, monitored for all facilities: 25 states. 

Monitoring Requirement: Use of psychotropic medications; 
Child welfare, monitored for less than all facilities: 9 states; 
Child welfare, monitored for all facilities: 30 states; 
Health and mental health, monitored for less than all facilities: 15 
states; 
Health and mental health, monitored for all facilities: 22 states; 
Juvenile justice, monitored for less than all facilities: 14 states; 
Juvenile justice, monitored for all facilities: 22 states. 

Monitoring Requirement: Presence of educational programming; 
Child welfare, monitored for less than all facilities: 7 states; 
Child welfare, monitored for all facilities: 30 states; 
Health and mental health, monitored for less than all facilities: 18 
states; 
Health and mental health, monitored for all facilities: 16 states; 
Juvenile justice, monitored for less than all facilities: 13 states; 
Juvenile justice, monitored for all facilities: 23 states. 

Monitoring Requirement: Quality of educational programming; 
Child welfare, monitored for less than all facilities: 23 states; 
Child welfare, monitored for all facilities: 11 states; 
Health and mental health, monitored for less than all facilities: 23 
states; 
Health and mental health, monitored for all facilities: 8 states; 
Juvenile justice, monitored for less than all facilities: 17 states; 
Juvenile justice, monitored for all facilities: 18 states. 

Source: GAO analysis of state agenciesï¿½ responses to survey. 

Note: The survey question was as follows: In 2006, did your agency 
routinely monitor or followup, or authorize for monitoring or followup, 
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; (d) no, did 
not monitor; (e) no such facility in the state; (f) don't know; (g) no 
response. 

[End of figure] 

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. Periodic on-site reviews to 
monitor facility compliance with licensing requirements helps ensure 
that licensing standards are taken seriously, and that risks to youth 
well-being are quickly addressed. 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 on actions taken against facilities in the last 
3 years, but few reported suspending or revoking a facility's operating 
license. A full range of enforcement options allows states to respond 
to maltreatment in accordance with the severity of the incident and to 
escalate penalties as necessary to help prevent reoccurrence. Survey 
respondents, however, often reported that they did not employ the full 
range of enforcement options against the residential facilities under 
their purview. For example, most state agencies in our survey reported 
taking action to increase monitoring of facilities with identified 
problems, or requiring corrective action plans (See app. VIII and fig. 
8). 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. For these 
reasons, states may agree to keep a program open if a facility meets 
certain conditions. For example, we previously reported that, in West 
Virginia, a program's owners pleading no contest to the charge of child 
neglect resulting in death negotiated an agreement with the state to 
keep the program open in exchange for a change in ownership and 
management. 

Figure 8: State Agency Actions Taken within the Last 3 Years against 
Government Residential Facilities: 

[See PDF for image] 

This figure is a combined horizontal bar graph depicting the following 
data: 

Action taken: Government facility was closed or license, certification, 
or operating authority was suspended or revoked; 
State agency took action, child welfare: 1; 
State agency did not take action, child welfare: 19; 
State agency took action, health and mental health: 0; 
State agency did not take action, health and mental health: 18; 
State agency took action, juvenile justice: 3; 
State agency did not take action, juvenile justice: 34. 

Action taken: Youth were removed; 
State agency took action, child welfare: 7; 
State agency did not take action, child welfare: 12; 
State agency took action, health and mental health: 2; 
State agency did not take action, health and mental health: 16; 
State agency took action, juvenile justice: 11; 
State agency did not take action, juvenile justice: 26. 

Action taken: Banned new admissions or instituted admission 
restrictions; 
State agency took action, child welfare: 7; 
State agency did not take action, child welfare: 14; 
State agency took action, health and mental health: 4; 
State agency did not take action, health and mental health: 15; 
State agency took action, juvenile justice: 7; 
State agency did not take action, juvenile justice: 30. 

Action taken: Referred or recommended criminal investigations for abuse 
or neglect that carry fines or imprisonment; 
State agency took action, child welfare: 10; 
State agency did not take action, child welfare: 11; 
State agency took action, health and mental health: 7; 
State agency did not take action, health and mental health: 8; 
State agency took action, juvenile justice: 24; 
State agency did not take action, juvenile justice: 10. 

Action taken: Increased monitoring; 
State agency took action, child welfare: 16; 
State agency did not take action, child welfare: 5; 
State agency took action, health and mental health: 10; 
State agency did not take action, health and mental health: 8; 
State agency took action, juvenile justice: 32; 
State agency did not take action, juvenile justice: 6. 

Action taken: Required program improvement or corrective action plan; 
State agency took action, child welfare: 19; 
State agency did not take action, child welfare: 2; 
State agency took action, health and mental health: 17; 
State agency did not take action, health and mental health: 2; 
State agency took action, juvenile justice: 32; 
State agency did not take action, juvenile justice: 4. 

Source: GAO analysis of state agenciesï¿½ responses to survey. 

Note: The survey question was as follows: Over the last 3 reporting 
years, did your agency take any of the following actions at its 
government-operated facilities as a result of allegations or findings 
of noncompliance, improper operations, physical abuse or sexual abuse 
or neglect of youth, or other negative outcomes? Respondents could also 
answer "don't know" or "no response." 

[End of figure] 

Coordination Needed within and among States for Youth Served by 
Multiple Agencies or across State Lines: 

Improving coordination to share information among state agencies was a 
high priority for improving oversight of residential facilities 
according to survey respondents. Such coordination is needed because 
some youth may have needs requiring a multi-agency response. A lack of 
coordination in these instances can result in situations where 
monitoring activities overlap at some facilities and aspects of youth 
well-being in other facilities fall through the cracks. Officials in 
the states we visited raised concerns that ensuring facilities have 
appropriate education programs for youth is particularly challenging 
unless state agencies coordinate their oversight efforts. Lack of 
coordination, particularly with the state education agency, has 
resulted in cases where facilities remain licensed to operate even 
though education quality is poor and youth may be unable to transfer 
education credits upon returning to schools within their communities. 

Many state agencies we surveyed reported that they did not routinely 
share information with other state agencies regarding negative findings 
from their monitoring reviews of residential facilities, or when 
facility licenses were suspended or revoked (see fig. 9). Sharing such 
information is important because it may influence another agency's 
decision to place youth in the facility. 

Figure 9: Number of State Agencies Reporting That They Did Not 
Routinely Share Oversight Information Regarding Certain Residential 
Facilities: 

[See PDF for image] 

This figure is a combined horizontal bar graph depicting the following 
data: 

Oversight action: Licenses suspended or revoked; 
Number of child welfare agencies reporting: 12; 
Number of health and mental health agencies reporting: 12; 
Number of juvenile justice agencies reporting: 14. 

Oversight action: Results of monitoring activities; 
Number of child welfare agencies reporting: 18; 
Number of health and mental health agencies reporting: 18; 
Number of juvenile justice agencies reporting: 22. 

Oversight action: Reports of adverse incidents; 
Number of child welfare agencies reporting: 17; 
Number of health and mental health agencies reporting: 17; 
Number of juvenile justice agencies reporting: 18. 

Oversight action: Findings of noncompliance,sanctions, or other 
consequences; 
Number of child welfare agencies reporting: 17; 
Number of health and mental health agencies reporting: 20; 
Number of juvenile justice agencies reporting: 20. 

Source: GAO analysis of state agenciesï¿½ responses to survey. 

Note: The survey question was as follows: What oversight information 
regarding residential facilities does your agency routinely share with 
other state or local government agencies or place on an accessible Web 
site? Response options for this question were (a) new licenses issued; 
(b) licenses suspended or revoked; (c) plans to expand or reduce 
programs; (d) schedule of upcoming routine monitoring activities (e.g., 
record reviews or site visits); (e) results of monitoring activities; 
(f) reports of adverse incidents; (g) findings of noncompliance, 
sanctions, or other consequences not listed above. 

[End of figure] 

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. These interstate 
placements can be initiated by state agencies or private parties, such 
as parents. Out-of-state placement is more difficult than in-state 
placement, 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. Table 3 shows the 
top five states in which state child welfare agencies we surveyed 
reported the greatest number of youth in out-of-state residential 
facilities. 

Table 3: State Child Welfare Agencies Reporting the Greatest Number of 
Youth Placed in Out-of-State Residential Facilities: 

Sending state: California; 
Total number of youth: 1,903; 
Number of placement states: 26. 

Sending state: Pennsylvania; 
Total number of youth: 593; 
Number of placement states: 18. 

Sending state: Alaska; 
Total number of youth: 482; 
Number of placement states: 14. 

Sending state: Rhode Island; 
Total number of youth: 330; 
Number of placement states: 11. 

Sending state: Connecticut; 
Total number of youth: 282; 
Number of placement states: 13. 

Source: GAO analysis of state child welfare agency survey responses. 

Note: The survey questions were as follows: (1) As of October 1, 2006, 
how many youth from your state were residing in residential facilities 
providing targeted services in other states? Response options: (a) 
number of youth under the care and supervision of your agency residing 
in facilities operated by another state or local government agency, (b) 
number of youth under the care and supervision of your agency residing 
in private facilities in the other state, (c) number of youth under 
parental or nongovernment custodial care residing in private facilities 
in the other state? Respondents could also check not available. And (2) 
On October 1, 2006, in what other states were youth under the care and 
supervision of your agency residing? 

[End of table] 

Another reason that 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. 
Such information may be particularly important in cases where state 
licenses cannot serve this purpose. Four of the top five states that 
received the greatest number of out-of-state youth (see table 4)-- 
according to child welfare agencies we surveyed--exempted one or more 
types of facilities from state licensing requirements. 

Table 4: State Child Welfare Agencies Reporting the Greatest Number of 
Youth Received from Other States for Placement in Residential 
Facilities: 

Receiving state: Utah; 
Number of youth: 1,827; 
Number of sending states: 38. 

Receiving state: Pennsylvania; 
Number of youth: 1,778; 
Number of sending states: 5. 

Receiving state: Montana; 
Number of youth: 1,060; 
Number of sending states: 5. 

Receiving state: Massachusetts; 
Number of youth: 628; 
Number of sending states: 15. 

Receiving state: South Carolina; 
Number of youth: 336; 
Number of sending states: 26. 

Source: GAO analysis of state child welfare agency survey responses. 

Note: The survey questions were as follows: (1) As of October 1, 2006, 
how many youth under the care and supervision of other states, any 
trial jurisdictions, or countries other than the United States were 
residing in residential facilities providing targeted services in your 
state? Response options: Number of (a) youth placed in facilities 
operated by your state agency and (b) youth placed in private 
facilities in your state? Respondents could also check not available. 
And (2) On October 1, 2006, from what other states were youth aged 12 
to 17 residing in residential facilities providing targeted services in 
your state? 

[End of table] 

Finally, our testimony last October showed that information sharing 
across states is also important because operators of programs shut down 
in one state for youth maltreatment or death due to negligence 
sometimes open new programs in another state, and states with weaker 
licensing and monitoring practices may be especially vulnerable to this 
practice. Our testimony last October highlighted a 1990 case where a 
wilderness camp operator moved from Utah to Nevada, and back to Utah as 
facilities were repeatedly shut down by authorities, and how many youth 
died in two of these programs.[Footnote 25] 

Federal Agencies Challenged to Address Weaknesses in State Oversight of 
Residential Facilities: 

HHS, DOJ, and Education all have oversight processes to hold states 
accountable for the well-being of youth in certain residential settings 
under the grant programs they administer. However, limitations in 
federal oversight authority and inconsistent monitoring practices 
hinder federal efforts to ensure that states are keeping youth in 
residential facilities safe from harm. Most notably, these agencies 
cannot hold state agencies accountable for conditions in private 
facilities unless the facilities serve youth in state programs 
supported by federal funds. When they did have the authority, agencies 
differed in their oversight practices regarding the extent that 
agencies had established program requirements specific to residential 
facilities, had conducted on-site reviews of residential facilities, 
and had taken actions to enforce compliance with federal requirements. 

HHS, DOJ, and Education Cannot Hold States Accountable for Exclusively 
Private Facilities: 

HHS, DOJ, and Education have some authority to hold states accountable 
for certain aspects of youth well-being in facilities that serve youth 
under the grant programs they administer--whether state operated or 
private--but cannot hold states accountable for conditions in 
facilities that are exclusively private. The federal government has 
oversight authority in cases where states voluntarily choose to accept 
federal requirements in exchange for receiving federal program funds. 
[Footnote 26] In practice, states have agreed to comply with federal 
oversight requirements in exchange for funds supporting their state 
systems of child welfare, health and mental health, juvenile justice, 
and education. Accordingly, under the federal programs that we examined 
at HHS, DOJ, and Education, states are accountable for ensuring that 
facilities receiving funds through these programs are in compliance 
with federal program requirements. However, these agencies cannot hold 
states accountable for conditions in exclusively private facilities. 

Federal Requirements Do Not Always Address Suicide Prevention and Other 
Risks to Youth Well-Being: 

Federal agencies and programs do not always hold states accountable for 
addressing some of the primary risks to youth well-being in residential 
facilities. 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 5.) 

Table 5: Federal Program Requirements for States That Address Certain 
Risks to Youth Well-Being in Residential Facilities: 

Agency and subagency: HHS: Child Welfare; 
Abuse and neglect prevention: Yes; 
Suicide prevention: No; 
Use of seclusion and restraint: No; 
Education quality: Yes. 

Agency and subagency: HHS: Medicaid; 
Abuse and neglect prevention: Yes; 
Suicide prevention: Yes; 
Use of seclusion and restraint: Yes[A]; 
Education quality: No. 

Agency and subagency: HHS: Substance Abuse and Mental Health; 
Abuse and neglect prevention: No; 
Suicide prevention: No; 
Use of seclusion and restraint: No; 
Education quality: No. 

Agency and subagency: DOJ: Juvenile Justice and Delinquency Prevention; 
Abuse and neglect prevention: No; 
Suicide prevention: No; 
Use of seclusion and restraint: No; 
Education quality: Yes. 

Agency and subagency: 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 subagency: 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 U.S. Department of Health and Human Services, 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] 

HHS, DOJ, and Education all reported that they do not have the 
authority to require that states have suicide prevention plans as a 
criterion for receiving funds under the grant programs that they 
administer, although HHS and DOJ have documented a need to address 
suicide prevention. The Centers for Disease Control and Prevention-- 
which is part of HHS--issued a report that identified suicide as the 
third leading cause of death in 2004 among all U.S. youth.[Footnote 27] 
In addition, a 2004 study commissioned by DOJ recommends increased 
mental health screening for suicide prevention among incarcerated 
youth.[Footnote 28] 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, agency officials said that federal programs also do not 
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 rule making concerning the use 
of seclusion and restraint in nonmedical community-based children's 
facilities.[Footnote 29] 

Federal Oversight Does Not Ensure States Are Monitoring Youth Well- 
Being in Residential Facilities: 

Federal agencies have several means of ensuring that states are 
monitoring youth well-being in residential facilities that receive 
government funds, 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 on-site 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 to determine state compliance 
with specific statutory requirements, but HHS oversight reviews of 
state child welfare systems do not necessarily include children in 
residential facilities. 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 agencies have authority to enforce state 
compliance with federal requirements, these provisions vary in their 
rigor and use, and only DOJ has levied financial penalties.[Footnote 
30] 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. 

Options for Taking Action to Promote Youth Well-Being in Residential 
Facilities: 

Protecting youth in residential facilities--many of whom are troubled 
and vulnerable to harm either from themselves or from others--requires 
particular vigilance on the part of parents and responsible 
governmental 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. States, federal agencies, and Congress have several 
options that they can use to improve standards of well-being for youth 
in residential facilities, monitor facility compliance with the 
standards, and take necessary corrective action. Although individual 
states are primarily responsible for taking action to improve the 
welfare of youth domiciled within their borders, federal agencies may 
establish additional safeguards for those youth that are served in 
residential facilities under federally funded state programs. Further, 
Congress has several options to consider--such as direct regulation of 
residential facilities, modifying conditions of participation for 
existing federal programs, and creating new program funding and 
requirements. Each of these options entails trade-offs among the cost 
to the government, the extent of federal involvement, and the extent 
that protections would apply to youth in various types of facilities. 

* States. States could take action to improve the well-being of youth 
in residential facilities through their licensing processes, contract 
provisions, or accreditation requirements. Expanding licensing coverage 
would allow states to establish minimum standards for youth in all 
facilities, but may require state legislation to provide necessary 
authority, as well as increased funding for oversight and enforcement. 
Creating common contract provisions for facilities serving youth is 
another way state agencies could safeguard youth well-being across 
state agencies for those private facilities under contract with the 
state. Accreditation for all facilities that serve youth is another 
option that could benefit states in several ways. Accreditation by a 
national organization provides universal standards that are applied not 
only within states, but across state lines. Accreditation in lieu of 
licensing requirements may help minimize increases in state spending as 
a result of expanding oversight coverage. 

