Residential Facilities: State and Federal Oversight Gaps May	 
Increase Risk to Youth Well-Being (24-APR-08, GAO-08-696T).	 
                                                                 
Nationwide, federal funding to states supported more than 200,000
youth in facilities seeking help for behavioral or emotional	 
challenges in 2004. Recent federal reviews and investigations	 
highlighted maltreatment in some facilities, resulting in	 
hospitalizations and deaths. This testimony discusses (1) what is
known about incidents that adversely affect youth well-being in  
residential facilities, (2) the extent that state oversight	 
ensures youth well-being in these facilities, and (3) the factors
that affect the ability of federal agencies to hold states	 
accountable for youth well-being in residential facilities. This 
testimony is based on GAO's ongoing work, which included national
surveys to state agencies of child welfare, health and mental	 
health, and juvenile justice for the year 2006. GAO achieved an  
85 percent response rate for each of the three surveys. The work 
also included site visits to four states (California, Florida,	 
Maryland, and Utah) and discussions with the Departments of	 
Education (Education), Justice (DOJ), and Health and Human	 
Services (HHS). Interim work related to this testimony was	 
completed between November 2006 and March 2008, in accordance	 
with generally accepted government auditing standards.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-696T					        
    ACCNO:   A81862						        
  TITLE:     Residential Facilities: State and Federal Oversight Gaps 
May Increase Risk to Youth Well-Being				 
     DATE:   04/24/2008 
  SUBJECT:   Accountability					 
	     Child abuse					 
	     Data collection					 
	     Data integrity					 
	     Educational facilities				 
	     Federal agencies					 
	     Federal aid for criminal justice			 
	     Federal aid to states				 
	     Federal funds					 
	     Federal regulations				 
	     Federal/state relations				 
	     Health and behavioral care standards		 
	     Health care facilities				 
	     Investigations by federal agencies 		 
	     Juvenile correctional facilities			 
	     Mental care facilities				 
	     Reporting requirements				 
	     Risk management					 
	     Sexual abuse					 
	     Staff utilization					 
	     Standards						 
	     State programs					 
	     Suicide prevention 				 
	     Surveys						 
	     Teenagers						 
	     Wrongful death					 
	     Youth						 
	     program goals or objectives			 
	     Program implementation				 

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GAO-08-696T

   

     * [1]In summary
     * [2]Youth Maltreatment Occurred in Facilities Across the Nation,
     * [3]Gaps in State Oversight of Residential Facilities May Place

          * [4]Certain Facilities Are Exempt from State Licensing Requireme
          * [5]State Licensing Standards Do Not Address Some Primary Risks
          * [6]State Practices Inconsistent in Monitoring and Enforcing Fac
          * [7]State Agencies Reported a Lack of Coordination to Share Over

     * [8]Federal Agencies Challenged to Address Weaknesses in State O
     * [9]Concluding Remarks
     * [10]GAO Contacts and Acknowledgments

          * [11]Order by Mail or Phone

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Testimony: 

Before the Committee on Education and Labor, House of Representatives: 

United States Government Accountability Office: 
GAO: 

For Release on Delivery: 
Expected at 10:00 a.m. EDT:
Thursday, April 24, 2008: 

Residential Facilities: 

State and Federal Oversight Gaps May Increase Risk to Youth Well-Being: 

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

GAO-08-696T: 

GAO Highlights: 

Highlights of GAO-08-696T, a report to the Committee on Education and 
Labor, House of Representatives. 

Why GAO Did This Study: 

Nationwide, federal funding to states supported more than 200,000 youth 
in facilities seeking help for behavioral or emotional challenges in 
2004. Recent federal reviews and investigations highlighted 
maltreatment in some facilities, resulting in hospitalizations and 
deaths. This testimony discusses (1) what is known about incidents that 
adversely affect youth well-being in residential facilities, (2) the 
extent that state oversight ensures youth well-being in these 
facilities, and (3) the factors that affect the ability of federal 
agencies to hold states accountable for youth well-being in residential 
facilities. This testimony is based on GAOï¿½s ongoing work, which 
included national surveys to state agencies of child welfare, health 
and mental health, and juvenile justice for the year 2006. GAO achieved 
an 85 percent response rate for each of the three surveys. The work 
also included site visits to four states (California, Florida, 
Maryland, and Utah) and discussions with the Departments of Education 
(Education), Justice (DOJ), and Health and Human Services (HHS). 
Interim work related to this testimony was completed between November 
2006 and March 2008, in accordance with generally accepted government 
auditing standards. 

What GAO Found: 

Survey respondents from 49 states reported investigating complaints of 
youth maltreatment in residential facilities in 2006, including 
physical abuse, neglect, and sexual abuse, and 28 states reported 
deaths. There were no discernible patterns in the types of facilities 
involved, including whether facilities were operated by government or 
private entities, or located in urban or rural areas. State officials 
said that the number of maltreatment incidents was greater than the 
total reported to HHSï¿½1,503 incidents in 2005--due to barriers in data 
collection and reporting, including inconsistent funding and authority. 

States license and monitor residential facilities, but state agencies 
reported oversight gaps that may place youth in some facilities at 
higher risk for maltreatment and death. Some types of facilities are 
exempt from state licensing requirementsï¿½primarily state operated 
juvenile justice facilities and private residential schools and 
academies. Licensing standards did not always address suicide 
prevention and other common risks. State agencies reported an inability 
to conduct yearly on-site visits to facilities because of fluctuating 
levels of staff resources dedicated by states, and infrequently sharing 
negative findings from their oversight results. 

