Residential Facilities
Improved Data and Enhanced Oversight Would Help Safeguard the Well-Being of Youth with Behavioral and Emotional Challenges
GAO-08-346, May 13, 2008
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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.
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 DOJ's 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 facilities--particularly juvenile justice facilities and boarding schools--are 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 facility's operating license, in some cases due to lack of alternatives in placing the displaced youth. 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.
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Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
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Recommendations for Executive Action
Recommendation: 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, the Secretary of Health and Human Services (HHS) take action to determine what barriers remain in those states that do not report case-file data for residential facilities to National Child Abuse and Neglect Data System (NCANDS) and explore options to help states address existing barriers.
Agency Affected: Department of Health and Human Services
Status: Closed - Implemented
Comments: 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. In 2010, HHS reported that the Child Maltreatment 2008, case-level data were received from 49 states, including the District of Columbia and Puerto Rico. The agency also reported that its technical assistance efforts related to the remaining two states' ability to report case-level data continue.
Recommendation: To help target federal civil rights investigations among states and facilities that can provide maximum benefit, the U.S. Attorney General should work with the Secretary of HHS to obtain access to the NCANDS case-file data for residential facilities.
Agency Affected: Department of Justice
Status: Open
Comments: DOJ agreed with this recommendation. (HHS stated that ACF would be pleased to work with DOJ in implementing this recommendation; however, ACF was unclear how the National Child Abuse and Neglect Data System (NCANDS) data would be useful in targeting investigations. GAO's report shows that 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.)
Recommendation: The Attorney General should 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.
Agency Affected: Department of Justice
Status: Open
Comments: DOJ agreed with this recommendation.
Recommendation: To help ensure that the existing federal regulatory structure protects youth well-being across government and private residential facilities supported by federal programs, HHS, Department of Justice, and the Department of Education should 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 Affected: Department of Justice
Status: Open
Comments: 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, DOJ 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. If DOJ determines that they do not have authority to do this, it could request it from Congress.
Recommendation: To help ensure that the existing federal regulatory structure protects youth well-being across government and private residential facilities supported by federal programs, HHS, Department of Justice, and the Department of Education should 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 Affected: Department of Justice
Status: Open
Comments: HHS (and DOJ) indicated that they are conducting state oversight consistent with existing statutory authority and resources. 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, there are 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. It HHS determines that it does not have authority to do this, it could request it from Congress. HHS's FY 2010 recommendation update indicates that the status of this recommendation has not changed.
Recommendation: To help ensure that the existing federal regulatory structure protects youth well-being across government and private residential facilities supported by federal programs, HHS, Department of Justice, and the Department of Education should 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 Affected: Department of Justice
Status: Open
Comments: 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, DOJ 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. If DOJ determines that they do not have authority to do this, it could request it from Congress.