* Federal agencies. Federal agencies could also take action by holding 
states accountable for the well-being of youth in residential 
facilities that participate in programs supported by federal funding-- 
such as state child welfare, health and mental health, and juvenile 
justice programs. Federal agencies could increase state accountability 
by modifying the conditions of participation for relevant programs. 
These program conditions could include priorities for placing youth 
first in facilities that are accredited or held to recognized standards 
of care, or include specific standards of well-being and oversight, 
such as suicide prevention and seclusion and restraint. This may be 
most effective if the federal agencies worked together to develop 
minimum standards for all relevant federal programs, possibly through 
an interagency council or the Office of Management and Budget. If the 
federal agencies determine they do not have authority to modify program 
conditions of participation, they could seek such authority from 
Congress. This option would not increase federal program spending, but 
federal agency action would not extend to exclusively private 
facilities. 

* Congress. Congress also has several options to consider. These 
options include direct federal regulation of facilities that house 
youth under certain conditions, or establishing conditions of 
participation in existing or new federal programs.[Footnote 31] These 
options are not mutually exclusive--some may be taken in combination 
with other federal or state action. 

* Direct regulation. States have reported that thousands of youth are 
placed in out-of-state facilities, and we have previously testified 
before Congress on the extent of marketing and advertising across 
states lines. Under the Constitution, Congress would have a basis to 
directly regulate private facilities that participate in activities 
involving interstate commerce.[Footnote 32] Congress might regulate 
such facilities by establishing a federal program that preempts state 
law and regulation, or provide states the option of carrying out an 
equivalent state program. These actions would result in increased 
federal spending. Congress could choose to minimize federal spending 
and oversight activities by requiring accreditation of residential 
facilities by a national organization.[Footnote 33] In considering a 
federal mandate, Congress may need to evaluate concerns about federal 
versus state responsibilities, practical feasibility, and the ability 
to offset attendant costs to the federal government. This option would 
have the benefit of capturing exclusively private facilities, but only 
those facilities that have the requisite connection to interstate 
commerce. 

* Add requirements in law to existing federal programs. Congress could 
change existing program law to add requirements states must meet to 
receive federal programs funds. For example, it could include specific 
standards of well-being and oversight in areas where youth are known to 
be at risk, such as suicide prevention and seclusion and restraint. 
This would provide the advantage of developing minimum requirements for 
youth well-being that cut across agencies and programs. This option 
would not increase federal program spending. However, because it is 
directed at federal programs that provide funding to states, it would 
not safeguard youth in exclusively private facilities. 

* Establish a new federal program. Congress could also establish a new 
federal program that would provide financial assistance to states that 
agree to comply with federal requirements, such as those to expand the 
scope and rigor of oversight to cover all residential facilities. This 
option would address oversight coverage for youth in all facilities in 
a state, but would be effective only in states that choose to comply 
with federal requirements in exchange for the new program funding. This 
option would also increase spending for the federal government. 

Conclusion: 

States' freedom to legislate and the existing patchwork of federal 
legislation and oversight addressing youth well-being have led to 
substantial disparity in protecting the well-being and civil rights of 
some of the nation's most vulnerable youth. There are no easy 
solutions. However, states, federal agencies, and Congress have various 
options to consider in restructuring the current federal-state 
oversight system to better protect youth from harm. While Congress, 
federal agencies, and states will need time to consider these options, 
and weigh the trade-offs that each option entails, more can be done now 
within the existing regulatory structure to address outstanding 
concerns. 

State and federal agencies acknowledge the need for comprehensive and 
complete data for each case of death, maltreatment, and other adverse 
incidents that occur in residential facilities, but barriers remain in 
collecting and reporting this information. Absent complete data and 
mechanisms to share information among relevant state and federal 
oversight agencies, officials are missing opportunities to assess the 
full magnitude of child maltreatment in residential facilities and 
respond to the extent of their authority in addressing issues or 
targeting investigations, such as those conducted by DOJ's Civil Rights 
Division. Further, absent enhanced oversight among federal agencies, 
these agencies will continue to miss opportunities to use available 
information to address identified risks to youth and hold states 
accountable for youth well-being under the current regulatory 
structure. Unless sufficient accountability is set up within state or 
federal regulatory structures using the oversight processes provided by 
federal program authority, state licensing systems, national 
accreditation, or other options, the well-being and civil rights of 
youth in some facilities will remain at risk. 

Recommendations for Executive Action: 

To help policymakers craft solutions that best address the magnitude of 
maltreatment and other threats to youth well-being in residential 
facilities, and also to facilitate federal oversight across states and 
agencies, we recommend that the Secretary of HHS take action to 
determine what barriers remain in those states that do not report case- 
file data for residential facilities to NCANDS and explore options to 
help states address existing barriers. 

To help target federal civil rights investigations among states and 
facilities that can provide maximum benefit, we recommend that the U.S. 
Attorney General work with the Secretary of HHS to obtain access to the 
NCANDS case-file data for residential facilities. We also recommend 
that the Attorney General work with HHS, the Office of Juvenile Justice 
and Delinquency Prevention, and Education to obtain access to other 
sources of relevant information within relevant subagencies, such as 
HHS' Centers for Disease Control and Prevention. 

To help ensure that the existing federal regulatory structure protects 
youth well-being across government and private residential facilities 
supported by federal programs, we recommend that HHS, DOJ, and 
Education work to enhance their oversight of state accountability for 
youth well-being in residential facilities. Such efforts could include 
ensuring that residential facilities are included in federal oversight 
reviews and on-site visits to states. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to HHS, DOJ, and Education for 
comment. HHS' comments are reproduced in appendix X, and DOJ's comments 
are reproduced in appendix XI. Education's Office of Special Education 
and Rehabilitative Services provided comments on behalf of the 
department that are reproduced in appendix IX. HHS and DOJ also 
provided technical comments that we incorporated, as appropriate. 

Federal Agency Comments on GAO Report Recommendations: 

Overall, HHS and DOJ either generally agreed, or did not disagree, with 
each of our recommendations. They also suggested further action that 
could be taken to address the report findings related to gaps in data 
and oversight for residential facilities. Education did not directly 
respond to the report recommendations but rather discussed its role and 
responsibilities for oversight of certain programs. 

HHS did not agree or disagree with our recommendation that the 
Secretary take action to identify and help states address barriers in 
reporting case-file data for residential facilities to NCANDS, and DOJ 
did not comment on this recommendation. HHS stated that the number of 
states reporting case-level data and the quality of data submitted has 
improved over the years, and that its Administration for Children and 
Families (ACF) will continue to work with states to improve the 
collection of information wherever possible and feasible. We recognize 
that federal law provides states with some latitude in reporting data 
"to the maximum extent practicable." However, we remain concerned about 
the gaps in reported data that have persisted over a decade since the 
reporting requirement has been in place, which is why we have 
recommended that HHS take action to help address remaining barriers. 

DOJ agreed with our recommendation that the Attorney General work with 
the Secretary of HHS to obtain NCANDS data that can help target civil 
rights investigations. HHS stated that ACF would be pleased to work 
with DOJ in implementing this recommendation; however, ACF was unclear 
how the NCANDS data would be useful in targeting investigations. As our 
report shows (see app. III), custom data analysis provided by HHS's 
NCANDS contractor provides important information on the number and type 
of maltreatment incidents by facility staff in each state that DOJ can 
use, in combination with other information sources, to prioritize 
investigations among states. 

DOJ also agreed with our recommendation that the Attorney General work 
with its Office of Juvenile Justice and Delinquency Prevention, HHS, 
and Education to obtain access to other sources of relevant oversight 
information within the subagencies of these departments. HHS did not 
address this recommendation. 

In regard to our recommendation that HHS, DOJ, and Education work to 
enhance their oversight of state accountability for youth well-being in 
residential facilities, DOJ and HHS indicated that they are conducting 
state oversight consistent with existing statutory authority and 
resources. In addition, DOJ cited several measures it has implemented, 
such as training and technical assistance to states as well as use of 
interdepartmental working relationships, which will help ensure that 
the existing federal regulatory structure protects youth well-being 
across facilities supported by federal programs. We agree that the 
efforts cited by DOJ can help to improve conditions for youth in 
residential facilities. However, given the continued reports of 
maltreatment in residential facilities by state agencies we surveyed, 
and results of investigations by DOJ's Civil Rights Division, we 
continue to recommend that HHS, DOJ, and Education seek to identify 
ways to enhance their oversight of state accountability for youth well- 
being. For example, HHS and Education could include residential 
facilities in federal oversight reviews. Also, our recommendations 
focus on agency actions that could be done or begun quickly under the 
current legal and regulatory framework; however, in our discussion of 
policy options we identify additional longer-term measures that federal 
agencies could consider taking. For example, agencies could modify the 
conditions of participation for relevant grant programs to require 
states to give priority to facilities that are accredited or held to 
recognized standards of care. We further note that if these agencies 
determine they do not have authority to do this, they could request it 
from Congress. 

DOJ and HHS also commented on further actions that federal agencies 
could take beyond the GAO recommendations. Specifically, DOJ identified 
interagency coordination as an important way to enhance youth well- 
being in residential facilities and stated that the existing 
Coordinating Council on Juvenile Justice and Delinquency Prevention 
could be used for this purpose. DOJ suggested that this council could 
be a vehicle establishing minimum standards of care for all relevant 
federal programs. We offer a similar approach in our discussion of 
longer-term policy options. HHS noted the likely benefits of requiring 
facilities to notify parents of certain actions, such as disciplinary 
actions, restraint, or seclusion. 

Finally, HHS stated that the report findings and recommendations should 
more prominently address the issue of unlicensed facilities. In our 
discussion of longer-term policy options, we note that states could 
improve the well-being of youth in residential facilities by expanding 
their licensing coverage, among other options. We also describe actions 
Congress could take to address gaps in licensing and oversight since, 
under the current framework, federal agencies do not have oversight 
authority for private facilities unless those facilities serve youth in 
state programs supported by federal funds. However, we also note that 
many facility types are licensed and that licensing alone, absent 
comprehensive standards, regular monitoring, and effective use of 
sanctions for noncompliance, cannot ensure youth well-being in 
residential facilities. 

Education commented that while it is responsible for ensuring state 
compliance with certain federal education programs for youth--and 
recognizing that a protective and safe school environment is necessary 
for all students--it is not in the department's statutory or regulatory 
authority to ensure oversight of the total well-being of youth in 
residential facilities. Although Education would not be responsible for 
the total well-being of these youth, we believe that the report 
findings highlighting the gaps in safeguarding the educational well- 
being of youth in residential facilities warrant greater Education 
oversight of state accountability for the education of youth in 
residential facilities. 

Federal Agency Comments on GAO Report Findings: 

HHS commented that table 5 of the report shows that the Substance Abuse 
and Mental Health Services Administration has no program requirements 
that address certain risks to youth well-being, and noted that the 
agency has no regulatory oversight of individual residential facilities 
at the local level. To clarify, the federal program requirements in 
table 5 do not relate to federal requirements for individual 
facilities, but to federal program requirements for state oversight of 
residential facilities, as stated. The report text following the table 
states the position of HHS, DOJ, and Education that they do not have 
the authority to require states to address these risks in their 
oversight of facilities. 

Copies of this report are being sent to the Honorable Margaret 
Spellings, Secretary of Education; the Honorable Michael O. Leavitt, 
Secretary of Health and Human Services; the Honorable Michael B. 
Mukasey, U.S. Attorney General; and relevant congressional committees 
and other interested parties. We will also make copies available to 
others upon request. In addition, the report will be made available at 
no charge on GAO's Web site at [hyperlink, http://www.gao.gov]. Please 
contact me on (202) 512-7215 if you or your staff have any questions 
about this report. Other contacts and major contributors are listed in 
appendix XII. 

Sincerely yours, 

Signed by: 

Kay E. Brown: 
Director: 
Education, Workforce, and Income Security Issues: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

We were asked to examine (1) the nature of the incidents that adversely 
affect the well-being of youth in residential facilities, (2) how state 
licensing and monitoring requirements address the well-being of youth 
in residential facilities, and (3) how federal agencies hold states 
accountable for youth well-being in residential facilities. We used 
multiple data collection methods to obtain this information. We 
conducted three Web-based surveys of state child welfare, health and 
mental health, and juvenile justice directors and conducted site visits 
in four states where we interviewed state officials. Because of 
overlapping state agency program jurisdictions, and differences in how 
residential treatment centers and the services they provide are 
defined, we were unable to quantify the number of residential 
facilities and youth served. We also interviewed federal child welfare, 
health and mental health, juvenile justice, and education officials and 
representatives from national organizations concerning state child 
welfare, health and mental health, and juvenile justice programs and 
federal roles and responsibilities for overseeing residential 
facilities. In addition, we reviewed several national studies and 
related GAO reports to identify adverse incidents affecting youth in 
residential facilities and key federal and state oversight policies and 
practices. Finally, we analyzed agency documentation, legislation, and 
other documentation related to child welfare, health and mental health, 
and juvenile justice programs and requirements. We performed our work 
between November 2006 and April 2008, in accordance with generally 
accepted government auditing standards. 

For purposes of this study, we defined residential facilities as those 
that require youth--ages 12 through 17--to reside at the facility and 
that provide program services for youth with behavioral and emotional 
challenges. These types of facilities include (1) juvenile justice, 
youth offender, juvenile delinquency, and incorrigibility programs; (2) 
treatment programs for youth with behavioral, emotional, mental health, 
and substance abuse issues and homes for pregnant teens; (3) 
alternative schools, e.g., schools for discipline or character 
education; and (4) therapeutic group homes, such as a home that 
specializes in supporting and treating youth with severe emotional 
disorders. The types of residence include schools, academies, camps, 
ranches, boarding homes, dormitories, treatment centers, and juvenile 
detention centers.[Footnote 34] 

Web-based survey: 

To obtain state perspectives on our objectives, we conducted three Web- 
based surveys of state child welfare, health and mental health, and 
juvenile justice directors in the 50 states, the District of Columbia, 
and Puerto Rico. The surveys were conducted using a self-administered 
electronic questionnaire posted on the Web. We contacted directors via 
e-mail announcing the survey and sent follow-up e-mails to encourage 
responses. The survey data were collected between May and September 
2007. We received at least one completed survey from 50 states and the 
District of Columbia. We received completed surveys from 44 child 
welfare agencies, 45 health and mental health agencies, and 44 juvenile 
justice agencies. In 32 states and the District of Columbia, all three 
agencies completed the survey. We received at least one survey back 
from each state, except Puerto Rico. We invited Puerto Rico to 
participate in the survey but did not receive any response from its 
offices. This report does not contain all of the results from the 
survey. The survey and a more complete tabulation of the results can be 
viewed by accessing the following link: [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-08-631SP]. 

Table 6: Status of State Agency Responses to GAO Survey on Residential 
Facilities for Youth: 

States that responded to all three surveys: 

State: Alaska; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Arkansas; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: California; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Colorado; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Connecticut; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: District of Columbia; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Delaware; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Florida; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Georgia; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Hawaii; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Idaho; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Indiana; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Kansas; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Massachusetts; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Maryland; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Maine; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Michigan; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Minnesota; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Missouri; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Montana; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: North Carolina; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: North Dakota; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Nebraska; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: New Hampshire; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: New York; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Ohio; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Pennsylvania; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: South Carolina; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Tennessee; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Utah; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Virginia; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Washington; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Wisconsin; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

States that responded to two surveys: 

State: Alabama; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Empty]. 

State: Arizona; 
Child welfare: [Empty]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Iowa; 
Child welfare: [Empty]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Illinois; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Empty]. 

State: Kentucky; 
Child welfare: [Empty]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Louisiana; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Empty]. 

State: Mississippi; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Empty]. 

State: New Mexico; 
Child welfare: [Check]; 
Health/mental health: [Empty]; 
Juvenile justice: [Check]. 

State: Oklahoma; 
Child welfare: [Check]; 
Health/mental health: [Empty]; 
Juvenile justice: [Check]. 

State: Oregon; 
Child welfare: [Check]; 
Health/mental health: [Empty]; 
Juvenile justice: [Check]. 

State: Rhode Island; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Empty]. 

State: South Dakota; 
Child welfare: [Check]; 
Health/mental health: [Empty]; 
Juvenile justice: [Check]. 

State: Texas; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Empty]. 

State: Vermont; 
Child welfare: [Empty]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: West Virginia; 
Child welfare: [Empty]; 
Health/mental health: [Check]; 
Juvenile justice: [Check]. 

State: Wyoming; 
Child welfare: [Check]; 
Health/mental health: [Check]; 
Juvenile justice: [Empty]. 

States that responded to one survey: 

State: New Jersey; 
Child welfare: [Empty]; 
Health/mental health: [Empty]; 
Juvenile justice: [Check]. 

State: Nevada; 
Child welfare: [Empty]; 
Health/mental health: [Empty]; 
Juvenile justice: [Check]. 

Source: GAO analysis of state agencies' survey responses. 

Note: {Check] = survey received, [Empty] = no survey received. 