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

Monitoring Requirement: Physical plant; 
Monitored for less than all residential facilities: Child welfare: 4; 
Monitored for less than all residential facilities: Health and mental 
health: 16; 
Monitored for less than all residential facilities: Juvenile justice: 
13; 
Monitored for all residential facilities: Child welfare: 36; 
Monitored for all residential facilities: Health and mental health: 22; 
Monitored for all residential facilities: Juvenile justice: 24. 

Monitoring Requirement: Staffing issues; 
Monitored for less than all residential facilities: Child welfare: 5; 
Monitored for less than all residential facilities: Health and mental 
health: 15; 
Monitored for less than all residential facilities: Juvenile justice: 
13; 
Monitored for all residential facilities: Child welfare: 36; 
Monitored for all residential facilities: Health and mental health: 22; 
Monitored for all residential facilities: Juvenile justice: 23. 

Monitoring Requirement: Use of approved seclusion and restraint; 
Monitored for less than all residential facilities: Child welfare: 7; 
Monitored for less than all residential facilities: Health and mental 
health: 13; 
Monitored for less than all residential facilities: Juvenile justice: 
10; 
Monitored for all residential facilities: Child welfare: 33; 
Monitored for all residential facilities: Health and mental health: 23; 
Monitored for all residential facilities: Juvenile justice: 25. 

Monitoring Requirement: Use of psychotropic medications; 
Monitored for less than all residential facilities: Child welfare: 9; 
Monitored for less than all residential facilities: Health and mental 
health: 15; 
Monitored for less than all residential facilities: Juvenile justice: 
14; 
Monitored for all residential facilities: Child welfare: 31; 
Monitored for all residential facilities: Health and mental health: 22; 
Monitored for all residential facilities: Juvenile justice: 22. 

Monitoring Requirement: Presence of educational programming; 
Monitored for less than all residential facilities: Child welfare: 7; 
Monitored for less than all residential facilities: Health and mental 
health: 18; 
Monitored for less than all residential facilities: Juvenile justice: 
17; 
Monitored for all residential facilities: Child welfare: 31; 
Monitored for all residential facilities: Health and mental health: 8; 
Monitored for all residential facilities: Juvenile justice: 18. 

Source: GAO analysis of state agencies' responses to survey. 
 
Note: Other agency responses included no such facility in state, donï¿½t 
know, and no response. 

[End of table] 

HHS, DOJ, and Education hold states accountable for youth well-being, 
but federal efforts are hindered by the scope of the agenciesï¿½ 
oversight authority and practices. Most notably, these agencies do not 
have the authority to hold states accountable for youth in private 
residential facilities unless they serve youth in state programs that 
receive federal funds. For facilities that were under federal purview, 
federal requirements did not always address the identified risks to 
youthï¿½including such risks as suicide and inappropriate use of 
seclusion and restraintï¿½and program requirements were inconsistent. In 
monitoring state compliance, federal agencies did not always include 
residential facilities in their oversight reviews. 

What GAO Recommends: 

GAO recommendations will be included in its final report upon 
completion of ongoing work. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-696T]. For more 
information, contact Kay E. Brown (202) 512-7215 or [email protected]. 

[End of section] 

Mr. Chairman and Members of the Committee: 

Thank you for inviting me here today to discuss our ongoing work 
reviewing how state and federal agencies protect the well-being of 
youth in residential facilities who are receiving services for their 
behavioral or emotional challenges. Nationwide, federal funding to 
states supported more than 200,000 youth in government or private 
facilities in 2004. In addition, an unknown number of youth are placed 
in facilities by parents or others. These facilities include boarding 
schools and academies, boot camps, and wilderness camps. Overall, 
residential facilities play an important role in serving youth who 
cannot be safely served in their communities while living at home, due 
to risk of running away or harm to themselves or others. However, 
recent federal reviews highlighted youth fatalities in residential 
facilities due to neglect or maltreatment, and ongoing federal 
investigations continue to document incidents of abuse and neglect in 
some facilities for youth that in some cases have been severe enough to 
result in hospitalization or death. 

As you know, states are primarily responsible for ensuring the well- 
being of youth in facilities and other settings, and do so by setting 
their own standards of care certain facilities must meet to obtain and 
maintain an operating license. Federal agencies also set requirements 
for youth well-being that states agree to uphold in exchange for 
receiving federal program funds, such as those administered by the 
Department of Health and Human Services (HHS) to support state systems 
of care for child welfare, mental health, and substance abuse; the 
Department of Justice (DOJ), for state juvenile justice systems; and 
the Department of Education (Education), for state education systems. 
Further, if patterns of maltreatment are identified and found to 
violate the civil rights of youth in certain facilities that are 
operated or substantially sponsored by state and local governments, the 
federal Civil Rights of Institutionalized Persons Act (CRIPA) 
authorizes the Attorney General of the United States to conduct 
investigations and bring actions against state and local governments. 
However, under the current regulatory framework, federal oversight 
authority does not extend to private facilities that serve only youth 
placed and funded by parents or other private entities. In some states, 
safeguarding youth in these facilities is the primary responsibility of 
parents and facility staff. 

My remarks today will focus on the following issues with regard to 
youth well-being in residential facilities in terms of: 

(1) what is known about the incidents that adversely affect the well- 
being of youth in residential facilities; 

(2) the extent that state oversight ensures the well-being of youth in 
residential facilities, and; 

(3) the factors that affect the ability of federal agencies to hold 
states accountable for youth well-being in residential facilities. 