[End of table] 

To develop the survey questions, we reviewed several national studies 
and related GAO reports to determine issues pertaining to the licensing 
and monitoring of residential facilities for youth. We analyzed agency 
documentation to identify the oversight roles and responsibilities of 
the departments of Health and Human Services, Justice, and Education. 
In addition, we examined related surveys administered by other 
organizations to identify relevant issues pertaining to adverse 
incidents affecting youth and state practices regarding their licensing 
and monitoring of residential facilities. 

We worked to develop the questionnaire with social science survey 
specialists. Because these were not sample surveys, there are no 
sampling errors. However, the practical difficulties of conducting any 
survey may introduce errors, commonly referred to as nonsampling 
errors. For example, differences in how a particular question is 
interpreted, in the sources of information that are available to 
respondents, or how the data are entered into a database can introduce 
unwanted variability into the survey results. We took steps in the 
development of the questionnaires, the data collection, and data 
analysis to minimize these nonsampling errors. For example, prior to 
administering the survey, we pretested the content and format of the 
questionnaire with several states to determine whether (1) the survey 
questions were clear, (2) the terms used were precise, (3) respondents 
were able to provide the information we were seeking, and (4) the 
questions were unbiased. We made changes to the content and format of 
the final questionnaire based on pretest results. In that these were 
Web-based surveys in which respondents entered their responses directly 
into our database, there was a reduced possibility of data entry error. 
We also performed computer analyses to identify inconsistencies in 
responses and other indications of possible error and called back 
respondents to verify responses as needed. We also collected paper 
documentation to support survey responses from the agencies in our case 
study states. 

We used standard descriptive statistics to analyze survey questions. 
For certain open-ended survey questions, such as other causes of deaths 
and interstate locations where youth were placed, we used standard 
content analysis methods, including independent coding by two raters 
and tests of concurrence and rates of agreement. All disagreements 
between raters were resolved by discussion. In addition, an independent 
analyst verified that the computer programs used to analyze the data 
were written correctly. 

While we asked state officials to complete the survey for their agency, 
some officials responded for their state as a whole. This includes 
Alaska and Nebraska's health, mental health, and substance abuse 
survey; Colorado's juvenile justice and rehabilitation survey; and 
Montana's child welfare services survey. In a few states, residential 
facilities are licensed by a central licensing agency whose information 
was not included among the three surveyed agency responses (e.g., 
Kansas' Department of Health and Environment; Massachusetts' Department 
of Early Education and Care; and Utah's Office of Licensing). 

Site visits: 

We visited four states--California, Florida, Maryland, and Utah. We 
based our criteria for selecting these states on the following five 
criteria: (1) the breadth of state policies regarding processes for 
licensing and monitoring residential programs; (2) reports of child 
abuse, neglect, and fatalities; (3) administration of residential 
programs by states or by county governments; (4) initiation of broad 
changes to licensing and monitoring policies; and (5) geographic 
location of the state. During these visits, we interviewed state child 
welfare, health and mental health, and juvenile justice officials and 
collected relevant state agency policies and procedures and reports. In 
addition, we obtained information on adverse incidents and state 
licensing and monitoring practices from protection and advocacy 
agencies, state attorney general offices, state auditors, and U.S. 
Attorneys' offices in each of the four selected states. Information 
that we gathered on our site visits represents only the conditions 
present in the states and local areas at the time of our site visits. 
We cannot comment on any changes that may have occurred after our 
fieldwork was completed. Furthermore, our fieldwork focused on in-depth 
analysis of only a few selected states. On the basis of our site visit 
information, we cannot generalize our findings beyond the states we 
visited. 

NCANDS Data Reliability: 

We also obtained data on the extent, nature, and cause of youth abuse 
and neglect in residential facilities from Cornell University--the 
designated archive for the National Child Abuse and Neglect Data System 
(NCANDS). The Department of Health and Human Services (HHS) conducts 
extensive edit checks of the NCANDS for internal reliability. All edit 
check programs are shared with the states. HHS also funds the National 
Resource Center for Information Technology in Child Welfare. This 
resource center provides technical assistance to states to improve 
reporting to NCANDS, improve statewide information systems, and better 
utilize state data. We obtained NCANDS data for fiscal year 2005, the 
latest year for which such data are available, from Cornell University, 
the designated archive for NCANDS. We worked with representatives from 
Cornell who manage NCANDS to develop appropriate databases for 
identifying the extent, nature, and cause of youth abuse and neglect in 
residential facilities. Our analysis of NCANDS, however, showed that 
the reliability of the data could be affected by several factors, 
including missing state data, the differences in state definitions for 
NCANDS data elements, the nonparticipation of 2 states, and the 
inability of 37 states to identify the type of perpetrator in all 
instances of abuse and neglect. NCANDS data weaknesses are also 
summarized in the report. As a result of these issues, we found that it 
is likely that the total number of national incidents of abuse and 
neglect by residential facility staff is underreported. 

[End of section] 

Appendix II: Circumstances Surrounding State-Reported Suicides in 
Residential Facilities for Youth, 2006: 

Nearly all state-reported suicides occurred in licensed private 
residential facilities that received government funds. Generally, these 
residential facilities provided health and mental health services. 
Pennsylvania also reported that a suicide occurred in a government 
correctional facility that was not required to be licensed. 
Recommendations intended to address the circumstances surrounding state-
reported suicides included steps to provide statewide training in 
suicide awareness and prevention and improved suicide prevention 
protocols in residential facilities. 

Table 7: States Reporting Youth Suicides by Type of Facility, 
Authorization for Providing Services, and Related Investigatory 
Findings, 2006: 

State[A]: Alaska; 
Type of facility in which fatality occurred: Private treatment facility 
for health services that received government funds; 
Type of authorization for providing services (licensure, accreditation, 
general contractor authority): Licensed; 
Findings and recommendations from related investigations: The state 
agency recommended physical modifications to the building and changed 
policies and procedures to address staffing, supervision, and clinical 
services. 

State[A]: Arizona; 
Type of facility in which fatality occurred: Private treatment facility 
for health and mental health services that received government funds; 
Type of authorization for providing services (licensure, accreditation, 
general contractor authority): Licensed; 
Findings and recommendations from related investigations: The 
investigations prompted recommendations to provide staff training on 
interventions and hire additional staff to be present during crisis 
episodes. 

State[A]: California; 
Type of facility in which fatality occurred: Private group home for 
child welfare services that received government funds; 
Type of authorization for providing services (licensure, accreditation, 
general contractor authority): Licensed; 
Findings and recommendations from related investigations: The state 
agency instructed the facility administrator to discuss with staff 
behaviors that may lead to suicide. The agency also recommended 
additional training for facility staff. In addition, facility staff and 
clients were to receive counseling regarding the incident. Following 
the investigation, the agency cited the facility for lack of care and 
supervision and closed it. 

State[A]: Iowa; 
Type of facility in which fatality occurred: Private facility for child 
welfare and juvenile justice treatment services that received 
government funds; 
Type of authorization for providing services (licensure, accreditation, 
general contractor authority): Licensed and accredited; 
Findings and recommendations from related investigations: Residential 
facilities initiated improved suicide prevention protocols and one 
facility improved its communication among staff. 

State[A]: Nebraska; 
Type of facility in which fatality occurred: Private treatment facility 
for health and mental health services that received government funds; 
Type of authorization for providing services (licensure, accreditation, 
general contractor authority): Licensed and accredited; 
Findings and recommendations from related investigations: No formal 
recommendations resulted from the agency's internal investigation and 
it did not know whether other agencies made recommendations. 

State[A]: Pennsylvania; 
Type of facility in which fatality occurred: Government correctional 
facility for juvenile justice services; 
Type of authorization for providing services (licensure, accreditation, 
general contractor authority): Unlicensed (state did not require 
government facilities to be licensed); 
Findings and recommendations from related investigations: The state 
agency contracted with an expert on suicides in residential facilities 
to provide recommendations for preventing future suicides. 

State[A]: Texas; 
Type of facility in which fatality occurred: Private treatment facility 
for health and mental health services that received government funds; 
Type of authorization for providing services (licensure, accreditation, 
general contractor authority): Licensed; 
Findings and recommendations from related investigations: The state 
agency provided a residential facility with technical assistance on 
implementing policies to search for contraband that youth might bring 
to the facility. 

State[A]: Wisconsin; 
Type of facility in which fatality occurred: Private treatment facility 
for health and mental health services that received government funds; 
Type of authorization for providing services (licensure, accreditation, 
general contractor authority): Licensed; 
Findings and recommendations from related investigations: The facility 
implemented a quality improvement plan that includes revisions to 
facility's policy on suicide precautions and staff orientation, 
development, and in-service training. In addition, the agency sponsored 
statewide training in suicide awareness and prevention for managers and 
others who work with youth in group homes and residential settings. 

Source: GAO analysis of survey responses and additional state-reported 
information. 

[A] Alabama did not respond to our request for additional information 
on the circumstances surrounding its reported suicide. 

[End of table] 

[End of section] 

Appendix III: State-Reported Incidents of Staff Maltreatment of Youth 
in Residential Facilities, Fiscal Year 2005: 

NCANDS data show that 34 of 41 states that provide facility-level data 
reported incidents where residential facility staff maltreated youth in 
fiscal year 2005. Reported incidents of neglect or deprivation of 
necessities in each state generally exceeded other types of 
maltreatment, although certain states reported more cases of physical 
or sexual abuse. In 22 states, facility staff committed multiple 
maltreatments, as indicated by the number of maltreatment cases 
exceeding the number of unique perpetrators. Among the 10 states that 
did not provide facility level data, 7 states did not track data for 
residential facilities in a form that could be shared with NCANDS, 1 
state did not report data in 2005 due to outstanding legal issues, and 
2 states did not report any data to NCANDS. 

Table 8: State-Reported Incidents of Staff Maltreatment of Youth in 
Residential Facilities, Fiscal Year 2005: 

State: Alabama; 
Unique perpetrators: 4; 
Unique maltreatments: 4; 
Maltreatment type: Physical abuse: 3; 
Maltreatment type: Neglect or deprivation of necessities: 0; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 1; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Arkansas; 
Unique perpetrators: 2; 
Unique maltreatments: 2; 
Maltreatment type: Physical abuse: 1; 
Maltreatment type: Neglect or deprivation of necessities: 0; 
Maltreatment type: Medical neglect: 1; 
Maltreatment type: Sexual abuse: 0; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Arizona; 
Unique perpetrators: 9; 
Unique maltreatments: 18; 
Maltreatment type: Physical abuse: 0; 
Maltreatment type: Neglect or deprivation of necessities: 17; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 1; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: California; 
Unique perpetrators: 56; 
Unique maltreatments: 69; 
Maltreatment type: Physical abuse: 15; 
Maltreatment type: Neglect or deprivation of necessities: 45; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 2; 
Maltreatment type: Psychological or emotional maltreatment: 6; 
Maltreatment type: Other: 1; 
Maltreatment type: Unknown or Missing: 0. 

State: Colorado; 
Unique perpetrators: 25; 
Unique maltreatments: 70; 
Maltreatment type: Physical abuse: 8; 
Maltreatment type: Neglect or deprivation of necessities: 54; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 4; 
Maltreatment type: Psychological or emotional maltreatment: 2; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 2. 

State: District of Columbia; 
Unique perpetrators: 4; 
Unique maltreatments: 4; 
Maltreatment type: Physical abuse: 3; 
Maltreatment type: Neglect or deprivation of necessities: 0; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 1; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Florida; 
Unique perpetrators: 46; 
Unique maltreatments: 87; 
Maltreatment type: Physical abuse: 7; 
Maltreatment type: Neglect or deprivation of necessities: 52; 
Maltreatment type: Medical neglect: 4; 
Maltreatment type: Sexual abuse: 6; 
Maltreatment type: Psychological or emotional maltreatment: 6; 
Maltreatment type: Other: 12; 
Maltreatment type: Unknown or Missing: 0. 

State: Illinois; 
Unique perpetrators: 18; 
Unique maltreatments: 27; 
Maltreatment type: Physical abuse: 18; 
Maltreatment type: Neglect or deprivation of necessities: 4; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 5; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Indiana; 
Unique perpetrators: 47; 
Unique maltreatments: 75; 
Maltreatment type: Physical abuse: 27; 
Maltreatment type: Neglect or deprivation of necessities: 36; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 12; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Kansas; 
Unique perpetrators: 3; 
Unique maltreatments: 3; 
Maltreatment type: Physical abuse: 1; 
Maltreatment type: Neglect or deprivation of necessities: 0; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 2; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Kentucky; 
Unique perpetrators: 15; 
Unique maltreatments: 17; 
Maltreatment type: Physical abuse: 9; 
Maltreatment type: Neglect or deprivation of necessities: 4; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 4; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Louisiana; 
Unique perpetrators: 2; 
Unique maltreatments: 2; 
Maltreatment type: Physical abuse: 0; 
Maltreatment type: Neglect or deprivation of necessities: 2; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 0; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Massachusetts; 
Unique perpetrators: 95; 
Unique maltreatments: 153; 
Maltreatment type: Physical abuse: 29; 
Maltreatment type: Neglect or deprivation of necessities: 116; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 8; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Maryland; 
Unique perpetrators: 1; 
Unique maltreatments: 1; 
Maltreatment type: Physical abuse: 0; 
Maltreatment type: Neglect or deprivation of necessities: 1; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 0; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Maine; 
Unique perpetrators: 1; 
Unique maltreatments: 1; 
Maltreatment type: Physical abuse: 0; 
Maltreatment type: Neglect or deprivation of necessities: 0; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 1; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Minnesota; 
Unique perpetrators: 7; 
Unique maltreatments: 10; 
Maltreatment type: Physical abuse: 0; 
Maltreatment type: Neglect or deprivation of necessities: 9; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 1; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Missouri; 
Unique perpetrators: 27; 
Unique maltreatments: 34; 
Maltreatment type: Physical abuse: 11; 
Maltreatment type: Neglect or deprivation of necessities: 6; 
Maltreatment type: Medical neglect: 2; 
Maltreatment type: Sexual abuse: 15; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Montana; 
Unique perpetrators: 3; 
Unique maltreatments: 5; 
Maltreatment type: Physical abuse: 0; 
Maltreatment type: Neglect or deprivation of necessities: 2; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 3; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: North Carolina; 
Unique perpetrators: 45; 
Unique maltreatments: 71; 
Maltreatment type: Physical abuse: 4; 
Maltreatment type: Neglect or deprivation of necessities: 56; 
Maltreatment type: Medical neglect: 1; 
Maltreatment type: Sexual abuse: 6; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 4; 
Maltreatment type: Unknown or Missing: 0. 

State: Nebraska; 
Unique perpetrators: 1; 
Unique maltreatments: 1; 
Maltreatment type: Physical abuse: 0; 
Maltreatment type: Neglect or deprivation of necessities: 1; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 0; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: New Jersey; 
Unique perpetrators: 66; 
Unique maltreatments: 66; 
Maltreatment type: Physical abuse: 12; 
Maltreatment type: Neglect or deprivation of necessities: 45; 
Maltreatment type: Medical neglect: 6; 
Maltreatment type: Sexual abuse: 2; 
Maltreatment type: Psychological or emotional maltreatment: 1; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: New York[A]; 
Unique perpetrators: 186; 
Unique maltreatments: 469; 
Maltreatment type: Physical abuse: 97; 
Maltreatment type: Neglect or deprivation of necessities: 92; 
Maltreatment type: Medical neglect: 5; 
Maltreatment type: Sexual abuse: 14; 
Maltreatment type: Psychological or emotional maltreatment: 53; 
Maltreatment type: Other: 208; 
Maltreatment type: Unknown or Missing: 0. 

State: Ohio; 
Unique perpetrators: 18; 
Unique maltreatments: 18; 
Maltreatment type: Physical abuse: 9; 
Maltreatment type: Neglect or deprivation of necessities: 3; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 6; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Pennsylvania; 
Unique perpetrators: 38; 
Unique maltreatments: 40; 
Maltreatment type: Physical abuse: 24; 
Maltreatment type: Neglect or deprivation of necessities: 1; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 15; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Rhode Island; 
Unique perpetrators: 24; 
Unique maltreatments: 36; 
Maltreatment type: Physical abuse: 3; 
Maltreatment type: Neglect or deprivation of necessities: 10; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 0; 
Maltreatment type: Psychological or emotional maltreatment: 1; 
Maltreatment type: Other: 22; 
Maltreatment type: Unknown or Missing: 0. 

State: South Carolina; 
Unique perpetrators: 21; 
Unique maltreatments: 28; 
Maltreatment type: Physical abuse: 8; 
Maltreatment type: Neglect or deprivation of necessities: 14; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 6; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: South Dakota; 
Unique perpetrators: 2; 
Unique maltreatments: 7; 
Maltreatment type: Physical abuse: 0; 
Maltreatment type: Neglect or deprivation of necessities: 6; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 1; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Tennessee; 
Unique perpetrators: 36; 
Unique maltreatments: 53; 
Maltreatment type: Physical abuse: 30; 
Maltreatment type: Neglect or deprivation of necessities: 14; 
Maltreatment type: Medical neglect: 1; 
Maltreatment type: Sexual abuse: 8; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Texas; 
Unique perpetrators: 56; 
Unique maltreatments: 82; 
Maltreatment type: Physical abuse: 34; 
Maltreatment type: Neglect or deprivation of necessities: 45; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 3; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Virginia; 
Unique perpetrators: 6; 
Unique maltreatments: 12; 
Maltreatment type: Physical abuse: 3; 
Maltreatment type: Neglect or deprivation of necessities: 5; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 4; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Vermont; 
Unique perpetrators: 1; 
Unique maltreatments: 2; 
Maltreatment type: Physical abuse: 0; 
Maltreatment type: Neglect or deprivation of necessities: 0; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 2; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Washington; 
Unique perpetrators: 1; 
Unique maltreatments: 1; 
Maltreatment type: Physical abuse: 1; 
Maltreatment type: Neglect or deprivation of necessities: 0; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 0; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State: Wisconsin; 
Unique perpetrators: 9; 
Unique maltreatments: 9; 
Maltreatment type: Physical abuse: 0; 
Maltreatment type: Neglect or deprivation of necessities: 4; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 4; 
Maltreatment type: Psychological or emotional maltreatment: 0; 
Maltreatment type: Other: 1; 
Maltreatment type: Unknown or Missing: 0. 

State: West Virginia; 
Unique perpetrators: 12; 
Unique maltreatments: 26; 
Maltreatment type: Physical abuse: 6; 
Maltreatment type: Neglect or deprivation of necessities: 13; 
Maltreatment type: Medical neglect: 0; 
Maltreatment type: Sexual abuse: 1; 
Maltreatment type: Psychological or emotional maltreatment: 6; 
Maltreatment type: Other: 0; 
Maltreatment type: Unknown or Missing: 0. 

State reported no incidents of abuse and neglect in residential 
facilities: 
Delaware;
Hawaii; 
Idaho; 
Iowa; 
New Hampshire;
Nevada; 
Utah. 

State did not track data on abuse and neglect in residential facilities 
in a format compatible with NCANDS: 
Alaska; 
Connecticut; 
Michigan; 
Mississippi; 
New Mexico; 
Oklahoma; 
Wyoming; 

State did not report data on abuse and neglect in residential 
facilities: 
Georgia. 

State did not report any NCANDS data: 
North Dakota; 
Oregon. 

State: Total; 
Unique perpetrators: 887; 
Unique maltreatments: 1,503; 
Maltreatment type: Physical abuse: 363; 
Maltreatment type: Neglect or deprivation of necessities: 657; 
Maltreatment type: Medical neglect: 20; 
Maltreatment type: Sexual abuse: 138; 
Maltreatment type: Psychological or emotional maltreatment: 75; 
Maltreatment type: Other: 248; 
Maltreatment type: Unknown or Missing: 2. 

Source: NCANDS. 

[A] According to NCANDS data archive officials, the large number of 
incidents in New York, including "other" maltreatment types, may be 
attributable to the child welfare agency's broader definition of what 
constitutes a residential facility and "other" types of abuse and 
neglect compared to narrower definitions used by other states. The 
comparability of data among states is difficult because of the 
variability in state definitions and state compliance with report 
requirements. 

[End of table] 

[End of section] 

Appendix IV: Licensing Status for Selected Residential Facilities: 

Table 9: Licensing Status for Selected State-Operated Residential 
Facilities: 

Facility type and state agency: State-Operated facilities: Child 
welfare; 
Required: 13; 
Exempt: 7; 
No such facility in state: 3; 
No oversight: 20. 

Facility type and state agency: State-Operated facilities: Health and 
mental health; 
Required: 23; 
Exempt: 6; 
No such facility in state: 1; 
No oversight: 14. 

Facility type and state agency: State-Operated facilities: Juvenile 
justice; 
Required: 13; 
Exempt: 28; 
No such facility in state: 2; 
No oversight: 1. 

Source: GAO analysis of state agencies' survey responses. 

Note: Other responses included "Don't know" and "No response." 

[End of table] 

Table 10: State Agencies Reporting the Licensing Status for State- 
Operated Residential Facilities That Serve Youth: 

State: Alaska; 
Child welfare: NO; 
Health and mental health: NO; 
Juvenile justice: Exempt. 

State: Alabama; 
Child welfare: NO; 
Health and mental health: NO; 
Juvenile justice: NS. 

State: Arizona; 
Child welfare: NS; 
Health and mental health: Required; 
Juvenile justice: Required. 

State: Arkansas; 
Child welfare: NO; 
Health and mental health: Required; 
Juvenile justice: NO. 

State: California; 
Child welfare: Exempt; 
Health and mental health: NR; 
Juvenile justice: Exempt. 

State: Colorado; 
Child welfare: Required; 
Health and mental health: Required; 
Juvenile justice: Required. 

State: Connecticut; 
Child welfare: Exempt; 
Health and mental health: Exempt; 
Juvenile justice: Exempt. 

State: District of Columbia; 
Child welfare: DK; 
Health and mental health: NO; 
Juvenile justice: Required. 

State: Delaware; 
Child welfare: Exempt; 
Health and mental health: Required; 
Juvenile justice: Exempt. 

State: Florida; 
Child welfare: NO; 
Health and mental health: Required; 
Juvenile justice: Exempt. 

State: Georgia; 
Child welfare: NO; 
Health and mental health: Exempt; 
Juvenile justice: Exempt. 

State: Hawaii; 
Child welfare: NO; 
Health and mental health: Required; 
Juvenile justice: Exempt. 

State: Iowa; 
Child welfare: NS; 
Health and mental health: Required; 
Juvenile justice: Exempt. 

State: Idaho; 
Child welfare: NF; 
Health and mental health: NF; 
Juvenile justice: Exempt. 

State: Illinois; 
Child welfare: NO; 
Health and mental health: Required; 
Juvenile justice: NS. 

State: Indiana; 
Child welfare: Required; 
Health and mental health: Required; 
Juvenile justice: Required. 

State: Kansas; 
Child welfare: Exempt; 
Health and mental health: Required; 
Juvenile justice: Exempt. 

State: Kentucky; 
Child welfare: NS; 
Health and mental health: NO; 
Juvenile justice: Required. 

State: Louisiana; 
Child welfare: NO; 
Health and mental health: Required; 
Juvenile justice: NS. 

State: Massachusetts; 
Child welfare: NO; 
Health and mental health: NO; 
Juvenile justice: Required. 

State: Maryland; 
Child welfare: NO; 
Health and mental health: Required; 
Juvenile justice: Exempt. 

State: Maine; 
Child welfare: NO; 
Health and mental health: NO; 
Juvenile justice: Exempt. 

State: Michigan; 
Child welfare: Required; 
Health and mental health: Required; 
Juvenile justice: Required. 

State: Minnesota; 
Child welfare: Required; 
Health and mental health: Required; 
Juvenile justice: Required. 

State: Missouri; 
Child welfare: NO; 
Health and mental health: Required; 
Juvenile justice: Exempt. 

State: Mississippi; 
Child welfare: NO; 
Health and mental health: Required; 
Juvenile justice: NS. 

State: Montana; 
Child welfare: Required; 
Health and mental health: Required; 
Juvenile justice: Exempt. 

State: North Carolina; 
Child welfare: NO; 
Health and mental health: Exempt; 
Juvenile justice: Exempt. 

State: North Dakota; 
Child welfare: NF; 
Health and mental health: NO; 
Juvenile justice: Exempt. 

State: Nebraska; 
Child welfare: NO; 
Health and mental health: Required; 
Juvenile justice: Exempt. 

State: New Hampshire; 
Child welfare: Required; 
Health and mental health: NO; 
Juvenile justice: Exempt. 

State: New Jersey; 
Child welfare: NS; 
Health and mental health: NS; 
Juvenile justice: Exempt. 

State: New Mexico; 
Child welfare: Required; 
Health and mental health: NS; 
Juvenile justice: NF. 

State: Nevada; 
Child welfare: NS; 
Health and mental health: NS; 
Juvenile justice: Required. 

State: New York; 
Child welfare: NF; 
Health and mental health: NO; 
Juvenile justice: Exempt. 

State: Ohio; 
Child welfare: Exempt; 
Health and mental health: Exempt; 
Juvenile justice: Required. 

State: Oklahoma; 
Child welfare: Required; 
Health and mental health: NS; 
Juvenile justice: Exempt. 

State: Oregon; 
Child welfare: NO; 
Health and mental health: NS; 
Juvenile justice: Exempt. 

State: Pennsylvania; 
Child welfare: Exempt; 
Health and mental health: Exempt; 
Juvenile justice: Exempt. 

State: Rhode Island; 
Child welfare: Required; 
Health and mental health: NO; 
Juvenile justice: NS. 

State: South Carolina; 
Child welfare: Required; 
Health and mental health: Required; 
Juvenile justice: Required. 

State: South Dakota; 
Child welfare: NO; 
Health and mental health: NS; 
Juvenile justice: Exempt. 

State: Tennessee; 
Child welfare: Required; 
Health and mental health: 
Required; Juvenile justice: NF. 

State: Texas; 
Child welfare: NO; 
Health and mental health: 
Required; Juvenile justice: NS. 

State: Utah; 
Child welfare: NO; 
Health and mental health: NO; 
Juvenile justice: Exempt. 

State: Virginia; 
Child welfare: Required; 
Health and mental health: Required; 
Juvenile justice: Required. 

State: Vermont; 
Child welfare: NS; 
Health and mental health: NO; 
Juvenile justice: Exempt. 

State: Washington; 
Child welfare: NO; 
Health and mental health: Exempt; 
Juvenile justice: Exempt. 

State: Wisconsin; 
Child welfare: Required; 
Health and mental health: NO; 
Juvenile justice: Exempt. 

State: West Virginia; 
Child welfare: NS; 
Health and mental health: Required; 
Juvenile justice: Required. 

State: Wyoming; 
Child welfare: Exempt; 
Health and mental health: NO; 
Juvenile justice: NS. 

Source: GAO analysis of state agencies' survey responses. 

Notes: NF = no such facility in state, NO = no oversight, DK = don't 
know, NS = no survey, NR = no response. 

[End of table] 

The survey questions were as follows: Which, if any, of the following 
types of government-operated facilities providing residential 
[targeted; health, mental health, substance abuse; juvenile justice or 
rehabilitation] services for youth are currently exempt from licensing 
or monitoring in your state by statute or state regulation? State- 
operated facility: (a) exempt from licensing, (b) exempt from 
monitoring, (c) exempt from both, (d) exempt from neither; (e) no such 
facility in state, (f) don't know, and (g) no response. The question 
was administered only to agencies that reported that their agency 
operates or has oversight over government-operated residential 
facilities providing services to youth age 12-17. 

Table 11: Licensing Status for Selected Residential Facilities That 
Receive Government Funds: 

Facility type and state agency: Treatment Centers: Child welfare; 
Licensure required: 39; 
Exempt from licensing: 1; 
No such facility in state: 1; 
Don't know or no response: 3. 

Facility type and state agency: Treatment Centers: Health and mental 
health; 
Licensure required: 35; 
Exempt from licensing: 0; 
No such facility in state: 2; 
Don't know or no response: 8. 

Facility type and state agency: Treatment Centers: Juvenile justice; 
Licensure required: N/A; 
Exempt from licensing: N/A; 
No such facility in state: N/A; 
Don't know or no response: N/A. 

Facility type and state agency: Wilderness camps: Child welfare; 
Licensure required: 24; 
Exempt from licensing: 3; 
No such facility in state: 10; 
Don't know or no response: 7. 

Facility type and state agency: Wilderness camps: Health and mental 
health; 
Licensure required: 16; 
Exempt from licensing: 3; 
No such facility in state: 9; 
Don't know or no response: 17. 

Facility type and state agency: Wilderness camps: Juvenile justice; 
Licensure required: 13; 
Exempt from licensing: 1; 
No such facility in state: 17; 
Don't know or no response: 13. 

Facility type and state agency: Ranches: Child welfare; 
Licensure required: 14; 
Exempt from licensing: 3; 
No such facility in state: 20; 
Don't know or no response: 7. 

Facility type and state agency: Ranches: Health and mental health; 
Licensure required: 8; 
Exempt from licensing: 3; 
No such facility in state: 16; 
Don't know or no response: 18. 

Facility type and state agency: Ranches: Juvenile justice; 
Licensure required: 6; 
Exempt from licensing: 2; 
No such facility in state: 22; 
Don't know or no response: 14. 

Facility type and state agency: Boot camps: Child welfare; 
Licensure required: 10; 
Exempt from licensing: 6; 
No such facility in state: 20; 
Don't know or no response: 8. 

Facility type and state agency: Ranches: Health and mental health; 
Licensure required: 6; 
Exempt from licensing: 2; 
No such facility in state: 15; 
Don't know or no response: 22. 

Facility type and state agency: Ranches: Juvenile justice; 
Licensure required: 4; 
Exempt from licensing: 3; 
No such facility in state: 25; 
Don't know or no response: 12. 

Facility type and state agency: Residential schools and academies: 
Child welfare; 
Licensure required: 19; 
Exempt from licensing: 18; 
No such facility in state: 4; 
Don't know or no response: 3. 

Facility type and state agency: Residential schools and academies: 
Health and mental health; 
Licensure required: 15; 
Exempt from licensing: 10; 
No such facility in state: 1; 
Don't know or no response: 19. 

Facility type and state agency: Residential schools and academies: 
Juvenile justice; 
Licensure required: 14; 
Exempt from licensing: 14; 
No such facility in state: 5; 
Don't know or no response: 11. 

Facility type and state agency: Detention centers: Child welfare; 
Licensure required: N/A; 
Exempt from licensing: N/A; 
No such facility in state: N/A; 
Don't know or no response: N/A. 

Facility type and state agency: Detention centers: Health and mental 
health; 
Licensure required: N/A; 
Exempt from licensing: N/A; 
No such facility in state: N/A; 

Don't know or no response: N/A. 

Facility type and state agency: Detention centers: Juvenile justice; 
Licensure required: 14; 
Exempt from licensing: 11; 
No such facility in state: 6; 
Don't know or no response: 13. 

Source: GAO analysis of state agencies' survey responses. 

[End of table] 

Table 12: State Child Welfare Agencies Reporting the Licensing Status 
for Selected Private Residential Facilities That Serve Youth and 
Receive Government Funding: 

State: Alaska; 
Treatment facilities: NR; 
Wilderness camps: NR; 
Ranch: NF; 
Boot camps: DK; 
Residential schools and academies[A]: NR. 

State: Alabama; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Arizona; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Arkansas; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: California; 
Treatment facilities: Required; 
Wilderness camps: NF; Ranch: 
Required; Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Colorado; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Connecticut; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: District of Columbia; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: NF. 

State: Delaware; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Florida; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Georgia; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Hawaii; 
Treatment facilities: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Exempt. 

State: Iowa; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Idaho; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Illinois; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: NF; 
Boot camps: DK; 
Residential schools and academies[A]: NF. 

State: Indiana; 
Treatment facilities: NF; 
Wilderness camps: Exempt; 
Ranch: Exempt; 
Boot camps: Exempt; 
Residential schools and academies[A]: Required. 

State: Kansas; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Kentucky; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Louisiana; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: DK; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: Massachusetts; 
Treatment facilities: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Required. 

State: Maryland; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Required. 

State: Maine; 
Treatment facilities: 
Required; Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Michigan; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Minnesota; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Missouri; 
Treatment facilities: Required; 
Wilderness camps: Exempt; 
Ranch: Required; 
Boot camps: Exempt; 
Residential schools and academies[A]: Exempt. 

State: Mississippi; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Montana; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Exempt; 
Boot camps: Required; 
Residential schools and academies[A]: Required. 

State: North Carolina; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: DK; 
Boot camps: Exempt; 
Residential schools and academies[A]: Exempt. 

State: North Dakota; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Nebraska; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: New Hampshire; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: New Jersey; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: New Mexico; 
Treatment facilities: Required; 
Wilderness camps: Exempt; 
Ranch: Exempt; 
Boot camps: Exempt; 
Residential schools and academies[A]: Exempt. 

State: Nevada; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: New York; 
Treatment facilities: Exempt; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Ohio; 
Treatment facilities: Required; 
Wilderness camps: NR; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Oklahoma; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Required. 

State: Oregon; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: Exempt; 
Residential schools and academies[A]: Required. 

State: Pennsylvania; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Rhode Island; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: South Carolina; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: South Dakota; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Tennessee; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Texas; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Exempt. 

State: Utah; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Virginia; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Required. 

State: Vermont; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Washington; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Exempt; 
Residential schools and academies[A]: Required. 

State: Wisconsin; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: West Virginia; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Wyoming; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

Source: GAO analysis of state agencies' survey responses. 

Note: N/A = not applicable, NF = No such facility in state, DK = don't 
know, NS = no survey, NR = no response. 