This testimony was developed using multiple methodologies, and was 
limited to residential facilities we defined as those that require 
youth--ages 12 through 17--to reside at the facility and that provide 
program services[Footnote 1] for youth with behavioral and emotional 
challenges. We surveyed three state agencies--child welfare, health and 
mental health, and juvenile justice[Footnote 2]--about residential 
facilities that were government operated, privately operated that 
received government funds, and privately operated with no government 
funding. To further our understanding, we visited four states-- 
California, Florida, Maryland, and Utah--and interviewed relevant 
officials. These states were selected based on the diversity of their 
state licensing and monitoring policies for residential programs, 
reports of child maltreatment, and geographic location. The scope of 
our work did not include the quality of services provided at 
residential facilities. We also obtained data from HHS's National Child 
Abuse and Neglect Data System (NCANDS); reviewed federal statutes, 
regulations, and guidance; and interviewed HHS, DOJ, and Education 
officials, as well as national association representatives and other 
experts on residential facilities for youth. The scope of our work did 
not include the quality of services provided at residential facilities. 
We performed our work between November 2006 and March 2008, in 
accordance with generally accepted government auditing standards. 

In summary: 

* Youth maltreatment and death occurred in government and private 
residential facilities across the nation, according to states we 
surveyed; however, data limitations hinder efforts to quantify the full 
extent of the problem. State-reported data collected by HHS in 2005 
showed 1,503 incidents of maltreatment by facility staff in 34 states, 
including physical abuse, neglect or deprivation of necessities, and 
sexual abuse. Moreover, 28 states responding to our survey reported at 
least one death in residential facilities in 2006, with accidents and 
suicides among the most common types of fatalities. These reported 
data, however, did not capture information from all facilities. Many 
states lack authority under state law to collect data on exclusively 
private facilities, and data that states did report were often 
incomplete. As a result, the number of adverse incidents was likely 
more numerous and widespread than reported. 

* All states have processes in place to license and monitor certain 
residential facilities, but states reported oversight gaps that may 
place youth in some facilities at higher risk for maltreatment and 
death. Most notably, state agencies exempted some types of government 
and private facilities from licensing requirements altogether, 
primarily juvenile justice facilities and private schools and 
academies. In addition, licensing standards do not always address 
suicide and other common risks to youth well-being. Although monitoring 
is key to ensuring facility compliance with standards, agencies in 
states we visited reported an inability to conduct yearly on-site 
reviews of conditions at each facility, because of fluctuating levels 
of staff resources committed by the state. Similarly, although 
information sharing can strengthen oversight for facilities shared by 
multiple agencies, many state agencies reported that they did not 
routinely share information with other state agencies about negative 
findings or when facility licenses were suspended or revoked. 

* HHS, DOJ, and Education all have processes to hold states accountable 
for the well-being of youth, but federal efforts are hindered by the 
scope of the agencies' oversight authority and monitoring practices. 
Most notably, these agencies do not have the authority to hold states 
accountable for youth well-being in private residential facilities 
unless they serve youth in state programs that receive federal funds. 
For facilities under federal purview, federal requirements did not 
always address the primary risks to youth well-being, such as suicide, 
and requirements were inconsistent among programs. In monitoring state 
compliance, federal agencies did not always include residential 
facilities in their oversight reviews. 

Youth Maltreatment Occurred in Facilities Across the Nation, but Data 
Are Limited and Not Used to Target Federal Civil Rights Investigations: 

Nearly all states (49) responding to our survey reported investigating 
complaints of youth maltreatment in residential facilities in 2006, 
including facilities operated by government as well as private 
entities, and located in both urban or rural areas. The types of 
maltreatment reported by states included physical abuse, neglect or 
deprivation of necessities, and sexual abuse that sometimes resulted in 
hospitalization or death. State reported data to NCANDS from 2005 
showed that 34 states reported 1,503 incidents of youth maltreatment by 
facility staff. Of these incidents, neglect or deprivation of 
necessities was the most frequent cause of youth maltreatment, followed 
by physical abuse, as shown in figure 1. 

Figure 1: Percentage of State-Reported Incidents of Youth Maltreatment 
by Residential Facility Staff, Fiscal Year 2005: 

[See PDF for image] 

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

Percentage of State-Reported Incidents of Youth Maltreatment by 
Residential Facility Staff, Fiscal Year 2005: 
Physical abuse: 24%; 
Neglect or deprivation of necessities: 44%; 
Sexual abuse: 9%; 
Other[A]: 23%. 

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

[End of figure] 

Of the states we surveyed, 28 reported that at least one youth had died 
in a residential facility in 2006. These deaths were primarily due to 
accidents and suicide, but also due to homicide and application of 
seclusion and restraint (see fig. 2). 

Figure 2: Number of States That Reported Specific Causes of Youth 
Fatalities in Residential Facilities, 2006: 

[See PDF for image] 

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

Number of States That Reported Specific Causes of Youth Fatalities in 
Residential Facilities, 2006: 
Accidental causes: 16 states; 
Suicide: 9 states; 
Other causes (specify): 9 states; 
Homicide: 3 states; 
Medically related accident: 3 states; 
Application of seclusion or restraint techniques: 2 states; 
Did not know: 4 states. 

Source: GAO analysis of state agency responses to survey. 

Notes: 

The survey question was as follows: Of the total youth deaths that you 
reported, how many died from each of the following causes: (a) suicide, 
(b) homicide, (c) application of seclusion and restraint techniques, 
(d) medically related accident, (e) accident that occurred while in a 
runaway or absence without leave status, (f) other accidental cause, 
and (g) other causes? 