[A] The survey question for private residential schools and academies 
did not distinguish between private facilities that received government 
funding and those that did not. 

[End of table] 

The survey questions pertaining to private residential facilities that 
received or did not receive government funds for state child welfare, 
health and mental health, and juvenile justice agencies were as 
follows: Which, if any, of the following types of residences that 
provide [targeted; health, mental health, or substance abuse; juvenile 
justice and rehabilitation] services for youth are currently exempt 
from licensing or routine monitoring in your state by statute or state 
regulations: (a) exempt from licensure, (b) exempt from monitoring, (c) 
exempt from both, (d) not exempt from either, (e) no such residence in 
state, (f) don't know, and (g) no response? Check only one for each 
row. 

Are residential educational institutions, such as schools or academies 
that specialize in serving students with behavior or discipline 
problems (e.g., providing discipline, character education, or behavior 
modification training in addition to more traditional education), 
exempt from licensing or monitoring by your agency by statute or state 
regulation: (a) exempt from licensure, (b) exempt from monitoring, (c) 
exempt from both, (d) not exempt from either, (e) no such residence in 
state, (f) don't know, and (g) no response? Check only one for each 
row. 

Table 13: State Health and Mental Health Agencies Reporting the 
Licensing Status for Selected Private Residential Facilities That Serve 
Youth and Receive Government Funding: 

State: Alaska; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Alabama; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Arizona; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Arkansas; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: NF; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: California; 
Treatment facilities: Required; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Required. 

State: Colorado; 
Treatment facilities: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Required. 

State: Connecticut; 
Treatment facilities: Required; 
Wilderness camps: Exempt; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: District of Columbia; 
Treatment facilities: 
Required; Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: DK. 

State: Delaware; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: Florida; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: NR. 

State: Georgia; 
Treatment facilities: NR; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: DK; 
Residential schools and academies[A]: Required. 

State: Hawaii; 
Treatment facilities: Required; 
Wilderness camps: Exempt; 
Ranch: Exempt; 
Boot camps: Exempt; 
Residential schools and academies[A]: DK. 

State: Iowa; 
Treatment facilities: Required; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Required. 

State: Idaho; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Illinois; 
Treatment facilities: Required; 
Wilderness camps: Exempt; 
Ranch: Exempt; 
Boot camps: Exempt; 
Residential schools and academies[A]: Required. 

State: Indiana; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Required. 

State: Kansas; 
Treatment facilities: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: Kentucky; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Louisiana; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Massachusetts; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: Required; 
Residential schools and academies[A]: Required. 

State: Maryland; 
Treatment facilities: Required; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Exempt. 

State: Maine; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Michigan; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Minnesota; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Missouri; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Mississippi; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Montana; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Exempt; 
Boot camps: Required; 
Residential schools and academies[A]: Required. 

State: North Carolina; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Exempt. 

State: North Dakota; 
Treatment facilities: NR; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Nebraska; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: New Hampshire; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: New Jersey; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: New Mexico; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Nevada; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: New York; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Ohio; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NR. 

State: Oklahoma; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Oregon; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Pennsylvania; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Rhode Island; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: South Carolina; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: South Dakota; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Tennessee; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Texas; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Utah; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Virginia; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Vermont; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Washington; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: NR. 

State: Wisconsin; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: West Virginia; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Wyoming; 
Treatment facilities: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

Source: GAO analysis of state agencies' survey responses. 

Notes: NF = no such facility in state, DK = don't know, NS = no survey, 
NR = no response. 

[A] The survey question for private residential schools and academies 
did not distinguish between private facilities that received government 
funding and those that did not. 

[End of table] 

Table 14: State Juvenile Justice Agencies Reporting the Licensing 
Status for Selected Private Residential Facilities That Serve Youth and 
Receive Government Funding: 

State: Alaska; 
Detention centers: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: NR. 

State: Alaska; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Arizona; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Arkansas; 
Detention centers: Exempt; 
Wilderness camps: Exempt; 
Ranch: Exempt; 
Boot camps: Exempt; 
Residential schools and academies[A]: Exempt. 

State: California; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Colorado; 
Detention centers: Exempt; 
Wilderness camps: Required; 
Ranch: Exempt; 
Boot camps: Exempt; 
Residential schools and academies[A]: Required. 

State: Connecticut; 
Detention centers: Exempt; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: District of Columbia; 
Detention centers: Exempt; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Delaware; 
Detention centers: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Florida; 
Detention centers: Exempt; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Georgia; 
Detention centers: Exempt; 
Wilderness camps: Required; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Required. 

State: Hawaii; 
Detention centers: Exempt; 
Wilderness camps: DK; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: Iowa; 
Detention centers: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: 
Required; Residential schools and academies[A]: Exempt. 

State: Idaho; 
Detention centers: Exempt; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Illinois; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Indiana; 
Detention centers: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: Kansas; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Kentucky; 
Detention centers: 
Required; Wilderness camps: 
Required; Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Required. 

State: Louisiana; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Massachusetts; 
Detention centers: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Maryland; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Maine; 
Detention centers: DK; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: Michigan; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: NR. 

State: Minnesota; 
Detention centers: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Missouri; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Required. 

State: Mississippi; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Montana; 
Detention centers: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Required. 

State: North Carolina; 
Detention centers: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Required. 

State: North Dakota; 
Detention centers: Required; 
Wilderness camps: NF; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Nebraska; 
Detention centers: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: NR. 

State: New Hampshire; 
Detention centers: Exempt; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: New Jersey; 
Detention centers: NR; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: New Mexico; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Nevada; 
Detention centers: DK; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: New York; 
Detention centers: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Ohio; 
Detention centers: Required; 
Wilderness camps: DK; 
Ranch: DK; Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Oklahoma; 
Detention centers: Required; 
Wilderness camps: Required; 
Ranch: DK; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Oregon; 
Detention centers: Exempt; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Pennsylvania; 
Detention centers: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Rhode Island; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: South Carolina; 
Detention centers: NF; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: South Dakota; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Tennessee; 
Detention centers: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Texas; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Utah; 
Detention centers: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Virginia; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Vermont; 
Detention centers: NF; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Washington; 
Detention centers: DK; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: Exempt; 
Residential schools and academies[A]: Exempt. 

State: Wisconsin; 
Detention centers: Exempt; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: West Virginia; 
Detention centers: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Wyoming; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

Source: GAO analysis of state agencies' survey responses. 

Notes: NF = no such facility in state, DK = don't know, NS = no survey, 
NR = no response. 

[A] The survey question for private residential schools and academies 
did not distinguish between private facilities that received government 
funding and those that did not. 

[End of table] 

Table 15: Licensing Status for Selected Exclusively Private Residential 
Facilities: 

Facility type and state agency: Treatment centers: Child welfare; 
Licensure required: 30; 
Exempt from licensing: 3; 
No such facility in state: 3; 
Don't know or no response: 8. 

Facility type and state agency: Treatment centers: Health and mental 
health; 
Licensure required: 30; 
Exempt from licensing: 0; 
No such facility in state: 4; 
Don't know or no response: 11. 

Facility type and state agency: Treatment centers: Juvenile justice; 
Licensure required: N/A; 
Exempt from licensing: N/A; 
No such facility in state: N/A; 
Don't know or no response: N/A. 

Facility type and state agency: Wilderness camps: Child welfare; 
Licensure required: 18; 
Exempt from licensing: 3; 
No such facility in state: 11; 
Don't know or no response: 12. 

Facility type and state agency: Wilderness camps: Health and mental 
health; 
Licensure required: 14; 
Exempt from licensing: 2; 
No such facility in state: 9; 
Don't know or no response: 20. 

Facility type and state agency: Wilderness camps: Juvenile justice; 
Licensure required: 5; 
Exempt from licensing: 4; 
No such facility in state: 15; 
Don't know or no response: 20. 

Facility type and state agency: Ranches: Child welfare; 
Licensure required: 11; 
Exempt from licensing: 1; 
No such facility in state: 18; 
Don't know or no response: 14. 

Facility type and state agency: Ranches: Health and mental health; 
Licensure required: 11; 
Exempt from licensing: 2; 
No such facility in state: 12; 
Don't know or no response: 20. 

Facility type and state agency: Ranches: Juvenile justice; 
Licensure required: 2; 
Exempt from licensing: 5; 
No such facility in state: 17; 
Don't know or no response: 20. 

Facility type and state agency: Boot camps: Child welfare; 
Licensure required: 8; 
Exempt from licensing: 2; 
No such facility in state: 22; 
Don't know or no response: 12. 

Facility type and state agency: Boot camps: Health and mental health; 
Licensure required: 6; 
Exempt from licensing: 1; 
No such facility in state: 14; 
Don't know or no response: 24. 

Facility type and state agency: Boot camps: Juvenile justice; 
Licensure required: 0; 
Exempt from licensing: 5; 
No such facility in state: 19; 
Don't know or no response: 20. 

Facility type and state agency: Residential schools and academies: 
Child welfare; 
Licensure required: 19; 
Exempt from licensing: 18; 
No such facility in state: 4; 
Don't know or no response: 3. 

Facility type and state agency: Residential schools and academies: 
Health and mental health; 
Licensure required: 15; 
Exempt from licensing: 10; 
No such facility in state: 1; 
Don't know or no response: 19. 

Facility type and state agency: Residential schools and academies: 
Juvenile justice; 
Licensure required: 14; 
Exempt from licensing: 14; 
No such facility in state: 5; 
Don't know or no response: 11. 

Facility type and state agency: Detention centers: Child welfare; 
Licensure required: N/A; 
Exempt from licensing: N/A; 
No such facility in state: N/A; 
Don't know or no response: N/A. 

Facility type and state agency: Detention centers: Health and mental 
health; 
Licensure required: N/A; 
Exempt from licensing: N/A; 
No such facility in state: N/A; 
Don't know or no response: N/A. 

Facility type and state agency: Detention centers: Juvenile justice; 
Licensure required: 3; 
Exempt from licensing: 5; 
No such facility in state: 18; 
Don't know or no response: 18. 

Source: GAO analysis of state agencies' survey responses. 

[End of table] 

Table 16: State Child Welfare Agencies Reporting the Licensing 
Requirements for Selected Exclusively Private Residential Facilities 
That Serve Youth and Receive No Government Funding: 

State: Alaska; 
Treatment facilities: Required; 
Wilderness camps: Exempt; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: NR. 

State: Alabama; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Arizona; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Arkansas; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: California; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Colorado; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Connecticut; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: District of Columbia; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: NF. 

State: Delaware; 
Treatment facilities: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Florida; 
Treatment facilities: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Exempt. 

State: Georgia; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Hawaii; 
Treatment facilities: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Exempt. 

State: Iowa; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Idaho; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Illinois; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: NF; 
Boot camps: DK; 
Residential schools and academies[A]: NF. 

State: Indiana; 
Treatment facilities: NF; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Required. 

State: Kansas; 
Treatment facilities: Exempt; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Kentucky; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Louisiana; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: Massachusetts; 
Treatment facilities: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Required. 

State: Maryland; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Required. 

State: Maine; 
Treatment facilities: NR; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Michigan; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Minnesota; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Missouri; 
Treatment facilities: Required; 
Wilderness camps: Exempt; 
Ranch: Required; 
Boot camps: Exempt; 
Residential schools and academies[A]: Exempt. 

State: Mississippi; 
Treatment facilities: Exempt; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Montana; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Exempt; 
Boot camps: Required; 
Residential schools and academies[A]: Required. 

State: North Carolina; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: DK; 
Boot camps: Exempt; 
Residential schools and academies[A]: Exempt. 

State: North Dakota; 
Treatment facilities: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Exempt. 

State: Nebraska; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: New Hampshire; 
Treatment facilities: DK; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: New Jersey; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: New Mexico; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Nevada; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: New York; 
Treatment facilities: Exempt; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Ohio; 
Treatment facilities: Required; 
Wilderness camps: NR; 
Ranch: NF; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Oklahoma; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Required. 

State: Oregon; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Pennsylvania; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Rhode Island; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: South Carolina; 
Treatment facilities: NF; 
Wilderness camps: Exempt; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: South Dakota; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Tennessee; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Texas; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Exempt. 

State: Utah; 
Treatment facilities: DK; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Virginia; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Required. 

State: Vermont; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Washington; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Wisconsin; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: West Virginia; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Wyoming; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; Boot camps: NF; 
Residential schools and academies[A]: Required. 

Source: GAO analysis of state agencies' survey responses. 

Notes: NF = no such facility in state, DK = don't know, NS = no survey, 
NR = no response. 

[A] The survey question for private residential schools and academies 
did not distinguish between private facilities that received government 
funding and those that did not. 

[End of table] 

Table 17: State Health and Mental Health Agencies Reporting the 
Licensing Requirements for Selected Exclusively Private Residential 
Facilities That Serve Youth and Receive No Government Funding: 

State: Alaska; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Alabama; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Arizona; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Arkansas; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: California; 
Treatment facilities: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Required. 

State: Colorado; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Connecticut; Treatment facilities: 
Required; Wilderness camps: Exempt; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: District of Columbia; 
Treatment facilities: Required; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: DK. 

State: Delaware; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: Florida; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: NR. 

State: Georgia; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: DK; 
Residential schools and academies[A]: Required. 

State: Hawaii; 
Treatment facilities: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: Iowa; 
Treatment facilities: NF; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Required. 

State: Idaho; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Illinois; 
Treatment facilities: Required; 
Wilderness camps: Exempt; 
Ranch: Exempt; 
Boot camps: Exempt; 
Residential schools and academies[A]: Required. 

State: Indiana; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Required. 

State: Kansas; 
Treatment facilities: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: DK. 

State: Kentucky; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Louisiana; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Massachusetts; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: DK; 
Residential schools and academies[A]: Required. 

State: Maryland; 
Treatment facilities: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Maine; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Michigan; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Minnesota; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Missouri; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Mississippi; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Required. 

State: Montana; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Exempt; 
Boot camps: Required; 
Residential schools and academies[A]: Required. 

State: North Carolina; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Exempt. 

State: North Dakota; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Nebraska; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: New Hampshire; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Required. 

State: New Jersey; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: New Mexico; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Nevada; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: New York; 
Treatment facilities: NF; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Ohio; 
Treatment facilities: 
Required; Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NR. 

State: Oklahoma; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Oregon; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Pennsylvania; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Rhode Island; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: South Carolina; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: South Dakota; 
Treatment facilities: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Tennessee; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Texas; 
Treatment facilities: Required; 
Wilderness camps: DK; 
Ranch: Required; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Utah; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Virginia; 
Treatment facilities: Required; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: Required; 
Residential schools and academies[A]: Exempt. 

State: Vermont; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Required. 

State: Washington; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: NR. 

State: Wisconsin; 
Treatment facilities: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: West Virginia; 
Treatment facilities: Required; 
Wilderness camps: NR; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Wyoming; 
Treatment facilities: Required; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

Source: GAO analysis of state agencies' survey responses. 

Note: NF = no such facility in state, DK = don't know, NS = no survey, 
NR = no response. 

[A] The survey question for private residential schools and academies 
did not distinguish between private facilities that received government 
funding and those that did not. 

[End of table] 

Table 18: State Juvenile Justice Agencies Reporting the Licensing 
Status for Selected Exclusively Private Residential Facilities That 
Serve Youth and Receive No Government Funding: 

State: Alaska; 
Detention centers: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: NS. 

State: Alabama; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Arizona; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Arkansas; 
Detention centers: Exempt; 
Wilderness camps: Exempt; 
Ranch: Exempt; 
Boot camps: Exempt; 
Residential schools and academies[A]: Exempt. 

State: California; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Colorado; 
Detention centers: Exempt; 
Wilderness camps: Required; 
Ranch: Exempt; 
Boot camps: Exempt; 
Residential schools and academies[A]: Required. 

State: Connecticut; 
Detention centers: Exempt; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: District of Columbia; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Delaware; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Florida; 
Detention centers: Exempt; 
Wilderness camps: Exempt; 
Ranch: Exempt; 
Boot camps: Exempt; 
Residential schools and academies[A]: Exempt. 

State: Georgia; 
Detention centers: NF; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Required. 

State: Hawaii; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Iowa; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Idaho; 
Detention centers: NF; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Illinois; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Indiana; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: Kansas; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Kentucky; 
Detention centers: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Required. 

State: Louisiana; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Massachusetts; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Maryland; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Maine; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: Michigan; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: NR. 

State: Minnesota; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Missouri; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Required. 

State: Mississippi; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Montana; 
Detention centers: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Required. 

State: North Carolina; 
Detention centers: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: Required. 

State: North Dakota; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Nebraska; 
Detention centers: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: NR. 

State: New Hampshire; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: New Jersey; 
Detention centers: NR; 
Wilderness camps: NR; 
Ranch: NR; 
Boot camps: NR; 
Residential schools and academies[A]: DK. 

State: New Mexico; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Nevada; 
Detention centers: DK; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: DK. 

State: New York; 
Detention centers: Required; 
Wilderness camps: Exempt; 
Ranch: Exempt; 
Boot camps: Exempt; 
Residential schools and academies[A]: Exempt. 