Other causes of youth fatalities in residential facilities include 
natural causes, choking, and internal bleeding. 

[End of figure] 

Overall, officials from the states we visited said that the number of 
maltreatment incidents and deaths was greater than reported due to 
barriers in collecting and maintaining data. When available, 
comprehensive reporting of incident data can be used by state and 
federal agencies to assess the extent of maltreatment in residential 
facilities, inform risk assessments, target oversight resources, and 
develop policies to address trends. However, the lack of authority 
under state law hinders many states from collecting data on certain 
facilities--such as exclusively private facilities--and expanding 
oversight to cover them. In addition, states that have such authority 
reported difficulties sustaining data collection in times of budget 
shortages. National data in NCANDS for 2005--derived from state 
reports--suffers from these same limitations, as well as others. First, 
some states did not report data for residential facilities to NCANDS, 
[Footnote 3] so the data may understate the number of maltreatments and 
fatalities. Second, many states (37) did not consistently identify 
whether the individual maltreating youth was facility staff, a parent, 
or other individual. Last, NCANDS only tracked fatalities resulting 
from maltreatment, not suicide or accidents that may be an indicator of 
neglect or other problem that needs resolution. 

In the states we visited, youth maltreatment in facilities was 
attributed to several factors--such as a lack of experienced staff, 
insufficient staff training, or lack of appropriate supervision-- 
particularly in smaller facilities. For example, county officials in 
one state told us that adverse incidents were most likely to occur in 
contractor operated six-bed group homes--frequently used by state 
probation and child welfare agencies--where the state reimbursement 
rate is generally not high enough to hire skilled personnel and provide 
staff with ongoing training, support, and oversight. 

However, while in most facilities youth maltreatment may occur 
infrequently as a result of isolated circumstances, investigations of 
government and private facilities serving youth conducted under DOJ's 
Civil Rights Division (Division) have found a pattern or practice of 
civil rights violations in some facilities, including physical and 
sexual abuse, medical neglect, and inadequate education. At the end of 
fiscal year 2006, the latest year for which data were available, 
federal investigators reported active cases involving over 175 
facilities in 34 states.[Footnote 4] Annual reports from DOJ over the 
past several years have documented their findings of youth maltreatment 
in certain juvenile justice or mental health facilities: 

Physical and sexual abuse occurred without management intervention: In 
one facility, staff hit youth and slammed them to the ground. Staff hog-
tied and shackled youth to poles in public places, and girls were 
forced to eat their own vomit if they threw up while exercising in the 
hot sun. Staff routinely broke and wired shut the jaws of youth who 
showed disrespect in another facility. In some facilities, staff 
engaged in sexual acts with boys. Youth-on-youth violence occurred on 
an almost daily basis in some facilities, at times resulting in 
injuries that required hospitalization. Youth were sexually assaulted 
and threatened with sexual assault by other youth in some facilities, 
all without effective intervention from management. 

Severe neglect resulted in poor education, suffering, and death: In a 1-
year period at one facility, three boys committed suicide. In one 
suicide, staff lacked the appropriate tool to cut the noose from a 
victim's neck and also did not have oxygen in the tank they brought to 
help resuscitate him. The dental clinic at one facility was full of 
mouse droppings, dead roaches, and cobwebs; medications in the cabinet 
had expired over 10 years ago. In a state-operated mental health 
facility used by adolescents, older psychotropic medications, with 
serious side effects, were administered to sedate patients. One 
adolescent received 22 such psychotropic sedatives over a 2-month 
period. In another facility, youth were not provided with special 
education services as required by federal law. 

The Special Litigation Section of DOJ's Civil Rights Division receives 
more credible allegations of violations of youth rights than it can 
investigate. During fiscal year 2006 alone, the Division received 
approximately 5,000 citizen letters; hundreds of telephone complaints, 
and 135 inquiries from Congress and the White House. Division officials 
stated that with additional sources of information, they could better 
target their scarce investigative resources. Officials said that 
receiving more detailed information from NCANDS on the incidents of 
maltreatment and death occurring in specific facilities would be 
helpful, as would the results of federal agency monitoring reviews of 
states that highlight findings related to residential facilities. 
Except in one instance,[Footnote 5] officials said that no federal 
agencies--including HHS, Education, and DOJ's Office of Juvenile 
Justice and Delinquency Prevention (OJJDP)--were coordinating with the 
Division to provide pertinent oversight results. 

Gaps in State Oversight of Residential Facilities May Place Well-being 
of Some Youth at Risk: 

All states have processes in place to license and monitor certain 
residential facilities, but our survey identified several gaps that 
allow some of the common causes of youth maltreatment and death to go 
unaddressed. These gaps include the fact that some types of government 
and private facilities are exempt from licensing requirements, 
licensing standards do not always address the primary causes of youth 
maltreatment and death, and state agencies inconsistently monitor and 
enforce facility compliance and share their monitoring results. 

Certain Facilities Are Exempt from State Licensing Requirements: 

Licensing all facilities in a state--government or private facilities-
-can help ensure that residential facilities meet relevant state 
standards. Among state-operated facilities, however, more than half 
(28) of juvenile justice agencies reported exempting facilities from 
licensing.[Footnote 6] In addition, many state agencies reported that 
certain types of private facilities were also exempt from licensing, 
regardless of whether they received some government funding or were 
exclusively private. Private residential schools and academies--a 
category that includes boarding schools and training or reform schools-
-were exempted more often from licensing than other types of private 
facilities, according to survey respondents. Conversely, treatment 
facilities were the type most commonly required to have a license. 
Agencies in six states reported they exempted faith-based facilities 
from licensure.[Footnote 7] In addition, many agencies reported not 
knowing the licensing status of certain types of private facilities or 
reported that they did not have certain types of facilities in their 
state.[Footnote 8] Some states are considering laws that would expand 
their licensing authority for private facilities. 