State: Ohio; 
Detention centers: Exempt; 
Wilderness camps: Exempt; 
Ranch: Exempt; 
Boot camps: Exempt; 
Residential schools and academies[A]: Exempt. 

State: Oklahoma; 
Detention centers: Required; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Oregon; 
Detention centers: NF; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Pennsylvania; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Exempt. 

State: Rhode Island; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: South Carolina; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: Required. 

State: South Dakota; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Tennessee; 
Detention centers: Required; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Texas; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

State: Utah; 
Detention centers: NF; 
Wilderness camps: Required; 
Ranch: Required; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Virginia; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Vermont; 
Detention centers: NF; 
Wilderness camps: Required; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Required. 

State: Washington; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: Exempt. 

State: Wisconsin; 
Detention centers: DK; 
Wilderness camps: DK; 
Ranch: DK; 
Boot camps: DK; 
Residential schools and academies[A]: DK. 

State: West Virginia; 
Detention centers: NF; 
Wilderness camps: NF; 
Ranch: NF; 
Boot camps: NF; 
Residential schools and academies[A]: NF. 

State: Wyoming; 
Detention centers: NS; 
Wilderness camps: NS; 
Ranch: NS; 
Boot camps: NS; 
Residential schools and academies[A]: NS. 

Source: GAO analysis of state agencies' survey responses. 

Notes: NF = no such facility in state, DK = don't know, NS = no survey, 
NR = no response. 

[A] The survey question for private residential schools and academies 
did not distinguish between private facilities that received government 
funding and those that did not. 

[End of table] 

[End of section] 

Appendix V: State Agency Accreditation Requirements for Residential 
Facilities for Youth: 

Table 19: Number of States that Require at Least Some of the 
Residential Facilities That They License or Certify to Have Independent 
Accreditation: 

Facility type: Government operated; 
Child welfare agencies: Accreditation required for at least some: 8; 
Child welfare agencies: Accreditation not required: 15; 
Health and mental health agencies: Accreditation required for at least 
some: 16; 
Health and mental health agencies: Accreditation not required: 12; 
Juvenile justice agencies: Accreditation required for at least some: 
12; 
Juvenile justice agencies: Accreditation not required: 29. 

Facility type: Private receiving government funds; 
Child welfare agencies: Accreditation required for at least some: 8; 
Child welfare agencies: Accreditation not required: 27; 
Health and mental health agencies: Accreditation required for at least 
some: 16; 
Health and mental health agencies: Accreditation not required: 19; 
Juvenile justice agencies: Accreditation required for at least some: 7; 
Juvenile justice agencies: Accreditation not required: 27. 

Facility type: Exclusively private pay; 
Child welfare agencies: Accreditation required for at least some: 4; 
Child welfare agencies: Accreditation not required: 26; 
Health and mental health agencies: Accreditation required for at least 
some: 5; 
Health and mental health agencies: Accreditation not required: 21; 
Juvenile justice agencies: Accreditation required for at least some: 2; 
Juvenile justice agencies: Accreditation not required: 11. 

Source: GAO analysis of state agencies' survey responses. 

[End of table] 

The survey questions were as follows: Are government-operated 
facilities, including county-operated facilities, required to have any 
of the following in order to provide residential [targeted; health, 
mental health, or substance abuse; juvenile or rehabilitation] services 
to youth: independent accreditation to provide services, such as 
Council on Accreditation (COA), Commission on Accreditation 
Rehabilitation Facilities (CARF), Joint Commission on Accreditation of 
Health Care Organizations (JCAHO): (a) required for all, (b) required 
for most, (c) required for some, (d) not required, (e) don't know, and 
(f) no response. Which if any of the following types of initial 
licensure or certification does your agency require for private 
facilities that plan to provide residential [targeted; health, mental 
health, or substance abuse; juvenile or rehabilitation] services to 
youth age 12 to 17 and receive [any government funds, e.g., facilities 
with state or county contracts or facilities certified to accept 
Medicaid or Medicare): independent accreditation to provide services, 
such as Council on Accreditation (COA), Commission on Accreditation 
Rehabilitation Facilities (CARF), Joint Commission on Accreditation of 
Health Care Organizations (JCAHO): (a) required, (b) not required, (c) 
don't know, and (d) no response. Which if any of the following types of 
initial licensure or certification does your agency require for private 
facilities that plan to provide residential [targeted; health, mental 
health, or substance abuse; juvenile or rehabilitation] to youth age 12 
to 17 and receive no government funds (e.g., faith-based and other 
private facilities that are totally funded by the private sector): 
independent accreditation to provide services, such as Council on 
Accreditation, Commission on Accreditation Rehabilitation Facilities, 
Joint Commission on Accreditation of Health Care Organizations: (a) 
required, (b) not required, (c) don't know, and (d) no response. 

[End of section] 

Appendix VI: Selected State Licensing Standards for Residential 
Facilities for Youth: 

Table 20: Number of State Agencies Reporting That They Require Licensed 
Government-Operated and Private Residential Facilities to Meet Certain 
Standards, 2006: 

Standards: Pass inspection of physical plant: Required for all; 
Child welfare: Government-operated facilities: 20; 
Child welfare: Private facilities: 37; 
Health and mental health: Government-operated facilities: 27; 
Health and mental health: Private facilities: 35; 
Juvenile justice: Government-operated facilities: 41; 
Juvenile justice: Private facilities: 16. 

Standards: Pass inspection of physical plant: Required for less than 
all; 
Child welfare: Government-operated facilities: 2; 
Child welfare: Private facilities: 0; 
Health and mental health: Government-operated facilities: 1; 
Health and mental health: Private facilities: 1; 
Juvenile justice: Government-operated facilities: 2; 
Juvenile justice: Private facilities: 0. 

Standards: Provide evidence of safe child care practices: Required for 
all; 
Child welfare: Government-operated facilities: 19; 
Child welfare: Private facilities: 35; 
Health and mental health: Government-operated facilities: 23; 
Health and mental health: Private facilities: 30; 
Juvenile justice: Government-operated facilities: 37; 
Juvenile justice: Private facilities: 16. 

Standards: Provide evidence of safe child care practices: Required for 
less than all; 
Child welfare: Government-operated facilities: 3; 
Child welfare: Private facilities: 1; 
Health and mental health: Government-operated facilities: 3; 
Health and mental health: Private facilities: 3; 
Juvenile justice: Government-operated facilities: 5; 
Juvenile justice: Private facilities: 0. 

Standards: Have written procedures for reporting physical or sexual 
abuse or neglect of youth: Required for all; 
Child welfare: Government-operated facilities: 21; 
Child welfare: Private facilities: 37; 
Health and mental health: Government-operated facilities: 28; 
Health and mental health: Private facilities: 35; 
Juvenile justice: Government-operated facilities: 43; 
Juvenile justice: Private facilities: 16. 

Standards: Have written procedures for reporting physical or sexual 
abuse or neglect of youth: Required for less than all; 
Child welfare: Government-operated facilities: 1; 
Child welfare: Private facilities: 0; 
Health and mental health: Government-operated facilities: 0; 
Health and mental health: Private facilities: 1; 
Juvenile justice: Government-operated facilities: 0; 
Juvenile justice: Private facilities: 0. 

Standards: Meet all staff qualifications requirements, including 
training: Required for all; 
Child welfare: Government-operated facilities: 20; 
Child welfare: Private facilities: 36; 
Health and mental health: Government-operated facilities: 26; 
Health and mental health: Private facilities: 34; 
Juvenile justice: Government-operated facilities: 42; 
Juvenile justice: Private facilities: 16. 

Standards: Meet all staff qualifications requirements, including 
training: Required for less than all; 
Child welfare: Government-operated facilities: 2; 
Child welfare: Private facilities: 0; 
Health and mental health: Government-operated facilities: 1; 
Health and mental health: Private facilities: 2; 
Juvenile justice: Government-operated facilities: 1; 
Juvenile justice: Private facilities: 0. 

Standards: Perform staff background checks: Required for all; 
Child welfare: Government-operated facilities: 21; 
Child welfare: Private facilities: 37; 
Health and mental health: Government-operated facilities: 26; 
Health and mental health: Private facilities: 31; 
Juvenile justice: Government-operated facilities: 43; 
Juvenile justice: Private facilities: 16. 

Standards: Perform staff background checks: Required for less than all; 
Child welfare: Government-operated facilities: 1; 
Child welfare: Private facilities: 0; 
Health and mental health: Government-operated facilities: 2; 
Health and mental health: Private facilities: 4; 
Juvenile justice: Government-operated facilities: 0; 
Juvenile justice: Private facilities: 0. 

Standards: Meet staff-to-child ratios: Required for all; 
Child welfare: Government-operated facilities: 20; 
Child welfare: Private facilities: 34; 
Health and mental health: Government-operated facilities: 22; 
Health and mental health: Private facilities: 28; 
Juvenile justice: Government-operated facilities: 32; 
Juvenile justice: Private facilities: 15. 

Standards: Meet staff-to-child ratios: Required for less than all; 
Child welfare: Government-operated facilities: 2; 
Child welfare: Private facilities: 3; 
Health and mental health: Government-operated facilities: 5; 
Health and mental health: Private facilities: 8; 
Juvenile justice: Government-operated facilities: 10; 
Juvenile justice: Private facilities: 1. 

Standards: Provide evidence of appropriate educational programming: 
Required for all; 
Child welfare: Government-operated facilities: 19; 
Child welfare: Private facilities: 31; 
Health and mental health: Government-operated facilities: 23; 
Health and mental health: Private facilities: 31; 
Juvenile justice: Government-operated facilities: 41; 
Juvenile justice: Private facilities: 16. 

Standards: Provide evidence of appropriate educational programming: 
Required for less than all; 
Child welfare: Government-operated facilities: 2; 
Child welfare: Private facilities: 1; 
Health and mental health: Government-operated facilities: 6; 
Health and mental health: Private facilities: 4; 
Juvenile justice: Government-operated facilities: 2; 
Juvenile justice: Private facilities: 0. 

Standards: Have procedures in place for use of approved seclusion and 
restraint techniques: Required for all; 
Child welfare: Government-operated facilities: 19; 
Child welfare: Private facilities: 34; 
Health and mental health: Government-operated facilities: 23; 
Health and mental health: Private facilities: 31; 
Juvenile justice: Government-operated facilities: 41; 
Juvenile justice: Private facilities: 16. 

Standards: Have procedures in place for use of approved seclusion and 
restraint techniques: Required for less than all; 
Child welfare: Government-operated facilities: 3; 
Child welfare: Private facilities: 3; 
Health and mental health: Government-operated facilities: 5; 
Health and mental health: Private facilities: 4; 
Juvenile justice: Government-operated facilities: 2; 
Juvenile justice: Private facilities: 0. 

Standards: Have written suicide prevention plans: Required for all; 
Child welfare: Government-operated facilities: 13; 
Child welfare: Private facilities: 20; 
Health and mental health: Government-operated facilities: 15; 
Health and mental health: Private facilities: 20; 
Juvenile justice: Government-operated facilities: 40; 
Juvenile justice: Private facilities: 12. 

Standards: Have written suicide prevention plans: Required for less 
than all; 
Child welfare: Government-operated facilities: 8; 
Child welfare: Private facilities: 14; 
Health and mental health: Government-operated facilities: 9; 
Health and mental health: Private facilities: 13; 
Juvenile justice: Government-operated facilities: 3; 
Juvenile justice: Private facilities: 4. 

Source: GAO analysis of state agencies' survey responses. 

Note: Other responses included "Don't know" and "No response." 

[End of table] 

The survey questions were as follows: When your state 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 staff qualifications requirements, including training; (e) 
perform staff background check; (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 technique; (i) have written suicide prevention plan. Are each 
of the following items required for private residential facilities 
providing targeted services for youth to obtain initial licensure from 
your agency? (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 staff 
qualifications requirements, including training; (e) perform staff 
background check; (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 technique; (i) have 
written suicide prevention plan. 

[End of section] 

Appendix VII: Selected State Monitoring Requirements for Residential 
Facilities for Youth: 

Table 21: Number of State Agencies Reporting That They Monitored, for 
All or Less Than All, Selected Issues at Residential Facilities for 
Youth, 2006: 

Issues: Physical plant: Monitored for all; 
Child welfare: Government-operated facility: 15; 
Child welfare: Private facility that received any government funds: 35; 
Child welfare: Exclusively private facility: 29; 
Health and mental health: Government-operated facility: 14; 
Health and mental health: Private facility that received any government 
funds: 22; 
Health and mental health: Exclusively private facility: 16; 
Juvenile justice: Government-operated facility: 34; 
Juvenile justice: Private facility that received any government funds: 
24; 
Juvenile justice: Exclusively private facility: 9. 

Issues: Physical plant: Monitored for less than all; 
Child welfare: Government-operated facility: 6; 
Child welfare: Private facility that received any government funds: 4; 
Child welfare: Exclusively private facility: 6; 
Health and mental health: Government-operated facility: 13; 
Health and mental health: Private facility that received any government 
funds: 16; 
Health and mental health: Exclusively private facility: 14; 
Juvenile justice: Government-operated facility: 8; 
Juvenile justice: Private facility that received any government funds: 
13; 
Juvenile justice: Exclusively private facility: 14. 

Issues: Staffing issues (e.g., background checks, qualifications, 
ongoing training): Monitored for all; 
Child welfare: Government-operated facility: 16; 
Child welfare: Private facility that received any government funds: 35; 
Child welfare: Exclusively private facility: 28; 
Health and mental health: Government-operated facility: 15; 
Health and mental health: Private facility that received any government 
funds: 22; 
Health and mental health: Exclusively private facility: 16; 
Juvenile justice: Government-operated facility: 34; 
Juvenile justice: Private facility that received any government funds: 
23; 
Juvenile justice: Exclusively private facility: 8. 

Issues: Issues: Staffing issues (e.g., background checks, 
qualifications, ongoing training): Monitored for less than all; 
Child welfare: Government-operated facility: 6; 
Child welfare: Private facility that received any government funds: 5; 
Child welfare: Exclusively private facility: 7; 
Health and mental health: Government-operated facility: 13; 
Health and mental health: Private facility that received any government 
funds: 15; 
Health and mental health: Exclusively private facility: 14; 
Juvenile justice: Government-operated facility: 7; 
Juvenile justice: Private facility that received any government funds: 
13; 
Juvenile justice: Exclusively private facility: 14. 

Issues: Use of approved seclusion and restraint: Monitored for all; 
Child welfare: Government-operated facility: 14; 
Child welfare: Private facility that received any government funds: 32; 
Child welfare: Exclusively private facility: 26; 
Health and mental health: Government-operated facility: 14; 
Health and mental health: Private facility that received any government 
funds: 23; 
Health and mental health: Exclusively private facility: 13; 
Juvenile justice: Government-operated facility: 32; 
Juvenile justice: Private facility that received any government funds: 
25; 
Juvenile justice: Exclusively private facility: 10. 

Issues: Use of approved seclusion and restraint: Monitored for less 
than all; 
Child welfare: Government-operated facility: 7; 
Child welfare: Private facility that received any government funds: 7; 
Child welfare: Exclusively private facility: 9; 
Health and mental health: Government-operated facility: 11; 
Health and mental health: Private facility that received any government 
funds: 13; 
Health and mental health: Exclusively private facility: 16; 
Juvenile justice: Government-operated facility: 10; 
Juvenile justice: Private facility that received any government funds: 
10; 
Juvenile justice: Exclusively private facility: 12. 

Issues: Use of psychotropic medications: Monitored for all; 
Child welfare: Government-operated facility: 13; 
Child welfare: Private facility that received any government funds: 30; 
Child welfare: Exclusively private facility: 24; 
Health and mental health: Government-operated facility: 13; 
Health and mental health: Private facility that received any government 
funds: 22; 
Health and mental health: Exclusively private facility: 12; 
Juvenile justice: Government-operated facility: 27; 
Juvenile justice: Private facility that received any government funds: 
22; 
Juvenile justice: Exclusively private facility: 9. 

Issues: Use of psychotropic medications: Monitored for less than all; 
Child welfare: Government-operated facility: 8; 
Child welfare: Private facility that received any government funds: 9; 
Child welfare: Exclusively private facility: 9; 
Health and mental health: Government-operated facility: 12; 
Health and mental health: Private facility that received any government 
funds: 15; 
Health and mental health: Exclusively private facility: 16; 
Juvenile justice: Government-operated facility: 14; 
Juvenile justice: Private facility that received any government funds: 
14; 
Juvenile justice: Exclusively private facility: 13. 

Issues: Number of complaints of physical or sexual abuse: Monitored for 
all; 
Child welfare: Government-operated facility: 13; 
Child welfare: Private facility that received any government funds: 24; 
Child welfare: Exclusively private facility: 27; 
Health and mental health: Government-operated facility: 15; 
Health and mental health: Private facility that received any government 
funds: 26; 
Health and mental health: Exclusively private facility: 15; 
Juvenile justice: Government-operated facility: 34; 
Juvenile justice: Private facility that received any government funds: 
28; 
Juvenile justice: Exclusively private facility: 12. 