One reason that private residential facilities may be exempt from 
licensing requirements is that state agencies do not have the necessary 
statutory or regulatory authority. Regarding residential schools and 
academies, for example, all agencies in 15 of the 33 states that 
responded to all three agency surveys reported that they did not have 
either the authority or the regulatory responsibility to license these 
facilities.[Footnote 9] 

The lack of licensing for all facilities serving youth has several 
consequences, in that there are no commonly accepted definitions of 
facility types. Within individual states, facility operators may bypass 
state licensing requirements by self-identifying their business as a 
type that is exempt from state licensing. In Texas, for example, a 
residential program self-identified as a private boarding school is not 
regulated by the state licensing agency, but the same facility would 
require a license if it self-identified as a residential treatment 
center or therapeutic camp. Inconsistent licensing practices across 
states can have implications as well. For example, a 2007 directory 
showed that Utah, which only recently implemented licensing 
requirements covering wilderness camps, was home to over 25 percent of 
registered wilderness programs in the United States. 

Facility licensing is also important because parents and others 
considering placing youth in private facilities at their own expense do 
not always have the information they need to screen facilities and make 
an informed decision. In our testimony on private facilities last 
October,[Footnote 10] we described cases in which program leaders told 
parents their programs could provide services that they were not 
qualified to offer, claimed to have credentials in therapy or medicine 
that they did not have, and led parents to trust them with youth who 
had serious mental disabilities. One national association for programs 
serving youth with behavioral and emotional difficulties testified 
before Congress that state licensing was important because the field 
does not currently have the capacity to certify facility integrity. 

Some states are considering laws that would expand their licensing 
authority for private facilities, while some use other methods to 
provide protections for youth. For example, Florida, among other 
states, includes requirements addressing youth well-being in contracts 
facilities must sign to serve youth under state care. Florida officials 
estimated that 85 percent of residential facilities in the state's 
juvenile justice system are private facilities under contract with the 
state. The agency uses the contract provisions to help ensure that 
facilities provide youth with needed services in compliance with agency 
regulations as well as state statutes. 

Accreditation is another method used by some states in lieu of, or to 
augment, state licensing requirements. For example, Ohio and Wyoming 
require specific health-related facilities to obtain accreditation 
instead of licensure as a condition to serving youth under state care. 
Of the states responding to our survey, a greater number of health and 
mental health agencies reported requiring facilities to be accredited 
by private organizations, due in part to conditions of participation 
for certain federal programs.[Footnote 11] The accreditation process 
may require providers to meet higher standards than those required by 
state licensing bodies; however, accreditation does not necessarily 
ensure the safety and well-being of youth. Officials from an 
accrediting organization told us that they do not always inform the 
state if a facility's accreditation status has been suspended or 
limited. In general, fewer states reported requiring accreditation than 
not across the three agencies we surveyed. 

State Licensing Standards Do Not Address Some Primary Risks to Youth 
Well-being: 

Our survey results showed that the licensing standards that states have 
in place for certain government and private residential facilities 
address many, but not all, of the most common risks to youth well-being 
that states had identified in our survey. The extent that state 
licensing standards cover the various aspects of youth well-being is 
important to safeguard youth from harm. Almost all states reported that 
when they required licensing, they required facilities to meet 
standards related to the safety of the physical plant, proper use of 
seclusion and restraint techniques, reporting of adverse incidents, and 
qualification requirements and background checks for staff.[Footnote 
12] These standards can help reduce the risk of harm due to accidental 
causes and staff maltreatment. However, other requirements addressing 
risks to youth are less often included as a part of licensing. For 
example, while states reported that almost all juvenile justice 
facilities are required to have written suicide prevention plans, about 
a third of state child welfare and health and mental health agencies 
reported that they do not have similar requirements for government 
facilities. In addition, most of the agencies in our survey did not 
require private facilities to have written suicide prevention plans. 

State Practices Inconsistent in Monitoring and Enforcing Facility 
Compliance: 

State agencies reported monitoring youth well-being in residential 
facilities, but survey results showed that certain aspects of youth 
well-being were not included in all monitoring activities, as shown in 
figure 3. Periodic on-site reviews to monitor and enforce facility 
compliance help ensure that licensing standards are taken seriously and 
that risks to youth well-being are quickly addressed. Among six 
different aspects of youth well-being we asked about in our survey, the 
quality of educational programming and the use of psychotropic 
medications were most likely to be reviewed at only some or none of the 
facilities monitored by child welfare, health and mental health, and 
juvenile justice agencies. Conversely, staffing issues were most often 
included in all monitoring reviews of government and private 
facilities. 

Figure 3: Fig. 3: Aspects of Well-Being Monitored by State Agencies in 
Private Residential Facilities That Served Youth and Received 
Government Funding: 

[See PDF for image] 

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

Monitoring Requirement: Physical plant; 
Monitored for less than all residential facilities: Child welfare: 4; 
Monitored for less than all residential facilities: Health and mental 
health: 16; 
Monitored for less than all residential facilities: Juvenile justice: 
13; 
Monitored for all residential facilities: Child welfare: 36; 
Monitored for all residential facilities: Health and mental health: 22; 
Monitored for all residential facilities: Juvenile justice: 24. 

Monitoring Requirement: Staffing issues; 
Monitored for less than all residential facilities: Child welfare: 5; 
Monitored for less than all residential facilities: Health and mental 
health: 15; 
Monitored for less than all residential facilities: Juvenile justice: 
13; 
Monitored for all residential facilities: Child welfare: 36; 
Monitored for all residential facilities: Health and mental health: 22; 
Monitored for all residential facilities: Juvenile justice: 23. 

Monitoring Requirement: Use of approved seclusion and restraint; 
Monitored for less than all residential facilities: Child welfare: 7; 
Monitored for less than all residential facilities: Health and mental 
health: 13; 
Monitored for less than all residential facilities: Juvenile justice: 
10; 
Monitored for all residential facilities: Child welfare: 33; 
Monitored for all residential facilities: Health and mental health: 23; 
Monitored for all residential facilities: Juvenile justice: 25. 

Monitoring Requirement: Use of psychotropic medications; 
Monitored for less than all residential facilities: Child welfare: 9; 
Monitored for less than all residential facilities: Health and mental 
health: 15; 
Monitored for less than all residential facilities: Juvenile justice: 
14; 
Monitored for all residential facilities: Child welfare: 31; 
Monitored for all residential facilities: Health and mental health: 22; 
Monitored for all residential facilities: Juvenile justice: 22. 

Monitoring Requirement: Presence of educational programming; 
Monitored for less than all residential facilities: Child welfare: 7; 
Monitored for less than all residential facilities: Health and mental 
health: 18; 
Monitored for less than all residential facilities: Juvenile justice: 
17; 
Monitored for all residential facilities: Child welfare: 31; 
Monitored for all residential facilities: Health and mental health: 8; 
Monitored for all residential facilities: Juvenile justice: 18. 

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

Note: The survey question was as follows: In 2006, did your agency 
routinely monitor or follow-up, or authorize for monitoring or follow- 
up, any of the following issues--in the absence of a complaint--at 
private residential facilities that received government funding 
providing targeted services for youth? Response options for this 
question were: (a) yes, monitored for all; (b) yes, monitored for some; 
(c) no, did not monitor; (d) no such facility in the state; (e) don't 
know; (f) no response. 

[End of figure] 

In addition, three of the four states we visited reported that they 
were unable to meet their goals for conducting annual monitoring visits 
at residential facilities due to a lack of resources. States reported 
that visiting facilities was necessary at least once a year, if not 
more often, to ensure that conditions for youth had not changed due to 
changes in personnel, ownership, or funding. However, the number of 
facilities visited each year depended on the fluctuating levels of 
resources committed by the state. In Maryland, agency officials said 
that state resources were redirected, as necessary, to meet state goals 
for monitoring residential facilities for youth. In Florida and Utah, 
however, agency officials said that imbalances between the current 
workload and staff resources constrained the state's capacity to 
conduct efficient, effective, and timely monitoring of residential 
facilities. A facility operator in California said that on-site 
monitoring had been as infrequent as once every 5 years. 

State agencies reported taking actions against facilities with 
identified problems in the last 3 years, but few reported suspending or 
revoking a facility's operating license. Options used included 
increased monitoring or requiring corrective action plans. Maryland 
state officials said that they may be less likely to close facilities 
when they fall below state standards if there is a shortage of 
facilities in the state and closing the facility would limit the 
state's ability to serve the youth who would be displaced by a closing. 
In addition, these officials noted that shutting down a facility is 
extremely disruptive to the youth who are placed there. 

State Agencies Reported a Lack of Coordination to Share Oversight 
Results: 

Many state agencies reported that they did not routinely share 
information with others regarding negative findings from their 
monitoring reviews. State agency coordination to share monitoring 
results can strengthen oversight in situations where facilities are 
used by multiple agencies and can help ensure that youth are not placed 
in facilities that another agency has already identified as having 
problems. However, one or more state agencies reported that they did 
not routinely share reports of adverse incidents (17) or when facility 
licenses had been suspended or revoked (12). 

Improving coordination among agencies across states is also important 
because almost all states reported in our survey that they placed some 
youth in out-of-state residential facilities. For example, child 
welfare agencies in the top 5 states reported placing over 3,500 youth 
in at least 26 states. Out-of-state placement can be difficult to 
manage, but may be used when the demand for services exceeds the 
state's capacity, particularly for cases requiring highly specialized 
services--such as therapeutic treatment for youth who committed arson, 
or who were involved in gangs. State agencies or parents may also place 
youth in other states where family members reside. Interstate 
coordination is important is to ensure that agencies sending youth for 
placement in other states are able to screen out facilities that have 
had negative findings uncovered during monitoring reviews or have 
outstanding allegations of maltreatment. Information sharing about 
adverse conditions in facilities may be particularly important in cases 
where state licenses cannot serve to help in making appropriate 
placement decisions. Four of the top five states that received the 
greatest number of out-of-state placements--according to child welfare 
agencies we surveyed--exempted one or more types of facilities from 
state licensing requirements. 

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

HHS, DOJ, and Education hold states accountable for youth well-being in 
certain residential facilities, but their scope of authority is 
limited, and gaps in agency oversight practices result in inconsistent 
protections for youth. Most notably, these agencies can hold states 
accountable for conditions in facilities that serve youth through 
programs supported by federal funds[Footnote 13]--whether government or 
private--but cannot hold states accountable for conditions in 
facilities that are exclusively private. When federal agencies do have 
oversight authority under certain federal programs, however, they do 
not always hold states accountable for addressing some of the primary 
risks to youth well-being. For example, in comparing requirements 
across HHS, DOJ, and Education, only HHS reported requiring states to 
address abuse and neglect prevention under certain federal programs. 
(See table 1.) 