Issues: Number of complaints of physical or sexual abuse: Monitored for 
less than all; 
Child welfare: Government-operated facility: 9; 
Child welfare: Private facility that received any government funds: 5; 
Child welfare: Exclusively private facility: 8; 
Health and mental health: Government-operated facility: 12; 
Health and mental health: Private facility that received any government 
funds: 12; 
Health and mental health: Exclusively private facility: 15; 
Juvenile justice: Government-operated facility: 15; 
Juvenile justice: Private facility that received any government funds: 
8; 
Juvenile justice: Exclusively private facility: 10. 

Issues: Number of other complaints, if any (e.g. health or safety 
concerns): Monitored for all; 
Child welfare: Government-operated facility: 15; 
Child welfare: Private facility that received any government funds: 32; 
Child welfare: Exclusively private facility: 26; 
Health and mental health: Government-operated facility: 16; 
Health and mental health: Private facility that received any government 
funds: 24; 
Health and mental health: Exclusively private facility: 14; 
Juvenile justice: Government-operated facility: 33; 
Juvenile justice: Private facility that received any government funds: 
28; 
Juvenile justice: Exclusively private facility: 10. 

Issues: Number of other complaints, if any (e.g. health or safety 
concerns): Monitored for less than all; 
Child welfare: Government-operated facility: 7; 
Child welfare: Private facility that received any government funds: 7; 
Child welfare: Exclusively private facility: 9; 
Health and mental health: Government-operated facility: 11; 
Health and mental health: Private facility that received any government 
funds: 12; 
Health and mental health: Exclusively private facility: 15; 
Juvenile justice: Government-operated facility: 9; 
Juvenile justice: Private facility that received any government funds: 
8; 
Juvenile justice: Exclusively private facility: 11. 

Issues: Presence of educational programming: Monitored for all; 
Child welfare: Government-operated facility: 15; 
Child welfare: Private facility that received any government funds: 30; 
Child welfare: Exclusively private facility: 24; 
Health and mental health: Government-operated facility: 13; 
Health and mental health: Private facility that received any government 
funds: 16; 
Health and mental health: Exclusively private facility: 12; 
Juvenile justice: Government-operated facility: 35; 
Juvenile justice: Private facility that received any government funds: 
23; 
Juvenile justice: Exclusively private facility: 9. 

Issues: Presence of educational programming: Monitored for less than 
all; 
Child welfare: Government-operated facility: 5; 
Child welfare: Private facility that received any government funds: 7; 
Child welfare: Exclusively private facility: 9; 
Health and mental health: Government-operated facility: 13; 
Health and mental health: Private facility that received any government 
funds: 18; 
Health and mental health: Exclusively private facility: 14; 
Juvenile justice: Government-operated facility: 6; 
Juvenile justice: Private facility that received any government funds: 
13; 
Juvenile justice: Exclusively private facility: 12. 

Issues: Quality of educational programming: Monitored for all; 
Child welfare: Government-operated facility: 6; 
Child welfare: Private facility that received any government funds: 11; 
Child welfare: Exclusively private facility: 6; 
Health and mental health: Government-operated facility: 7; 
Health and mental health: Private facility that received any government 
funds: 8; 
Health and mental health: Exclusively private facility: 6; 
Juvenile justice: Government-operated facility: 27; 
Juvenile justice: Private facility that received any government funds: 
18; 
Juvenile justice: Exclusively private facility: 8. 

Issues: Quality of educational programming: Monitored for less than 
all; 
Child welfare: Government-operated facility: 14; 
Child welfare: Private facility that received any government funds: 23; 
Child welfare: Exclusively private facility: 23; 
Health and mental health: Government-operated facility: 16; 
Health and mental health: Private facility that received any government 
funds: 23; 
Health and mental health: Exclusively private facility: 20; 
Juvenile justice: Government-operated facility: 13; 
Juvenile justice: Private facility that received any government funds: 
17; 
Juvenile justice: Exclusively private facility: 12. 

Source: GAO analysis of state agencies' survey responses. 

Note: Other responses included "Don't know", "No response" and "No such 
facility in the state." 

[End of table] 

We asked state child welfare, health and mental health, and juvenile 
justice agencies the following question: 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 
government-operated residential facilities, private residential 
facilities that received government funding, and exclusively private 
pay residential facilities providing targeted services for youth? 
Response options for this question were: (a) yes, monitored for all, 
(b) yes, monitored for most, (c) yes, monitored for some, (d) no, did 
not monitor, (e) no such facility in the state, (f) don't know, (g) no 
response. 

[End of section] 

Appendix VIII: State Agency Actions Taken within the Last 3 Years 
against Government and Private Residential Facilities: 

Table 22: Number of State Agencies Taking Actions against Government 
and Private Residential Facilities within the Last 3 Years: 

Action taken: Government facility was closed or license, certification, 
or operating authority was suspended or revoked; Government operated; 
Child welfare: Yes: 1; 
Child welfare: No: 19; 
Health and mental health: Yes: 0; 
Health and mental health: No: 18; 
Juvenile justice: Yes: 3; 
Juvenile justice: No: 34. 

Action taken: Private license or authority to operate was suspended: 
Private receiving government funds; 
Child welfare: Yes: 11; 
Child welfare: No: 21; 
Health and mental health: Yes: 4; 
Health and mental health: No: 18; 
Juvenile justice: Yes: 9; 
Juvenile justice: No: 16. 

Action taken: Private license or authority to operate was suspended: 
Exclusively private; 
Child welfare: Yes: 4; 
Child welfare: No: 28; 
Health and mental health: Yes: 3; 
Health and mental health: No: 19; 
Juvenile justice: Yes: 3; 
Juvenile justice: No: 22. 

Action taken: Private license or authority to operate was revoked or 
not renewed, or facility was closed: Private receiving government 
funds; 
Child welfare: Yes: 17; 
Child welfare: No: 15; 
Health and mental health: Yes: 8; 
Health and mental health: No: 13; 
Juvenile justice: Yes: 11; 
Juvenile justice: No: 13. 

Action taken: Private license or authority to operate was revoked or 
not renewed, or facility was closed: Exclusively private; 
Child welfare: Yes: 7; 
Child welfare: No: 25; 
Health and mental health: Yes: 3; 
Health and mental health: No: 18; 
Juvenile justice: Yes: 1; 
Juvenile justice: No: 23. 

Action taken: Youth were removed: Government operated; 
Child welfare: Yes: 7; 
Child welfare: No: 12; 
Health and mental health: Yes: 2; 
Health and mental health: No: 16; 
Juvenile justice: Yes: 11; 
Juvenile justice: No: 26. 

Action taken: Youth were removed: Private receiving government funds; 
Child welfare: Yes: 26; 
Child welfare: No: 9; 
Health and mental health: Yes: 13; 
Health and mental health: No: 8; 
Juvenile justice: Yes: 18; 
Juvenile justice: No: 12. 

Action taken: Youth were removed: Exclusively private; 
Child welfare: Yes: 5; 
Child welfare: No: 30; 
Health and mental health: Yes: 4; 
Health and mental health: No: 17; 
Juvenile justice: Yes: 4; 
Juvenile justice: No: 26. 

Action taken: Banned new admissions or instituted admission 
restrictions: Government operated; 
Child welfare: Yes: 7; 
Child welfare: No: 14; 
Health and mental health: Yes: 4; 
Health and mental health: No: 15; 
Juvenile justice: Yes: 7; 
Juvenile justice: No: 30. 

Action taken: Banned new admissions or instituted admission 
restrictions: Private receiving government funds; 
Child welfare: Yes: 27; 
Child welfare: No: 8; 
Health and mental health: Yes: 16; 
Health and mental health: No: 6; 
Juvenile justice: Yes: 22; 
Juvenile justice: No: 7. 

Action taken: Banned new admissions or instituted admission 
restrictions: Exclusively private; 
Child welfare: Yes: 4; 
Child welfare: No: 31; 
Health and mental health: Yes: 4; 
Health and mental health: No: 18; 
Juvenile justice: Yes: 4; 
Juvenile justice: No: 25. 

Action taken: Referred or recommended criminal investigations for abuse 
or neglect that carry fines or imprisonment: Government operated; 
Child welfare: Yes: 10; 
Child welfare: No: 11; 
Health and mental health: Yes: 7; 
Health and mental health: No: 8; 
Juvenile justice: Yes: 24; 
Juvenile justice: No: 10. 

Action taken: Referred or recommended criminal investigations for abuse 
or neglect that carry fines or imprisonment: Private receiving 
government funds; 
Child welfare: Yes: 19; 
Child welfare: No: 11; 
Health and mental health: Yes: 11; 
Health and mental health: No: 9; 
Juvenile justice: Yes: 17; 
Juvenile justice: No: 11. 

Action taken: Referred or recommended criminal investigations for abuse 
or neglect that carry fines or imprisonment: Exclusively private; 
Child welfare: Yes: 6; 
Child welfare: No: 24; 
Health and mental health: Yes: 3; 
Health and mental health: No: 17; 
Juvenile justice: Yes: 7; 
Juvenile justice: No: 21. 

Action taken: Increased Monitoring: Government operated; 
Child welfare: Yes: 16; 
Child welfare: No: 5; 
Health and mental health: Yes: 10; 
Health and mental health: No: 8; 
Juvenile justice: Yes: 32; 
Juvenile justice: No: 6. 


Action taken: Increased Monitoring: Private receiving government funds; 
Child welfare: Yes: 32; 
Child welfare: No: 3; 
Health and mental health: Yes: 20; 
Health and mental health: No: 2; 
Juvenile justice: Yes: 30; 
Juvenile justice: No: 0. 

Action taken: Increased Monitoring: Exclusively private; 
Child welfare: Yes: 6; 
Child welfare: No: 29; 
Health and mental health: Yes: 8; 
Health and mental health: No: 14; 
Juvenile justice: Yes: 8; 
Juvenile justice: No: 22. 

Action taken: Required program improvement or corrective action plan; 
Government operated; 
Child welfare: Yes: 19; 
Child welfare: No: 2; 
Health and mental health: Yes: 17; 
Health and mental health: No: 2; 
Juvenile justice: Yes: 32; 
Juvenile justice: No: 4. 

Action taken: Required program improvement or corrective action plan; 
Private receiving government funds; 
Child welfare: Yes: 35; 
Child welfare: No: 0; 
Health and mental health: Yes: 22; 
Health and mental health: No: 1; 
Juvenile justice: Yes: 28; 
Juvenile justice: No: 1. 

Action taken: Required program improvement or corrective action plan; 
Exclusively private; 
Child welfare: Yes: 12; 
Child welfare: No: 23; 
Health and mental health: Yes: 10; 
Health and mental health: No: 13; 
Juvenile justice: Yes: 7; 
Juvenile justice: No: 22. 

Source: GAO analysis of state agencies' survey responses. 

[End of table] 

We asked state child welfare, health and mental health, and juvenile 
justice agencies the following question: Over the last 3 reporting 
years, did your agency take any of the following actions at its 
government-operated facilities, private facilities that received 
government funds, or private facilities that did not receive government 
funds as a result of allegations or findings of noncompliance, improper 
operations, physical abuse or sexual abuse or neglect of youth, or 
other negative outcomes? Respondents could also answer "don't know" or 
"no response." 

[End of section] 

Appendix IX: Comments from the Department of Education: 

United States Department Of Education: 
Office Of Special Education And Rehabilitative Services: 
The Assistant Secretary: 
400 Maryland Ave. SW: 
Washington, DC 20202-2500: 
[hyperlink, http://www.ed.gov]: 
"Our mission is to ensure equal access to education and to promote 
educational excellence throughout the nation." 

April 22, 2008: 
	
Ms. Kay E. Brown: 
Director, Education, Workforce And Income Security Issues: 
Government Accountability Office: 
441 G Street, NW: 
Washington, D.C. 20548: 

Dear Ms. Brown: 

This is in response to your request for comments on the Government 
Accountability Office (GAO) draft report, "Residential Facilities: 
Improved Data and Enhanced Oversight Would Help Safeguard the Well-
Being of Youth with Behavioral and Emotional Challenges" (GAO-08-346). 
We appreciate the opportunity to comment on the draft report. 

The national surveys conducted by GAO for this draft report are not of 
State educational agencies (SEAs), the entities for which the U.S. 
Department of Education (Department) has oversight responsibility under 
the Individuals with Disabilities Education Act (IDEA). Instead, the 
national surveys conducted by GAO for this draft report were of State 
child welfare, health and mental health and juvenile justice agencies. 
The draft report includes approximately 50 pages of data tables showing 
significant variability in the extent, level and nature of State 
oversight of residential schools and academies, detention centers, boot 
camps, ranches, wilderness camps and treatment facilities. However, 
survey questions about the presence of educational programming and the 
quality of educational programming in the several States surveyed, in 
various settings, were not directed at SEAs. The draft report therefore 
gives only a partial picture of State monitoring of educational 
programs for students with disabilities who are publicly placed in 
residential facilities. 

As noted in the draft report, States have the primary responsibility 
for ensuring the well-being of youth in residential facilities and 
other settings, and States are responsible for licensure, accreditation 
and monitoring of facilities in accordance with State standards of 
care. Some students "with emotional and behavioral challenges" cited in 
the GAO draft report's age cohort of 12-17 would be receiving services 
under the IDEA if they met the eligibility criteria for services under 
that law. 

The role of the Department in administering the IDEA is to ensure that 
SEAs carry out their general supervision responsibilities in section 
612(a)(11) of IDEA. Each SEA is responsible for ensuring that IDEA 
requirements are met in the State, and that each education program in 
the State, including programs administered by any other State or local 
agency, meets the education standards of the SEA. The Department's 
periodic monitoring of SEAs' implementation of the IDEA under section 
616 of IDEA includes a review of State monitoring and oversight 
activities. This could include a review of the SEAs' procedures for 
monitoring special education programs for students with disabilities 
who are publicly placed in public or private residential facilities to 
ensure that such children and youth with disabilities receive a free 
appropriate public education. The IDEA regulations also include State 
complaint procedures requiring each SEA to adopt written procedures for 
resolving any signed written complaint at the State level, alleging 
that a public agency has violated a requirement of Part B of IDEA or 
the Part B of IDEA regulations. The Department monitors States' 
implementation of their complaint procedures to ensure that complaints 
are resolved in a timely manner. 

States and the Secretary of the Interior are required to make annual 
submissions of data to the Secretary of Education and the public under 
section 618 of IDEA. These data include the number and percentage of 
children with disabilities, by disability category, who are educated in 
a variety of settings, including public or private residential 
facilities. Fewer than one half of one percent of all children 
receiving special education and related services are placed in a 
residential setting by a public education agency under IDEA. These 
residential placements are for students with significant cognitive 
disabilities, students who are blind or deaf, students with traumatic 
brain injury and other conditions, typically of low incidence, 
requiring intensive and specialized services not available in a less 
restrictive setting. Thus, residential settings are uncommon placements 
for serving children under IDEA. 

Data on children with disabilities served under the IDEA (available on-
line at [Hyperlink, http://www.ideadata.org/]) do not necessarily 
correspond to GAO's study categories of "behavioral and emotional 
challenges" nor do the age ranges match the study ranges, but IDEA data 
do give insight about placements. In Fall 2006, 9,373 students ages 6 
through 21 with "emotional disturbance" served under IDEA were in 
residential facilities, while 7,741 students with emotional disturbance 
were served in correctional facilities. The latter facilities would 
presumably include the "detention center" category in the study. In 
comparison, roughly 450,000 students with "emotional disturbance" were 
served in all educational environments under IDEA. 

In addition to children with disabilities served under IDEA, some 
children are served under the Prevention and Intervention Programs for 
Children and Youths Who Are Neglected, Delinquent, or at Risk (Title I, 
Part D of the Elementary and Secondary Education Act, as amended by the 
No Child Left Behind Act of 2001). Students provided supplemental 
educational services under Title I, Part D in institutional settings 
represent only a small percentage of all youth detained or serving 
sentences in juvenile or adult residential facilities. The role of the 
Department in administering the Title I, Part D program is to improve 
educational services for children and youth in local and State 
institutions for neglected or delinquent children and youth. The 
Department's monitoring of SEAs' implementation of the Title I, Part D 
program includes a review of State monitoring and oversight activities 
to ensure compliance with all statutory and regulatory requirements. 

Some of the students described in the GAO draft report also may be 
receiving education and services pursuant to Section 504 of the 
Rehabilitation Act of 1973, which prohibits disability-based 
discrimination by the recipients of federal financial assistance. Among 
other things, at the elementary and secondary level Section 504 
requires that qualified individuals with disabilities be provided with 
regular or special education and related aids and services that are 
designed to meet the needs of individuals with disabilities as 
adequately as the needs of individuals without disabilities are met. 
Section 504 is enforced by the Department's Office for Civil Rights 
(OCR) through complaint investigation, proactive compliance reviews and 
the provision of technical assistance. Additional information about 
Section 504 compliance activities is available from OCR at [Hyperlink, 
http://www.ed.gov/ocr]. 