Table 1: Federal Program Requirements for States that Address Certain 
Risks to Youth Well-being in Residential Facilities: 

Agency and program area: HHS: Child welfare; 
Abuse and neglect prevention: Yes; 
Suicide prevention: No; 
Use of seclusion and restraint: No; 
Education quality: Yes. 

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

Agency and program area: HHS: Substance abuse and mental health; 
Abuse and neglect prevention: Yes; 
Suicide prevention: No; 
Use of seclusion and restraint: No; 
Education quality: No. 

Agency and program area: DOJ: Juvenile justice and delinquency 
prevention; 
Abuse and neglect prevention: No; 
Suicide prevention: No; 
Use of seclusion and restraint: No; 
Education quality: No. 

Agency and program area: Education: Elementary and secondary education; 
Abuse and neglect prevention: No; 
Suicide prevention: No; 
Use of seclusion and restraint: No; 
Education quality: Yes[B]. 

Agency and program area: Education: Special education and 
rehabilitative services; 
Abuse and neglect prevention: No; 
Suicide prevention: No; 
Use of seclusion and restraint: No; 
Education quality: Yes[B]. 

Source: Analysis of HHS, DOJ, and Education documents. 

[A] Applies only to psychiatric residential treatment facilities. 

[B] Applies only to public agencies and children placed by public 
agencies in private facilities. 

[End of table] 

Federal program requirements are limited even for risks such as 
suicide, a problem documented by several federal agencies. For example, 
the Centers for Disease Control and Prevention (CDC)--which is part of 
HHS--have identified suicide as the third leading cause of death in 
2004 among all U.S. youth,[Footnote 14] and suicide was one of the 
leading causes of death among youth in residential facilities, as 
reported by states in this study. In addition, a study commissioned by 
DOJ recommends increased mental health screening for suicide prevention 
among incarcerated youth.[Footnote 15] DOJ officials we spoke with 
generally agreed with the need to focus on suicide prevention in 
residential facilities, and suggested that additional federal 
requirements in this area would be helpful. DOJ and HHS have Web sites 
that list resources states can use for this purpose, but HHS officials 
said that states are more responsive to a requirement or more specific 
agency guidance. 

Similarly, federal programs also do not generally require that states 
ensure the proper use of seclusion and restraint practices, which have 
come under intense scrutiny in recent years. Researchers and clinicians 
have chronicled the inherent physical and psychological risks in each 
use of these types of interventions---including death, disabling 
physical injuries, and significant trauma. Currently, federal seclusion 
and restraint requirements cover youth placed in psychiatric 
residential treatment facilities that receive Medicaid payments. 
However, requirements do not extend to other types of facilities, and 
federal officials told us that these techniques continue to be used in 
ways that sometimes cause injury and death. HHS is preparing a draft 
notice of proposed rulemaking concerning the use of seclusion and 
restraint in non-medical community-based children's facilities. 
[Footnote 16] 

Federal agencies have several means of oversight for youth well-being, 
but perhaps one of the most rigorous is unannounced site visits to the 
youth's place of residence. According to the federal and state 
officials we spoke with, only an on-site visit to the facility can 
reveal whether services in the administrative reports are provided 
under conditions that ensure youth well-being. For example, DOJ 
officials observed that students in one of the facilities they visited 
received their educational instruction while in cages, and reported 
that it would have been difficult to detect this practice in an 
administrative review. 

Among the federal agencies we reviewed, all included visits to states 
to ensure compliance with federal requirements, but agencies did not 
always include visits to residential facilities. DOJ officials target 
juvenile justice facilities, such as correctional facilities and 
detention centers, during on-site reviews, but HHS officials do not 
necessarily include residential facilities in their oversight reviews 
of state child welfare systems. HHS selects a sample of child case 
files for site visits, and because most children are in foster home 
settings, residential facilities are usually not included. 

Similarly, while federal programs contain provisions agencies can use 
to enforce state compliance with federal requirements, these provisions 
vary in their rigor and use, and only DOJ has levied financial 
penalties.[Footnote 17] To date, HHS and Education have required state 
corrective action plans as a method of enforcement, but officials said 
that they may also assess financial penalties in the future. 

Concluding Remarks: 

As the results of our work show, protecting youth in residential 
facilities--many of whom are troubled and vulnerable to harm from 
themselves or from others--requires particular vigilance on the part of 
parents and responsible government agencies. However, abuse, neglect, 
and civil rights violations documented in all types of residential 
facilities--government and private, licensed and unlicensed--show that 
the current federal-state oversight structure is inadequate to protect 
youth from maltreatment. Comprehensive results of our work will be 
included in a report to be released next month. This report will 
provide some options for action that states, federal agencies, and 
Congress may consider in any restructuring effort. We anticipate our 
report will also include recommendations for action that federal 
agencies can implement now under the existing regulatory structure. 

Mr. Chairman, this completes my prepared statement. I would be happy to 
respond to any questions you or other Members of the committee may 
have. 

GAO Contacts and Acknowledgments: 

For further information regarding this testimony, please contact me at 
(202) 512-7215. Individuals making key contributions to this testimony 
include Lacinda Ayers, Carolyn Boyce, Doreen Feldman, Art Merriam, Jim 
Rebbe, and Mark Ward. 

[End of testimony] 

Footnotes: 

[1] Our review included facilities that provided one or more of the 
following types of programs: juvenile justice, youth offender, juvenile 
delinquency, and incorrigibility programs; treatment programs for youth 
with behavioral, emotional, mental health, and substance abuse issues; 
homes for pregnant teens; schools for discipline or character 
education; and therapeutic group homes, such as a home that specializes 
in supporting and treating youth with severe emotional disorders. 

[2] In this report, we use the term states to refer collectively to the 
50 states plus the District of Columbia and Puerto Rico. We did not 
survey state education agencies because they generally do not license 
residential facilities for youth. 

[3] In fiscal year 2005, 10 states did not submit reports showing the 
number of fatalities in residential facilities, 2 states did not submit 
a report, 7 states did not track facility incident data in a format 
that could be shared with NCANDS, and 1 state involved in litigation 
did not report facility data. 

[4] For additional information see U.S. Department of Justice 
Department of Justice Activities Under the Civil Rights for 
Institutionalized Persons Act, Fiscal Year 2006, U.S. Department of 
Justice (Washington, D.C.: 2007). 

[5] According to DOJ officials, the Civil Rights Division has been 
granted access to HHS's Centers for Medicare and Medicaid Services 
(CMS) database that contains the annual survey results for CMS 
oversight of residential facilities. 

[6] The survey question was as follows: Which, if any, of the following 
types of government operated facilities providing residential targeted 
(child welfare, health mental health, juvenile justice) services for 
youth are currently exempt from licensing or monitoring in your state 
by statute or state regulations--state operated facilities? Response 
options were (a) exempt from licensing by our agency, (b) exempt from 
routine monitoring by our agency, (c) exempt from both, (d) not exempt 
from either, (e) no such facility in state, (f) don't know, and (g) no 
response. 

[7] These six states are Arizona, Arkansas, Iowa, Maine, Missouri, and 
South Carolina. In addition, licensing officials we interviewed in 
Florida stated that faith-based facilities had the option of being 
licensed by the state or by a faith-based licensing authority. The 
survey question was as follows: Which, if any, of the following types 
of private facilities providing residential targeted services for youth 
are currently exempt from licensing or routine monitoring in your state 
by statute or state regulation: Faith-based facilities? (a) exempt from 
licensure by our agency, (b) exempt from routine monitoring by our 
agency, (c) exempt from both, (d) not exempt from either, (e) no such 
facility in state, (f) don't know, and (g) no response. 

[8] Across agencies, states most often responded that they did not have 
private boot camps, ranches, and wilderness camps. Among state juvenile 
justice agencies, for example, 25 reported having no private boot camps 
in their state that received government funding, 22 reported having no 
ranches, and 17 reported having no wilderness camps. Somewhat fewer 
states reported not having exclusively private boot camps (19), ranches 
(17), and wilderness camps (14). 

[9] Two of the 15 states--Massachusetts and Utah--have a central agency 
that is responsible for licensing residential facilities. While we did 
not receive all three surveys from Texas, it also exempts residential 
schools and academies from licensing. 

[10] GAO, Residential Treatment Programs: Concerns regarding Abuse and 
Death in Certain Programs for Troubled Youth [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-08-146T] (Washington, D.C.: 
October 10, 2007) 

[11] For example, HHS's Medicaid program, a federal-state health 
insurance program for low-income and other specific populations, 
requires that providers of certain health or mental health services 
obtain accreditation from an approved accrediting organization to 
certify that the facility meets standards for safety, quality of care, 
treatment, and services. 

[12] Note: the survey question was as follows: When your agency 
develops or opens a government-operated residential facility that 
provides targeted services to youth, is the facility required to meet 
state standards in any of the following areas? (a) pass inspection of 
physical plant, (b) provide evidence of safe child care practices, (c) 
have written procedures for reporting physical or sexual abuse or 
neglect of youth, (d) meet all staff qualifications requirements, 
including training, (e) perform staff background checks, (f) meet 
specified staff-to-child ratios (g) provide evidence of appropriate 
educational programming, (h) have procedures in place for use of 
approved seclusion and restraint techniques, and (i) have written 
suicide prevention plans. A similar question was asked for private 
facilities. 

[13] This derives from Congress' powers under Article I, Section 8 of 
the U.S. Constitution and provisions of federal law establishing 
conditions for state grants. Congress, as part of its spending power, 
can attach conditions to states' receipt of federal funds. 

[14] For additional information, see Department of Health and Human 
Services' Centers for Disease Control Morbidity and Mortality Weekly 
Report on Suicide Trends Among Youths and Young Adults, aged 10-24 
years--United States, 1990--2004. 

[15] National Center on Institutions and Alternatives. Juvenile Suicide 
in Confinement: A National Survey. February 2004. 

[16] This draft notice has been submitted for departmental review and 
clearance. This rule is being promulgated in response to the Children's 
Health Act of 2000 (Pub. L. No. 106-310, tit. XXXII, ï¿½3208) (amending 
Title V of the Public Health Service Act)), which requires that public 
or private non-medical, community-based facilities for children 
receiving support in any form from any program supported, in whole or 
part, with funds appropriated under the Children's Health Act, shall 
protect and promote the rights of each resident of a facility, 
including the right to be free from any restraint or involuntary 
seclusion imposed for purposes of discipline or convenience. The 
statute requires HHS to define in regulation the types of facilities 
covered by this provision's requirements. 

[17] Federal funding was reduced by $1,552,200 among 8 states and 
territories in 2007. 

[End of section] 

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