While it is not in the Department's statutory or regulatory authority 
through IDEA or Title I, Part D to ensure oversight of the total well-
being of youth in residential facilities, we recognize that a 
protective and safe school environment, that is consistent with a 
State's responsibility for monitoring and oversight of school programs, 
is necessary for all students. Please let us know if you need 
additional information regarding activities underway at the Department 
to ensure appropriate oversight for State accountability for youth well-
being in residential facilities and other settings. 

Sincerely, 

Signed by: 
Tracy R. Justesen: 

[End of section] 

Appendix X: Comments from the Department of Health and Human Services: 

Department Of Health & Human Services: 
Office of the Assistant Secretary for Legislation: 
Washington, D.C. 20201: 

May 7, 2008: 

Kay Brown: 
Acting Director: 
Education, Workforce, and Income Security Issues: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Brown: 

Enclosed are the Department's comments on the U.S. Government 
Accountability Office's (GAO) draft report entitled: Residential 
Facilities: Improved Date and Enhanced Oversight Would Help Safeguard 
the Well-Being of Youth with Behavioral and Emotional Challenges (GAO 
08-346). 

The Department appreciates the opportunity to review and comment on 
this report before its publication. 

Sincerely, 

Signed by: 

Jennifer R. Luong, for: 
Vincent J. Ventimiglia, Jr. 
Assistant Secretary for Legislation: 

Attachment: 

Comments Of The Department Of Health And Human Services (HHS) On The 
U.S. Government Accountability Office's (GAO) Draft Report Entitled: 
"Residential Facilities: Improved Data And Enhanced Oversight Would 
Help Safeguard The Well-Being Of Youth With Behavorial And Emotional 
Challenges" (GAO-08-346): 

GAO Recommendations: 

To help policymakers craft solutions that best address the magnitude of 
maltreatment and other threats to youth well-being in residential 
facilities, and also to facilitate federal oversight across states and 
agencies, we recommend that the Secretary of HHS take action to 
determine what barriers remain in those states that do not report case-
file data for residential facilities to NCANDS and explore options to 
help states address existing barriers. 

To help target federal civil rights investigations among states and 
facilities that can provide maximum benefit, we recommend that the U.S. 
Attorney General direct its Civil Rights Division to request access to 
HHS's NCANDs case-file data for residential facilities. We also 
recommend that the Attorney General have the Division query HHS, the 
Office of Juvenile Justice and Delinquency Prevention, and Education 
regarding other sources of relevant information within relevant 
subagencies, such as HHS' Centers for Disease Control and Prevention. 

To help ensure that the existing federal regulatory structure protects 
youth well-being across government and private residential facilities 
supported by federal programs, we recommend that HHS, DOJ, and 
Education work to enhance their oversight of state accountability for 
youth well-being in residential facilities. Such efforts could include 
ensuring that residential facilities are included in federal oversight 
reviews and on-site visits to states. 

HHS Response: 

As described in the report, the National Child Abuse and Neglect Data 
System (NCANDS) is a voluntary national data collection system. States 
are encouraged, to the extent practical, to report information for all 
data elements and technical assistance is provided to assist them in 
doing so. This Federal/State partnership has been very effective over 
the years in increasing the quantity and quality of information 
reported by States to the Federal Government on incidents of abuse and 
neglect reported to State Child Protective Service agencies. 

The number of States or jurisdictions (including the District of 
Columbia and Puerto Rico) reporting case-level information has 
increased each year and for the most recent data available, Federal 
Fiscal Year (FFY) 2006, the number of States submitting case-level data 
increased to 51, up from 49 submitting case-level data for the FFY 2005 
reporting year (the data used by GAO for the report). 

Addressing barriers to capturing more complete information on incidents 
of abuse and neglect, including child maltreatment-related fatalities 
occurring in residential facilities, will require continued 
improvements in the reporting of information on perpetrators and the 
reporting of case-level information on fatalities. ACF has seen 
improvements in both of these areas and ACF will continue to work with 
States to improve the collection of information on perpetrators and on 
fatalities, wherever possible and feasible. 

ACF would be pleased to work with the Department of Justice (DOJ) to 
provide NCANDS information that DOJ might find useful; however, it is 
important to note that NCANDS captures no identifying information on 
individual children, perpetrators, or facilities and, therefore, ACF is 
unclear whether the information would prove useful in targeting civil 
rights investigations. 

ACF's current oversight activities vis-a-vis GAO's third-paragraph 
recommendation are commensurate with existing statutory authority and 
resources. 

A key issue for consideration would be a requirement that facilities 
inform parents/caregivers about the use of disciplinary action, 
restraint, seclusion or critical incidents to ensure that there are 
communications and to affirm a family's "right to know" what is 
happening with their child. 

SAMHSA is listed in the report in Table 5 on page 36 as having no 
program requirements to address certain risks to youth well-being. It 
is important to note that SAMHSA has no legal authorization in this 
area. SAMHSA has taken extensive action within its legal authorities to 
address issues of seclusion and restraint, suicide prevention, etc., 
but does not have regulatory oversight of individual residential 
facilities at the local level. 

The issue of unlicensed facilities should be more clearly addressed in 
the report and recommendations. While licensing issues are discussed on 
pages 24-26, there is only a very brief mention of State licensing 
systems in the conclusion and there are no recommendations related to 
this issue. It is SAMHSA's understanding that this was a reason that 
the study was conducted and therefore SAMHSA recommends that this issue 
be discussed prominently and in more detail. 

[End of section] 

Appendix XI: Comments from the Department of Justice: 

U.S. Department of Justice: 
Washington, DC 20530: 

April 24, 2008: 

Ms. Kay Brown: 
Acting Director, Education, Workforce, and Income Security: 
Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Brown: 

Thank you for the opportunity to comment on the draft Government 
Accountability Office (GAO) report entitled "Residential Facilities: 
Improved Data and Enhanced Oversight Would Help Safeguard the Well-
Being of Youth with Behavioral and Emotional Challenges" (GAO-08-346). 
The Department of Justice (Department) understands the rationale behind 
the first two recommendations; the GAO has recommended additional 
efforts that may enhance oversight. With regard to the third 
recommendation, we believe that the Department's Office of Justice 
Programs' Office of Juvenile Justice and Delinquency Prevention (OJJDP) 
already has implemented measures that have started to and, over time, 
will achieve the results the GAO intended to bring about. Consequently, 
we believe it would be beneficial if the report highlighted the 
existing accomplishments of OJJDP. 

To help target federal civil rights investigations among states and 
facilities that can provide maximum benefit, the GAO recommends that 
the Attorney General work with the Secretary of HHS to obtain access to 
the case data file found in the National Child Abuse and Neglect Data 
System for residential facilities. Also, the GAO recommends that the 
Attorney General work with HHS, the OJJDP, and Education to obtain 
access to other sources of relevant information within relevant sub-
agencies, such as HHS' Centers for Disease Control and Prevention. The 
Department agrees with these two recommendations and intends to address 
our compliance in our statutorily required response to the Congress. 

In its third recommendation, the GAO proposes that the Department, HHS, 
and Education work to enhance their oversight of state accountability 
for youth well-being in residential facilities. The OJJDP currently 
invests a considerable amount of resources for training and provides 
even more funding for technical assistance on this issue either at a 
state's request or proactively. For example, today, the OJJDP is 
intensively assisting two states with conditions of confinement issues 
while, at the same time, fulfilling the OJJDP's statutory obligations. 
In addition, in fiscal year 2007, the OJJDP Administrator created a new 
working relationship with the Department's Civil Rights Division for 
the purpose of producing better coordinated responses with states. That 
relationship already has produced beneficial results. Finally, the 
OJJDP intends to continue providing oversight of state accountability 
for youth well-being in residential facilities to the full-extent of 
the OJJDP's applicable statutory authority, including federal oversight 
reviews and on-site visits to states. including these accomplishments 
in the report would be worthwhile. 

The OJJDP agrees with the GAO that working with HHS and Education is an 
important way to enhance youth well-being in residential facilities and 
that such effort can be coordinated, in part, through the Coordinating 
Council on Juvenile Justice and Delinquency Prevention (Council). One 
of the functions of the statutorily created Council is to coordinate 
all federal juvenile delinquency programs and all federal programs and 
activities involving detaining and caring for unaccompanied juveniles. 
Further, the Council is charged with examining how separate programs 
can be coordinated among federal, state, and local governments. The 
Department is a key player on the Council. 

For the reasons given above, we recommend GAO's third recommendation 
include specific actions for each agency, and suggest that HHS and 
Education develop, in consultation with the Department of Justice and 
through the Council, minimum standards of care for all relevant federal 
programs. 

If you have any questions, you or your staff may contact Richard Theis, 
Audit Liaison Group, on (202) 514-0469. 

Sincerely, 

Signed by: 

Lee J. Lofthus: 
Assistant Attorney General for Administration: 

[End of section] 

Appendix XII GAO Contacts and Staff Acknowledgments: 

GAO Contact: 

Kay E Brown, (202)512-7215, [email protected]: 

Staff Acknowledgments: 

Cindy Ayers (Assistant Director) and Arthur T. Merriam Jr. (Analyst-in- 
Charge) managed all aspects of the assignment. Kathleen Drennan, 
Vernette Shaw, and Mark E. Ward made significant contributions to this 
report, in all aspects of the work. In addition, Denise M. Fantone 
contributed to the initial design of the engagement; Carolyn Boyce 
provided technical support in design and methodology, survey research, 
and statistical analysis; Doreen Feldman and James Rebbe provided legal 
support; and Charles Willson assisted in the message and report 
development. 

[End of section] 

Related GAO Products: 

Residential Facilities: State and Federal Oversight Gaps May Increase 
Risks to Youth Well-Being, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-08-696T], (Washington, D.C.: April 24, 2008). 

Residential Programs: Selected Cases of Death, Abuse, and Deceptive 
Marketing, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-713T], 
(Washington, D.C.: April 24, 2008). 

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. 

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. [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-03-397]. Washington, D.C.: April 
21, 2003. 

Mental Health: Extent of Risk from Improper Restraint or Seclusion Is 
Unknown. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?T-HEHS-00-26]. 
Washington, D.C.: October 26, 1999. 

Mental Health: Improper Restraint or Seclusion Use Places People at 
Risk. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?HEHS-99-176]. 
Washington, D.C.: September 7, 1999. 

Prison Boot Camps: Short-Term Prison Costs Reduced, but Long-Term 
Impact Uncertain. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GGD-93-
69]. Washington, D.C.: April 29, 1993. 

[End of section] 

Footnotes: 

[1] For additional information see 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.: Oct. 10, 2007. 

[2] 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. 

[3] In this report, we use the term states to refer collectively to the 
50 states plus the District of Columbia and Puerto Rico. 

[4] We did not survey state education agencies, because they generally 
do not license residential facilities for youth. 

[5] Private facilities may receive government funds through contracts 
with state or county agencies to serve youth under state systems of 
care, such as juvenile justice, or as certified providers of care under 
government health insurance programs, such as Medicaid. Private funding 
may be provided by parents or others placing youth in a facility who 
are not under the cognizance of a government agency. 

[6] Parents may determine that it is best for some youth to live in an 
alternative setting, or youth who are at risk of running away or are a 
danger to themselves or others may be placed in a facility. 

[7] U.S. Department of Health and Human Services, State Regulation of 
Residential Facilities for Children with Mental Illness. DHHS Pub. No. 
(SMA) 07-4167. Rockville, Maryland: Center for Mental Health Services, 
Substance Abuse and Mental Health Services Administration, 2006. 

[8] Last reauthorized in 2003, CAPTA authorizes state grants to help 
states with their child protective service functions, and Children's 
Justice Act grants to improve states' investigation and prosecution of 
child maltreatment. 

[9] U.S. Department of Health and Human Services, Child Maltreatment 
2005, Appendix A lists the required data elements. 

[10] How a state organizes its child abuse and neglect reporting and 
investigation systems, and therefore whether it investigates and 
captures reports of abuse and neglect at exclusively private 
facilities, is the state's prerogative. 

[11] Three major national accreditation organizations for residential 
facilities include the Council on Accreditation (COA), the Commission 
on Accreditation of Rehabilitation Facilities (CARF), and the Joint 
Commission (JC). COA partners with human service organizations 
worldwide to improve service delivery outcomes by developing, applying, 
and promoting accreditation standards. CARF is an independent, 
nonprofit accreditor of human service providers in the areas of 
behavioral health, child and youth services, and medical 
rehabilitation. JC accredits and certifies health care organizations 
and programs in the United States in an effort to improve the safety 
and quality of care provided to the public through the provision of 
health care accreditation and related services that support performance 
improvement in health care organizations. 

[12] For example, states receiving Title IV-B funds are required to 
submit a 5-year child and family services plan that sets forth the 
goals that the state intends to accomplish and assurances that that 
states will review their progress. 

[13] Whether a private facility is covered by CRIPA would depend on the 
level of governmental involvement. For example, if a state or local 
government enters into a contract with a private facility to house 
certain juveniles, the facility might be considered an institution 
covered by the statute. However, CRIPA states that privately owned and 
operated facilities are not covered by the statute where the only 
connection between the facility and the state is a state license or the 
facility's receipt of Medicaid and certain other federal payments on 
behalf of residents of the facility. 

[14] We could not determine the number of deaths in each state because 
of the possibility of duplicative reporting across agencies. 

[15] 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. 

[16] In 2005, 37 states were unable to consistently identify whether 
the individual maltreating youth was facility staff, a parent, or other 
individual. 

[17] For additional information see U.S. Department of Health and Human 
Services, Administration on Youth and Families, Child Maltreatment 2005 
(Washington, DC: U.S. Government Printing Office, 2007). 

[18] For additional information see U.S. Department of Justice, 
Department of Justice Activities under the Civil Rights for 
Institutionalized Persons Act, Fiscal Year 2006 (Washington, D.C. 
2007). 

[19] According to DOJ officials, the Civil Rights Division has been 
granted access to HHS's Centers for Medicare & Medicaid Services (CMS) 
database that contains the annual survey results for CMS oversight of 
residential facilities. 

[20] These six states were 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. Note: 
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, (g) no response. 

[21] Among state juvenile justice survey respondents, 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 survey respondents reported 
not having exclusively private boot camps (19), ranches (17), and 
wilderness camps (14). 

[22] Two of the 15 states--Massachusetts and Utah--have a central 
agency that is responsible for licensing residential facilities. 

[23] For example, HHS's Medicaid program, a joint federal-state program 
to provide health care coverage for certain low-income, aged, or 
disabled individuals, requires that states providing inpatient 
psychiatric services in a nonhospital setting to individuals under age 
21 must ensure that such services are accredited by one of three 
specified accrediting organizations or a comparable one recognized by 
the state. 

[24] 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, (i) have written suicide prevention plans. A 
similar question was asked for asked for private facilities. 

[25] 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.: Oct. 
10, 2007. 

[26] Congress, as part of its spending power under Article I, Section 
8, of the U.S. Constitution, can attach conditions to states' receipt 
of federal funds. 

[27] 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, 1990-200, (Atlanta, Georgia, Sept. 7, 2007 / 
56(35); 905-908). 

[28] National Center on Institutions and Alternatives. Juvenile Suicide 
in Confinement: A National Survey. February 2004. 

[29] 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, Title XXXII, ï¿½ 3208 (amending 
Title V of the Public Health Service Act)), which requires that public 
or private nonmedical, 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. 

[30] Federal funding was reduced by $1,552,200 among eight states and 
territories in 2007. 

[31] See related discussion in a recent report by the Congressional 
Research Service, Family Law: Congress's Authority to Legislate on 
Domestic Relations Questions, Updated October 25, 2007, Washington, 
D.C. (RL31201). 

[32] For example, the Commerce Clause serves as the basis for federal 
regulation of child pornography that moves in interstate or foreign 
commerce. Moreover, courts have found that the Child Support Recovery 
Act, which criminalizes failure to pay past child support obligations 
to a child residing in a different state than the parent, is a 
constitutional exercise of congressional authority under the Commerce 
Clause. 

[33] The Centers for Medicare & Medicaid Services, for example, have 
accreditation requirements for certain facilities as a condition of 
payment under its programs. To be effective, this approach would 
require a mechanism to ensure that the accrediting body communicates 
any problems or loss of accreditation to the appropriate state and 
federal entities. 

[34] As a result of this definition, the following facilities were 
excluded from the review as they do not primarily serve adolescents or 
provide behavior modification services: (1) adult prisons; (2) 
hospitals, nursing homes, and facilities that serve youth who are 
medically fragile; (3) family or group foster care homes, orphanages, 
homeless shelters, halfway houses, and other facilities where the 
primary services are housing and ordinary child care; (4) recreational 
facilities such as summer sports camps; (5) college preparatory 
schools; and (6) facilities that serve only children under 12 years of 
age. 

[End of section] 

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